____________________________________________________________
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
Sudden
Pectoris
Death
Men Women Men Women
35-64 43% 28%
65-84 55% 44%
41%
28%
59%
41%
9%
11%
4%
7.4%
____________________________________________________________
Framingham Study 44 year follow-up.
Estimated 10-Year Rate (%)
Estimated 10-Year CHD Risk in
55-Year-Old Adults According to Levels of
Various Risk Factors Framingham Heart Study
40
35
30
25
20
15
10
5
0
37
27
25
20
Men
Women
13
5
8
5
A
B
C
A
D
B
C
D
Blood Pressure (mm Hg)
120/80 140/90 140/90 140/90
Total Cholesterol (mg/dL)
200
240
240
240
HDL Cholesterol (mg/dL)
50
50
40
40
Diabetes
No
No
Yes
Yes
Cigarettes
No
No
No
Yes
Estimated 10-Year Stroke Risk in 55-Year-Old Adults
According to Levels of Various Risk Factors
Estimated 10-Year Rate (%)
Framingham Heart Study
30
27
25
22.4
19.1
20
14.8
15
8.4
10
5
2.6
6.3
5.4
4
3.5
2
1.1
0
A
B
C
D
Men
A
Systolic BP*
95-105
Diabetes
No
Cigarettes
No
Prior Atrial Fib. No
Prior CVD
No
B
130-148
No
No
No
No
Source: Stroke 1991;22:312-318.
E
F
Women
C
130-148
Yes
No
No
No
D
130-148
Yes
Yes
No
No
E
130-148
Yes
Yes
Yes
No
F
130-148
Yes
Yes
Yes
Yes
*BP in millimeters of mercury (mmHg)
Estimated 10-Year Rate (%)
30
27
25
22.4
Men
20
W omen
19.1
14.8
15
8.4
10
5
2.6
5.4
4
2
1.1
6.3
3.5
0
A
B
A
Systolic BP*
95-105
Diabetes
No
Cigarettes
No
Prior Atrial Fib. No
Prior CVD
No
C
B
130-148
No
No
No
No
D
C
130-148
Yes
No
No
No
D
130-148
Yes
Yes
No
No
E
E
130-148
Yes
Yes
Yes
No
F
F
130-148
Yes
Yes
Yes
Yes
*BP in millimeters of mercury (mmHg)
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
NONE
MATERNAL
PATERNAL
2.5
2.5
22
2.2
1.5
1.7
1.7
1.7
11
1.0
1.0
0.5
0.5
00
Men
MEN
Women
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
Q1
(<182)
Q2
(182-202)
Q3
(203-220)
Q4
(221-244)
Q5
(>244)
Serum Cholesterol Quintile (mg/dL)
Q = serum cholesterol quintile. Kannel WB et al. Am Heart
J. 1986;112:825-836.
_______________________________________________________________________________
Lifetime Risk of CHD Increases
with Serum Cholesterol
___________________________________________________________________________
60
Percent
Cholesterol
50
<200 mg
200-239 mg
40
>240 mg
57
30
44
20
34
29
10
33
19
0
Men
Women
Framingham Study: Subjects age 40 years
DM Lloyd-Jones et al Arch Intern Med 2003; 1966-1972
Percent of Population
45
40
35
30
25
20
15
10
5
0
39.0
32.0 32.0
Total Population
32.0
34.0
NH Whites
Men
32.0 30.0
31.0
NH Blacks
Mexican
Americans
Women
Age-adjusted prevalence of Adults age 20 and older with LDL
cholesterol of 130 mg/dL or higher, by race/ethnicity and sex
(NHANES: 2003-2004). Source: NCHS and NHLBI. NH – non-Hispanic.
Percent of Population
30
25
28
26
25
20
16
13
15
10
9
9
7
5
0
Total
NH Whites
Men
NH Blacks
Mexican
Americans
Women
Age-adjusted prevalence of Adults age 20 and older
with HDL cholesterol <40 mg/dL, by race/ethnicity
and sex (NHANES: 2003-2004).
Source: NCHS and NHLBI. NH – non-Hispanic.
Mean Serum Total Cholesterol
208
206
204
206
204
205
204
202
202
202
201
199
200
197
198
196
194
192
NH White
NH Black
1988-94
1999-02
Mexican American
2003-04
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.
Mean Total Blood Cholesterol
180
175
171
170
165
165 166
161
163 163
160
155
172
170
166
163 164
174
168
161
156
155
150
145
White Males
Black Males
1976-80
1988-94
White Females
1999-02
Black Females
2003-04
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
12%
Hazard Ratio*
<120/80 mm Hg
120-129/80-84 mm Hg
130-139/85-89 mm Hg
10%
SBP
10.1
8%
7.6
6%
5.8
4%
2%
4.4
2.8
1.9
0%
Women
Men
Framingham Study: Subjects Ages 35-90 yrs.
<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
Percent of Population
83.8
90.0
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
73.9
69.5
63.6
55.4
49.1
37.5 37.4
23.2
11.2
18.3
6.4
20-34
35-44
45-54
Men
55-64
65-74
75+
Women
Prevalence of high blood pressure in Adults by age
and sex (NHANES: 1999-2004). Source: NCHS and NHLBI.
