Daniel I. Steinberg, MD
Does adding novel risk markers to a combination of the Framingham Risk Score (FRS) and ethnicity (FRS-E) improve prediction of coronary heart disease (CHD) or cardiovascular disease (CVD) in intermediate-risk, asymptomatic adults?
Prospective cohort study (Multi-Ethnic Study of Atherosclerosis [MESA]) with a median 7.6 years of follow-up.
6 centers in the USA.
1330 participants 45 to 84 years of age (mean age 64 y, 67% men) who took part in the first MESA examination (Jul 2000 to Aug 2002), did not have known CVD at baseline, had intermediate risk for CHD (FRS estimated 10-y risk > 5% and < 20%), and had complete data on all 6 novel risk markers. Participants with diabetes mellitus were excluded.
FRS (age, sex, smoking status, systolic blood pressure, use of blood pressure medication, and high-density lipoprotein and total cholesterol levels) combined with ethnicity and each of 6 risk markers: ankle–brachial index (ABI), coronary artery calcium (CAC) score, carotid intima–media thickness (cIMT), high-sensitivity C-reactive protein (hsCRP) level, family history of CHD, and brachial flow–mediated dilatation (FMD).
Incident CHD (myocardial infarction, definite or probable angina followed by coronary revascularization, resuscitated cardiac arrest, or CHD death) and incident CVD (incident CHD, stroke, or CVD death).
7.1% of participants had CHD events, and 9.2% had CVD events. CAC, ABI, hsCRP, and family history were independently associated with incident CHD in 4 multivariable analyses (hazard ratio [HR] 2.60, 95% CI 1.94 to 3.50; HR 0.79, CI 0.66 to 0.95; HR 1.28, CI 1.00 to 1.64; and HR 2.18, CI 1.38 to 3.42, respectively). Area under the receiver-operating characteristic curve of each risk marker added to FRS-E for predicting CHD and CVD events is shown in the Table. Net reclassification improvement was highest with FRS-E plus CAC (CHD 0.659, CVD 0.466) and lowest with FRS-E plus brachial FMD (CHD 0.024, CVD 0.023).
Adding novel risk markers to a combination of the Framingham Risk Score plus ethnicity improved prediction of coronary and cardiovascular events in intermediate-risk adults.
Area under the receiver-operating characteristic curve (AUC) of FRS-E plus novel risk markers for predicting clinical events*
*ABI = ankle–brachial index; CAC = coronary artery calcium; FRS-E = Framingham Risk Score plus ethnicity; hsCRP = high-sensitivity C-reactive protein.
†Compared with FRS-E alone.
‡Corrected AUC data and P values provided by author.
Daniel I. Steinberg. Novel risk markers improved Framingham Risk Score cardiovascular event prediction in intermediate-risk adults. Ann Intern Med. 2012;157:JC6–13. doi: 10.7326/0003-4819-157-12-201212180-02013
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Published: Ann Intern Med. 2012;157(12):JC6-13.
Cardiology, Coronary Risk Factors.
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