Framingham risk score and severity of coronary artery disease

Objectives

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. Easy-to-perform and reliable parameters are needed to predict the presence and severity of CAD and to implement efficient diagnostic and therapeutic modalities. We aimed to examine whether the Framingham risk scoring system can be used for this purpose.

Methods

A total of 222 patients (96 women, 126 men; mean age, 59.1?±?11.9 years) who underwent coronary angiography were enrolled in the study. Presence of >?%50 stenosis in a coronary artery was assessed as critical CAD. The Framingham risk score (FRS) was calculated for each patient. CAD severity was assessed by the Gensini score. The relationship between the FRS and the Gensini score was analyzed by correlation and regression analyses.

Results

The mean Gensini score was 18.9?±?25.8, the median Gensini score was 7.5 (0–172), the mean FRS was 7.7?±?4.2, and the median FRS was 7 (0–21). Correlation analysis revealed a significant relationship between FRS and Gensini score (r?=?0.432, p?Conclusion Our work suggests that the FRS system is a simple and feasible method that can be used for prediction of CAD severity. As the sample size was small in our study, further large-scale studies are needed on this subject to draw solid conclusions.     

Parental history is an independent risk factor for coronary artery disease: the Framingham Study

Family history of CAD, defined as parental death by CAD, was found to be a significant independent predictor of CAD in a logistic regression model controlling for standard risk factors and length of follow-up among the 5209 participants in the Framingham Study. Persons with a positive parental history have a 29% increased risk of CAD, and the strength of the association between parental history and CAD is similar to that found for other standard risk factors such as systolic blood pressure, cholesterol level, and cigarette smoking. No evidence was found that persons with a family history of CAD have a decreased capacity to cope with the deleterious effects of known risk factors; that is, no significant interaction was found between any of the risk factors and parental history of CAD. Among men with low risk for CAD by risk-factor profile (i.e., nonsmoking, thin, nonhypertensive persons), more than two thirds of those who experience CAD have a positive parental history. This study suggests that CAD among persons who are predicted to be at low risk by standard risk factors may have a substantial genetic component and that the risk associated with parental history may not be reduced by modification of these factors. Nevertheless, among persons with a positive family history, those with a favorable risk profile are at substantially less risk for CAD than those with an unfavorable risk profile.     

Echocardiographic determinants of clinical outcome in subjects with coronary artery disease (the Framingham Heart Study).

Echocardiographic predictors of clinical outcome were examined in subjects from the Framingham Heart Study with overt coronary artery disease. The study population consisted of 185 men and 147 women with coronary artery disease who underwent M-mode echocardiography and were followed for a mean of 3.90 years. At baseline, 37 men (18.4%) and 16 women (10.9%) had reduced fractional shortening, 43 men (23.2%) and 28 women (19%) had left ventricular (LV) dilatation, and 76 men (41%) and 76 women (51.7%) had LV hypertrophy. During the follow-up period new cardiovascular disease events (coronary disease, stroke, transient ischemic attack, claudication, heart failure and deaths from cardiovascular disease) occurred in 60 men (32%) and 58 women (39%). With use of age-adjusted proportional hazards analyses, LV mass/height in men (relative risk [RR] = 1.25/50 g/m increment, 95% confidence interval [CI] 1.01 to 1.55) and LV end-diastolic diameter in women (RR = 1.36/5 mm increment, 95% CI 1.05 to 1.76) were predictors of new cardiovascular disease events. Cardiovascular risk was also associated with LV end-systolic diameter in both sexes (in men RR = 1.28/1 SD increment, 95% CI 1.02 to 1.63; in women RR = 1.40/1 standard deviation increment, 95% CI 1.09 to 1.82). Reduced fractional shortening alone (RR = 1.91, 95% CI 1.11 to 3.31) and in combination with LV dilatation (RR = 2.13, 95% CI 1.13 to 4.02) was associated with the incidence of new cardiovascular disease outcomes in men.(ABSTRACT TRUNCATED AT 250 WORDS)     

QRS interval fails to predict coronary disease incidence. The Framingham Study

The Framingham Study cohort of 5209 white men and women was examined to determine the long-term incidence of manifestations of new coronary heart disease as a function of QRS interval on subjects' baseline electrocardiograms (recorded at the 9th biennial examination). Over 18 years of follow-up, age-adjusted incidence of myocardial infarction, angina pectoris, and coronary death appeared unrelated to baseline QRS prolongation in both sexes, by Cox regression. Subjects with left bundle-branch block fared no worse than those with right pattern. These relations held whether or not subjects with baseline electrocardiographic abnormalities other than intraventricular block were excluded from consideration. In sum, QRS duration is an unimportant predictor of coronary disease in this Framingham population.     

