Revised Framingham Stroke Risk Profile to Reflect Trends

Study Questions:

What is the relative accuracy of the standard (Old) Framingham Heart Study (FHS) compared with a revised (New) version of the Framingham Stroke Risk Profile (FSRP) in predicting the risk of all-stroke and ischemic stroke, and when validating the New FSRP in two external cohorts, the low-risk French 3 Cities (3C) and the high-risk US REGARDS studies?

Methods:

The authors computed the old FSRP as originally described, and a new model that used the most recent epoch-specific risk factors’ prevalence and hazard ratios for persons ≥55 years and for the subsample of ≥65 years (to match the age range in REGARDS and 3C studies, respectively), and compared the efficacy of these models in predicting 5- and 10-year stroke risks.

Results:

The mean age-adjusted 10-year stroke probability is 6.9% in the new FSRP sample compared with 9.6% in the old FSRP sample, suggesting a decrease of 28% over 20 years. The new FSRP was a better predictor of current stroke risks in all three samples than the old FSRP (calibration chi-squares of new/old FSRP: in men 64.0/12.1, 59.4/30.6, and 20.7/12.5; in women 42.5/4.1, 115.4/90.3, and 9.8/6.5 in FHS, REGARDS, and 3C, respectively). In the REGARDS, the new FSRP was a better predictor among whites compared to blacks.

Conclusions:

A more contemporaneous, new FSRP better predicts current risks in three large community samples, and could serve as the basis for examining geographic and racial differences in stroke risk and the incremental diagnostic utility of novel stroke risk factors.

Perspective:

Both old and new FSRPs incorporate history of atrial fibrillation, left ventricular hypertrophy, coronary and other vascular disease, and congestive heart failure as well as stroke risk factors. Thus, its predictive value for stroke is very good. However, the new FSRP does not have the clinical value of the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease Risk Calculator, the most recent version of which provides a 10-year risk estimate of first atherosclerotic cardiovascular events including coronary and stroke in men and women ages 21-79 years. It incorporates race (black or others), age/gender, systolic blood pressure (BP), diastolic BP, BP treatment status, diabetes, smoking status, and total and high-density lipoprotein cholesterol. In addition to guidelines for statin use in the 2013 version, the 2016 version provides recommendations for use of aspirin based on the United States Preventive Task Force guideline, and treatment for hypertension based on Joint National Committee-8.


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