Relative Importance of Borderline and Elevated Levels of Coronary Heart Disease Risk Factors

  1. Ramachandran S. Vasan, MD;
  2. Lisa M. Sullivan, PhD;
  3. Peter W.F. Wilson, MD;
  4. Christopher T. Sempos, PhD;
  5. Johan Sundström, MD, PhD;
  6. William B. Kannel, MD;
  7. Daniel Levy, MD; and
  8. Ralph B. D'Agostino, PhD
  1. From the Framingham Heart Study, Framingham, Massachusetts; Medical University of South Carolina, Charleston, South Carolina; State University of New York at Buffalo, Buffalo, New York; National Heart, Lung, and Blood Institute, Bethesda, Maryland; and Boston University, Boston, Massachusetts.

    Abstract

    Background: Clinical trials indicate that a sizable proportion of adults have multiple borderline coronary risk factors and may benefit from treatment.

    Objective: To estimate the relative and absolute contributions of borderline and elevated risk factors to the population burden of coronary heart disease (CHD) events.

    Design: A prospective cohort study and a national cross-sectional survey.

    Setting: The Framingham Study and the Third National Health and Nutrition Examination Survey (NHANES III).

    Participants: White non-Hispanic persons in the Framingham Study and in NHANES III who were between 35 to 74 years of age and had no CHD.

    Measurements: Occurrence of first CHD events according to 5 major CHD risk factors: blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol levels, glucose intolerance, and smoking. Three categories—optimal, borderline, and elevated—were defined for each risk factor per national guidelines. Sex-specific 10-year CHD event rates from the Framingham Study were applied to numbers of at-risk individuals estimated from NHANES III and the 2000 U.S. Census.

    Results: Twenty-six percent of men and 41% of women had at least 1 borderline risk factor in NHANES III. According to estimates, more than 90% of CHD events will occur in individuals with at least 1 elevated risk factor, and approximately 8% will occur in people with only borderline levels of multiple risk factors. Absolute 10-year CHD risk exceeded 10% in men older than age 45 years who had 1 elevated risk factor and 4 or more borderline risk factors and in those who had at least 2 elevated risk factors. In women, absolute CHD risk exceeded 10% only in those older than age 55 years who had at least 3 elevated risk factors.

    Limitations: The generalizability of the findings to persons of other ethnic backgrounds is unknown.

    Conclusions: Borderline CHD risk factors alone account for a small proportion of CHD events.

    Article and Author Information

    • Potential Financial Conflicts of Interest: None disclosed.

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

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

    • Drs. Sullivan and D'Agostino: Boston University Statistics and Consulting Unit, 704 Commonwealth Avenue, 5th Floor, Boston, MA 02215.

    • Dr. Wilson: Department of Endocrinology, Diabetes, and Medical Genetics, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 215, Charleston, SC 29425.

    • Dr. Sempos: Department of Social & Preventive Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 14214.

    • Dr. Sundström: Department of Public Health & Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden.

    • Author Contributions: Conception and design: R.S. Vasan, L.M. Sullivan, P.W.F. Wilson, J. Sundström, W.B. Kannel, D. Levy, R.B. D'Agostino.

    • Analysis and interpretation of the data: R.S. Vasan, L.M. Sullivan, P.W.F. Wilson, C.T. Sempos, J. Sundström, W.B. Kannel, D. Levy, R.B. D'Agostino.

    • Drafting of the article: R.S. Vasan, L.M. Sullivan, J. Sundström, W.B. Kannel, D. Levy, R.B. D'Agostino.

    • Critical revision of the article for important intellectual content: R.S. Vasan, P.W.F. Wilson, C.T. Sempos, J. Sundström, W.B. Kannel, D. Levy.

    • Final approval of the article: R.S. Vasan, L.M. Sullivan, P.W.F. Wilson, C.T. Sempos, J. Sundström, W.B. Kannel, D. Levy, R.B. D'Agostino.

    • Provision of study materials or patients: P.W.F. Wilson, D. Levy, R.B. D'Agostino.

    • Statistical expertise: L.M. Sullivan, R.B. D'Agostino.

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

    • Administrative, technical, or logistic support: P.W.F. Wilson, D. Levy, R.B. D'Agostino.

    • Collection and assembly of data: P.W.F. Wilson, D. Levy, R.B. D'Agostino.

    Responses to this article

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      • Nicholas J Wald and
      • Malcolm Law
      Ann Intern Med published online October 26, 2009
    • Risk Factors: Rules of Thumb for Real Win
      • Enrique J. Sánchez-Delgado
      Ann Intern Med published online October 26, 2009

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    1. Ann Intern Med March 15, 2005 vol. 142 no. 6 393-402
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