1. Coronary Artery Disease(CAD)
Ms. Leonardo Roever

2. Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors

3. 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.

4. 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.

5. Cardiovascular disease deaths vs. cancer deaths by age
(United States: 2004). Source: NCHS and NHLBI.

6. Development of Atherosclerotic Plaques
2.03
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Lipid core
Thrombus
Ross R. Nature. 1993;362:

7. Progression of Arteriosclerosis

8. 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

9. PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis30
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:

10. 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.

11. 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, (Adapted from Falk et al.)
Falk E et al, Circulation, 1995.

12. 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:

13. 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)

14. 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.

15. 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.

16. Prevalence of cardiovascular diseases in adults age 20 and older by age and sex (NHANES: ). Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.

17. Prevalence of coronary heart disease by age and sex (NHANES :1999-2004). Source: NCHS and NHLBI.

18. Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex
ARIC:
Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study, These data don’t include silent MIs.

19. Annual Rate of First Heart Attacks by Age, Sex and Race
ARIC:
Source: NHLBI’s ARIC surveillance study,

20. Prevalence of stroke by age and sex (NHANES: 1999-2004)
Prevalence of stroke by age and sex (NHANES: ). Source: NCHS and NHLBI.

22. Prevalence of heart failure by age and sex (NHANES: 1999-2004)
Prevalence of heart failure by age and sex (NHANES: ). Source: NCHS and NHLBI.

23. Hospital discharges for heart failure by sex
(United States: ). Source: NHDS, NCHS and NHLBI.
Note: Hospital discharges include people discharged alive, dead and status unknown..

24. Cardiovascular disease mortality trends for males and females (United States: ). Source: NCHS and NHLBI.

25. Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

26. 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
_________________________________________________________________

27. 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
% 28% % 59% 9% 4%
% 44% % 41% 11% 7.4%
Framingham Study 44 year follow-up.
____________________________________________________________

28. 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)
HDL Cholesterol (mg/dL)
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:

29. 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*
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:

30. A B C D E F
Systolic BP*
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:

31. 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

32. Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors
Multivariable Risk

33. 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 13 5 24 15 14 26 17 7 23 10 38 32
*Trends Significant at P P.07.

34. 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
( ) Q3
( ) Q4
( ) Q5
(>244)
Serum Cholesterol Quintile (mg/dL)
Q = serum cholesterol quintile.
Kannel WB et al. Am Heart J. 1986;112:

35. 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;

36. Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/dL or higher, by race/ethnicity and sex (NHANES: ). Source: NCHS and NHLBI. NH – non-Hispanic.

37. Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/dL, by race/ethnicity and sex (NHANES: ). Source: NCHS and NHLBI. NH – non-Hispanic.

38. Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey (NHANES : , and ). Source: NCHS and NHLBI. NH – non-Hispanic.

39. Trends in mean total blood cholesterol among adolescents ages by race, sex, and survey (NHES: ; NHANES: and ). Source: NCHS and NHLBI.

41. Relation of Non-Hypertensive Blood Pressure to Cardiovascular Disease Vasan R, et al. N Engl J Med 2001; 345:
10-year Age- Adjusted Cumulative Incidence
Hazard Ratio*
SBP Women Men
<120/
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 yrs.

42. Prevalence of high blood pressure in Adults by age and sex (NHANES: ). Source: NCHS and NHLBI.

43. Extent of awareness, treatment and control of high blood pressure by age (NHANES : ) Source: NCHS and NHLBI.

44. Age-adjusted prevalence trends for high blood pressure in Adults age 20 and older by race/ethnicity, sex and survey (NHANES: and ). Source: NCHS and NHLBI.

45. Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity (NHANES: ).
Source: NCHS and NHLBI.

46. 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 *** 7.4*** *** 4.1*** Biennial Rate per CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0.001
_____________________________________________________________

47. 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

48. Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS:2004).
Source: MMWR. 2004;54: NH – non-Hispanic.

49. 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, NH – non-Hispanic.

