Putting cardiovascular risk into perspective

Abstract

The Framingham Risk Score (FRS) is the gold standard for assessing cardiovascular (CV) risk.1 Individuals are categorized as having 10-year risk for CV disease event (myocardial infarction, stroke, peripheral arterial disease, congestive heart failure) that is low (0%–10%), moderate (11%–19%) or high (≥20%) based on risk factors that include age, sex, total cholesterol, high-density lipoprotein cholesterol, smoking status and systolic blood pressure. Those with diagnosed coronary artery disease (CAD), cerebrovascular disease, peripheral arterial disease or heart failure (HF) are automatically deemed to have a high 10-year risk.1 While the FRS is a useful clinical tool, it should be noted that it underestimates risk in certain categories of patients: in younger individuals, women, individuals with metabolic syndrome and those with chronic kidney disease.1 In addition, family history (evidence of CV disease in a first-degree relative younger than 60 years) is associated with a 1.7- and 2-fold increased risk of CV disease for women and men, respectively, which is not taken into account in the FRS. This factor helps to explain why 10% to 15% of patients with CAD have no apparent major CAD risk factors.1 As such, family history must be considered when assessing CV disease risk. Health professionals and patients may be much less concerned about individuals with low or moderate risk compared with those at high risk, and therefore may be less likely to recommend healthy lifestyle changes or medications. Moreover, in this population of patients, diagnoses such as angina may not be considered as often when the most remarkable complaints are symptoms such as excessive shortness of breath on exertion. This autobiographical case underscores the importance of heeding symptoms that may be suggestive of CV disease, regardless of risk assessment estimates. In addition, patients should be educated to appreciate the fact that low to moderate CV risk estimates do not imply that healthy lifestyle strategies are any less desirable.