The Framingham Heart Disease Epidemiology Study opened the eyes of the public and medical community about specific risk factors and how they might contribute to heart disease. In fact, the term “risk factor” was coined by Framingham researchers as a direct result of their findings.
A coronary risk profile is a measure of a person's chance of having some type of heart-related problem in the next 10 years. It is determined by using a simple score sheet based on risk factors identified by the Framingham study. The overall coronary risk profile takes into account both controllable risk factors (e.g., diet, smoking status) and uncontrollable risk factors (e.g., age, gender).
A person at higher risk can take preventive measures recommended by their physician, such as lifestyle changes and/or medication, to lower their chances of a heart-related problem.
While there is no guarantee that healthy living or medication will keep heart disease completely at bay, they can improve a person's physical and emotional quality of life. Also, because risk factors are often related to each other, making changes in one area can lead to positive differences in other areas. Lowering the risk factor for a certain disease or condition is one of the best preventive measures an individual can take to guard his or her health.
About coronary risk profiles
The coronary risk profile is a measure of an individual’s chance of having some sort of heart-related problem in the next 10 years. Risk can never be a firm measurement, and future disease or events (such as a heart attack) cannot be definitively predicted or ruled out. However, the risk assessment helps shape appropriate preventive measures that can be helpful to patients and physicians.
To help people determine their risk of having a heart-related problem in the next 10 years, the authors of the Framingham Heart Disease Epidemiology Study developed a simple one-page worksheet. The worksheet measures heart health using both controllable and uncontrollable risk factors. These risk factors include:
Age
Gender
Total cholesterol
HDL cholesterol
Systolic blood pressure (and whether a person is being treated for high blood pressure)
Whether or not a person smokes
The score sheet, however, is intended only as a general guideline for patients and physicians. It does not take into account all the known risk factors for heart disease, such as family medical history or exercise habits. Instead, it is meant to provide a starting point for discussions of heart-healthy living and may lead to greater scrutiny of known risk factors.
The original Framingham Heart Study was performed only on statistics gleaned from white males. Researchers are currently working to develop coronary risk profile sheets specific to other populations.
Calculating heart disease risk
The Framingham Heart Disease Epidemiology Study produced a strategy to calculate the risk of developing one of the following conditions in the next 10 years:
Angina (certain type of chest pain, pressure or discomfort)
Heart attack
Heart-related death
To calculate this risk, the score sheet looks at uncontrollable and controllable risk factors, including:
Age
Gender
Total cholesterol
HDL cholesterol
Systolic blood pressure (and whether a person is being treated for high blood pressure)
Whether or not a person smokes
Each of these factors is assigned a point value. These points are added and then divided by the total risk factors present in a person of similar age and gender who is at low risk. The final risk is presented as a multiple of the ideal low-risk person.
In other words, a person with a reading of 5 would be five times more likely to suffer a major heart-related problem in the next 10 years than someone of similar age and gender who is at low risk.
As researchers learn more, they are working to identify new risk factors for heart disease, although these are not yet part of the standard Framingham risk-assessment model. These new risk factors include:
Homocysteine. Framingham research has found that high levels of homocysteine may contribute to heart disease, stroke and reduced blood flow to the hands and feet. Homocysteine may contribute to the buildup of fatty substances in the arteries, increase platelet “stickiness” and make blood vessels less flexible. The level of homocysteine appears to have genetic factors and dietary factors, and it can be lowered through dietary changes or taking folic acid and vitamin B supplements.
Lipoprotein(a) or Lp(a). This lipoprotein is a component of LDL cholesterol. It is thought to inhibit the breakup of blood clots.
Infectious disease. Framingham investigators are pursuing links between heart disease and viruses, which may harm blood vessel walls and aggravate atherosclerosis. Such diseases include chlamydia, H. pylori and cytomegalovirus.