Mortality in individuals without known coronary artery disease but with discordance between the Framingham risk score and coronary artery calcium

A risk-management approach based on the Framingham risk score (FRS), although useful in preventing future coronary artery disease (CAD) events, is unable to identify a considerable portion of patients with CAD who need aggressive medical management. Coronary artery calcium (CAC), an anatomic marker of atherosclerosis, correlates well with presence and extent of CAD. This study investigated mortality risk associated with CAC score and FRS in subjects classified as "low risk" versus "high risk" based on FRS. In total 730 veterans without known CAD (61 ± 10 years old, 12.8% women) underwent measurement of their FRS and CAC. Subjects were classified as "discordant low risk" (DLR) if their FRS was <10% and CAC score was ≥ 100 (n = 108, 14.8%) or "discordant high risk" (DHR) if their FRS was ≥ 20% and CAC score was 0 (n = 104, 14.2%). Survival analysis was used to compare mortality rates associated with FRS and CAC in DLR versus DHR subjects. Mortality rate during the mean 48-month follow-up was 7.3% (n = 53) including 18.5% (n = 20) in the DLR group and 7.7% (n = 8) in the DHR group, respectively. Adjusted relative risks of mortality were 5.46 (95% confidence interval [CI] 2.44 to 12.20, p = 0.0001) in subjects with CAC score ≥ 100 compared to CAC score 0 and 1.35 (95% CI 1.01 to 4.32, p = 0.04) in subjects with FRS ≥ 20% compared to FRS <10%. Adjusted relative risk of mortality was 3.6 (95% CI 1.57 to 8.34, p = 0.003) for DLR compared to DHR. Areas under the receiver operator curve to predict mortality were 0.72 for FRS, 0.82 for CAC score, and 0.92 for the combination. In conclusion, the prognostic value of CAC to predict future mortality is superior to the FRS. Addition of CAC score to FRS significantly improves the identification and prognostication of patients without known CAD.     

Sudden death risk in overt coronary heart disease: the Framingham Study

Over 30 years of surveillance of 5127 subjects free of CHD, 760 men and 574 women developed overt CHD, and there were 160 sudden deaths in men and 73 in women. Among those who sustained clinically manifest CHD, the sudden death risk was increased 6.7 times that of those without an interim event. Although the relative risk was comparable in the two sexes, CHD did not eliminate the female advantage over men. Myocardial infarction imposed a greater sudden death risk than angina pectoris, and silent infarctions were as dangerous as symptomatic infarctions. Onset of CHD put young and old at equal risk of sudden death. Some 40% of sudden deaths occurred in the 4% of the general population with overt CHD. The proportion of coronary attacks presenting as sudden death increased from 13% at ages 35 to 64 years to 20% at ages 65 to 94 years. The fraction of CHD deaths classified as sudden deaths was lower in those with than without interim CHD. In those with established CHD, factors reflecting ischemic myocardial damage and cardiac failure were the chief predictors of sudden death. The proportion of CHD deaths presenting as sudden deaths has not declined in subjects with prior CHD over three decades, despite a national decline in the overall CHD mortality rate.     

Psychosocial and other features of coronary heart disease: insights from the Framingham Study

