Coronary Artery Disease(CAD) Ms. Leonardo Roever
Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors
Leading causes of death for all males and females Deaths in Thousands A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease Leading causes of death for all males and females (United States: 2004). Source: NCHS and NHLBI.
Coronary Heart Disease Heart Failure Diseases of the Arteries Defects Rheumatic Fever/ Rheumatic Heart Disease Stroke High Blood Pressure Congenital Cardiovascular Other Percentage breakdown of deaths from cardiovascular diseases (United States:2004) Source: NCHS and NHLBI.
Cardiovascular disease deaths vs. cancer deaths by age (United States: 2004). Source: NCHS and NHLBI.
Development of Atherosclerotic Plaques 2.03 Fatty streak Normal Lipid-rich plaque Foam cells Fibrous cap Lipid core Thrombus Ross R. Nature. 1993;362:801-809.
Progression of Arteriosclerosis
Atherosclerotic Plaque Rupture and Thrombus Formation Growth of thrombus Intraluminal thrombus Blood Flow Rupture of atherosclerotic plaque and subsequent thrombosis of the vessel is responsible for the development of acute ischemic coronary syndromes. A lipid-rich core (particularly in the shoulder regions of lesions), abundance of inflammatory cells, a thin fibrous cap and dysfunctional overlying endothelium characterize plaques that are prone to rupture. Reference Weissberg PL. Eur Heart J Supplements 1999:1:T13–18. Intraplaque thrombus Lipid pool Adapted from Weissberg PL. Eur Heart J Supplements 1999:1:T13–18
PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis 30 Raised lesions 30 Men Women Fatty streaks 20 20 10 10 Intimal surface (%) 15-19 20-24 25-29 30-34 15-19 20-24 25-29 30-34 15-19 20-24 25-29 30-34 10 20 30 White White 30 20 10 15-19 20-24 25-29 30-34 Black Black Age (y) PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999;281:727-735.
Coronary Remodeling Progression Expansion overcome: lumen narrows Compensatory expansion maintains constant lumen Normal vessel Minimal CAD Moderate CAD Severe CAD (Adapted from Glagov et al.) Glagov et al, N Engl J Med, 1987.
Most Myocardial Infarctions Are Caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) Falk E et al, Circulation, 1995.
Vulnerable Versus Stable Atherosclerotic Plaques 2.05 Vulnerable Plaque Lumen Thin fibrous cap Inflammatory cell infiltrates: proteolytic activity Lipid-rich plaque Lipid Core Fibrous Cap Stable Plaque Thick fibrous cap Smooth muscle cells: more extracellular matrix Lipid-poor plaque Lumen Lipid Core Fibrous Cap Libby P. Circulation. 1995;91:2844-2850.
Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al., Eur J Radiol 2000) Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al., Radiology 2004)
Features of a Ruptured Atherosclerotic Plaque 2.07 Eccentric, lipid-rich Fragile fibrous cap Prior luminal obstruction < 50% Visible rupture and thrombus Constantinides P. Am J Cardiol. 1990;66:37G-40G.
Clinical Manifestations of Atherosclerosis 2.09 Coronary heart disease Stable angina, acute myocardial infarction, sudden death, unstable angina Cerebrovascular disease Stroke, TIAs Peripheral arterial disease Intermittent claudication, increased risk of death from heart attack and stroke American Heart Association, 2000.
Prevalence of cardiovascular diseases in adults age 20 and older by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.
Prevalence of coronary heart disease by age and sex (NHANES :1999-2004). Source: NCHS and NHLBI.
Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex ARIC: 1987-2000 Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study, 1987-2000. These data don’t include silent MIs.
Annual Rate of First Heart Attacks by Age, Sex and Race ARIC: 1987-2000 Source: NHLBI’s ARIC surveillance study, 1987-2000.
Prevalence of stroke by age and sex (NHANES: 1999-2004) Prevalence of stroke by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
Prevalence of heart failure by age and sex (NHANES: 1999-2004) Prevalence of heart failure by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
Hospital discharges for heart failure by sex (United States: 1979-2004). Source: NHDS, NCHS and NHLBI. Note: Hospital discharges include people discharged alive, dead and status unknown..
Cardiovascular disease mortality trends for males and females (United States: 1979-2004). Source: NCHS and NHLBI.
