QRISK or Framingham for predicting cardiovascular risk?BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2673 (Published 07 July 2009) Cite this as: BMJ 2009;339:b2673
All rapid responses
The editorial by Rod Jackson et. al. highlights a limitation with
both QRISK and Framingham algorithm showing only a modest discrimination
performance in identifying which patients will subsequently have
cardiovascular events. This raises concerns about the value of these
instruments for public health purposes and stresses a need to identify
more pragmatic approaches.
We are currently researching effective strategies to improve the life
span of patients with schizophrenia who die prematurely from the same
causes as the general population. It has become apparent that since the
mid 1990s cardiovascular risk has not predicted overall mortality (1). We
have found that smoking (2), low fitness measured as maximal aerobic
capacity (3), untreated hypertension (4) and BMI over 40 (5) strongly
predict early death. Passive smoking is an additional negative factor.
Moderate alcohol consumption and a healthy diet are positive factors (6).
Total cholesterol may actually be a positive predictor of longevity in the
elderly (7). We plan to incorporate these risk factors (both losses and
gains in life years) into a simple algorithm to develop a shortened life-
span scale. We are not aware of such a scale
We would welcome correspondence with readers who would be interested
in collaborating on a shortened life-span scale.
1. Tunstall-Pedoe H, Woodward M, Tavendale R, Brook RA, McCluskey MK.
Comparison of the prediction by 27 different factors of coronary heart
disease and death in men and women of the Scottish heart health study:
cohort study. BMJ 1997; 315:722-729
2. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to
smoking: 50 years' observations on male British doctors. BMJ 2004;
3. Lee CD, Blair SN, Jackson AS. Cardiorespiratory fitness, body
composition, and all-cause and cardiovascular disease mortality in men. Am
J Clin Nutr. 1999 Mar; 69(3):373-80
4. Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO.
Morbidity and mortality in the Swedish Trial in Old Patients with
Hypertension (STOP-Hypertension). Lancet 1991; 338(8778): 1281-5
5. Prospective Studies Collaboration. Body-mass Index and cause-
specific mortality in 900,000 adults. Lancet. 2009; 373 (9669) 1083-1096
6. Mozaffarian D, Kamineni A, Carnethon M, Djoussé L, Mukamal KJ,
Siscovick D. Lifestyle risk factors and new-onset diabetes mellitus in
older adults: the cardiovascular health study. Arch Intern Med. 2009;
7. Okamura T, Hayakawa T, Hozawa A, Kadowaki T, Murakami Y, Kita Y,
Abbott RD, Okayama A, Ueshima H. Lower levels of serum albumin and total
cholesterol associated with decline in activities of daily living and
excess mortality in a 12-year cohort study of elderly Japanese. J Am
Geriatr Soc. 2008 Mar; 56(3):529-35. Epub 2007 Dec 26.
M Beary no competing interest
H J Wildgust: consultancy work for Eli Lilly and John Wiley & Sons
Competing interests: No competing interests
QRISK or Framingham for predicting cardiovascular risk? Start with
the Pulse Mass Index
In the issue of BMJ 7 July 2009, Collins and Altman compare the QRISK
and the Framingham risk score for the cardiovascular risk prediction and
find that the QRISK is better on every performance measure, and should be
recommended in the UK.
And Rod Jackson et. al. in this editorial comment that because QRISK2
performs better than QRISK1, further improvements are likely in future
For simplicity I suggest to start with the Pulse Mass Index as
screening, and then go to QRISK or Framingham, as I explain bellow.
Julia Hippisley-Cox et. al. in the QRISK2, (BMJ 28 June 2008) used 14
risk factors to predict the cardiovascular risk. Of them, body mass index
(BMI), as well as those that can have an influence in the resting heart
rate (RHR), like smoking, deprivation, atrial fibrillation, type 2
diabetes and rheumatoid arthritis, are in fully agreement with our
findings published in The Lancet 13 March 1999 (1), in which using the
Pulse by Mass Index for a preliminary evaluation of the global
cardiovascular risk, it had a correlation of 95% with the Framingham risk
This findings have important implications: clinical,
for a rapid, inexpensive, non-technologically demanding assessment of the
individual patient, as well as epidemiological, in view that around 80% of
all cardiovascular deaths occur in developing countries.
The Pulse Mass Index (PMI) is a simple, clinical, non-laboratory
based, not electronic system dependant, preliminary assessment of the
cardiovascular risk calculated with the formula:
Pulse (Resting Heart Rate) multiplied by Body Mass Index and divided
Most patients with a Pulse Mass Index of 1.3 or more will probably
have a high global cardiovascular risk when calculated by the Framingham
Risk Score. In the meantime, we have validated this correlation in over
The importance of the Body Mass Index in the risk assessment have
been supported in this decade, both by Hippisley-Cox et. al. as well as
also last year by the Framingham Heart Study (Circulation 12 February
2008), among many others.
The importance of the Pulse (Resting Heart Rate) as cardiovascular
risk factor becomes increasingly recognized.
Since September 2008, several studies like BEAUTIFUL, EUROPA, WHI (in
women, BMJ 3 Feb. 2009) and others, have confirmed the importance of an
elevated Resting Heart Rate as a risk factor for cardiovascular events and
The practical advantage of the Pulse Mass Index as a rapid
preliminary approach, followed by the QRISK or FRS, or other scores for
the evaluation of cardiovascular risk, should be of more extensive
clinical use worlwide, and not only in the developing countries.
Prof. Enrique Sánchez-Delgado, M.D.
Director of Medical Education
Hospital Metropolitano Vivan Pellas
1. Collins GS, Altman DG. An independent external validation and
evaluation of QRISK cardiovascular risk prediction: a prospective open
cohort study. BMJ 2009;339:b2584.
1. Enrique Sánchez-Delgado, Heinz Liechti. Lancet 1999;353:924-925
Competing interests: No competing interests