Cardiovascular Epidemiology Definitions Historical Perspectives and Assessing Risk

Cardiovascular Epidemiology: Definitions Historical Perspectives and Assessing Risk of CVD Recent trends and population differences in CHD and CHD risk factors

Deaths in Thousands A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease Leading causes of death for all males and females (United States: 2004). Source: NCHS and NHLBI.

Coronary Heart Disease Heart Failure Diseases of the Arteries Defects Rheumatic Fever/ Rheumatic Heart Disease Stroke High Blood Pressure Congenital Cardiovascular Other Percentage breakdown of deaths from cardiovascular diseases (United States: 2004) Source: NCHS and NHLBI.

Cardiovascular disease deaths vs. cancer deaths by age (United States: 2004). Source: NCHS and NHLBI.

Development of Atherosclerotic Plaques Fatty streak Normal Lipid-rich plaque Foam cells Fibrous cap Thrombus Ross R. Nature. 1993; 362: 801 -809. Lipid core

Atherosclerotic Plaque Rupture and Thrombus Formation Intraluminal thrombus Growth of thrombus Blood Flow Intraplaque thrombus Adapted from Weissberg PL. Eur Heart J Supplements 1999: 1: T 13– 18 Lipid pool

PDAY: Percentage of Right Coronary Artery Intimal Surface Affected With Early Atherosclerosis 30 Intimal surface (%) Men Raised lesions 30 Fatty streaks 20 20 10 10 0 30 0 15 -19 20 -24 25 -29 30 -34 White 30 20 20 10 10 0 0 15 -19 20 -24 25 -29 30 -34 Black Age (y) PDAY= Pathobiological Determinants of Atherosclerosis in Youth. Strong JP, et al. JAMA. 1999; 281: 727 -735. Women 15 -19 20 -24 25 -29 30 -34 White 15 -1920 -2425 -2930 -34 Black

Coronary Remodeling Progression Compensatory expansion maintains constant lumen Normal vessel (Adapted from Glagov et al. ) Glagov et al, N Engl J Med, 1987. Minimal CAD Moderate CAD Expansion overcome: lumen narrows Severe CAD

Most Myocardial Infarctions Are Caused by Low-Grade Stenoses Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al. ) Falk E et al, Circulation, 1995.

Vulnerable Versus Stable Atherosclerotic Plaques Vulnerable Plaque Lumen Fibrous Cap Lipid Core • Thin fibrous cap • Inflammatory cell infiltrates: proteolytic activity • Lipid-rich plaque Stable Plaque Lumen Lipid Core Fibrous Cap Libby P. Circulation. 1995; 91: 2844 -2850. • Thick fibrous cap • Smooth muscle cells: more extracellular matrix • Lipid-poor plaque

Correlation of CT angiography of the coronary arteries with intravascular ultrasound illustrates the ability of MDCT to demonstrate calcified and non-calcified coronary plaques (Becker et al. , Eur J Radiol 2000) Non-calcified, soft, lipid-rich plaque in left anterior descending artery (arrow) (Somatom Sensation 4, 120 ml Imeron 400). The plaque was confirmed by intravascular ultrasound (Kopp et al. , Radiology 2004)

Features of a Ruptured Atherosclerotic Plaque • Eccentric, lipid-rich • Fragile fibrous cap • Prior luminal obstruction < 50% • Visible rupture and thrombus Constantinides P. Am J Cardiol. 1990; 66: 37 G-40 G.

Clinical Manifestations of Atherosclerosis • Coronary heart disease – Stable angina, acute myocardial infarction, sudden death, unstable angina • Cerebrovascular disease – Stroke, TIAs • Peripheral arterial disease – Intermittent claudication, increased risk of death from heart attack and stroke American Heart Association, 2000.

