FRAMINGHAM RISK FACTORS IN THE ED
Overly concerning and falsely reassuring??
THE FRAMINGHAM STUDY
Framingham Heart Study aimed to identify risk factors that contributed to CVD
The population that they studied was over 5000 patients and they ranged in age from 30-62.
Further cohorts have been subsequently added to the studied population
The Study has produced approximately 1,200 articles
WHAT ARE THE RISK FACTORS
•
Age
•
Diabetes
•
Smoking
•
Raised Systolic Blood Pressure
•
Total cholesterol
•
HDL cholesterol
•
BMI (replacing lipids in a simpler model)
WHAT DO THESE RISK FACTORS MEAN
Can be used to prognosticate 10 year risk of developing IHD
HOW ARE THEY USED IN ED?
? Innappropriately ?
JAYES ET AL
Prospective evaluation of > 1700 patients presenting to ED with symptoms suggestive of
acute coronary ischaemia who were admitted to coronary care units
11% of patients were deemed to have acute ischaemic heart disease
Published the results by way of relative risks
JAYES ET AL
Diabetes had a relative risk of 2.4 in men, 2.0 in women
Family history of myocardial infarction a relative risk of 2.1 in men
Smoking a relative risk of 1.5. in men (1.0-2.4)
HAN ET AL
Retrospective analysis of internet tracking registry of > 17,000 patients with possible ACS
Primary outcome was acute coronary syndrome
Nearly 11,000 patients enrolled
Just over 8% had ACS
HAN ET AL
Risk factors
< 40 years
40-65
>65
0
1
1
1
1
2.6
1.5
1.0
2
9.2
1.8
1.2
3
7.8
2.6
1.0
4 or 5
22.5
3.7
1.2
Adjusted Odds Ratios for ACS
See paper for CI’s
BODY ET AL
A single centre prospective diagnostic cohort study
Patients over 25 years of age with chest pain that the ED clinician suspected to be cardiac in
origin
The primary outcome was a diagnosis of AMI
Just under 800 patients analysed and 18.6% of patient were positive for AMI
BODY ET AL RESUSCITATION 2008
Number of risk factors
LR+
LR-
≥1
1.1
0.6
≥2
0.9
1.1
≥3
0.8
1.1
≥4
1.2
1.0
Presence of cardiac risk factors did not yield significant likelihood ratios for ACS
IN SUMMARY
Framingham Risk factors applied to the acute
setting can lead to false elevation of risk in
their presence, or false reassurance in their
absence to the degree of risk of ACS
REFERNECES
The Framingham Heart Study
Jayes R et al. Do patients' coronary risk factor reports predict acute cardiac ischemia in the
emergency department. J Clin Epidemiol 1992;45: 621-626
Han et al., The Role of Cardiac Risk Factor Burden in Diagnosing Acute Coronary Syndromes
in the Emergency Department Setting. Ann Emerg Med. 2007; 49
Body R et al. Do risk factors for chronic coronary heart disease help diagnose acute
myocardial infarction in the Emergency Department? Resuscitation 2008 ;79 ,41 - 45