Framingham risk score and prediction of lifetime risk for coronary heart disease

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Abstract

We investigated whether the Framingham risk score, which was designed to estimate the 10-year risk of coronary heart disease (CHD), differentiates lifetime risk for CHD. All subjects in the Framingham Heart Study examined from 1971 to 1996 who were free of CHD were included. Subjects were stratified into age- and gender-specific tertiles of Framingham risk score, and lifetime risk for CHD was estimated. We followed 2,716 men and 3,500 women; 939 developed CHD and 1,363 died free of CHD. At age 40 years, in risk score tertiles 1, 2, and 3, respectively, the lifetime risks for CHD were 38.4%, 41.7%, and 50.7% for men and 12.2%, 25.4%, and 33.2% for women. At age 80 years, risks were 16.4%, 17.4%, and 38.8% for men and 12.8%, 22.4%, and 27.4% for women. The Framingham risk score stratified lifetime risk well for women at all ages. It performed less well in younger men but improved at older ages as remaining life expectancy approached 10 years. Lifetime risks contrasted sharply with shorter term risks: at age 40 years, the 10-year risks of CHD in tertiles 1, 2, and 3, respectively, were 0%, 2.2%, and 11.6% for men and 0%, 0.7%, and 2.3% for women. The Framingham 10-year CHD risk prediction model discriminated short-term risk well for men and women. However, it may not identify subjects with low short-term but high lifetime risk for CHD, likely due to changes in risk factor status over time. Further work is needed to generate multivariate risk models that can reliably predict lifetime risk for CHD.

Section snippets

Subjects

The Framingham Heart Study was established in 1948, when 5,209 residents, 28 to 62 years old, of Framingham, Massachusetts, were enrolled in a prospective epidemiologic cohort study. In 1971, an additional 5,124 subjects (offspring of original cohort subjects and spouses of offspring) were enrolled in the Framingham Offspring Study. Study design and entry criteria for the 2 cohorts have been detailed elsewhere.12, 13 For the present analysis, to reflect more contemporary experience, all

Study sample

We followed 2,716 men and 3,500 women from 1971 to 1996. During follow-up, 939 subjects developed CHD and 1,363 died free of CHD. Table 1lists the number of subjects contributing data and the mean Framingham risk scores for each age- and gender-specific risk score tertile. There was a stepwise increase in mean risk score with advancing age, because advancing age confers increased risk for CHD and because of a greater burden of CHD risk factors with advancing age.

Lifetime risk for CHD by Framingham risk score

Table 2presents the lifetime

Discussion

The Framingham risk score, which was designed to predict 10-year risk for CHD, was very effective in predicting the short-term cumulative risk for CHD, even in the context of competing risk of death from noncoronary causes. In women, the risk score was also very effective at stratifying the remaining lifetime risk for CHD, with 1.5- to 3-fold higher absolute risk in the highest versus lowest tertile of risk score at all ages. In men, the risk score discriminated lifetime risk well only at older

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Dr. Lloyd-Jones is supported by grant 1 K23 HL04253 from the National Institutes of Health, Bethesda, Maryland. The Framingham Heart Study is supported by contract N01-HC-25195 from the National Institutes of Health/National Heart, Lung, and Blood Institute, Bethesda, Maryland.

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