Definitions • CARDIOVASCULAR DISEASE or CVD includes CORONARY ARTERY DISEASE and other cardiac conditions (congenital, arrhythmias, and congestive heart failure) • CORONARY ARTERY DISEASE (CAD) or CORONARY HEART DISEASE (CHD) (often broadly referred to as ISCHEMIC HEART DISEASE (IHD): primarily myocardial infarction and sudden coronary death, broader definition may include angina pectoris, atherosclerosis, positive angiogram, revascularization, and myocardial infarction

Definitions (cont. ) • REVASCULARIZATION includes coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), stent, and atherectomy • CEREBROVASCULAR DISEASE includes stroke (ischemic or hemorrhagic) and transient ischemic attack (TIA) • PERIPHERAL VASCULAR DISEASE includes carotid artery disease and intermittent claudication • SURROGATE MEASURES include: carotid intimal medial thickness (IMT), coronary calcium, angiographic stenosis, brachial ultrasound flow mediated dilatation (FMD)

Prevalence of cardiovascular diseases in adults age 20 and older by age and sex (NHANES: 1999 -2004). Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.

Prevalence of coronary heart disease by age and sex (NHANES : 1999 -2004). Source: NCHS and NHLBI.

Annual Number of Americans Having Diagnosed Heart Attack by Age and Sex ARIC: 1987 -2000 Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study, 1987 -2000. These data don’t include silent MIs.

Annual Rate of First Heart Attacks by Age, Sex and Race ARIC: 1987 -2000 Source: NHLBI’s ARIC surveillance study, 1987 -2000.

Prevalence of stroke by age and sex (NHANES: 1999 -2004). Source: NCHS and NHLBI.

Prevalence of heart failure by age and sex (NHANES: 1999 -2004). Source: NCHS and NHLBI.

Hospital discharges for heart failure by sex (United States: 1979 -2004). Source: NHDS, NCHS and NHLBI. Note: Hospital discharges include people discharged alive, dead and status unknown. .

0 Cardiovascular disease mortality trends for males and females (United States: 1979 -2004). Source: NCHS and NHLBI.

Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

______________________________ Lifetime Risk of Coronary Heart Disease in the Framingham Study _______________________________ Men At age 40 years: 48. 6% At age 70 years: 34. 9% Women 31. 7% 24. 2% _________________________________ Lloyd-Jones et al. Lancet 1999; 353: 89 -92

______________________________ First Coronary Events: Framingham Study ____________________________ Percent as Specified Event Myocardial Infarction Age Men Women Angina Pectoris Men Women 35 -64 43% 28% 65 -84 55% 44% 41% 28% 59% 41% Sudden Death Men Women 9% 4% 11% 7. 4% ______________________________ Framingham Study 44 year follow-up.

Estimated 10 -Year CHD Risk in 55 -Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study A B C D Blood Pressure (mm Hg) 120/80 140/90 Total Cholesterol (mg/d. L) 200 240 240 HDL Cholesterol (mg/d. L) 50 50 40 40 Diabetes No No Yes Cigarettes No No No Yes mm Hg = millimeters of mercury mg/d. L = milligrams per deciliter of blood Source: Circulation 1998; 97: 1837 -1847.

Estimated 10 -Year Stroke Risk in 55 Year-Old Adults According to Levels of Various Risk Factors Framingham Heart Study Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD A 95 -105 No No B 130 -148 No No Source: Stroke 1991; 22: 312 -318. C 130 -148 Yes No No No D 130 -148 Yes No No E 130 -148 Yes Yes No F 130 -148 Yes Yes *BP in millimeters of mercury (mm. Hg)

Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD A 95 -105 No No B 130 -148 No No C 130 -148 Yes No No No D 130 -148 Yes No No E 130 -148 Yes Yes No F 130 -148 Yes Yes *BP in millimeters of mercury (mm. Hg) Estimated 10 -year stroke risk in 55 -year-old adults according to levels of various risk factors (FHS). Source: Wolf et al. , Stroke. 1991; 22: 312 -318.

