BMJ  2003;327:1267 (29 November), doi:10.1136/bmj.327.7426.1267

Primary care

Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study

¹ Department of Social Medicine, University of Bristol, Bristol BS8 2PR, ² Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London NW3 2PF, ³ Department of Community Health Sciences, St George's Hospital Medical School, London SW17 0RE, ⁴ Tayside Centre for General Practice, University of Dundee, Dundee DD2 4AD

Objective To establish the predictive accuracy of the Framingham risk score for coronary heart disease in a representative British population.

Design Prospective cohort study.

Setting 24 towns in the United Kingdom.

Participants 6643 British men aged 40-59 years and free from cardiovascular disease at entry into the British regional heart study.

Main outcome measures Comparison of observed 10 year coronary heart disease mortality and event rates with predicted rates for each individual, using the relevant Framingham risk equation.

Results Of 6643 men, 2.8% (95% confidence interval 2.4% to 3.2%) died from coronary heart disease compared with 4.1% predicted (relative overestimation 47%, P < 0.0001). A fatal or non-fatal coronary heart disease event occurred in 10.2% (9.5% to 10.9%) of the men compared with 16.0% predicted (relative overestimation 57%, P < 0.0001). These relative degrees of overestimation were similar at all levels of coronary heart disease risk, so that overestimation of absolute risk was greatest for those at highest risk. A simple adjustment provided an improved level of accuracy. In a "high risk score" approach, most cases occur in the low risk group. In this case, 84% of the deaths from coronary heart disease and non-fatal events occurred in the 93% of men classified at low risk (< 30% in 10 years) by the Framingham score.

Conclusion Guidelines for the primary prevention of coronary heart disease advocate offering preventive measures to individuals at high risk. Currently recommended risk scoring methods derived from the Framingham study significantly overestimate the absolute coronary risk assigned to individuals in the United Kingdom.

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