Percent of Population
80
70
60
50
40
30
20
10
0
74.6
75.3
62.5
68.4
52.3
39.8
35.8
34.3
24.6
Awareness
Treatment
20-39
40-59
Controlled
60+
Extent of awareness, treatment and control of high
blood pressure by age (NHANES : 1999-2004.)
Source: NCHS and NHLBI.
Percent of Population
50
37.5 39.0
40
30
25.6
28.5
38.2
41.4
28.0
26.9 26.2
22.9
25.0
27.0
20
10
0
NH WhiteOnly Men
NH WhiteOnly
Women
NH Black
or AA Men
NH Black
or AA
Women
1988-94
1999-04
Mexican
Men
Mexican
Women
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.
Percent of Population
90
80
70
60
50
40
30
20
10
0
72.9
76.9
62.4
63.4
66.9
49.1
37.2
33.6
25.1
Awareness
NH Whites
Treatment
NH Blacks
Controlled
Mexican Americans
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
35-64 164
135
65-94 234
235
Risk
Excess Risk
Ratio
per 1000
Men Women 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
250
Non-Smoker
Reg. Cig. Smoker
Filter Cig. Smoker
210
206 210
200
150
119
112
100
59
50
0
Total CHD
Myocardial
Infarction
Percent of Population
40
35
30
25
20
15
10
5
0
37.3
33.4
24.1 23.9
20.4 20.2
18.9 17.8
15
11.3
Men
NH White
NH Black
Hispanic
Women
Asian
American Indian or Alaska Native
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.
Percent of Population
45
40
35
30
25
20
15
10
5
0
24.9
27
24.8
19.2
14
NH Whites
11.9
NH Blacks
Males
Hispanics
Females
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 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
13.2
Percent of Population
14.0
12.0
10.7
10.9
11.0
10.0
8.0
6.7
5.6
6.0
4.0
2.0
0.0
Men
NH Whites
Women
NH Blacks
Mexican Americans
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.
Deaths/1000 Person Years
50.0
44.1
45.0
40.0
35.0
28.1
30.0
25.0
26.1
21.1
20.0
17.0
15.0
16.7
10.9
10.0
5.0
30.0
2.6
4.3 4.8
6.3
7.8
17.1
14.4
11.5
8.6
No MetS or DM
MetS w/o DM
MetS w/DM
DM only
Prior CVD
Prior CVD and DM
5.3
0.0
CHD Mortality
CVD Mortality
Total Mortality
Mortality rates in U.S. adults, age 30-75, with metabolic
syndrome (MetS), 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
(1971-74) and (1989-93)
Risk Factor Sum
3
2.4
1.8
(1971)
(1989)
Risk factors accumulate with weight gain
1.2
0.6
0
Q1
Q2
Q3
Q4
Q5
Overall
Thin
Obese
Risk variables include bottom quintile for HDL-C and top
quintiles for cholesterol, SBP, triglycerides and glucose
Percent of Population
40
34
30.2
30
26
20.6
20
10.7
12.2
15.7
12.8
17.1
16.8
10
0
Men
1960-62
Women
1971-74
1976-80
1988-94
2001-2004
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.
Percent of Population
20
18
16
14
12
10
8
6
4
2
0
18.7
16.3
11.6
11
6.6
6.4
4.3
3.6
6-11
1971-74
12-19
1976-80
1988-94
2001-2004
Trends in prevalence of overweight among U.S.
children and adolescents by age and survey
(NHANES, 1971-74, 1976-80, 1988-94 and 20012004). Source: Health, United States, 2006, unpublished data. NCHS.
Percent of Population
24
21.3
20
16
15.2
16.1
15.9
12.1
12
8.2
8
4
0
Males
NH Whites
Females
NH Blacks
Hispanics
Prevalence of overweight among students in
grades 9-12 by race/ethnicity and sex
(YRBS: 2005). Source: BMI 95th percentile or higher.
MMWR. 2006 55: No. SS-5. NH – non-Hispanic.
Percent of Population
45.7
50
40
30
37.5
34.2
26.4
27.0
32.5
25.0
39.6
33.9
31.5
24.0
28.3
23.8
21.6
20.4
18.4
20
34.4
44.8
36.3
31.8
10
0
NH
W
te
hi
M
e
al
NH
k
ac
l
B
M
e
al
c
ni
a
sp
i
H
M
e
al
ific
ac
P
n/
a
i
As
Am
I
.
de
n
sla
e
al
rM
a
k
as
l
/A
n
a
di
n
I
e
M
e
al
tiv
a
N
NH
W
te
hi
m
Fe
1994
e
al
NH
k
ac
l
B
m
Fe
e
al
Hi
c
ni
a
sp
e
al
m
e
F
I
de
n
sla
ic fic
Pa
/
n
.I
is a
m
A
A
em
F
r
e
al
a
e
iv
t
Na
...
sk
a
Al
/
n
ia
d
n
2004
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.
Percent of Population
50
45
40
35
30
25
20
15
10
5
0
46.9
NH White
38.2
NH Black
Hispanic
39
30.2
26.5
21.3
Male
Female
Sex and Race/Ethnicity
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.