50. Risk of Cardiovascular Events in Diabetics Framingham Study
_________________________________________________________________
Age-adjusted
Biennial Rate Age-adjusted
Per Risk Ratio
Cardiovascular Event Men Women Men Women
Coronary Disease ** ***
Stroke *** 2.6***
Peripheral Artery Dis *** 6.4***
Cardiac Failure *** 7.8***
All CVD Events *** 3.7***
Subjects year Follow-up **P<.001,***P<.0001
_________________________________________________________________

51. Age-adjusted prevalence of physician-diagnosed diabetes in Adults age 18 and older by race/ethnicity and sex (NHANES: ). Source: NCHS and NHLBI. NH – non-Hispanic.

52. 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: Follow-up Study). ** Source: Malik et al., Circulation. 2004;110:
** Average of 13 years of follow-up Note: Age and gender adjusted.

53. Risk Factor Sum and Obesity
Framingham Study 3
( ) and ( )
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

54. Age-adjusted prevalence of obesity in Adults ages by sex and survey (NHES, ; NHANES, , , and ). Source: Health, United States, 2006, unpublished data. NCHS.
Note: Obesity is defined as a BMI of 30.0 or higher.

55. Trends in prevalence of overweight among U. S
Trends in prevalence of overweight among U.S. children and adolescents by age and survey (NHANES, , , and ).
Source: Health, United States, 2006, unpublished data. NCHS.

56. Prevalence of overweight among students in grades 9-12 by race/ethnicity and sex (YRBS: 2005). Source: BMI 95th percentile or higher. MMWR : No. SS-5. NH – non-Hispanic.

57. 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 NH – non-Hispanic.

58. 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.

59. 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)

60. Secular Trends in CHD and Stroke Mortality
From , 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%.

61. 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

62. 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

63. Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35-74,
Men
Women
Age-Adjusted to European Standard
Latest data year note in parentheses
Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

64. 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

65. 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

66. 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.

67. 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.

68. Pyramid of Risk (Werner et al
Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B:3B-10B)

69. Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches

70. 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

71. 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)

72. Communitywide CVD Prevention Programs
Stanford 3-Community Study ( ) 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 ( ) showed reductions in smoking, cholesterol, BP, and CHD risk
Minnesota Heart Health Program ( ) showed some increases in physical activity and in women reductions in smoking

73. 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

74. 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%

75. 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
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:
© 201, Professional Postgraduate Services®

76. Assessing CHD Risk in Men
ATP III Framingham Risk Scoring
Assessing CHD Risk in Men
Step 1: Age
Years Points
Systolic BP Points Points (mm Hg) if Untreated if Treated
< 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 Age Age Age Age 70-79
< ³
HDL-C (mg/dL) Points
³60 -1
<40 2
Step 3: HDL-Cholesterol
Step 5: Smoking Status
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker
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:
© 2001, Professional Postgraduate Services®

77. 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
< 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 1: Age
Years Points
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 Age Age Age Age 70-79
< ³
HDL-C (mg/dL) Points
³60 -1
<40 2
Step 3: HDL-Cholesterol
Step 5: Smoking Status
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker
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:
© 2001, Professional Postgraduate Services®

78. © 2001, Professional Postgraduate Services®
ATP III Framingham Risk Scoring
Step 1: Age
Men
Years Points
Women
Years Points
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:
© 2001, Professional Postgraduate Services®

79. 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 Age Age Age Age 70-79
< ³
Men
TC Points at Points at Points at Points at Points at (mg/dL) Age Age Age Age Age 70-79
< ³
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:
© 2001, Professional Postgraduate Services®

80. Step 3: HDL-Cholesterol
ATP III Framingham Risk Scoring
Step 3: HDL-Cholesterol
Men
Women
HDL-C (mg/dL) Points
³60 -1
<40 2
HDL-C (mg/dL) Points
³60 -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:
© 2001, Professional Postgraduate Services®

81. 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
< ³
Women
Systolic BP Points Points (mm Hg) if Untreated if Treated
< ³
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:
© 2001, Professional Postgraduate Services®

82. © 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 Age Age Age Age 70-79
Nonsmoker
Smoker
Women
Points at Points at Points at Points at Points at Age Age Age Age Age 70-79
Nonsmoker
Smoker
Note: Any cigarette smoking in the past month.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:
© 2001, Professional Postgraduate Services®

83. 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:
© 2001, Professional Postgraduate Services®

84. © 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:
© 2001, Professional Postgraduate Services®

85. 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:
© 2001, Professional Postgraduate Services®

86. 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

87. 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

88. 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%