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Lifetime Risk of Coronary Heart Disease in the Framingham Study ____________________________________________________________ Lifetime Risk of Coronary Heart Disease in the Framingham Study ______________________________________________________________ Men Women At age 40 years: 48.6% 31.7% At age 70 years: 34.9% 24.2% Lloyd-Jones et al. Lancet 1999; 353:89-92 _________________________________________________________________
First Coronary Events: Framingham Study ____________________________________________________________ First Coronary Events: Framingham Study ________________________________________________________ Percent as Specified Event Myocardial Angina Sudden Infarction Pectoris Death Age Men Women Men Women Men Women 35-64 43% 28% 41% 59% 9% 4% 65-84 55% 44% 28% 41% 11% 7.4% Framingham Study 44 year follow-up. ____________________________________________________________
Estimated 10-Year CHD Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D Blood Pressure (mm Hg) 120/80 140/90 140/90 140/90 Total Cholesterol (mg/dL) 200 240 240 240 HDL Cholesterol (mg/dL) 50 50 40 40 Diabetes No No Yes Yes Cigarettes No No No Yes mm Hg = millimeters of mercury mg/dL = milligrams per deciliter of blood Source: Circulation 1998;97:1837-1847.
Estimated 10-Year Stroke Risk in 55-Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes *BP in millimeters of mercury (mmHg) Source: Stroke 1991;22:312-318.
A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes *BP in millimeters of mercury (mmHg) Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318.
Offspring CVD Risk by Parental CVD Status: Framingham Study Parental CVD <55 men, <65 Women Risk Ratio 2.5 2 2.2 1.5 1.7 1.7 1.7 1 1.0 1.0 0.5 Men Women Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI
Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors Multivariable Risk
Risk of Coronary Heart Disease by Serum Cholesterol 30-Year Follow-up, The Framingham Study Age-Adjusted Annual Rate per 1000 Serum Cholesterol Age: 35-64* Age: 65-94 Men Women Men+ Women* 84-204 8 4 22 11 205-234 13 5 24 15 235-264 14 26 17 265-294 7 23 295-1124 10 38 32 *Trends Significant at P.001. +P.07.
Correlation Between Serum Cholesterol and CVD Mortality Multiple Risk Factor Intervention Trial (MRFIT) N=325,346 30 Untreated Patients 25 55-57 years 20 50-54 years 6-Year CVD Death Rate Per 1000 15 45-49 years 10 40-44 years 35-39 years 5 Q1 (<182) Q2 (182-202) Q3 (203-220) Q4 (221-244) Q5 (>244) Serum Cholesterol Quintile (mg/dL) Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986;112:825-836.
Lifetime Risk of CHD Increases with Serum Cholesterol _______________________________________________________________________________ Lifetime Risk of CHD Increases with Serum Cholesterol ___________________________________________________________________________ Cholesterol 57 44 34 33 29 19 Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/dL or higher, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/dL, by race/ethnicity and sex (NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey (NHANES : 1988-94, 1999-02 and 2003-04). Source: NCHS and NHLBI. NH – non-Hispanic.
Trends in mean total blood cholesterol among adolescents ages 12-17 by race, sex, and survey (NHES: 1966-70; NHANES: 1971-74 and 1988-94). Source: NCHS and NHLBI.
Relation of Non-Hypertensive Blood Pressure to Cardiovascular Disease Vasan R, et al. N Engl J Med 2001; 345:1291-1297 10-year Age- Adjusted Cumulative Incidence Hazard Ratio* SBP Women Men <120/80 1.0 1.0 120-129 1.5 1.3 130-139 2.5 1.6 H.R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<.001 10.1 7.6 5.8 4.4 2.8 1.9 Framingham Study: Subjects Ages 35-90 yrs.
Prevalence of high blood pressure in Adults by age and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
Extent of awareness, treatment and control of high blood pressure by age (NHANES : 1999-2004.) Source: NCHS and NHLBI.
Age-adjusted prevalence trends for high blood pressure in Adults age 20 and older by race/ethnicity, sex and survey (NHANES: 1988-94 and 1999-2004). Source: NCHS and NHLBI.
Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity (NHANES: 1999-2004). Source: NCHS and NHLBI.
CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up _______________________________________________________________ CVD Risk Imposed by ECG-LVH Framingham Study 36-yr. Follow-up _______________________________________________________________ Age-adjusted Risk Excess Risk Rate per 1000 Ratio per 1000 Age Men Women Men Women Men Women 35-64 164 135 4.7*** 7.4*** 129 117 65-94 234 235 2.8*** 4.1*** 51 178 Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0.001 _____________________________________________________________
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men <55 Yrs. 14-yr. Rate/1000 210 206 210 119 112 59
Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS:2004). Source: MMWR. 2004;54:1121-24. NH – non-Hispanic.
Prevalence of high school students in grades 9-12 reporting current cigarette smoking by race/ethnicity and sex. (YRBS:2005).Source: MMWR. 2006;55:SS-5. June 9, 2006. . NH – non-Hispanic.