Offspring CVD Risk by Parental CVD Status: Framingham Study Parental CVD <55 men, <65 Women Risk Ratio 2. 5 2 2. 2 1. 5 1. 7 1 1. 0 0. 5 0 Men Women Adjusted for: age, total/HDL Chol. ratio, SBP, smoking, diabetes, BMI

Risk imposed by a strong family history of heart attacks varies widely depending on the burden of modifiable risk factors Multivariable Risk

9 Doubts about cholesterol as late as 1989

Risk of Coronary Heart Disease by Serum Cholesterol 30 -Year Follow-up, The Framingham Study Age-Adjusted Annual Rate per 1000 Serum Cholesterol Age: 35 -64* Wome Men n Age: 65 -94 Men+ Women* 84 -204 8 4 22 11 205 -234 13 5 24 15 235 -264 14 4 26 17 265 -294 15 7 23 17 295 -1124 26 10 38 32 *Trends Significant at P. 001. +P. 07.

Correlation Between Serum Cholesterol and CVD Mortality 6 -Year CVD Death Rate Per 1000 30 Multiple Risk Factor Intervention Trial (MRFIT) N=325, 346 Untreated Patients 25 55 -57 years 20 50 -54 years 15 45 -49 years 10 40 -44 years 35 -39 years 5 0 Q 1 (<182) Q 2 (182 -202) Q 3 (203 -220) Q 4 (221 -244) Q 5 (>244) Serum Cholesterol Quintile (mg/d. L) Q = serum cholesterol quintile. Kannel WB et al. Am Heart J. 1986; 112: 825 -836.

________________________________________ Lifetime Risk of CHD Increases with Serum Cholesterol ______________________________________ Cholesterol 57 44 34 29 33 19 Framingham Study: Subjects age 40 years DM Lloyd-Jones et al Arch Intern Med 2003; 1966 -1972

Age-adjusted prevalence of Adults age 20 and older with LDL cholesterol of 130 mg/d. L or higher, by race/ethnicity and sex (NHANES: 2003 -2004). Source: NCHS and NHLBI. NH – non-Hispanic.

Age-adjusted prevalence of Adults age 20 and older with HDL cholesterol <40 mg/d. L, by race/ethnicity and sex (NHANES: 2003 -2004). Source: NCHS and NHLBI. NH – non-Hispanic.

Trends in mean total serum cholesterol among adults age 20 and older, by race/ethnicity, sex and survey (NHANES : 1988 -94, 1999 -02 and 2003 -04). Source: NCHS and NHLBI. NH – non-Hispanic.

Trends in mean total blood cholesterol among adolescents ages 12 -17 by race, sex, and survey (NHES: 1966 -70; NHANES: 1971 -74 and 1988 -94). Source: NCHS and NHLBI.

____________________________ CK Friedberg on Hypertension: Diseases of the Heart 1996 ______________________________ “There is a lack of correlation in most cases between the severity and duration of hypertension and development of cardiac complications. ” ________________________________

Relation of Non-Hypertensive Blood Pressure to Cardiovascular Disease Vasan R, et al. N Engl J Med 2001; 345: 1291 -1297 10 -year Age- Adjusted Cumulative Incidence Hazard Ratio* 10. 1 7. 6 5. 8 4. 4 SBP <120/80 120 -129 130 -139 Women Men 1. 0 1. 5 2. 5 1. 0 1. 3 1. 6 H. R. adjusted for age, BMI, Cholesterol, Diabetes and smoking *P<. 001 2. 8 1. 9 Framingham Study: Subjects Ages 35 -90 yrs.

Prevalence of high blood pressure in Adults by age and sex (NHANES: 1999 -2004). Source: NCHS and NHLBI.

Extent of awareness, treatment and control of high blood pressure by age (NHANES : 1999 -2004. ) Source: NCHS and NHLBI.

