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How generalizable are coronary risk prediction models? Comparison of Framingham and two national cohorts
Y Liao1, D L McGee, R S Cooper
1Department of Preventive Medicine and Epidemiology and the Division of General Internal Medicine, Loyola University Stritch School of Medicine, Maywood, IL 60153, USA.
Insights
The Framingham Heart Study model reasonably ranks coronary heart disease (CHD) risk but overestimates mortality in men. Newer national data show improved CHD survival, especially in women.
Area of Science:
- Cardiovascular epidemiology
- Public health research
- Biostatistics
Background:
- Established coronary heart disease (CHD) risk prediction models, like the Framingham Heart Study, are based on older data.
- Significant declines in CHD mortality rates have occurred due to improved risk factor management and medical interventions.
- The generalizability of older models to current populations is uncertain.
Purpose of the Study:
- To compare the predictive accuracy of the Framingham CHD risk model with functions derived from more recent national health surveys.
- To assess the performance of risk prediction models across different US population cohorts.
Main Methods:
- Utilized data from the Framingham Heart Study (1954-1958), NHANES I (1971-1975), and NHANES II (1976-1980).
- Included participants aged 35-69, free of CHD at baseline, and followed for up to 24 years.
- Compared Cox regression coefficients for major risk factors (age, blood pressure, cholesterol, smoking) and evaluated model performance using receiver operating characteristic (ROC) curves.
Main Results:
- Heterogeneity was observed in individual risk factor coefficients among the cohorts, particularly in men.
- Despite heterogeneity, risk functions collectively ranked individual risk similarly across cohorts (ROC areas: men 0.71-0.76, women 0.76-0.81).
- The Framingham model accurately predicted CHD survival in women but overestimated CHD mortality rates in men from NHANES I and NHANES II.
Conclusions:
- The Framingham risk model offers a reasonable rank ordering of CHD mortality risk for the US white population (1975-1990).
- The model's prediction of absolute CHD mortality risk is less accurate for contemporary populations.
- Updated models incorporating recent cohort data may be necessary for precise absolute risk prediction.
Background:
Previous models used to predict individual risk of death from coronary heart disease (CHD) were developed from data of 3 decades ago from the Framingham Heart Study. CHD mortality rates have declined markedly since that period as a result of improvement in both risk factor status and medical interventions. Generalization of the results from this one study to the population at large remains a matter of concern. We compared predictive functions derived from the major risk factors for CHD from Framingham and 2 more recent national cohorts, the First and Second National Health and Nutrition Examination Survey (NHANES I and NHANES II).
Methods And Results:
The participants included 1846 men and 2323 women 35 to 69 years of age and free of CHD at the fourth examination (1954 to 1958) from the Framingham Study; 2753 men and 3858 women from the NHANES I (1971 to 1975); and 2655 men and 3050 women from NHANES II (1976 to 1980). The 3 cohorts were monitored for 24, 20, and 15 years, respectively. Significant heterogeneity existed among studies in the magnitude of the Cox coefficients for the individual factors (ie, age, systolic blood pressure, serum total cholesterol, and smoking status), especially among men. When risk factors were considered collectively, however, functions derived from and applied to different cohorts had a similar ability to rank individual risk. The areas under the receiver operating characteristic curves were 0. 71 to 0.76 in men and 0.76 to 0.81 in women when different risk functions were applied to their own population or to a second population. The cumulative CHD survival observed in women in the 2 national cohorts was close to what was predicted from the Framingham equation. However, Framingham overestimated the cumulative CHD mortality rates in men in NHANES I and NHANES II.
Conclusions:
The Framingham risk model for the prediction of CHD mortality rates provides a reasonable rank ordering of risk for individuals in the US white population for the period 1975 to 1990. However, prediction of absolute risk is less accurate.