Risk of Cardiovascular Events in Diabetics Framingham Study _________________________________________________________________ Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Cardiovascular Event Men Women Men Women Coronary Disease 39 21 1.5** 2.2*** Stroke 15 6 2.9*** 2.6*** Peripheral Artery Dis. 18 18 3.4*** 6.4*** Cardiac Failure 23 21 4.4*** 7.8*** All CVD Events 76 65 2.2*** 3.7*** Subjects 35-64 36-year Follow-up **P<.001,***P<.0001 _________________________________________________________________
Age-adjusted prevalence of physician-diagnosed diabetes in Adults age 18 and older by race/ethnicity and sex (NHANES: 1999-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
Mortality rates in U.S. adults, age 30-75, with metabolic syndrome (MetS), with and without diabetes mellitus (DM) and pre-existing CVD (NHANES II: 1976-80 Follow-up Study). ** Source: Malik et al., Circulation. 2004;110:1245-50. ** Average of 13 years of follow-up. Note: Age and gender adjusted.
Risk Factor Sum and Obesity Framingham Study 3 (1971-74) and (1989-93) 2.4 (1971) (1989) Risk factors accumulate with weight gain 1.8 Risk Factor Sum 1.2 0.6 Q1 Q2 Q3 Q4 Q5 Overall Thin Obese Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose Wilson PWF, & Kannel WB Nutr Clin Care 1999; 1:44-50
Age-adjusted prevalence of obesity in Adults ages 20-74 by sex and survey (NHES, 1960-62; NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, unpublished data. NCHS. Note: Obesity is defined as a BMI of 30.0 or higher.
Trends in prevalence of overweight among U. S Trends in prevalence of overweight among U.S. children and adolescents by age and survey (NHANES, 1971-74, 1976-80, 1988-94 and 2001-2004). Source: Health, United States, 2006, unpublished data. NCHS.
Prevalence of overweight among students in grades 9-12 by race/ethnicity and sex (YRBS: 2005). Source: BMI 95th percentile or higher. MMWR. 2006 55: No. SS-5. NH – non-Hispanic.
Prevalence of leisure-time physical inactivity among adults age 18 and older by race/ethnicity, and sex. (BRFSS: 1994 and 2004). Source: MMWR, 2005;54:No. 39. NH – non-Hispanic.
Note: “Currently recommended levels” is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 5 or more of the 7 days preceding the survey. Prevalence of students in grades 9-12 who met currently recommended levels of physical activity during the past 7 days by race/ethnicity and sex (YRBS: 2005). Source: MMWR. 2006;55:No. SS-5. NH – non-Hispanic.
International Comparisons in CVD Morbidity and Mortality CVD accounts for 25-45% of deaths among different countries CVD death rates (per 100,000) range from 1310 in Russia to 201 in Japan (6.5 fold difference) in men and from 581 in Russia to 84 in France (7-fold difference) USA ranks 16th for both men (413) and women (201)
Secular Trends in CHD and Stroke Mortality From 1985-1992, greatest annual decline (6-7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland and Romania. Stroke death rates declined most in Australia, Italy, and France (8-9%), USA about 3%.
Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1999 Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1999 Age-Adjusted to European Standard Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74, 1990-1999 Men Women Age-Adjusted to European Standard Latest data year note in parentheses Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35-74, 1990-1999 Men Women Age-Adjusted to European Standard Latest data year note in parentheses Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases
Approaches to Primary and Secondary Prevention of CVD Primary prevention involves prevention of onset of disease in persons without symptoms. Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease. Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic
Risk Factor Concepts in Primary Prevention Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption. Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.
Population vs. High-Risk Approach Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a “tail” of high values. The “high-risk approach” involves identification and intensive treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”. But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the “average” risk group. Significant reduction in the population burden of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels.