Age-adjusted prevalence trends for high blood pressure in Adults age 20 and older by race/ethnicity, sex and survey (NHANES: 1988 -94 and 1999 -2004). Source: NCHS and NHLBI.

Extent of Awareness, Treatment and Control of High Blood Pressure by Race/Ethnicity (NHANES: 1999 -2004). Source: NCHS and NHLBI.

________________________________ CK Friedberg on Hypertension Diseases of the Heart 1966 ________________________________ “Hypertension imposes a load on the heart which for many years may be compensated by left ventricular hypertrophy”

________________________________ CVD Risk Imposed by ECG-LVH Framingham Study 36 -yr. Follow-up ________________________________ Age-adjusted Rate per 1000 Age Men Women 35 -64 135 65 -94 235 Risk Excess Risk Ratio per 1000 Men Women 4. 7*** 7. 4*** 129 117 2. 8*** 4. 1*** 51 178 _______________________________ Biennial Rate per 1000. CVD=CHD, stroke, peripheral vascular disease, heart failure ***P<0. 001

______________________________ Smoking Statement Issued in 1956 by American Heart Association ______________________________ “It is the belief of the committee that much greater knowledge is needed before any conclusions can be drawn concerning relationships between smoking and death rates from coronary heart disease. The acquisition of such knowledge may well require the use of techniques and research methods that have not hitherto been applied to this problem. ” ______________________________ Circulation 1960; vol. 23

CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study. Men <55 Yrs. 14 -yr. Rate/1000 206 210 119 112 59

Prevalence of current smoking for Adults age 18 and older by race/ethnicity and sex (NHIS: 2004). Source: MMWR. 2004; 54: 1121 -24. NH – non-Hispanic.

Prevalence of high school students in grades 9 -12 reporting current cigarette smoking by race/ethnicity and sex. (YRBS: 2005). Source: MMWR. 2006; 55: SS-5. June 9, 2006. . NH – non-Hispanic.

Diseases of The Heart Charles K Friedberg MD, WB ________________________________ Saunders Co. Philadelphia, 1949 “The proper control of diabetes is obviously desirable even though there is uncertainty as to whether coronary atherosclerosis is more frequent or severe in the uncontrolled diabetic” _______________________________

Risk of Cardiovascular Events in Diabetics Framingham Study _________________________________ Cardiovascular Event Coronary Disease Stroke Peripheral Artery Dis. Cardiac Failure All CVD Events Age-adjusted Biennial Rate Age-adjusted Per 1000 Risk Ratio Men Women 39 21 1. 5** 2. 2*** 15 6 2. 9*** 2. 6*** 18 18 3. 4*** 6. 4*** 23 21 4. 4*** 7. 8*** 76 65 2. 2*** 3. 7*** _________________________________ Subjects 35 -64 36 -year Follow-up **P<. 001, ***P<. 0001

Age-adjusted prevalence of physician-diagnosed diabetes in Adults age 18 and older by race/ethnicity and sex (NHANES: 1999 -2004). Source: NCHS and NHLBI. NH – non-Hispanic.

Mortality rates in U. S. adults, age 30 -75, with metabolic syndrome (Met. S), with and without diabetes mellitus (DM) and pre-existing CVD (NHANES II: 1976 -80 Follow-up Study). ** Source: Malik et al. , Circulation. 2004; 110: 1245 -50. ** Average of 13 years of follow-up. Note: Age and gender adjusted.

Skepticism About Importance of Obesity Keys A, Aravanis C, Blackburn H, et al. Ann Intern Med 1972; 77: 15 -27. Concluded that all the excess risk of coronary heart disease in the obese derives from its atherogenic accompaniments, illogically leaving the impression that obesity is therefore unimportant. Mann GV. N Engl J Med 1974; 291: 226 -232. “The contribution of obesity to CHD is either small or non-existent. It cannot be expected that treating obesity is either logical or a promising approach to the management of CHD”. Barrett-Connor EL. Ann Intern Med 1985; 103: 1010 -1019 NIH consensus panel is equivocal about the role of obesity as a cause of CHD.

