The Framingham Risk Score, or FRS, is a widely used and accepted predictor of heart disease. But it has a blind spot: It pays no attention to family health history, which means many patients might never see cardiovascular disease coming.
Mariam Kashani, MS, CRNP and a DNP student at the Johns Hopkins University School of Nursing, is working to identify and warn those overlooked by FRS and get them started on an aggressive program to limit the danger. Early results on how many people might fit that description could make the healthiest heart skip a beat.
"Cardiovascular disease is the No. 1 cause of death and disability in the United States," Kashani says. "Being categorized as low-risk when you are, in fact, truly high-risk could leave patients unaware and unarmed to take action to protect themselves."
Kashani, working at Walter Reed National Military Medical Center in Bethesda, Md., created a clinical-decision support tool to re-analyze 239 patients (out of 493) in the Integrative Cardiac Health Project who were labeled low- or intermediate-risk by FRS. Of the 239, 48 percent were found to have a family history of premature heart disease and were immediately reclassified as high-risk. The FRS bases the probability of cardiovascular disease within the next 10 years on age, sex, cholesterol levels, blood pressure, and whether or not the person is a smoker, not family history.
Within the reclassified group, ultrasound of the carotid artery showed that 61 percent had atherosclerotic plaque, a precursor to heart disease. Those newly labeled high-risk begin a treatment plan that includes meeting cholesterol and blood pressure goals as well as advice on diet, exercise, stress and sleep management.
Women comprised 60 percent of that population, and the average patient was 48 years old. Kashani explains that early detection is extremely important for women, who "begin to lose their cardiovascular protective factors, like HDL [the 'good' cholesterol], during middle age."
Unfortunately, old habits are hard to change. And the FRS remains a frequently used screening tool by itself. "Although many practitioners ask their patients about family history, this information is still not being incorporated into the patient's risk stratification," Kashani says.
Few diagnostic tools are perfect. But Kashani's work suggests that using a clinical-decision support tool as an adjunct to Framingham can at least plug the gaps, and open some eyes, until a more ideal cardiovascular risk assessment method is developed.
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