Contributors to CHD include atherogenic personal attributes, living habits which promote these, signs of preclinical disease, and host susceptibility to these influences. Atherogenic traits include the blood lipids, blood pressure, and glucose tolerance. High LDL cholesterol is positively and high HDL cholesterol inversely related to CHD incidence. Hypertension, whether systolic or diastolic, labile or fixed, casual or basal, at any age in either sex contributes powerfully to coronary heart disease. The impact of diabetes on CHD is greater for women than for men and varies according to the level of the foregoing risk factors. The faulty life-style is typified by a diet excessive in calories, fat, and salt, a sedentary habit, unrestrained weight gain, and cigarettes. Alcohol used in moderation may be beneficial. Oral contraceptives worsen atherogenic traits and, when used for long periods beyond age 35 in conjunction with cigarettes, predispose to thromboembolism. Type A persons with an overdeveloped sense of time urgency, drive, and competitiveness develop an excess of angina pectoris. Men married to more highly educated women are at increased risk, as are men married to women in white-collar jobs. Preclinical signs of a compromised coronary circulation include silent MI, ECG-LVH, blocked intraventricular conduction, and repolarization abnormalities. Exercise ECG may elicit still earlier evidence. Measures of innate susceptibility include a family history of premature cardiovascular disease, diabetes, hypertension, and gout. Optimal prediction of CHD requires a quantitative combination of risk factors in multiple logistic risk formulations that identify high-risk persons with multiple marginal abnormalities. Preventive management should also be multifactorial.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lipids, diabetes, and coronary heart disease: insights from the Framingham Study

Both risk factors and the incidence of cardiovascular disease are higher in diabetic patients. Total serum cholesterol has the same impact on coronary heart disease (CHD) incidence in diabetic patients as in nondiabetic individuals. Abnormal blood lipids in diabetic patients include elevated very low-density lipoproteins (VLDL) and triglyceride and reduced levels of high-density lipoproteins (HDL). These are associated with obesity and precede the onset of diabetes. Diabetes increases the risk of all clinical manifestations of CHD, has a greater impact in women, and predisposes to cardiac failure and fatal outcome. In men, it predisposes to silent myocardial infarctions. CHD risk reduction in the diabetic patient requires multifactorial control. In evaluating the lipid-induced CHD risk, the level of low-density lipoprotein (LDL) cholesterol is not as valuable as the LDL/HDL cholesterol ratio, which is the most reliable criterion. Triglyceride levels make no independent contribution. Most CHD preventive measures, including weight control, exercise, avoidance of cigarettes, and improvement of glucose tolerance also increase HDL cholesterol, reduced levels of which are chiefly responsible for the poor LDL/HDL ratio in diabetics. Weight control merits a high priority because of its favorable influence on the lipid profile, glucose tolerance, and blood pressure.     

Dietary lipid predictors of coronary heart disease in men. The Framingham Study

The relationship between dietary lipids and the 16-year incidence of coronary heart disease (CHD) morbidity and mortality was examined in two male cohorts, aged 45 to 55 years (n = 420) and 56 to 65 years (n = 393) from the Framingham Study. Dietary lipids were assessed through a single 24-hour recall at the initiation of follow-up in 1966 to 1969. In the younger cohort, there were significant positive associations between the incidence of CHD and the proportion of dietary energy intake from total fat and monounsaturated fatty acids. The proportion of energy intake from saturated fatty acids had a marginally significant positive association with CHD. The associations remained even after adjustment for cardiovascular disease risk factors, including serum cholesterol level, suggesting that their effects are at least partially independent of other established risk factors. In contrast to the younger cohort, none of the dietary lipids were associated with CHD in the older cohort. Dietary intervention for the prevention of CHD in younger men is supported by these findings.     

Genetic predisposition to coronary artery disease

Understanding the genetic basis of coronary artery disease (CAD) can improve management and prevention. Family and twin studies, animal models and gene association studies support a genetic basis for CAD. Genes contribute to CAD development and progression, and response to risk factor modification and lifestyle choices. Family history is the best indicator of a predisposition to CAD and further refinement is possible with biochemical and DNA testing. Many inherited cardiovascular risk factors can be modified, such as LDL cholesterol, homocysteine and lipoprotein(a). Early detection of CAD might lead to earlier intervention for genetically susceptible individuals. However, data are lacking regarding the efficacy of this approach in preventing clinical events. Despite this lack of evidence, knowledge of genetic CAD susceptibility has value in providing risk information and guiding decision making. Further research that investigates outcomes regarding genetic risk assessment for CAD is necessary.     

Surgical approaches to coronary artery disease

Opinion statement In this rapidly evolving era of coronary surgery, technologic advances have allowed the development of new myocardial revascularization strategies. Although conventional coronary artery bypass grafting is being challenged by other promising surgical procedures such as off-pump coronary artery bypass grafting, it remains the gold standard in patients with multivessel disease. Accurate evaluations of these new procedures are ongoing to assess their effectiveness and to define their role in the armamentarium of myocardial revascularization.     