Relation of Weight Change to Changes in Atherogenic Traits: The Framingham Study Frantz Ashley, Jr. and William B Kannel J Chronic Dis 1974 “Weight gain is accompanied by atherogenic alterations in blood lipids, blood pressure, uric acid and carbohydrate tolerance. ” “It seems reasonable to expect that correction of overweight will improve the coronary risk problem. ” “Avoidance of overweight would seem a desirable goal in the general population if the appalling annual toll from disease is to be substantially reduced. ”

Risk Factor Sum and Obesity Framingham Study Risk Factor Sum 3 2. 4 1. 8 (1971 -74) and (1989 -93) (1989) (1971) Risk factors accumulate with weight gain 1. 2 0. 6 0 Q 1 Thin Q 2 Q 3 Q 4 Risk variables include bottom quintile for HDL-C and top quintiles for cholesterol, SBP, triglycerides and glucose Q 5 Obese Overall Wilson PWF, & Kannel WB Nutr Clin Care 1999; 1: 44 -50

Age-adjusted prevalence of obesity in Adults ages 20 -74 by sex and survey (NHES, 1960 -62; NHANES, 1971 -74, 1976 -80, 1988 -94 and 2001 -2004). Source: Health, United States, 2006, unpublished data. NCHS. Note: Obesity is defined as a BMI of 30. 0 or higher.

Trends in prevalence of overweight among U. S. children and adolescents by age and survey (NHANES, 1971 -74, 1976 -80, 1988 -94 and 2001 -2004). Source: Health, United States, 2006, unpublished data. NCHS.

Prevalence of overweight among students in grades 9 -12 by race/ethnicity and sex (YRBS: 2005). Source: BMI 95 th percentile or higher. MMWR. 2006 55: No. SS-5. NH – non-Hispanic.

Prevalence of leisure-time physical inactivity among adults age 18 and older by race/ethnicity, and sex. (BRFSS: 1994 and 2004). Source: MMWR, 2005; 54: No. 39. NH – non-Hispanic.

Note: “Currently recommended levels” is defined as activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day on 5 or more of the 7 days preceding the survey. Prevalence of students in grades 9 -12 who met currently recommended levels of physical activity during the past 7 days by race/ethnicity and sex (YRBS: 2005). Source: MMWR. 2006; 55: No. SS-5. NH – non-Hispanic.

International Comparisons in CVD Morbidity and Mortality • CVD accounts for 25 -45% of deaths among different countries • CVD death rates (per 100, 000) range from 1310 in Russia to 201 in Japan (6. 5 fold difference) in men and from 581 in Russia to 84 in France (7 -fold difference) • USA ranks 16 th for both men (413) and women (201)

Secular Trends in CHD and Stroke Mortality • From 1985 -1992, greatest annual decline (6 -7%) in CHD seen in Israel among men and France among women, USA intermediate (4%), increases in Poland Romania. • Stroke death rates declined most in Australia, Italy, and France (8 -9%), USA about 3%.

Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35 -74, 1999 • Age-Adjusted to European Standard • Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35 -74, 1999 • Age-Adjusted to European Standard • Data for 1999 unless noted Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

Change in Age-Adjusted Death Rates for Coronary Heart Disease by Country and Sex, Ages 35 -74, 1990 -1999 Men Women • Age-Adjusted to European Standard • Latest data year note in parentheses

Change in Age-Adjusted Death Rates for Stroke by Country and Sex, Ages 35 -74, 1990 -1999 Men Women • Age-Adjusted to European Standard • Latest data year note in parentheses Source: NHLBI 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases

Migrant Studies • Ni-Hon-San Study showed Japanese living in Japan to have the lowest cholesterol levels and lowest rates of CHD, those living in Hawaii to have intermediate rates for both, and those living in San Francisco to have the highest cholesterol levels and CHD incidence

