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A Risk Score for Predicting Near-Term Incidence of Hypertension: The Framingham Heart Study

Nisha I. Parikh, MD, MPH; Michael J. Pencina, PhD; Thomas J. Wang, MD; Emelia J. Benjamin, MD, ScM; Katherine J. Lanier, BS; Daniel Levy, MD; Ralph B. D'Agostino Sr, PhD; William B. Kannel, MD; and Ramachandran S. Vasan, MD
[+] Article and Author Information

From the Framingham Heart Study, Framingham, Massachusetts; Massachusetts General Hospital, Boston University, and Boston University School of Medicine, Boston, Massachusetts; and National Heart, Lung, and Blood Institute, Bethesda, Maryland.


Grant Support: By National Heart, Lung, and Blood Institute contracts N01-HC-25195 and K23-HL074077-01 (Dr. Wang) and 2K24HL04334 (Dr. Vasan).

Potential Financial Conflicts of Interest:Other: T.J. Wang (Novartis Institutes for Biomedical Research).

Requests for Single Reprints: Ramachandran S. Vasan, MD, Framingham Heart Study, 73 Mount Wayte Avenue, Suite 2, Framingham, MA 01702-5803; e-mail, vasan@bu.edu.

Current Author Addresses: Dr. Parikh: Cardiovascular Division, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, West Baker 4, Boston, MA 02215.

Drs. Pencina and D'Agostino and Ms. Lanier: Department of Mathematics and Statistics, Department of Biostatistics, Boston University, 111 Cummington Street, Boston, MA 02215.

Dr. Wang: Cardiology Division, GRB-800, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.

Drs. Benjamin, Levy, Kannel, and Vasan: Framingham Heart Study, 73 Mount Wayte Avenue, Suite 2, Framingham, MA 01702-5803.

Author Contributions: Conception and design: N.I. Parikh, M.J. Pencina, T.J. Wang, R.B. D'Agostino Sr., R.S. Vasan.

Analysis and interpretation of the data: N.I. Parikh, M.J. Pencina, K.J. Lanier, D. Levy, R.B. D'Agostino Sr., R.S. Vasan.

Drafting of the article: N.I. Parikh, M.J. Pencina, R.S. Vasan.

Critical revision of the article for important intellectual content: N.I. Parikh, M.J. Pencina, T.J. Wang, E.J. Benjamin, D. Levy, R.B. D'Agostino Sr., W.B. Kannel, R.S. Vasan.

Final approval of the article: N.I. Parikh, M.J. Pencina, T.J. Wang, E.J. Benjamin, R.B. D'Agostino Sr., W.B. Kannel, R.S. Vasan.

Statistical expertise: M.J. Pencina, R.B. D'Agostino Sr.,

Obtaining of funding: R.B. D'Agostino Sr., R.S. Vasan.

Administrative, technical or logistic support: R.S. Vasan.

Collection and assembly of data: N.I. Parikh, K.J. Lanier, D. Levy.


Ann Intern Med. 2008;148(2):102-110. doi:10.7326/0003-4819-148-2-200801150-00005
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We examined clinical predictors of hypertension onset among individuals with new-onset hypertension in the community and developed a risk score that included the following components, which are easily assessed in a physician's office in primary care settings: age, sex, systolic blood pressure, diastolic blood pressure, body mass index, parental hypertension, and cigarette smoking. Our risk score for hypertension had very good discrimination and calibration, and assessment of overoptimism suggests that the model will probably do well when applied to a different sample. Physicians can use the hypertension risk score to measure an individual's estimated risk for hypertension, to inform patients of their risks and help guide their choice of nonpharmacologic measures to prevent hypertension, and to aid in clinical counseling and decision making. In addition, the risk prediction score may be useful in designing interventions to prevent high blood pressure by aiding in selection of participants at the highest risk for hypertension, who are most likely to benefit from treatment. Given that hypertension was measured on only 1 occasion, however, our score may somewhat overestimate an individual's true risk for hypertension.

Topics

hypertension ; heart

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Figure 1.
Number of participants available for evaluation of hypertension incidence at baseline examination and number of participants with incident hypertension at follow-up examination.
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Figure 2.
Calculation of scores to predict 1-, 2-, and 4-year risk for new-onset hypertension.
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Figure 3.
Four-year predicted probability of hypertension in men and women, by selected risk factors.

Blood pressure was 120/80 mm Hg, unless otherwise indicated. Plus and minus signs below graph indicate the presence or absence of risk factors. BMI = body mass index; DBP = diastolic blood pressure; SBP = systolic blood pressure. *Both parents with hypertension.

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Relation between anxiety and the hypertension risk
Posted on January 24, 2008
Liu Hong
Institute of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an, China
Conflict of Interest: None Declared

Parikh NI et al do develop a simple risk prediction algorithm that estimates an individual's 1-, 2- and 4-year probability of developing hypertension. They examine the following candidate risk factors: age, sex, body weight, body mass index, physical activity index, systolic blood pressure, diastolic blood pressure, moderate alcohol intake, parental hypertension and cigarette smoking [1]. And their risk score does not take into account some predictors of hypertension that may not be routinely measured, such as nonsteroidal anti-inflammatory drugs, salt intake, vegetable, fat intake, or exercise. However, one important clinical predictor of hypertension, anxiety, is not involved in their investigation.

Anxiety is known to be closely associated with incident hypertension, and may be the precursor to hypertension [2,3]. The higher rate of hypertension incidence is found closely accompanied with anxiety for Chinese patients [4]. In general, the more nervous Chinese hospital patients fell, the higher blood pressure they get. Anxiety can easily be measured in a physician's office in primary care settings. For example, at each Framingham Heart Study examination, the investigators may record and evaluate the following factors of anxiety: the daily intensity (with a score range from 0 to 5; 0 being the minimum; 5 being the maximum level), duration (hours per month), and frequency (days per month). Parikh NI and colleagues do not provide any information regarding the relation of anxiety with the hypertension risk. The readers will be very interested to know whether anxiety is one significant predictor of hypertension for nonhypertensive white individuals.

Reference:

1 Parikh NI, Pencina MJ, Wang TJ, Benjamin EJ, Lanier KJ, Levy D, et al. A risk score for predicting near-term incidence of hypertension: the Framingham Heart Study. Ann Intern Med. 2008; 148(2): 102-10.

2 Spruill TM, Pickering TG, Schwartz JE, Mostofsky E, Ogedegbe G, Clemow L, et al. The impact of perceived hypertension status on anxiety and the white coat effect. Ann Behav Med. 2007; 34(1): 1-9.

3 Dimsdale JE. Symptoms of anxiety and depression as precursors to hypertension. JAMA. 1997; 277(7): 574-5.

4 Wei TM, Wang L. Anxiety symptoms in patients with hypertension: a community-based study. Int J Psychiatry Med. 2006; 36(3): 315-22.

Conflict of Interest:

None declared

No Title
Posted on March 31, 2008
Francisco Sánchez
Ediciones Mayo
Conflict of Interest: None Declared

Dear Dr. Nisha,

I was very impressed by a risk factor calculator for predicting hypertension. Could this calculator be used in the clinical follow-up of the pre-hypertense patient? I supposse there is an option for on-line calculation, althoung I haven´t seen any link in the paper. Thank-you very much and congratulations for this valuable item.

Francisco Sánchez Barcelona Spain

Conflict of Interest:

None declared

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