1. CARDIAC RISK ASSESSMENT TOOL
Team Red will be presenting the Framingham Cardiac Risk Assessment Tool utilized for cardiac assessment risk: 10 year cardiac risk.
Collaborative Learning Community Project
Angela Broughton, Claudette Johnson, Kimberly Kusch
TEAM RED
Grand Canyon University
NUR: 645E Advanced Health Assessment for Nurse Educators
Dr. Claudia Werner-Rutledge
January 19, 2013

2. Objectives Identify and describe a health risk assessment tool
Conduct, analyze and report results of a survey utilizing the tool
Analyze the tool based on validity, reliability and readability and appropriateness for the tool’s intended audience
Team Red will identify and describe a health risk assessment tool: Framingham Cardiac Risk Assessment Tool. We will also conduct, analyze and report results of a survey utilizing this tool. In addition, we will present an analysis of the tool’s validity, reliability and readability along with its appropriateness for its intended audience.

3. Risk Assessment Tool: Framingham
Description
Reason for choice
Widely used tool assisting in nationwide efforts to control the prevalence of heart disease and other diseases (Sheridan, Pignone & Mulrow, 2003)
Used to identify interventions to help decrease cardiac diseases and death which meets the goals of the Million Hearts initiative, Healthy People 2020 and the American Heart Association 2020 (American Heart Association (AHA), 2012)
Effective primary and secondary prevention could prevent or postpone as many as 56% of all deaths among people aged 30 to 84 years (Kottle, Jordan-Baechler & Parker, 2012)
Risk Assessment Tool for estimating 10-year risk of having a heart attack
This tool is designed for adults aged 20 and older who do not have heart disease or diabetes
The Framingham Risk Assessment Tool is designed for adults in the age for 20 and older who do not have heart disease or diabetes (Sheridan, Pignone & Mulrow, 2003). It estimates the 10-year risk of having a heart attack. This tool has been used in nationwide efforts to control the prevalence of heart disease including other disease (American Heart Association (AHA), 2012). According to the Framingham heart Study Organization (2012), the Framingham Heart Study began in 1948 under the direction of the National Heart, Lung and Blood Institute (NHLBI) with the purpose of identifying common factors contributing to Cardiovascular disease (CVD) and followed its first cohort of 5209 men and women between the ages of 30 and 62 from a Massachusetts town of Framingham (thus, the name of the tool). The tool was not only used for heart disease but also for stroke. This study has added a Cohort in 1971, 1994, 2002, and 2 in Through the years, the Framingham Study has led to major CVD risk factors identification: blood pressure, age, gender, blood triglycerides and cholesterol levels expanding the risk to psychological issues and dementia. The addition of physical traits and genetic patterns are the latest.
The Framingham Heart study objective is to identify the characteristics contributing to CVD, following its development for an extended time on specific patients who have not exhibited CVD symptoms or suffered a heart attack or stroke. The subjects were asked to return to the study every two years for detailed physical examination, medical history and laboratory testing. Though the original cohort is primarily Caucasian in race, racial and ethnic group assessments has been conducted in many other countries utilizing the Framingham assessment tool, it has integrated new diagnostic technology such as carotid ultrasound, CT scans and Magnetic resonance imaging (Framingham Heart Study Organization, 2012).
While pursuing the Study's established research goals, the NHLBI and the Framingham investigators are expanding their research into other areas such as the role of genetic factors in CVD. One project under way will utilize genetic material from immortalized cell lines of all of our cohorts. Framingham investigators also collaborate with leading researchers from around the country and throughout the world on projects in stroke and dementia, osteoporosis and arthritis, nutrition, diabetes, eye diseases, hearing disorders, lung diseases, and genetic patterns of common diseases (Kottle, Jordan-Baechler & Parker, 2012). The Framingham Risk Assessment Tool is designed for adults in the age for 20 and older who do not have heart disease or diabetes (Sheridan, Pignone & Mulrow, 2003). Estimating the 10-year risk of having a heart attack, this tool has been used in nationwide efforts to control the prevalence of heart disease. The tool has been utilized and used to identify interventions to help decrease cardiac diseases and death which meets the goals of the Million Hearts initiative, Healthy People 2020 and the American Heart Association Prevention efforts can prevent or postpone as many as 56% of all deaths among people aged 30 to 84% as published by the Centers for Disease Control (Kottle, Jordan-Baechler & Parker, 2012).
(Sheridan, Pignone & Mulrow, 2003)