Approaches to Primary and Secondary Prevention of CVD • Primary prevention involves prevention of onset of disease in persons without symptoms. • Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease. • Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic

Risk Factor Concepts in Primary Prevention • Nonmodifiable risk factors include age, sexc, race, and family history of CVD, which can identify high-risk populations • Behavioral risk factors include sedentary lifestyle, unhealthful diet, heavy alcohol or cigarette consumption. • Physiological risk factors include hypertension, obesity, lipid problems, and diabetes, which may be a consequence of behavioral risk factors.

Population vs. High-Risk Approach • Risk factors, such as cholesterol or blood pressure, have a wide bell-shaped distribution, often with a “tail” of high values. • The “high-risk approach” involves identification and intensive treatment of those at the high end of the “tail”, often at greatest risk of CVD, reducing levels to “normal”. • But most cases of CVD do not occur among the highest levels of a given risk factor, and in fact, occur among those in the “average” risk group. • Significant reduction in the population burden of CVD can occur only from a “population approach” shifting the entire population distribution to lower levels.

Pyramid of Risk (Werner et al. Canadian Journal of Cardiology 1998; 14(Suppl) B: 3 B-10 B)

Expected Shifts in Cholesterol Distribution from High-Risk, Population, and Combined Approaches

Population and Community. Wide CVD Risk Reduction Approaches • Populations with high rates of CVD are those with Western lifestyles of high-fat diets, physical inactivity, and tobacco use. • Targets of a population-wide approach must be these behaviors causative of the physiologic risk factors or directly causative of CVD. • Requires public health services such as surveillance (e. g. , BFRSS), education (AHA, NCEP), organizational partnerships (Singapore Declaration), and legislation/policy (Anti-Tobacco policies) • Activities in a variety of community settings: schools, worksites, churches, healthcare facilities, entire communities

A conceptual framework for public health practice in CVD prevention. (From Pearson et al. , J Public Health. 2001; 29: 69 – 78)

Communitywide CVD Prevention Programs • Stanford 3 -Community Study (1972 -75) showed mass media vs. no intervention in high-risk residents to result in 23% reduction in CHD risk score • North Karelia (1972 -) showed public education campaign to reduce smoking, fat consumption, blood pressure, and cholesterol • Stanford 5 -City Project (1980 -86) showed reductions in smoking, cholesterol, BP, and CHD risk • Minnesota Heart Health Program (1980 -88) showed some increases in physical activity and in women reductions in smoking

Materials Developed for US Community Intervention Trials • • • Mass media, brochures and direct mail Events and contests Screenings Group and direct education School programs and worksite interventions Physician and medical setting programs Grocery store and restaurant projects Church interventions Policies

Individual and High-Risk Approaches • Primary Prevention Guidelines (1995) and Secondary Prevention Guidelines (Revised 2001) released by the American Heart Association provide advice regarding risk factor assessment, lifestyle modification, and pharmacologic interventions for specific risk factors • Barriers exist in the community and healthcare setting that prevent efficient risk reduction • Surveys of CVD prevention-related services show disappointing results regarding cholesterollowering therapy, smoking cessation, and other measures of risk reduction

• Examination: Presentation – Height: 6 ft 2 in – Weight: 220 lb (BMI 28 kg/m 2) – Waist circumference: 41 in – BP: 150/88 mm Hg – P: 64 bpm – RR: 12 breaths/min • Cardiopulmonary exam: normal • Laboratory results: – – – TC: 220 mg/d. L HDL-C: 36 mg/d. L LDL-C: 140 mg/d. L TG: 220 mg/d. L FBS: 120 mg/d. L

Risk Assessment Count major risk factors • For patients with multiple (2+) risk factors – Perform 10 -year risk assessment • For patients with 0– 1 risk factor – 10 year risk assessment not required – Most patients have 10 -year risk <10%

