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Cononary Heart Disease Risk Assessment
General Note About Validity
M. Lenz and I. Mühlhauser (Kardiovaskuläre Risikoschätzung
für eine informierte Patientenentscheidung. Wie valide sind die
Prognoseinstrumente? Med. Klinik 99(11): 651-661, 2004) reviewed
12 cardiovascular risk assessment tools and respective validation
studies. They searched for discrimination between risk groups,
predictive values, prognostic agreement, and transferability across
populations. They found that Framingham-based instruments overestimate
cardiovascular risk for Central European populations by at least 30%.
Prior to application these instruments would need recalibration using
regional data before implementation. External validation of
these 12 instruments is weak to non-existent. Agreement between
instruments beyond chance is moderate.
Framingham CHD Prediction Score
- Authors: Kannel WB, McGee D, and Gordon T (1976)
- Risk factors included: Sex, age, blood pressure,
total cholesterol, LDL cholesterol, HDL cholesterol, smoking, diabetes
status, and left ventricular hypertrophy (LVH).
- Development: The Framingham CHD Prediction Score
was originally developed to assess the relative importance of CHD
risk factors and to quantify the absolute level of CHD risk for
individuals without a history of cardiovascular disease.
- Links to On-line Risk Assessment:
Cardiology Division at the VA Palo Alto Health Care System: Medical
National Cholesterol Education Program: Framingham CHD Risk
- Assessment in Minorities: The original
Framingham risk equations were updated in 1991 by Anderson et al.
to include the Framingham offspring, thereby providing estimates
for people between the ages of 30 and 74. A further update
incorporating risk factor categories was made by WIlson et al. in
1998. This update removed left ventricular hypertrophy from
the model. Because the Framingham Heart Study consists of
white middle-class individuals, subsequent validation in minorities
using data from other studies was carried out by D'Agostino et al.
(2001). Recalibration of the Framingham Risk Score model was
required for some ethnic minorities where the original scores overestimated
the 5-year risk of developing CHD. After recalibration the
Framingham Risk Score model worked well.
- Detailed Notes
UKPDS Risk Engine
- Authors: United Kingdom Prospective Diabetes
Study (UKPDS) Group (2001)
- Risk factors included: The model is specific
for individuals with a diagnosis of diabetes and incorporates glycaemia
(as HbA1c), systolic blood pressure, and lipid levels (total : HDL
cholesterol ratio) as risk factors, in addition to age at time of
diabetes diagnosis, sex, ethnic group, smoking status, and time
since diagnosis of diabetes. Because of treatment changes
after the diagnosis of diabetes, several of these values are the
mean of measurments taken one year apart. Values collected
only at the time of diagnosis did not have as great a predictive
- Development: The UKPDS model provides an equation
for estimating the risk of new CHD events in people with Type II
diabetes and no history of CHD or stroke. It provides formulae for
incidence rates, estimates of probability for CHD complications,
and the relative risks associated with potential risk factors. The
model provides equations for absolute risk, incorporating the effect
of multiple risk factors to give overall event rates.
- Assessment in Minorities: The study population
(n=4540) consisted of 7.8% Afro-Caribbean and 9.5% Asian Indian.
- Reference: RJ Stevens, V Kothari, AI Adler, IM
Stratton, and RR Holman on behalf of the United Kingdom Prospective
Diabetes Study (UKPDS) Group (2001). The UKPDS risk engine: a model
for the risk of coronary heart disease in Type II diabetes (UKPDS
56). Clinical Science 101: 671–679
Joint British Societies Coronary Risk Prediction Charts
- Authors: British Cardiac Society, British Hyperlipidaemia
Association, British Hypertension Society (1998)
- Risk factors included: Age, gender, smoking,
blood pressure, total cholesterol, HDL cholesterol, diabetes, and
ECG evidence of LVH. Blood pressure and cholesterol are treated
as continuous variables. Family history of CHD or atherosclerotic
disease is not included specifically in the calculation of CHD risk;
however, it can be included by increasing the risk estimate by 1.5.
- Development: These charts are based upon the
Framingham data. The aim of these joint recommendations is
to encourage a unified approach to the management of patients with
established CHD and/or other atherosclerotic disease, as well as
Individuals at high risk for developing CHD or other atherosclerotic
disease (i.e. those with hypertension, dyslipidaemia, diabetes mellitus,
family history of premature CHD, or a combination of these risk
factors). Patients with diabetes mellitus are at particularly high
risk of CHD. The specific objectives of CHD prevention,
and the prevention of other major atherosclerotic disease, are to
reduce the risk of a further major cardiac event—that is,
unstable angina or myocardial infarction (MI), or reinfarction,
the need for
coronary revascularisation procedures—and to reduce overall
mortality in patients with established CHD. In high risk individuals
in the general population, the objective is to substantially reduce
the risk of such individuals developing coronary disease or other
major atherosclerotic disease.