4. Framingham Tool Measures
Increase risk of heart attack
Age
Gender
Total Cholesterol
HDL Cholesterol
Smoking
Systolic Blood Pressure
The Framingham Risk Assessment Tool calculates one’s risk of the heart attack by collecting the following data: age, gender, total cholesterol, HDL cholesterol, smoking and systolic blood pressure. Entering these data in a calculator available online or in hard copy will estimate the total risk percentage (Sheridan, Pignone & Mulrow, 2003).
(Sheridan, Pignone & Mulrow, 2003)

5. Framingham Cardiac Risk Assessment Tool
AGE
The older the higher risk
TOTAL CHOLESTEROL
Borderline High
mg/dl
High
Greater than 240 mg/dl
HDL
CHOLESTEROL
Major risk
< 40 mg/dL
Moderate risk mg/dL
Low risk
>60 mg/dL
SMOKER
Smoked in last month?
Yes No
SYSTOLIC BLOOD PRESSURE
Take top number of reading
DIABETES
According to Sheridan, Pignone & Mulrow (2003), the tool is designed for adults, age 20 and above with no history of diabetes and heart disease. When it comes to age: The older the person, the higher the risk for heart disease.
Total serum cholesterol is the sum of all the cholesterol in the blood stream. The higher the cholesterol can indicate a greater risk for heart disease. It implies that a total cholesterol level of less than 200mg/dL puts a person at a lower risk while a level greater than 200mg/dL increases one’s risk. Specifically, mg/dL is considered borderline high; 240mg/dL and above is considered high. The level considered high has more than twice the heart disease risk in comparison to one with a level below 200 mg/dL (Sheridan, Pignone & Mulrow, 2003).
HDL (high density lipoprotein) also known as the “good” cholesterol, carry cholesterol from other parts of the body back to the liver leading to the cholesterol removal from the body. Therefore, HDL helps prevent the build-up of cholesterol in the arteries. Results of less than 40 mg/dL reveals a major risk for heart disease; 40 to 59 mg/dL shows a higher HDL is better; and 60 mg/dL and above is considered protective against heart disease (Sheridan, Pignone & Mulrow, 2003).
The question about smoking asked a response of yes or no to the question of: have you smoked a cigarette in the past month (Sheridan, Pignone & Mulrow, 2003).
Systolic blood pressure is the last information component required for the calculation (Sheridan, Pignone & Mulrow, 2003).
The calculation totals can predict 10 year coronary event risk. Results of greater or equal to 0-10% indicates low risk; 10-20% indicates intermediate risk; and greater than 20 % is high risk for coronary artery disease (CAD) (Sheridan, Pignone & Mulrow, 2003).
(Sheridan, Pignone & Mulrow, 2003).

6. The assessment process is outlined in the order noted here from 1-8
The assessment process is outlined in the order noted here from Responses to each question are converted to points for each category. Noted in this grid is the points indicated for responses to the various questions. The points are totaled and its total according to the grid on #8 is indicative of one’s 10 year cardiac heart disease risk (Sheridan, Pignone & Mulrow, 2003).
(Sheridan, Pignone & Mulrow, 2003)