Coronary vasodilator reserve and Framingham risk scores in subjects at risk for coronary artery disease.

BACKGROUND: The relationship between coronary vasodilator reserve and risk of coronary heart disease (CHD) in subjects without coronary artery disease (CAD) is not well known. METHODS AND RESULTS: We studied 289 subjects (mean age, 58 +/- 10 years) without overt CAD and at low (< 10%) to intermediate risk (10%-20%) for CHD based on Framingham risk scores (RAMPART [Relative and Absolute Myocardial Perfusion changes as measured by Positron Emission Tomography to Assess the Effects of ACAT Inhibition: A Double-Blind, Randomized, Controlled, Multicenter Trial]). Coronary flow reserve (CFR) and coronary vascular resistance (CVR) were calculated from rest and adenosine nitrogen 13 ammonia positron emission tomography studies. Framingham-estimated CHD risk was used to as a surrogate for outcomes. Compared with subjects with low-risk scores (n = 150), those with intermediate-risk scores (n = 139) had a higher minimal CVR (49.3 +/- 17.41 mm Hg x mL(-1) x min(-1) x g(-1) vs 52.4 +/- 16.4 mm Hg x mL(-1) x min(-1) x g(-1), P = .05) and lower CFR (2.8 +/- 1.0 vs 2.5 +/- 0.8, P = .02). CFR was inversely related to CHD risk (R = -0.2, P = .006), and CVR was directly related to CHD risk (R = 0.2, P < .001). The mean CFR was significantly lower in patients in the first quartile of CHD risk compared with those in the fourth quartile (2.3 +/- 0.7 vs 2.8 +/- 1.0, P = .02), and the minimal CVR was significantly higher (44 +/- 15 mm Hg x mL(-1) x min(-1) x g(-1) vs 53 +/- 14 mm Hg x mL(-1) x min(-1) x g(-1), P < or = .05). CONCLUSIONS: In subjects without clinical CAD and at low to intermediate risk, CFR assessed by positron emission tomography is inversely related to estimated 10-year CHD risk.     

Risk of coronary heart disease in subjects with chest discomfort: the Framingham Heart Study

PURPOSE: To examine the risk of coronary heart disease (CHD) events in subjects of the Framingham Study reporting new chest discomfort. SUBJECTS AND METHODS: Original cohort subjects with chest discomfort were classified by their history into three groups: definite angina, possible angina, or nonanginal chest discomfort. Subjects were followed for 2 years for CHD events, including coronary insufficiency, myocardial infarction, or CHD death. RESULTS: Compared to that in subjects without chest discomfort, the relative odds of a CHD event was 3.7 (95% confidence interval [CI] 2.11, 6.60) in men with definite angina and 3.0 (95% CI 1.33, 6.69) in men with possible angina. Comparable increased CHD risk was also observed in women with definite or possible angina, with relative odds of 5.4 (95% CI 3.08, 9.30) and 2.9 (95% CI 1.13, 7.17), respectively. The increase in CHD risk associated with definite or possible angina persisted after adjustment for cardiac risk factor profile. There was no increase in risk associated with nonanginal chest discomfort. CONCLUSION: CHD risk is increased in subjects with new chest discomfort that on the basis of history is consistent with definite or possible angina, whereas CHD risk is not increased in subjects with nonanginal chest discomfort. The presence of chest discomfort and its characteristics facilitate the classification of subjects into meaningful categories that offer prognostic information beyond that provided by traditional CHD risk factors.     

64排CT冠状动脉斑块分析对冠状动脉直接支架术指导作用的研究

目的 探讨64排CT冠状动脉斑块分析对冠状动脉直接支架术的指导意义.方法 连续入选接受64排CT冠状动脉成像（CTA）并冠状动脉直接支架术治疗的患者42例,置入支架44枚.根据支架释放后有无残余狭窄分为2组,组间对比64排CT冠状动脉成像所示斑块的性质、斑块的CT值、钙化长度、横断面最大钙化面积.结果 残余狭窄组患者斑块的最大CT值大于无残余狭窄组（P＜0.01）.Logistic回归分析显示,当斑块的CT值达到648～679时,支架释放时出现残余狭窄的概率为70％～90％.结论 冠状动脉直接支架术支架释放后出现残余狭窄与斑块的最大CT值有关,当斑块有明显大的CT值时,采用直接支架术需谨慎.