The computer program “Cardiac Risk Assessor” developed
for these recommendations is the preferred method of calculating
absolute 10 year CHD risk for an individual based on the Framingham
function; it can also be used to calculate cardiovascular risk (including
stroke) over the same period. This program is designed only for
use with Microsoft Excel (version 5 or higher).
The computer program or thecharts should not be used in patients
with established CHD or other atherosclerotic disease, familial
hypercholesterolaemia, or malignant hypertension. The CHD risk is
calculated as a probability (%) of developing CHD (non-fatal MI
or coronary death) over 10 years. Family history is not included
in this risk equation from the Framingham study. Adjusting the computed
risk upwards by a factor of 1.5 is appropriate in patients who have
a first degree male relative developing CHD, or other atherosclerotic
disease, before the age of 55 years, or a female first degree relative
with a similar history before the age of 65 years.
- Online Link: Risk
Charts posted by Diabetes UK.
- Assessment in Minorities: In ethnic minorities
the Framingham risk equation should be used with caution as it has
not been validated in these populations.
- Reference: British Cardiac Society, British Hyperlipidaemia
Association, British Hypertension Society,
endorsed by the British Diabetic Association (1998) Joint British
recommendations on prevention of
coronary heart disease in clinical practice. Heart, 80(supplement
- Acquiring the Computer Program: An MS DOS version
of the Cardiac Risk Assessor program is available from Professor
Paul Durrington, Department of Medicine, Manchester Royal Infirmary,
Oxford Road, Manchester M13 9WL, UK.
- Authors: Assmann G, Cullen P, Schulte H (2002)
- Risk factors included: In order of importance:
age, LDL cholesterol, smoking, HDL cholesterol, systolic blood pressure,
family history of premature MI, diabetes mellitus, triglycerides.
This study included only men.
- Development: The Prospective Cardiovascular
Münster (PROCAM) study included 5389 men ages 35 to 65 at the
time of recruitment. At the time of recruitment individuals
who had a history of MI, stroke, or angina pectoris, or if the ECG
showed signs of ischemic heart disease, were excluded from the study.
For each risk factor, categories were constructed based on the National
Cholesterol Education Program III guidelines and the number of points
for each category are presented in a table. The PROCAM score
is generated by summing the points received for each risk factor.
Another table shows the risk of having an acute coronary event (fatal
or nonfatal MI or acute coronary death) depending on the PROCAM
score. The discrimination of the PROCAM model (based upon
receiver-operating characteristics curve analysis) was 82.4%. In
comparison, the Framingham model discrimination was significantly
less (77.8%) in the same population. The Framingham model
consistently overestimated the risk in this population.
- Assessment in Minorities: The study population
included no minorities, women, or men over the age of 65 at the
time of recruitment.
- Reference: Assmann G, Cullen P, Schulte H (2002)
Simple scoring scheme for calculating the risk of acute coronary
events based on the 10-year follow-up of the Prospective Cardiovascular
Münster (PROCAM) study. Circulation 105: 310-315.
The European SCORE Project
- Authors: Conroy RM, Pyörälä
K, Fitzgerald AP, Sans S et al. (2003)
- Risk factors included: Sex, age, smoking, systolic
blood pressure, and either total cholesterol or the total/HDL cholesterol
ratio. Diabetes was excluded due to the lack of universally
collected information with consistent definitions. Only minor
differences in risk assessment between the models using total cholesterol
and those using the total/HDL cholesterol ratio were observed.
- Development: The SCORE (Systematic COronary
Risk Evaluation) project was initiated to develop a risk scoring
system for use in the clinical management of cardiovascular risk
in European clinical practice. The project assembled a pool
of datasets from 12 European cohort studies, mainly carried out
in general population settings. Ten-year risk of fatal cardiovascular
disease was calculated using a Weibull model in which age was used
as a measure of exposure time to risk rather than as a risk factor.