7. Survey Results
53 y/o Male
25 y/o Male
41 y/o F
74 y/o F
25 y/o F
61 y/o M
69 y/o M
37 y/o F
78 y/o M
54 y/o F
Age 6 -9 14 -7 10 11 -3 13
Smoker 3 7 4
Total Cholesterol
(335)=5
(155)=0
(131)=0
(210)=1
(169)=4
(242)=2
(193)=1
(178)=4
(105)=0
(175)=2
HDL Cholesterol
(41)=1
(65)=-1
(38)=2
(76)=-1
(55)=0
(92)=1
(48)=1
(43)=1
(27)=2
(34)=2
Systolic BP/BP Meds
(124) (no)=1
(119)(no)=0
(125) (no)=1
(132) (no)=2
(126) (no)=1
(106) (yes)=0
(131) (yes)=2
(110) (no)=0
(160)(no)=3
(154) (yes)=5
Total: 16
-10 -2 15 2 18 19
10 year Risk
25%
Less than 1% 1% 4% 0% 8%
20%
Equal to >30%
In the Framingham Risk Assessment of 10 randomly selected individuals, the results are as shown. The ages of individuals chosen for the purpose of testing this risk assessment tool ranged from 25 years of age to 78 years of age. Out of the 10 individuals, 30% were smokers while 70% were non-smokers. Total cholesterol levels ranged from 105 at the lowest to 335 at the highest while HDL cholesterol levels ranged from 27 at the lowest to 92 at the highest. The most recent systolic blood pressure of the individuals in this analysis ranged from 106 at the lowest to 160 at the highest. Three out of ten individuals tested were taking blood pressure medications, while the remaining seven individuals in the study were not prescribed any anti-hypertensive medications. Total scores in the Framingham Risk Assessment tool ranged from -10 to 19, signifying that out of all participants, the 10 year risk ranged from less than 1% to equal to or greater than 30% risk of developing a myocardial infarction or death from coronary disease within the next 10 years. In this analysis it is important to note that according to the National Heart, Lung, and Blood Institute and the National Institutes of Health (n.d.) the risk score may not adequately reflect the long-term or lifetime coronary heart disease risk of young adults, which is one in two for men and one in three for women.

8. Survey Analysis Equal comparison of data between men and women
Scores are significantly lower due to smoking status (70% nonsmokers)
Total cholesterol levels greater than 200 added a greater number of points to the total score of these individuals when compared to other categories
HDL (“good” cholesterol) levels did not seem to affect the total scores by large amounts
For women, hypertension added larger points to the total scores than for men.
It is important to remember that the presence of any one of these risk factors may warrant further attention even if the 10-year risk dose not appear to be high.
Men and women have different scores based on their risk assessment tools, however, in this analysis, five women were chosen and five men were chosen to complete this assessment tool, created an equal comparison of data regardless of the fact that men have a greater risk for developing coronary heart disease than women (NHLBI , n.d.). The risk of developing a myocardial infarction in the next 10 years with the individuals tested in this group are significantly lower due to the factor that only 30% of participants are smokers. The higher your total cholesterol, the greater your risk for heart disease (NHLBI, n.d.). Depending on age, total cholesterol levels greater than 200 seemed to add a greater number of points to the total score of these individuals when compared to other categories. High density lipoprotein (HDL) carries cholesterol in the blood from other parts of the body back to the liver, which leads to its removal from the body and keeps cholesterol from building up in the walls of the arties (NHLBI, n.d.). HDL (“good” cholesterol) levels did not seem to affect the total scores by large amounts as low HDL cholesterol levels only added two total points to the scores. Finally, when analyzing systolic blood pressure measurements, it seemed that regardless of whether individuals were currently on anti-hypertensive medications or not, a larger number of points (4-6) were added to the scores of women if their systolic blood pressure reached over 130 whereas men with systolic blood pressure measurements greater than 130 only added two to three points onto the total score. All in all, in analyzing this data, it is important to note that the presence of any cardiovascular disease risk factor requires appropriate attention because a single risk factor may mean that you have a high risk of developing cardiovascular disease in the long-run, even if the 10-year risk in the Framingham risk assessment tool does not appear to be high (NHLBI, n.d.).

