Assessing risk for coronary heart disease: Beyond Framingham

The Framingham Heart Study, initiated over 50 years ago, introduced the concept of risk factors for coronary heart disease (CHD) and has served as the standard for risk assessment over the years.1-4 Major risk factors identified by the Framingham HeartStudy, in- cluding age, sex, total cholesterol, high-density li- poprotein (HDL) cholesterol,smoking, and systolic blood pressure, have been incorporated into a scoring system thatidentifies subjects at high (>20%), interme- diate (10%–20%), and low (80% of the excess population risk for CHD.6-8 Recent clinical trials in high-risk subjectsdemonstrate dramatic reductions in risk (approximately 33%–50% in 5 y) with riskreduction therapies.9 This provides strong support for the concept that CHD and its sequela can be prevented by aggressive medical therapy and therapeutic lifestyle changes.Recent American Heart Association (AHA) guidelines (2002)4 for primary prevention ofcardiovascular disease and stroke recom- mend that risk-factor screening in adults shouldbegin at age 20 and should be repeated at least every 5 years in the absence of risk factors and every 2 years if risk factors are present. This panel recommends that global risk should be estimated in all adults >40 years of age. In this issue of the Journal, Cohn et al10 have proposed a method for risk assessment that focuses on measurements of early vasculardysfunction and disease markers rather than standard risk factors. Studies are ongoing intheir outpatient cardiovascular disease prevention clinic to validate the model by relating risk assessments to disease outcomes over tim