Predicting the 30-Year Risk of Cardiovascular Disease.

Predicting the 30-Year Risk of Cardiovascular Disease. The Framingham Heart Study

Michael J. Pencina PhD^*, Ralph B. D'Agostino Sr PhD, Martin G. Larson ScD, Joseph M. Massaro PhD, and Ramachandran S. Vasan MD

From the Department of Mathematics and Statistics (M.J.P., R.B.D., M.G.L., J.M.M.), School of Medicine (R.S.V.), and Department of Biostatistics (M.J.P., R.B.D., J.M.M.), Boston University, Boston Mass; and Framingham Heart Study, Framingham, Mass (M.J.P., R.B.D., M.G.L., J.M.M., R.S.V.).

^* To whom correspondence should be addressed. E-mail: mpencina@bu.edu.

Background—Present cardiovascular disease (CVD) risk prediction algorithms were developed for a 10-year follow upperiod. Clustering of risk factors at younger ages and increasing life expectancy suggest the need for longer-term risk prediction tools.

Methods and Results—We prospectively followed 4506 participants (2333 women) of the Framingham Offspring cohortaged 20 to 59 years and free of CVD and cancer at baseline examination in 1971–1974 for the development of "hard" CVD events (coronary death, myocardial infarction, stroke). We used a modified Cox model that allows adjustment for competing risk of noncardiovascular death to construct a prediction algorithm for 30-year risk of hard CVD. Cross-validated survival C statistic and calibration ² were used to assess model performance. The 30-year hard CVD event rates adjusted for the competing risk of death were 7.6% for women and 18.3% for men. Standard risk factors (male sex,systolic blood pressure, antihypertensive treatment, total and high-density lipoprotein cholesterol, smoking, and diabetes mellitus), measured at baseline, were significantly related to the incidence of hard CVD and remained significant when updated regularly on follow-up. Body mass index was associated positively with 30-year risk of hard CVD only in models that did not update risk factors. Model performance was excellent as indicated by cross-validated discrimination C=0.803 and calibration ²=4.25 (P=0.894). In contrast, 30-year risk predictions based on different applications of 10-year functions proved inadequate.

Conclusions—Standard risk factors remain strong predictors of hard CVD over extended follow-up. Thirty-year risk prediction functions offer additional risk burden information that complements that of 10-year functions.