9. Flesch Reading Ease Scale Flesch Reading Ease Scale
Readability
Evaluation tool
Result
Flesch Reading Ease Scale
Uses average sentence and word length
Word difficulty measured by use of syllables per word
Syntactic measured by words per sentence
Score of 0-100
Score of 0-40 indicates difficult to read
Score of indicates easy to read
Norm: words is acceptable readability
Flesch Reading Ease Scale
Acceptable readability
Easy to understand
Responses to questions: simple responses, data known to users, response requiring yes or no responses
Shortcoming: HDL and total cholesterol levels require testing
Responses calculated by hand or calculator
The use of the oldest, most reliable and most cited reading scale in healthcare articles, the Flesch Reading Ease Scale, will be used to determine its readability scale by using the average sentence and word length (Ancker, 2004). Word difficulty is measured by the use of syllables per word. Meanwhile, the use of words per sentence measures syntactic complexity of the material rendering a score from Score of 0-40 indicates difficult to read and scoring is indicative of easy to very easy to read materials. Stockmeyer (2009) suggests the standard of words for documents.
(Stockmeyer, 2009; Ancker, 2004)

10. Appropriateness for Audience
Evaluation tool
Result
Flesch- Kincaid Grade Level Scale
Reflects the minimum grade level necessary to understand reading a document (Ancker, 2004)
Formula: reading grade level = (0.39 x average sentence length) + (11.8 x average syllables per word) , with college level reading equaling to Grade 16 (Ancker, 2004)
Stockmeyer (2009) suggests a grade level score of 7-8 as a norm.
Flesh-Kincaid Grade level scale score of 7.
Indicates appropriateness for its intended users (ages 20 and up)
Words used are direct and easy to understand
Responses required are simple
Flesch-Kincaid Grade Level Scale takes into account the minimum grade level necessary to understand reading the document (Ancker, 2004). Reading grade level formula is as follows: reading grade level = (0.39 x average sentence length) + (11.8 x average syllables per word) , with college level reading equaling to Grade 16 (Ancker, 2004). Stockmeyer (2009) suggests a grade level score of 7-8 as a norm.
Analysis of the Framingham assessment tool indicates a Flesch Reading Ease Scale of 68 and a Flesh-Kincaid Grade level scale score of 7. Though other readability guidelines differ, based on the guidelines of the Flesch Readability and Flesh Kincaid Grade Level scales, this tool is readable and easy to understand (Ancker, 2004). The verbiage used in the survey is direct and easily understood by the target audience of 20 years and above. Testing responses required are simple with a yes or no and/or data known to its users. Access to most information is easily obtainable; however, not all population have HDL and LDL cholesterol levels available resulting in some individuals needing more invasive testing prior to participating in the Framingham risk assessment.
(Stockmeyer, 2009; Ancker, 2004)

11. Reliability Men Women Ethnic Groups
Predictor of 10 year coronary heart disease risk accuracy-95% and 83%
Predictor of 2 year coronary heart disease risk accuracy-67% and 98%
Research suggests that the Framingham Cardiac Risk Assessment Tool is a reliable measurement tool which has been used extensively in men, women, and various ethnic groups. It is considered the highest standard of a tool for risk assessment and has been consistently used over a number of years. It is comprehensive and effective in measuring cardiovascular risk in a variety of populations (Coke, 2010). When risk factors identified in the tool are optimally controlled data suggests that there is a substantially lower lifetime risk of developing cardiovascular disease (Gleeson & Crabbe, 2009). The two most commonly used and tested forms of the Framingham Cardiac Risk Assessment Tool are shown to have high sensitivity and specificity. Ten year coronary heart disease risk is considered 95% and 83% accurate on these two tools and two year risk is considered 67% and 98% accurate (Coke, 2010). The Framingham Cardiac Risk Assessment Tool is the most widely used tool for assessing cardiovascular disease in the United States and has been adapted for use in other cultures in other parts of the world (Batsis & Lopez-Jimenez, 2010).

