Abstract
BackgroundGuidelines for the prevention of coronary heart disease (CHD) recommend use of Framingham-based risk scores that were developed in white middle-aged populations. It remains unclear whether and how CHD risk prediction might be improved among older adults. We aimed to compare the prognostic performance of the Framingham risk score (FRS), directly and after recalibration, with refit functions derived from the present cohort, as well as to assess the utility of adding other routinely available risk parameters to FRS.MethodsAmong 2193 black and white older adults (mean age, 73.5 years) without pre-existing cardiovascular disease from the Health ABC cohort, we examined adjudicated CHD events, defined as incident myocardial infarction, CHD death, and hospitalization for angina or coronary revascularization.ResultsDuring 8-year follow-up, 351 participants experienced CHD events. The FRS poorly discriminated between persons who experienced CHD events vs. not (C-index: 0.577 in women; 0.583 in men) and underestimated absolute risk prediction by 51% in women and 8% in men. Recalibration of the FRS improved absolute risk prediction, particulary for women. For both genders, refitting these functions substantially improved absolute risk prediction, with similar discrimination to the FRS. Results did not differ between whites and blacks. The addition of lifestyle variables, waist circumference and creatinine did not improve risk prediction beyond risk factors of the FRS.ConclusionsThe FRS underestimates CHD risk in older adults, particularly in women, although traditional risk factors remain the best predictors of CHD. Re-estimated risk functions using these factors improve accurate estimation of absolute risk.
Highlights
Guidelines for the prevention of coronary heart disease (CHD) recommend the use of risk scores to identify adults at higher risk of CHD for whom preventive therapy–e.g., by lipid lowering drugs– has higher absolute benefits [1]
Actual risk prediction with Framingham risk score (FRS) might perform less well in older adults compared to middle-aged adults, and some traditional risk factors have weaker associations with CHD risk in the elderly; for example, total and low-density lipoprotein (LDL)-cholesterol are strong cardiovascular risk factors in middle-aged but not in older adults [7]
As it remains unclear whether and how CHD risk prediction might be improved in the growing population of elderly [8] to facilitate primary prevention strategies, we aimed to compare the prognostic performance of 1) the FRS, directly and 2) after recalibration [9], and 3) with functions derived from the Health ABC Study, a cohort of elderly white and black men and women [10]
Summary
Guidelines for the prevention of coronary heart disease (CHD) recommend the use of risk scores to identify adults at higher risk of CHD for whom preventive therapy–e.g., by lipid lowering drugs– has higher absolute benefits [1]. Actual risk prediction with FRS might perform less well in older adults compared to middle-aged adults, and some traditional risk factors have weaker associations with CHD risk in the elderly; for example, total and LDL-cholesterol are strong cardiovascular risk factors in middle-aged but not in older adults [7]. Guidelines for the prevention of coronary heart disease (CHD) recommend use of Framingham-based risk scores that were developed in white middle-aged populations. It remains unclear whether and how CHD risk prediction might be improved among older adults. We aimed to compare the prognostic performance of the Framingham risk score (FRS), directly and after recalibration, with refit functions derived from the present cohort, as well as to assess the utility of adding other routinely available risk parameters to FRS
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