ATP III Assessment of CHD Risk For persons without known CHD, other forms of atherosclerotic disease, or diabetes: • Count the number of risk factors: – Cigarette smoking – Hypertension (BP 140/90 mm. Hg or on antihypertensive medication) – Low HDL cholesterol (<40 mg/d. L)† – Family history of premature CHD u u CHD in male first degree relative <55 years CHD in female first degree relative <65 years – Age (men 45 years; women 55 years) • Use Framingham scoring for persons with 2 risk factors* (or with metabolic syndrome) to determine the absolute 10 -year CHD risk. (downloadable risk algorithms at www. nhlbi. nih. gov) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Assessing CHD Risk in Men Step 1: Age Years 20 -34 35 -39 40 -44 45 -49 50 -54 55 -59 60 -64 65 -69 70 -74 75 -79 Step 4: Systolic Blood Pressure Points -9 -4 0 3 6 8 10 11 12 13 Systolic BP (mm Hg) <120 120 -129 130 -139 140 -159 160 Points if Untreated if Treated 0 0 0 1 1 2 2 3 HDL-C (mg/d. L) 60 Points -1 50 -59 0 40 -49 1 <40 2 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 7: CHD Risk Step 2: Total Cholesterol TC Points at (mg/d. L) Age 20 -39 70 -79 <160 0 160 -199 4 200 -239 7 240 -279 9 11 Step 280 3: HDL-Cholesterol Step 6: Adding Up the Points at Age 40 -49 Age 50 -59 Age 60 -69 Age 0 3 5 6 8 0 2 3 4 5 0 1 1 2 3 0 0 0 1 1 Step 5: Smoking Status Points at Age 20 -39 70 -79 Nonsmoker 0 from the experience 8 of Smoker Points at Point Total 10 -Year Risk <0 <1% 0 1% 1 1% 2 1% 3 1% 4 1% 5 2% 6 2% 7 3% 8 4% 9 5% 10 6% Points at Point Total 10 -Year 11 12 13 14 15 16 17 8% 10% 12% 16% 20% 25% 30% Points at Age 40 -49 Age 50 -59 Age 60 -69 Age 0 0 Note: Risk estimates were derived the Framingham Heart Study, 5 3 a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. 0 1 © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Assessing CHD Risk in Women Step 4: Systolic Blood Pressure Step 1: Age Systolic BP (mm Hg) <120 120 -129 130 -139 140 -159 160 Years Points 20 -34 -7 35 -39 -3 40 -44 0 45 -49 3 50 -54 6 55 -59 8 60 -64 10 65 -69 12 70 -74 14 75 -79 16 Step 2: Total Cholesterol TC Points at (mg/d. L) Age 20 -39 70 -79 <160 0 160 -199 4 200 -239 8 240 -279 11 13 Step 280 3: HDL-Cholesterol HDL-C (mg/d. L) 60 Points -1 50 -59 0 40 -49 1 <40 2 Step 6: Adding Up the Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 7: CHD Risk Points at Age 40 -49 Age 50 -59 Age 60 -69 Age 0 3 6 8 10 0 2 4 5 7 0 1 2 3 4 0 1 1 2 2 Step 5: Smoking Status Points at Age 20 -39 70 -79 Nonsmoker 0 Smoker from the experience 9 of Points at Point Total 10 -Year Risk <9 <1% 9 1% 10 1% 11 1% 12 1% 13 2% 14 2% 15 3% 16 4% 17 5% 18 6% 19 8% Points at Point Total 10 -Year 20 21 22 23 24 25 11% 14% 17% 22% 27% 30% Points at Age 40 -49 Age 50 -59 Age 60 -69 Age 0 0 7 4 Note: Risk estimates were derived the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. 0 2 0 1 © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 1: Age Men Years 20 -34 35 -39 40 -44 45 -49 50 -54 55 -59 60 -64 65 -69 70 -74 75 -79 Women Points -9 -4 0 3 6 8 10 11 12 13 Years 20 -34 35 -39 40 -44 45 -49 50 -54 55 -59 60 -64 65 -69 70 -74 75 -79 Points -7 -3 0 3 6 8 10 12 14 16 Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 2: Total Cholesterol Men TC Points at Points Age 20 -39 Age 40 -49 Age 50 -59 Age 60 -69 0 4 7 9 11 0 3 5 6 8 0 2 3 4 5 0 1 1 2 3 TC (mg/d. L) Points at Age 20 -39 Points at Age 40 -49 Points at Age 50 -59 <160 160 -199 200 -239 240 -279 280 0 4 8 11 13 0 3 6 8 10 0 2 4 5 7 at (mg/d. L) 70 -79 <160 160 -199 200 -239 240 -279 280 Age 0 0 0 1 1 Women 79 Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. Points at Age 60 -69 Age 700 1 2 3 4 0 1 1 2 2 © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 3: HDL-Cholesterol Men HDL-C (mg/d. L) 60 Women Points -1 HDL-C (mg/d. L) 60 Points -1 50 -59 0 40 -49 1 <40 2 Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 4: Systolic Blood Pressure Men Systolic BP Points (mm Hg) if Untreated <120 0 120 -129 0 130 -139 1 140 -159 1 160 2 Women Systolic BP (mm Hg) <120 120 -129 130 -139 140 -159 160 Points if Treated 0 1 2 2 3 Points if Untreated if Treated 0 0 1 3 2 4 3 5 4 6 Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 5: Smoking Status Men at -79 Nonsmoker Smoker Women at -79 Nonsmoker Smoker Points at Points Age 20 -39 Age 40 -49 Age 50 -59 Age 60 -69 Age 70 0 8 0 5 0 3 Points at Points Age 20 -39 Age 40 -49 Age 50 -59 Age 60 -69 Age 70 0 9 0 7 0 4 0 1 0 2 0 1 Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 6: Adding Up the Points (Sum From Steps 1– 5) Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

