History of the Evolution of Cardiovascular Risk Factors and the Predictive Value of Traditional Risk-Factor-Based Risk Assessment

Abstract

The near epidemic rise in cardiovascular disease deaths in the early and middle twentieth century necessitated a more complete understanding of the risk factors for these illnesses. Through histologic examinations, animal studies, clinical and geographical observations and, ultimately, through large, prospective epidemiologic studies, the major traditional risk factors for cardiovascular disease were discovered, which paved the way for successful public health programs and interventions over the past few decades. However, cardiovascular disease remains a formidable global health challenge, especially in developing countries, and the utility of traditional risk factors as targets of therapy does not equate to accuracy for disease prediction. As up to 20% of those affected by coronary heart disease have no traditional risk factors, and since risk factor levels between those with and without cardiovascular disease overlap significantly, individual risk factors are poor predictors of cardiovascular events. Global risk assessment in the form of multivariable equations, such as the Framingham Risk Score that incorporate multiple traditional risk factors, have improved accuracy and are well suited for population screening through office-based practices. Recently, many limitations of current risk assessment with modified Framingham algorithms have emerged, including poor calibration in various ethnic groups, misclassification of risk in young people and women, and potential missed opportunities for preventive efforts by focusing solely on short-term risk. While traditional risk factors will certainly form the cornerstone of future cardiovascular risk assessment strategies, their utility will be enhanced by newly developed algorithms or paradigms for their use, or by incorporating novel risk factors and emerging risk assessment technologies into risk assessment.