12. Validity Research mostly supports the tool’s validity
Some concerns were identified
Ethnic Populations
-metabolic syndrome
Women
-minority
-elderly
Research is mostly in support of the Framingham Cardiac Risk Assessment Tool and supports its validity. The tool has been validated in many populations and ethnic groups and adjusted appropriately. This makes it a well known risk tool that allows assessment of risk across populations. However, there are some ethnic populations, especially those with a higher incidence of metabolic syndrome where adjustments to the tool are more difficult resulting in decreased validity (Batsis & Lopez-Jimenez, 2010).
There has been concern in recent years pertaining to its validity in women. Few studies incorporate minority or elderly women in their research and have limited value in discriminating low risk patients from intermediate risk (Gleeson & Crabbe, 2009). Also, the Framingham score tends to underestimate risk in women due to studies generally consisting of younger women under the age of fifty who tend to have a lower incidence of cardiovascular disease at this age. This can impact the clinical care of women. Treatment goals between the genders for similar levels of risk are different. The Framingham score is still seen as useful for guiding cholesterol treatment goals but preventive guidelines for cardiovascular disease are now emphasizing a woman’s risk throughout the lifetime (Gleeson & Crabbe, 2009). The Framingham risk assessment is suggested for incorporation in an initial clinical evaluation of female patients who do not currently carry a diagnosis of heart disease or diabetes (Gleeson & Crabbe, 2009).
Risk factors like premature history of cardiovascular disease, obesity, high sensitivity CRP, inflammatory cytokines, and lifestyle are factors that are not taken into account with the Framingham score. This can lead to underestimating risk in individuals especially those that fall into the intermittent range on the tool (Batsis & Lopez-Jimenez, 2010).

13. Conclusion The Framingham risk assessment tool:
Calculates one’s risk of the heart attack
Meets the standard readability, suitable for its intended age group of 20 and above
Found reliable as written in many literature and valid except for some concerns identified when testing women and ethnic groups.
In conclusion, the Framingham risk assessment tool calculates the risk for the heart attack. Furthermore, it meets the readability guidelines and meets its suitability for its intended age group of 20 and above age group. Overall, the Framingham Cardiac Risk Assessment Tool is found to be very reliable in the literature among many diverse populations. Validity is found to rank overall pretty high as well but there have been some concerns identified when testing women and certain ethnic groups. These factors should be considered when using this assessment.

14. References
American Heart Association (2012). Heart attack risk assessment. American Heart Association Organization. Retrieved from: Attack-Risk Assessment_UCM_303944_Article.jsp
Ancker, J. (2004). Developing the informed consent form: A review of readability literature and an experiment. AMWA Journal. 19(3),
Batsis, J. & Lopez-Jimenez, F. (2010). Cardiovascular risk assessment: From individual risk prediction to estimation of global risk and change in risk in the population. BMC Medicine, 8, 29. Doi: /
Coke, L. (2010). Cardiac risk assessment of the older cardiovascular patient: The Framingham global risk assessment tools. MEDSURG Nursing. Retrieved from
Gleeson, D. & Crabbe, D. (2009). Emerging concepts in cardiovascular disease risk assessment: Where do women fit in? Journal of the American Academy of Nurse Practitioners, 21, Doi: /
Kottle, T., Jordan Baechler, C., Parker, E. (2012). Accuracy of heart disease prevalence estimated from claims data compared with an electronic health record. Preventing Chronic Disease. 9 (1). DOI: Retrieved from:
National Heart, Lung, Blood Institute (NHLBI) (n.d.) National cholesterol education program, third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). National Institutes of Health (NIH). Retrieved from:
Sheridan, S. Pignone, M. & Mulrow, C. (2003, December). Framingham-based tools to calculate the global risk of coronary heart disease: a systematic review of tools for clinicians. Journal of Internal Medicine. 18 (12) Retrieved from:
Stockmeyer, N. (2009). Plain language. Michigan Bar Journal