The Framingham risk score is recommended for identifying individuals at high risk for a future event. However, the burden of cardiovascular disease resides in patients stratified as low and intermediate risk simply because of the large number of people receiving this classification. We propose the need to move beyond risk stratification for cardiovascular disease to identifying the presence of atherosclerosis in young to middle-aged adults who are truly at risk. The purpose of this analysis is to compare and contrast the role of Framingham risk stratification in the identification of atherosclerosis and risk for future events in a young to middle-aged population.
Men (≤ 55 years) and women (≤65 years) without prior coronary heart disease scheduled for elective cardiac catheterization were studied. Subjects underwent coronary angiogram, carotid ultrasound and fasting lipid testing on the same day. Framingham risk scores were calculated. Endpoints included the presences of atherosclerosis (carotid or coronary disease) and one-year outcomes (hard events and future revascularization).
Men (n=110) and women (n=136) were studied. Atherosclerosis was present in 170 subjects (carotid disease n=149, coronary disease n=124). Per Framingham risk classification, 73%, 8%, 19% of subjects presented as low, intermediate and high risk, respectively. Median follow-up was 19 months. 25 subjects developed 35 events that included death (n=2), stroke (n=5), MI (n=5), and revascularization (n=23). Neither lipid testing nor Framingham risk scores predicted the presence of atherosclerosis or future events. Overall, 16% of subjects with atherosclerosis who were classified as low or intermediate risk had events compared to 14% of those at high risk. No future events occurred in subjects without documented atherosclerosis.
Many young to middle-aged adults classified as low or intermediate-risk have atherosclerosis and develop cardiovascular events. Framingham risk scores were not predictive of either.
By shifting to a focus on identifying and aggressively treating atherosclerosis, screening can easily be accomplished using non-invasive strategies, such as carotid ultrasound to reduce the overall burden of disease.
Ana Schaper, None.