Comparison of the Framingham and Reynolds Risk Scores for Global Cardiovascular Risk Prediction in the Multiethnic Women’s Health Initiative

Study Questions:

How does the Reynolds Risk Score compare with Framingham-based risk scores in the prediction of cardiovascular disease (CVD) risk?


A case-cohort sample from the Women’s Health Initiative (WHI) Observational Cohort was used for the present study. Incident cases included myocardial infarction (MI), ischemic stroke, and CVD death. The control group was comprised of a random sample of women from the WHI without prior CVD. CVD risk was calculated using the ATP-III score, the Reynolds Risk Score, and the Framingham CVD model, reweighting to reflect cohort frequencies.


Major CVD cases (n = 1,722) included 752 MIs, 754 ischemic strokes, and 216 CVD deaths. The sample of controls was comprised of 1,994 without prior CVD. Cases included more smokers and diabetics, and generally higher risk factor levels. Blacks were slightly younger than whites, but had higher proportions of smokers and diabetics. The predicted 10-year risk varied widely between models, with 10% or higher risk in 6%, 10%, and 41% of women using the ATP-III, Reynolds, and Framingham CVD models, respectively. The ATP-III and Framingham CVD models overestimated risk for CHD and major CVD. After recalibration, the Reynolds model demonstrated improved discrimination over the ATP-III model through a higher c-statistic (0.765 vs. 0.757, p = 0.03), positive net reclassification improvement (NRI) (4.9%, p = 0.02), and positive integrated discrimination improvement (IDI) (4.1%, p < 0.0001) overall, excluding diabetics (NRI = 4.2%, p = 0.01), and in white (NRI = 4.3%, p = 0.04) and black (NRI = 11.4, p = 0.13) women. The Reynolds (NRI = 12.9, p < 0.0001) and ATP-III (NRI = 5.9%, p = 0.0001) models demonstrated better discrimination than the Framingham CVD model.


The investigators concluded that the Reynolds Risk Score was better calibrated than the Framingham-based models in this large external validation cohort. The Reynolds score demonstrated improved discrimination among both black and white women.


This well written paper suggests that the Reynolds Risk Score has significant clinical utility for addressing risk among women, and has significant implications for management of CVD risk factors.

Keywords: Myocardial Infarction, Research Personnel, European Continental Ancestry Group, Cardiovascular Diseases, Risk Factors, African Continental Ancestry Group, Diabetes Mellitus

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