Limitations

Exclusion of Potential Risk Factors in Prediction Equations

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An additional limitation of some risk charts, such as the Framingham risk score and the SCORE project, is that the equations do not include some other potentially important risk predictors of CHD. For instance, these equations do not take into account family history of heart disease despite the widely accepted importance of family history of premature CHD in clinical practice. It has been shown that a validated positive family history of CHD doubled cardiovascular risk for men and led to a 70% increase (nonsignificant) in risk for women over 8 years (18). In addition, the Framingham risk equation and the SCORE chart do not include potentially relevant factors/markers such as blood glucose level, hemoglobin A1C, triglycerides, C-reactive protein, indices of intra-abdominal (visceral) obesity and ectopic fat deposition, and physical activity/fitness. For some of these variables, it was felt that they could not be included in global risk assessment because of their strong ties to other major risk factors—their added contribution to CHD risk estimation was therefore not clear (19).  However, the exclusion of these risk factors does not mean that they are not clinically relevant. Many of them should in fact be considered when evaluating and managing patients at high CHD risk.

Reference

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18. Lloyd-Jones DM, Nam BH, D'Agostino RB, Sr., et al. Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults: a prospective study of parents and offspring. JAMA 2004; 291: 2204-11.

19. Grundy SM, Pasternak R, Greenland P, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 1999; 100: 1481-92.

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