STRENGTHS AND LIMITATIONS: The Framingham Global Risk Assessment Tools are gender specific and include different tools for individuals with a variety of cardiovascular outcomes. There are instances when the tool overestimates risk in low-risk populations and underestimates in high-risk groups. Studies have examined the accuracy of Framingham risk scores in women, different ethnic and social groups (Goh et al., 2013).
Goh, L.G., Dhaliwal, S.S., Lee, A.H., Bertolatti, D., & Della, P.R. (2013). Utility of established cardiovascular disease risk score models for the 10-year prediction of disease outcomes in women. Expert Review of Cardiovascular Therapy, 11(4), 425-435. doi: 10.1586/erc.13.26
Framingham Risk Score Calculator Pdf Download
Although patients with diabetes have 2 to 4 times increased risk of cardiovascular morbidity and mortality than individuals without diabetes, recent studies indicate that a significant part of patients are in a lower cardiovascular risk category. Men younger than 35 years, women younger than 45 years, patients with diabetes duration of less than 10 years without other risk factors have a much lower risk than patients who have traditional cardiovascular risk factors, and subclinical or established coronary artery disease (CAD). These patients are not risk equivalent as stated in previous studies. On the contrary, when in the presence of traditional risk factors or evidence of subclinical coronary disease (e.g. high coronary calcium score), the coronary risk is much increased and patients may be classified at a higher-risk category. Recent guidelines do not anymore consider diabetes as a CAD risk equivalent and recommend cardiovascular risk stratification for primary prevention. Stratification of diabetic patients improves accuracy in prediction of subclinical CAD, silent ischemia and future cardiovascular events. Stratification also discriminates higher from lower risk patients who may need intensive statin or aspirin prevention, while avoiding overtreatment in lower risk cases. It may also allow the clinician to decide whether to intensify risk reduction actions through specific newer drugs for glucose control such as SGLT-2 inhibitors or GLP-1 agonists, which recently have shown additional cardiovascular protector effect. This review addresses the assessment of cardiovascular disease risk using traditional and non-traditional cardiovascular risk factors. It also reviews the use of risk calculators and new reclassification tools, focusing on the detection of subclinical atherosclerosis as well as silent ischemia in the asymptomatic patients with diabetes.
Currently, the 2013 ACC/AHA guidelines [14], the 2016 ADA standards of diabetes care [15], the Brazilian Diabetes Society guidelines [16] and the 2016 European Society of Cardiology (ESC) [17] no longer consider diabetes as a coronary risk equivalent. The latest 2013 ACC/AHA guidelines [14, 18] now recommends stratification for patients with diabetes, when ages are from 40 to 75 years old, into two risk categories, using a global risk score calculator [14]. The recent ESC guideline considers that diabetes risk approaches the CHD risk when patients have more than 10 years of disease or when in the presence of renal dysfunction or microalbuminuria [17]. Patients younger than 40 years with a shorter duration of diabetes are currently defined as being part of a lower risk category. The categorization of diabetics into different cardiovascular risk groups by this way allows recognition of those who might benefit more from more intensive cardiovascular prevention. In the case of low-dose aspirin for example, considering the potential risk of gastrointestinal bleeding, defining cardiovascular risk by using a global risk score, might help guiding aspirin use in those with a greater net benefit.
High sensitivity C-reative protein (hs-CRP) is a marker of systemic inflammation and a predictor of incident CVD and CHD, independent of diabetes. In the study by Ridker et al. [59], 27,939 presumed healthy American women were followed up for a mean of 8 years for incident myocardial infarction, ischemic stroke, coronary revascularization or death from cardiovascular causes. They observed that hs-CRP was strongly related to the incidence of cardiovascular events, even after adjustments for age, smoking status, diabetes, categorical levels of blood pressure and the use of hormone therapy. In that study, hs-CRP performed better than LDL-c, indicating that hs-CRP may add substantial prognostic information to that conveyed by the Framingham risk score. The MESA study [23], confirmed that hs-CRP is independently associated with incident CHD, adding information to traditional risk factors of Framingham risk score.
Coronary arterial calcification is part of the development of atherosclerosis, occurring almost exclusively in atherosclerotic arteries being absent in normal vessel walls [67]. Atherosclerotic plaque proceeds through progressive stages where instability and rupture can be followed by calcification, providing stability to an unstable lesion [68]. Coronary artery calcium score (CAC) is determined by electron-beam (EBCT) and multi-detector (MDCT) computed tomography [69]. It has a strong correlation with the total coronary atherosclerotic burden and is able to define CHD risk, being an independent predictor of cardiovascular disease [70, 71].
