Framingham Heart Study Prediction

Estimating Coronary Heart Disease (CHD) Risk Using Framingham Heart Study Prediction Score Sheets

This update of the 1991 Framingham coronary prediction algorithm provides estimates of total CHD risk (risk of developing one of the following: angina pectoris, myocardial infarction, or coronary disease death) over the course of 10 years. Separate score sheets are used for men and women and the factors used to estimate risk include age, blood cholesterol (or LDL cholesterol), HDL cholesterol, blood pressure, cigarette smoking, and diabetes mellitus. Relative risk for CHD is estimated by comparison to low risk Framingham participants.

In addition to score sheets for men and women, a sample score sheet is provided to illustrate how they can be used.

Users of this risk algorithm should be aware of several caveats:

  1. The risk estimating score sheets are only for persons without known heart disease.
  2. The Framingham Heart Study risk algorithm encompasses only coronary heart disease, not other heart and vascular diseases.
  3. The Framingham Heart Study population is almost all Caucasian. The Framingham risk algorithm may not fit other populations quite as well.
  4. For some of the sex-age groups in Framingham, the numbers of events are quite small. Therefore, the estimates of risk for those groups may lack precision.
  5. Other organizations are considering how the information from the Framingham risk algorithm, as well as other assessments of risk, might best be incorporated into clinical practice. As new information and guidelines become available, they will be added.
  6. The Framingham risk score estimates the risk of developing CHD within a 10-year time period. This risk score may not adequately reflect the long-term or lifetime CHD risk of young adults, which is: one in two for men and one in three for women.
  7. The presence of any CHD risk factor requires appropriate attention because a single risk factor may confer a high risk for CHD in the long run, even if the 10-year risk does not appear to be high.
  8. Since age is a prominent determinant of the CHD risk score, the 10-year hazards of CHD are, on average, high in older persons. This may over-identify candidates for aggressive interventions. Relative risk estimates (risk in comparison with low risk individuals) may be more useful than absolute risk estimates in the elderly.
  9. The score derived from this algorithm should not be used in place of a medical examination.

Limitations — Risk assessments that stratify patients according to the number of defined risk factors can identify high-risk persons, but they tend to falsely reassure persons deemed to be at low risk who may have multiple marginal abnormalities. Since the segment of the population with borderline abnormalities of blood pressure and lipids has most of the coronary events, it is important not to overlook these subjects.

Sample Score Sheet for Estimating Coronary Heart Disease Risk

As an illustration for using the score sheets, consider a 55 year old man with a total cholesterol of 250 mg/dL, HDL cholesterol of 39 mg/dL, blood pressure of 146/88, diabetic and a non-smoker.

Use the Total Cholesterol Score Sheet when total cholesterol and HDL cholesterol are available. Use the LDL Cholesterol Score Sheet when LDL cholesterol and HDL cholesterol are available.

Age = 55 years
*Total cholesterol = 250 mg/dL
HDL cholesterol = 39 mg/dL
Blood pressure = 146/88 mm Hg
Diabetic = yes
Cigarette smoker = no
Point Total
Estimated 10 Year CHD Risk
Low 10 Year CHD Risk
Relative Risk (step 8 divided by step 9)
31/7 = 4.4
*Use of the LDL cholesterol approach in the scoresheets is appropriate when fasting LDL cholesterol estimates are available. The approach is analogous to that shown for total cholesterol categories. 
Score Sheet for Risk based on LDL Cholesterol Level
Score Sheet for Risk based on Total Cholesterol Level

Score Sheet for Risk based on LDL Cholesterol Level
Score Sheet for Risk based on Total Cholesterol Level

Online Framingham Risk Calculator

Dividing the subject's risk by the low risk provides an estimate of the relative risk, where 31% divided by 7% = 4.4, meaning that coronary risk for this individual is approximately 4 times that of a man the same age with a low risk profile.

The average and low risk of CHD over 10 years for a 55 year old man are 16% and 7% respectively . The average risk was derived from the experience of Framingham men and women, using their average risk factor levels to provide the estimates. The low risk was calculated using the following factors:

  1. persons of the same age
  2. ooptimal blood pressure
  3. total cholesterol 160-199 mg/dL
  4. HDL cholesterol 45 mg/dL for men or 55 mg/dL for women
  5. non-smoker
  6. no diabetes
Physician Information