ATP III Framingham Risk Scoring Step 7: CHD Risk for Men Point Total Risk <0 0 1 2 3 4 5 6 7 8 9 10 10 -Year Risk Point Total <1% 1% 1% 2% 2% 3% 4% 5% 6% 11 12 13 14 15 16 17 10 -Year 8% 10% 12% 16% 20% 25% 30% Note: Determine the 10 -year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

What is WJC’s 10 -year absolute risk of fatal/nonfatal MI? • A 12% absolute risk is derived from points assigned in Framingham Risk Scoring to: – – – Age: 6 TC: 3 HDL-C: 2 SBP: 2 Total: 13 points In 1992 he exercised 14 minutes in a Bruce protocol exercise stress test to 91% of his maximum predicted heart rate without any abnormal ECG changes. He started on a statin in 2001. But in Sept 2004, he needed urgent coronary bypass surgery.

ATP III Framingham Risk Scoring Step 7: CHD Risk for Women Point Total Risk <9 9 10 11 12 13 14 15 16 17 18 19 10 -Year Risk Point Total <1% 1% 1% 2% 2% 3% 4% 5% 6% 8% 20 21 22 23 24 25 10 -Year 11% 14% 17% 22% 27% 30% Note: Determine the 10 -year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001; 285: 2486 -2497. © 2001, Professional Postgraduate Services® www. lipidhealth. org

CHD Risk Equivalents • Risk for major coronary events equal to that in established CHD • 10 -year risk for hard CHD >20% Hard CHD = myocardial infarction + coronary death

Diabetes as a CHD Risk Equivalent • 10 -year risk for CHD 20% • High mortality with established CHD – High mortality with acute MI – High mortality post acute MI

CHD Risk Equivalents • Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) • Diabetes • Multiple risk factors that confer a 10 year risk for CHD >20%