Comparison of Framingham, PROCAM, SCORE, and Diamond Forrester to predict coronary atherosclerosis and cardiovascular events
Cardiologists are often confronted with patients presenting with chest pain, in whom clinical risk profiling is required. We studied four frequently used risk scores in their ability to predict for coronary artery disease (CAD) and major adverse cardiovascular events in patients presenting with stable chest pain at the cardiology outpatient clinic.
Methods and Results
We enrolled 1,296 stable chest pain patients, who underwent cardiac computed tomographic angiography (CCTA) to assess CAD (any, significant: stenosis ≥50%). Framingham (FRS), PROCAM, SCORE risk score, and Diamond Forrester pre-test probability were calculated. All patients were followed up for a mean 19 ± 9 months for all cardiovascular events (mortality, acute coronary syndrome, revascularization >90 days after CCTA). In ROC-analysis for prediction of significant CAD, the areas under the curve for FRS; 0.68 (95% confidence interval: 0.64-0.72) and for SCORE; 0.69 (95% confidence interval: 0.65-0.72) were significantly higher than for PROCAM; 0.64 (95% confidence interval: 0.61-0.68; P ≤ .001), as well as marginally higher than for Diamond Forrester; 0.65 (95% confidence interval: 0.61-0.68; P ≤ .05). Low FRS category showed the lowest number of patients with significant CAD, compared to patients with low risk using PROCAM, SCORE or Diamond Forrester (P < .001). Also, low FRS category showed less events (compared to PROCAM and SCORE; P < .001, for Diamond Forrester; P = .14).
Our data show that in a stable chest pain population, the ability of FRS and SCORE to predict for CAD was similar and better compared to PROCAM and Diamond Forrester. The number of low risk patients showing significant CAD or events was lower using FRS. Consequently, risk categorization using FRS seems to be safest to stratify stable chest pain patients prior to CCTA.
- D’Agostino RB, Russell MW, Huse DM, Ellison RC, Silbershatz H, Wilson PW, et al. Primary and subsequent coronary risk appraisal: New results from the Framingham study. Am Heart J 2000;139:272-81.
- Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association. Circulation 2011;123:933-44. CrossRef
- Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, et al. Chronic diseases and injuries in India. Lancet 2011;377:413-28. CrossRef
- Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.
- Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999;33:2092-197. CrossRef
- Min JK, Shaw LJ, Devereux RB, Okin PM, Weinsaft JW, Russo DJ, et al. Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol 2007;50:1161-70. CrossRef
- Mark DB, Berman DS, Budoff MJ, Carr JJ, Gerber TC, Hecht HS, et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010;55:2663-99. CrossRef
- Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F, et al. Guidelines on the management of stable angina pectoris: Executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 2006;27:1341-81. CrossRef
- Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350-8. CrossRef
- Meijboom WB, van Mieghem CA, Mollet NR, Pugliese F, Weustink AC, van Pelt N, et al. 64-slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease. J Am Coll Cardiol 2007;50:1469-75. CrossRef
- D’Agostino RB Sr, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: The Framingham Heart Study. Circulation 2008;117:743-53. CrossRef
- Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Munster (PROCAM) study. Circulation 2002;105:310-5. CrossRef
- Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: The SCORE project. Eur Heart J 2003;24:987-1003. CrossRef
- Pontone G, Andreini D, Bartorelli AL, Cortinovis S, Mushtaq S, Bertella E, et al. Diagnostic accuracy of coronary computed tomography angiography: A comparison between prospective and retrospective electrocardiogram triggering. J Am Coll Cardiol 2009;54:346-55. CrossRef
- Hausleiter J, Meyer T, Hadamitzky M, Huber E, Zankl M, Martinoff S, et al. Radiation dose estimates from cardiac multislice computed tomography in daily practice: Impact of different scanning protocols on effective dose estimates. Circulation 2006;113:1305-10. CrossRef
- Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, Griffith LS, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 1975;51:5-40.
- Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff MJ, et al. SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 2009;3:122-36. CrossRef
- Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—summary article: A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 2002;40:1366-74. CrossRef
- Berrington de Gonzalez A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009;169:2071-7. CrossRef
- Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56:1864-94. CrossRef
- Hulten EA, Carbonaro S, Petrillo SP, Mitchell JD, Villines TC. Prognostic value of cardiac computed tomography angiography a systematic review and meta-analysis. J Am Coll Cardiol 2011;57:1237–47. CrossRef
- Hense HW, Schulte H, Lowel H, Assmann G, Keil U. Framingham risk function overestimates risk of coronary heart disease in men and women from Germany—Results from the MONICA Augsburg and the PROCAM cohorts. Eur Heart J 2003;24:937-45. CrossRef
- Arbab-Zadeh A, Texter J, Ostbye KM, Kitagawa K, Brinker J, George RT, et al. Quantification of lumen stenoses with known dimensions by conventional angiography and computed tomography: Implications of using conventional angiography as gold standard. Heart 2010;96:1358-63. CrossRef
- Nair D, Carrigan TP, Curtin RJ, Popovic ZB, Kuzmiak S, Schoenhagen P, et al. Association of coronary atherosclerosis detected by multislice computed tomography and traditional risk-factor assessment. Am J Cardiol 2008;102:316-20. CrossRef
- Nucifora G, Schuijf JD, van Werkhoven JM, Jukema JW, Djaberi R, Scholte AJ, et al. Prevalence of coronary artery disease across the Framingham risk categories: Coronary artery calcium scoring and MSCT coronary angiography. J Nucl Cardiol 2009;16:368-75. CrossRef
- Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Cury RC, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging 2009;2:675-88. CrossRef
- Erbel R, Mohlenkamp S, Moebus S, Schmermund A, Lehmann N, Stang A, et al. Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: The Heinz Nixdorf Recall study. J Am Coll Cardiol 2010;56:1397-406. CrossRef
- Motoyama S, Sarai M, Harigaya H, Anno H, Inoue K, Hara T, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 2009;54:49-57. CrossRef
- Hadamitzky M, Distler R, Meyer T, Hein F, Kastrati A, Martinoff S, et al. Prognostic value of coronary computed tomographic angiography in comparison with calcium scoring and clinical risk scores. Circ Cardiovasc Imaging 2011;4:16-23. CrossRef
- Fuster V, Vahl TP. The role of noninvasive imaging in promoting cardiovascular health. J Nucl Cardiol 2010;17:781-90. CrossRef
- Comparison of Framingham, PROCAM, SCORE, and Diamond Forrester to predict coronary atherosclerosis and cardiovascular events
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Journal of Nuclear Cardiology
Volume 18, Issue 5 , pp 904-911
- Cover Date
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- Additional Links
- Framingham risk score
- Diamond Forrester
- cardiac CT-angiography
- Industry Sectors
- Author Affiliations
- 1. Department of Cardiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- 2. Emory University, School of Medicine, Atlanta, Georgia, USA
- 3. Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY, USA
- 4. Cardiology Center Netherlands, Utrecht, The Netherlands