Although the importance of CAC in risk stratification has increased significantly in the last years, ADA 2016 [15] still does not recommend CAC score for routine use in risk stratification of patients with diabetes, due to still open questions in cost-effectiveness. Further studies should address this point specially taking into account the risks of excessive exposition to radiation and costs.
For now, risk stratification in the patient with diabetes should include solely the traditional risk factors with or without risk calculators. Emerging risk factors are still awaiting confirmatory studies. Basically for being useful in clinical practice, first they must be strongly associated with the outcome. Secondly, there must be a reasonable potential for reclassification besides the traditional risk factors. They also must have good discrimination and calibration. Finally, they must have a favorable cost-effectiveness profile. Coronary artery calcium score, hs-CRP, family history of premature CVD and ABI can be useful tools. Estimated glomerular filtration rate (GFR) and microalbuminuria roles are still uncertain. CMIT is currently recommended against for using in clinical practice by 2013 AHA [18]. Better stratification of patients with diabetes may improve quality of indication of treatment in patients with diabetes.
Cardiovascular disease (CVD) risk factors are individually associated with frailty. This study examined whether Framingham CVD risk score (FRS) as an aggregate measure of CVD risk is associated with incident frailty among Chinese older adults.
By 2050, it is expected that one in four Chinese citizens will be 65 years of age or older [1]. Population aging is believed to be responsible for the growing prevalence of cardiovascular disease (CVD) and frailty in China. Frailty and CVD are two common and often coexisting conditions in the elderly that share many risk factors (hypertension, smoking, obesity, diabetes, and dyslipidemia), and exert a substantial influence on clinical outcomes [2, 3] (e.g., disability, sarcopenia and dementia). The generalized Framingham risk score (FRS) [generalized FRS; 2008] [4] is a standard tool for assessing the 10-year risk of CVD events (i.e., coronary heart disease, cerebrovascular disease, peripheral vascular disease, heart failure). In 2015, an updated FRS [2015] calculator ( -Risk-Score-Calculator-for-Coronary-Heart-Disease-745.html) was published. It has been shown that higher FRS is associated with multiple adverse health outcomes, e.g., incident chronic kidney disease (CKD) [5], sarcopenia [6], and cognitive decline [7]. Frailty is a geriatric syndrome characterized by reduced physiological reserve and increased vulnerability for poor recovery of homeostasis after a stressor event [8]. Frailty poses a high risk of developing negative health outcomes including incident disability [9], falls [10], fracture [11], and mortality [12].
There are a few studies evaluating the predictive value of Framingham risk score (FRS) for cardiovascular disease (CVD) risk assessment in patients with metabolic syndrome in Iran. Because of the emerging high prevalence of CVD among Iranian population, it is important to predict its risk among populations with potential predictive tools. Therefore, the aim of the current study is to evaluate the FRS and its determinants in patients with metabolic syndrome.
FRS was used to investigate the risk of cardiovascular disease [11]. FRS scores were calculated based on the six coronary risk factors including age, gender, TC, HDL-cholesterol, systolic blood pressure, and smoking habits. The cutoffs for calculating FRS were as follows: TC
Totally, 77.5% of patients were in low risk of CVD, whereas 16.3 and 6.3% were in intermediate and high risk of CVD, respectively. These values were comparable with the previous study performed in Kerman, Iran, while the corresponding numbers were 74.3, 18.1, and 7.6%, respectively. Moreover, in our study, the number of metabolic syndrome components in patients of high risk score was significantly higher than the other groups. Therefore, FRS can be used as a diagnostic tool for presence of metabolic syndrome as also confirmed by previous studies [5, 10, 13]. In the study by Takahashi et al. [8], same as our results, a positive correlation was observed between CAD risk score and the number of metabolic syndrome components; the greater the metabolic syndrome components, the higher the risk of developing CAD, although the results of studies in the predictive capacity of FRS in cardiovascular disease risk are inconsistent. Several studies reported that metabolic syndrome is a better predictor of CVD risk compared with FRS because of high dependency of FRS to age, underestimation of cardiovascular disorders in young ages, and lack of coverage several prominent features of metabolic syndrome such as obesity, hyper-triglyceridemia, and elevated high CRP levels [20, 21]; however, two previous US reports [22, 23] showed that FRS is more predictive for CVD risk than metabolic syndrome. More studies in different age groups and geographical locations are needed to address this question. 2ff7e9595c
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