Separate estimation equations were calculated for coronary heart
disease and for non-coronary cardiovascular disease. These were
calculated for high-risk and low-risk regions of Europe. Two parallel
estimation models were developed, one based on total cholesterol
and the other on total cholesterol/HDL cholesterol ratio. Four sets
of figures provide the risk of fatal CVD based upon European risk
region, gender, smoking status, age, systolic blood pressure, and
cholesterol. Because calculating the risks of non-fatal CVD
events is critically dependent on definitions and methods used in
their ascertainment , the SCORE project shifted its emphasis to
fatal CVD events only. Formulas for calculating the risk of
fatal CVD as well as the underlying risks of CHD and non-coronary
CVD are given in the Appendix.
- Assessment in Minorities: The SCORE project
was conducted using information from 12 European countries.
Race was never considered in the development of the SCORE project.
- Reference: Conroy RM, Pyörälä
K, Fitzgerald AP, Sans S, Menotti A, De Backer G, De Bacquer D,
Ducimetière P, Jousilahti P, Keil U, Njølstad I, Oganov
RG, Thomsen T, Tunstall-Pedoe H, Tverdal A, Wedel H, Whincup P,
Wilhelmsen L, Graham IM, SCORE project group. (2003) Estimation
of ten-year risk of fatal cardiovascular disease in Europe: the
SCORE project. European Heart Journal 24(11):987-1003.
New Zealand CVD Risk-Benefit Prediction Guide
- Authors: Jackson R and the Dyslipidaemia Advisory
- Risk factors included: Sex, age, diabetes status,
smoking status, blood pressure, and total/HDL cholesterol ratio.
- Development: This guide provides a simple quantitative
method for assessing a person's risk of CVC and the likely benefits
of lowering blood pressure or cholesterol with drugs. The
charts are based on the Framingham Heart Study prognostic algorithm
of Anderson et al. (1991). The benefit of drug treatment is
presented as the number of CVD events prevented per 100 treated
individuals for 5 years.
- Link to On-line
Risk Tables: Hosted by the National Heart Foundation
of New Zealand
- Assessment in Minorities: These charts
are based upon the Framingham algorithms of 1991 and do not include
any assessments in Minorities.
- References: Jackson R (2000) Updated New Zealand
cardiovascular disease risk-benefit predection guide. BMJ
Dyslipidaemia Advisory Group (1996) 1996 National Heart Foundation
clinical guidelines for the assessment and management of dyslipidaemia.
NZ Med J 109: 224-232.
Sheffield Risk Table
- Authors: Haq IU, Jackson PR, Yeo WW, Ramsay
- Risk factors included: The categorical variables
of sex, age, hypertension, smoking, diabetes, and left ventricular
hypertrophy. The continuous variable of total serum cholesterol
(mmol/L) is used in the earlier table (1995) and the total/HDL cholesterol
ratio is used in the later table (2000).
- Development: The Sheffield Risk Tables are based
upon a logistic regression equation predicting coronary death risk
derived from the Framingham population. For people without
a history of CVD the table presented in Haq et al. (1995) identifies
subjects who have a specified degree of coronary risk, shows the
serum cholesterol concentration that confers that degree of risk,
and identifies subjects who will not have this degree of risk, irrespective
of their cholesterol concentration. For each combination of
sex, hypertension, smoking, diabetes, and LVH, the table reports
the total cholesterol level that confers a 1.5% or greater risk
of having a fatal coronary event within one year. These are
the patients who could most benefit from treatment with an inhibitor
of hydroxymethylglutaryl-coenzyme-A reductase. The table was
updated by Wallis et al. (2000) and identifies people at thresholds
of 15% or 30% risk of a fatal CVD event over 10 years. The
table also incorporates the total/HDL cholesterol ratio rather than
simply total serum cholesterol. This updated table was tested
with a population of 1000 taken from the 1995 Scottish Health Survey.
The table had 97% sensitivity and 95% specificity for coronary risk
of >15% over 10 years when compared with the risk calculated
from the Framingham algorithms.
- Assessment in Minorities: Having been
based on the Framingham cohort, there is no specific assessment
in minorities. However, there is a note in Wallis et al. (2000)
that the table underestimates CHD risk in British Asians.
- References: Haq IU, Jackson PR, Yeop WW, Ramsay
LE (1995) Sheffield risk and treatment table for cholesterol lowering
for primary prevention of coronary heart disease. Lancet
Wallis EF, Ramsay LE, Haq IU, Ghahramani P, Jackson PR, Rowland-Yeo
K, Yeo WW (2000) Coronary and cardiovascular risk estimation for
primary prevention: validation of a new Sheffield table in the 1995
Scottish health survey population. BMJ 320: 671-676.
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