Pyramid of Risk (Werner et al Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)
Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches
Population and Community-Wide CVD Risk Reduction Approaches Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use. Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD. Requires public health services such as surveillance (e.g.,BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies) Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities
A conceptual framework for public health practice in CVD prevention A conceptual framework for public health practice in CVD prevention. (From Pearson et al., J Public Health. 2001; 29:69 –78)
Communitywide CVD Prevention Programs Stanford 3-Community Study (1972-75) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score North Karelia (1972-) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterol Stanford 5-City Project (1980-86) showed reductions in smoking, cholesterol, BP, and CHD risk Minnesota Heart Health Program (1980-88) showed some increases in physical activity and in women reductions in smoking
Individual and High-Risk Approaches Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factors Barriers exist in the community and healthcare setting that prevent efficient risk reduction Surveys of CVD prevention-related services show disappointing results regarding cholesterol-lowering therapy, smoking cessation, and other measures of risk reduction
Risk Assessment Count major risk factors For patients with multiple (2+) risk factors Perform 10-year risk assessment For patients with 0–1 risk factor 10 year risk assessment not required Most patients have 10-year risk <10%
ATP III Assessment of CHD Risk For persons without known CHD, other forms of atherosclerotic disease, or diabetes: Count the number of risk factors: Cigarette smoking Hypertension (BP 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL)† Family history of premature CHD CHD in male first degree relative <55 years CHD in female first degree relative <65 years Age (men 45 years; women 55 years) Use Framingham scoring for persons with 2 risk factors* (or with metabolic syndrome) to determine the absolute 10-year CHD risk. (downloadable risk algorithms at www.nhlbi.nih.gov) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 201, Professional Postgraduate Services® www.lpidhealth.org
Assessing CHD Risk in Men ATP III Framingham Risk Scoring Assessing CHD Risk in Men Step 1: Age Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2 ³160 2 3 Step 4: Systolic Blood Pressure Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 6: Adding Up the Points Step 7: CHD Risk Point Total 10-Year Risk Point Total 10-Year Risk <0 <1% 11 8% 0 1% 12 10% 1 1% 13 12% 2 1% 14 16% 3 1% 15 20% 4 1% 16 25% 5 2% ³17 ³30% 6 2% 7 3% 8 4% 9 5% 10 6% Step 2: Total Cholesterol TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1 ³280 11 8 5 3 1 HDL-C (mg/dL) Points ³60 -1 50-59 0 40-49 1 <40 2 Step 3: HDL-Cholesterol Step 5: Smoking Status Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
Assessing CHD Risk in Women ATP III Framingham Risk Scoring Assessing CHD Risk in Women Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 1 3 130-139 2 4 140-159 3 5 ³160 4 6 Step 4: Systolic Blood Pressure Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 6: Adding Up the Points Step 1: Age Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 75-79 16 Step 7: CHD Risk Point Total 10-Year Risk Point Total 10-Year Risk <9 <1% 20 11% 9 1% 21 14% 10 1% 22 17% 11 1% 23 22% 12 1% 24 27% 13 2% ³25 ³30% 14 2% 15 3% 16 4% 17 5% 18 6% 19 8% Step 2: Total Cholesterol TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 1 200-239 8 6 4 2 1 240-279 11 8 5 3 2 ³280 13 10 7 4 2 HDL-C (mg/dL) Points ³60 -1 50-59 0 40-49 1 <40 2 Step 3: HDL-Cholesterol Step 5: Smoking Status Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1 Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
© 2001, Professional Postgraduate Services® ATP III Framingham Risk Scoring Step 1: Age Men Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 Women Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 75-79 16 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
Step 2: Total Cholesterol ATP III Framingham Risk Scoring Step 2: Total Cholesterol TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1 ³280 11 8 5 3 1 Men TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 1 200-239 8 6 4 2 1 240-279 11 8 5 3 2 ³280 13 10 7 4 2 Women Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
Step 3: HDL-Cholesterol ATP III Framingham Risk Scoring Step 3: HDL-Cholesterol Men Women HDL-C (mg/dL) Points ³60 -1 50-59 0 40-49 1 <40 2 HDL-C (mg/dL) Points ³60 -1 50-59 0 40-49 1 <40 2 Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
Step 4: Systolic Blood Pressure ATP III Framingham Risk Scoring Step 4: Systolic Blood Pressure Men Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2 ³160 2 3 Women Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 1 3 130-139 2 4 140-159 3 5 ³160 4 6 Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
© 2001, Professional Postgraduate Services® ATP III Framingham Risk Scoring Step 5: Smoking Status Men Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Women Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1 Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
Step 6: Adding Up the Points (Sum From Steps 1–5) ATP III Framingham Risk Scoring Step 6: Adding Up the Points (Sum From Steps 1–5) Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
© 2001, Professional Postgraduate Services® ATP III Framingham Risk Scoring Step 7: CHD Risk for Men Point Total 10-Year Risk Point Total 10-Year Risk <0 <1% 11 8% 0 1% 12 10% 1 1% 13 12% 2 1% 14 16% 3 1% 15 20% 4 1% 16 25% 5 2% ³17 ³30% 6 2% 7 3% 8 4% 9 5% 10 6% Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
Step 7: CHD Risk for Women ATP III Framingham Risk Scoring Step 7: CHD Risk for Women Point Total 10-Year Risk Point Total 10-Year Risk <9 <1% 20 11% 9 1% 21 14% 10 1% 22 17% 11 1% 23 22% 12 1% 24 27% 13 2% ³25 ³30% 14 2% 15 3% 16 4% 17 5% 18 6% 19 8% Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services® www.lipidhealth.org
CHD Risk Equivalents Risk for major coronary events equal to that in established CHD 10-year risk for hard CHD >20% Hard CHD = myocardial infarction + coronary death
Diabetes as a CHD Risk Equivalent 10-year risk for CHD 20% High mortality with established CHD High mortality with acute MI High mortality post acute MI
CHD Risk Equivalents Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) Diabetes Multiple risk factors that confer a 10-year risk for CHD >20%