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Framingham Risk Calculator
Supporting Canadian Lipid Guidelines

And Simplified Lipid Guidelines

 

 

Instructions

Case Finding (Who to Screen)

About This Document

 

To Calculator

 

This is not a Palm application.It will run from the web, or it can be downloaded to your own computer and run from there as a web page.

 

Calculator Features

         Inputs include standard FRS risk factors, but include family history

         Interventions can be input to evaluate impact on the FRS and determine absolute risk reduction and numbers needed to treat

         Interventions include exercise (high and moderate intensity), Mediterranean diet and statins (high and moderate intensity)

         Risk and intervention parameters are tracked and graphed continuously to enhance patient understanding of impact of lifestyle and medications

         Cardiovascular age is calculated to enhance patient understanding

         Interventions are generated according to 2016 Canadian Cardiovascular Society (CCS) and 2015 Simplified Lipid Guidelines

         Changes can be made to risk factors or interventions without resetting the calculator

         Results and graphics can be printed

         See instructions for more information

 

 

This calculator focuses on primary prevention ofcardiovascular events in people without known heart disease.Derivation tables come from guidelines recently published by the Canadian Cardiovascular Society [1] and the College of Family Physicians of Canada [2] for lipids.ASA recommendations are taken from supplementary material supplied with the second reference.CCS guidelines retain some of the treatment thresholds and targets which are not well established in evidence, and the Simplified Lipid Guidelines recommendations are included in this calculator to allow for an alternative risk-based approach.Guidelines are largely based on randomized controlled studies, however family history recommendations are of necessity based on cohort studies, and interpretation of the literature with respect to diabetics is still somewhat mixed.ASA benefits are small in primary prevention, and therapy should be decided on a case by case basis.

 

Source studies are done mainly in North America.It has been shown that results may be suspect in the following groups:

  1. The predictive value of the Framingham Risk Score (FRS) falls with age.Results for elderly patients must be interpreted with caution [3].There is no reliable information on the utility of ASA over the age of 80.
  2. Although the FRS holds well for populations in Australia and New Zealand, it is less reliable in European and Asian populations [4].
  3. There is evidence that disadvantaged populations in lower socioeconomic circumstances may have a falsely low FRS, and may therefore not receive appropriate therapy recommendations [5].
  4. ASA recommendations in primary prevention lack consensus.The guidelines are better for men, whose risk is primarily myocardial infarction.They are less firm for women between 55 and 65, whose primary risk is stroke.

 

The mixed and atherogenic dyslipidemias, flagged most often by high triglycerides and low HDL, are not addressed by these guidelines.This is in part because the evidence base for management is less firm.Emerging or novel risk factors including the components of metabolic syndrome and selected criteria identified in the INTERHEART study [6] are built into an optional decision support calculator. They are helpful in identifying additional relative risk contributions by metabolic syndrome or multiple factors not evaluated by Framingham, and can be predictive in younger people who may be at high long term risk because of multiple low-grade risk factors.Metabolic syndrome and novel risk factors will be flagged if you choose decision support, and additional calculation of Total Cholesterol/HDL ratio and non-HDL cholesterol is available to help identify patients with these atherogenic (or mixed) dyslipidemias.

 

Decision analysis for primary prevention has become more evidence-based and complex.Use of tables is still possible, but it is prone to error and consumes a great deal of time.For decisions which have to be made several times a day by primary care providers, a more efficient means of calculation is necessary.Existing older calculators tend to underestimate risk substantially.Many of them are developed using U.S. units of measurement, which become confusing to those of us using SI units.This calculator incorporates the evidence in a Canadian context as of 2017, and is available on the web or by download for unrestricted use.It is not recommended or adopted by any credible organization, but it seems to be accurate, and results can be checked against source tables by the user until there is confidence that it works properly.The javascript source code is available for those who wish to make their own adaptations.

 

Caveat:Intervention recommendations are made with the understanding that the patient has been adequately informed and consulted.Tools such as risk reduction calculation, graphing of results and estimated cardiac age may help with this decision.Generation of numbers needed to treat (NNT) may help the physician to further frame a decision, although this figure will be less reliable for lifestyle interventions, which are mainly based on cohort studies.

 

References:

  1. Anderson TJ, et al.2016 Canadian Cardiovascular Society Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2016; 32: 1263-1282.
  2. Allan GM, et al. Simplified Lipid Guidelines: Prevention and management of cardiovascular disease in primary care. Canadian Family Physician 2015; 61: 857- 867.
  3.  deRuijter W, Westendorp R, Assendelft W, et al.  Use of Framingham risk score and new biomarkers to predict cardiovascular mortality in older people: population based observational cohort study. BMJ 2008;337:a3083 doi:10.1136/bmj.a3083
  4.  Eichler K, Puhan MA, Steurer J, Bachmann LM.  Prediction of first coronary events with the Framingham score: a systematic review.  Am Heart J. 2007; 153(5): 722-31, 731.e1-8.
  5. Brindle P, McConnachie A, Upton MN, et al.  The accuracy of the Framingham risk-score in different socioeconomic groups: a prospective study.  British J Gen Pract. 2005; 55: 838-845.
  6. Yusuf S, Hawken S, ‘unpuu S, Dans T, Avezum A, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): a case-control study. Lancet 2004; 364: 937-952.