Doctors no longer have to use Framingham equation to assessheart disease risk, NICE says
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1774 (Published 29 March 2010) Cite this as: BMJ 2010;340:c1774
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Framingham or the most appropriate assessment for predicting
cardiovascular risk? Try the Pulse Mass Index
The updated guideline from the National Institute for Health and
Clinical Excellence (NICE) said this week (BMJ 29 March 2010) that
Doctors in the UK should use the cardiovascular risk assessment tool they
consider most appropriate for the primary prevention of cardiovascular
disease.
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 (2), 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
score.
These 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 occurs 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, RHR) multiplied by the Body Mass Index
(BMI) and divided by 1730.
Most patients with a Pulse Mass Index of 1.2 or more will probably
have a high global cardiovascular risk when calculated by the Framingham
Risk Score. The same is the case if the result of simply multiplying RHR
by BMI is over 2100. In the meantime, we have validated this correlation
in over 2000 patients.
The importance of the Body Mass Index in the risk assessment has been
supported in this decade, both by Hippisley-Cox et. al. as well as also 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
mortality.
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 worldwide, and not only in the developing countries.
Prof. Enrique Sánchez-Delgado, M.D.
Director of Medical Education
Internal Medicine-Clinical Pharmacology, Hospital Metropolitano Vivian Pellas, Managua, Nicaragua
Reference:
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.
2.-Enrique Sánchez-Delgado, Heinz Liechti. Lancet 1999;353:924-925
Competing interests:
None declared
Competing interests: No competing interests
Re:Framingham or the most appropriate assessment for predicting cardiovascular risk? Try the Pulse Mass Index
The Pulse Mass Index (PMI) is a simple, clinical, assessment of the
cardiovascular risk calculated , useful specially in developing
countries.
Personally and some of my patients have reached the PMI
goals, but we still have a question.
I will illustrate my case in order to formulate my question:
I am 55 years old, for several years I mantained life style
modifications: Exercise 300-350 min a week, mainly a vegetarian
diet with grains, fish and yogurt.
My chemical profile average: T C 170-180, TG (125-138), HDL ( 60-
63).
My BMI ranged in the last 5 years ( 27.8-28.2). Basal HR ( 60
-64)
I have no functional aerobic impairment,( % FAI). My
performance in the field test, ( Balke and Cooper walk-run
protocols,) give an estimated oxygen consumption of 34.34- 36.1 mL
oxygen per Kg per min.
View the satisfactory results: Pulse (Resting Heart Rate) ,
metabolic parameters and good aerobic performance: ? Shall I
target my BMI ? My BMI in this setting is and independent
cardiovascular risk factor ?
Some of my patients maintain a similar strategy to mine, we
have a low cardiovascular risk, even if we are far from ideal
BMI. We like eating and drinking one or two glasses of wine, shall
we accept a compromise ?
The practical advantage of the Pulse Mass Index as a rapid
preliminary approach, should be of more extensive clinical use worldwide,
and not only in the developing countries.
Juan Herrera Salazar, MD., Pulmonologist, Universita Cattolica
del Sacro Cuore, Roma Italia, Director of the Clinica de Asma y
Alergia , Managua, Nicaragua
Reference:
1. Balke B (1963), a simple field test to for the assessment
of physical fitness.
Civil Aeromedical Research Institute Report, 63-18. Oklahoma city.
Federal aviation agency.
2. Validity and Reliability Analysis of Cooper's 12-Minute Run and
the Multistage Shuttle Run in Healthy Adults. J Strength Cond Res. 2011
Mar;25(3):597-605 .
Penry JT, Wilcox AR, Yun J. Oregon State University, Corvallis, Oregon.
3. Maximal oxygen intake and nomographic assessment of functional
aerobic impairment in cardiovascular disease R. A. Bruce M.D. a, b, , F.
Kusumi M.S. b, a and D. Hosmer Ph.D. b, aa Department of Medicine
(Cardiology), University of Washington, Seattle, Wash., USA
b Department of Biostatistics, University of Washington, Seattle, Wash.,
USA Received 16 May 1972. Available online 28 February 2004.
Competing interests: No competing interests