Factors that affect risk
Uncontrollable factors
The Framingham coronary risk score sheet uses both uncontrollable and controllable risk factors. Among uncontrollable risk factors, it takes into account only age and gender, which strongly correlate with heart disease. Men tend to have a greater overall risk of heart attack than women, beginning earlier in life.
However, women’s risk of heart attack rises after menopause and heart disease is the leading killer of American women. Also, many forms of heart disease, such as atherosclerosis, tend to affect older people more often than younger people.
There are other known risk factors for heart disease that are not included on the Framingham score sheet. These include:
A family history of cardiovascular disease.
Race. According to the American Heart Association, blacks (both male and female) are more likely to have coronary artery disease (CAD) than whites. Proportionately, CAD claims more black and white lives than Hispanic lives. Black women and Native American women are more likely to have a heart attack than white women.
Congenital disease heart. These are conditions that are present at birth. Although there is no known cause or preventive measures to protect against congenital heart disease, researchers are pursuing possible genetic causes that may someday lead to better therapies and diagnostic tools.
Patient history. Patients who have had cerebral vascular disease (e.g., stroke) are at higher risk of developing CAD.
Controllable factors
Similarly, the Framingham coronary risk score sheet uses only a few of the known controllable risk factors to measure risk. These include cholesterol levels, smoking and blood pressure. Other controllable risk factors that are not included on the Framingham coronary risk score sheet include:
Lack of regular exercise
Eating a high-fat, high-cholesteroldiet
Obesity (defined as having a body index mass greater than 30)
Uncontrolled stress or anger
Lifestyle changes that can reduce heart risk
People cannot control their age and gender, but they can control other risk factors used by Framingham. People are advised to adopt lifestyle habits that will reduce the chance of a heart-related problem in the next 10 years.
While there is no guarantee that heart-healthy living will keep heart disease at bay, these lifestyle changes can be beneficial to physical and emotional health and well-being, increasing overall quality of life. Also, because some risk factors are interconnected, making changes in one area can lead to positive differences in other areas as well.
Recommended lifestyle changes include:
Quitting smoking. The study showed that heart disease was directly linked to smoking, and the risk significantly dropped after quitting smoking.
Eating a heart-healthy diet that is low in saturated fats and oils and cholesterol. This includes eating foods high in heart-healthy vitamins and minerals, including certain B-vitamins, antioxidants, calcium and magnesium. Some experts also recommend additional supplements, such as garlic and omega-3 fatty acids. Specific diets that are being recommended by some experts include the Mediterranean diet and the DASH diet.
Achieving and maintaining a healthy weight. Being overweight or obese places extra stress on the heart, as well as increasing the risk of developing type 2 diabetes, a known risk factor for heart disease.
Engaging in regular exercise. The study found that exercise aided blood circulation and lessened the heart’s workload in times of stress/exertion. It also showed mental and emotional benefits. Moderate physical activity is recommended for at least 30 minutes per day, seven days a week. Shorter, daily periods of exercise are also helpful.
Using stress management and anger management techniques. Stress and anger were linked to cardiovascular events such as heart attack and stroke.
Controlling chronic conditions such as diabetes and high blood pressure (hypertension). Untreated, both of these conditions were shown to increase the risk of heart disease.
People are encouraged to be determined but patient as they make these changes, because they do not happen overnight. Making lifestyle changes gradually, meeting small goals along the way, can be a helpful approach.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to coronary artery risk profiles:
How often should I have my coronary risk profile determined?
How accurate is this measure?
What is my current coronary risk?
Is this above or below average for my gender and age?
Are there other factors to consider that are not included in the profile?
What part does family medical history play in my risk for heart problems?
What steps should I take to lower my coronary risk?
If I don't follow our program of lifestyle changes, will my risk necessarily get worse?
How quickly can I expect to reduce my risk if I make lifestyle changes?
Which risk factor is the most important for me to control?
What resources are available to help?
Can you recommend a dietitian to help with my diet changes?
How often should I have my cholesterol checked?
Should other family members complete a coronary risk profile?
