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One-Third Women Not Detected for Heart Risk by
Traditional Scoring
Cardiac CT scans recommended for some groups of women
Dec. 16, 2005 Previous studies showing heart
disease is not as quickly found or treated in women received more
evidence today with the release of two studies showing traditional
risk-factor scoring fails to identify approximately one-third of women
likely to develop coronary heart disease (CHD). This is the leading
cause of death of women in the United States.
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"Our best means of preventing coronary heart
disease is to identify those most likely to develop the condition, and
intervene with lifestyle changes and drug treatment before symptoms
start to appear," says the senior author of both studies, cardiologist
Roger Blumenthal, M.D., an associate professor and director of the
Ciccarone Preventive Cardiology Center at The Johns Hopkins University
School of Medicine and its Heart Institute.
"The goal is to strongly consider therapies, such
as aspirin, cholesterol-lowering medications and, possibly, blood
pressure medications for individuals at higher risk, so that heart
attacks will be less likely to occur in the future."
The Hopkins findings, the latest of which appear in
the American Heart Journal online today, is believed to be one of the
first critical assessments of the Framingham Risk Estimate (FRE) as the
principal test for early detection of heart disease. The researchers
wanted to determine why many of these women at risk for heart disease
are not identified earlier.
The FRE is a total estimate of how likely a person
is to suffer a fatal or nonfatal heart attack within 10 years, and it is
based on a summary estimate of major risk factors for coronary heart
disease, such as age, blood pressure, blood cholesterol levels and
smoking.
However, Blumenthal says, many women with
cardiovascular problems go undetected despite use of the Framingham
score. While the death rate for men from cardiovascular disease has
steadily declined over the last 20 years, the rate has remained
relatively the same for women, he says.
In their latest report, the Hopkins researchers
examined the risk of premature CHD in women whose average age was 50 and
who were participating in the Sibling and Family Heart Study, a
long-term study of how heart disease develops among family members.
Study subjects had no symptoms of heart disease, but had a sibling who
had been hospitalized for a coronary event, such as a heart attack
before age 60.
The researchers calculated each woman's Framingham
score and found that 98 percent were gauged to be at very low risk for
future CHD, with an FRE of less than 6 percent, while only 2 percent of
participants were judged to be at intermediate risk for future CHD, with
an FRE between 10 percent and 20 percent.
When the results were contrasted with evidence
gleaned from CT-scan measurements of calcium build-up in the arteries,
the researchers found that one-third of women originally classified as
very low risk actually had coronary atherosclerosis, a hardening and
narrowing of the arteries that can lead to heart attacks if not
controlled with drug therapy along with diet, exercise and other
lifestyle changes. Indeed, 12 percent of women in the study had advanced
stages of atherosclerosis, while another 6 percent had severe calcium
build-up.
"We wanted to verify if the Framingham score truly
captured who was most at risk, but it turns out to have underestimated a
large number of those who should be considered for preventive
therapies," says Blumenthal.
According to the researchers, performing cardiac CT
scans on everyone with a low Framingham score is not a practical option
for improving upon traditional risk-factor screening. To better
determine who should get scanned, even if they have a low risk
assessment, the Hopkins team began to search for additional predictors
of who was most at risk. They found that people with two or more risk
factors, such as obesity, smoking or metabolic syndrome, plus a family
history for heart disease were those most likely to have a high calcium
score. It is this group, the researchers say, who should be considered
for a fast cardiac CT scan regardless of low Framingham scores and if
the physician or patient is unsure about the need to go on long-term
preventive therapies.
In a related, second investigation, published
online in the May edition of the journal Atherosclerosis, the Hopkins
team analyzed the Framingham scores of 2,447 women age 45 to 65, all of
whom were participating in another long-term study in Ohio of adults
referred by a physician for a cardiac risk assessment.
Again, when the FRE results were compared to
calcium scores, 84 percent (408 of 489) of those classified as low risk
by FRE actually had some coronary atherosclerosis. Twenty percent of
those who were classified at intermediate risk by FRE had signs of
advanced atherosclerosis.
"Our results show that if a CT scan had not been
performed in addition to traditional risk-factor scoring, a large number
of women would have missed the chance to begin preventive therapies,"
says cardiologist Erin Michos, M.D., a clinical research fellow at
Hopkins and its Heart Institute. Michos led both Hopkins studies.
"For some women, especially those with a family
history of heart disease and multiple risk factors for it, additional
screening using CT scan and calcium scoring may be warranted," she adds.
About the study:
Funding for these studies, whose data analyses took
place between January 2003 and November 2004, was provided by the
National Institutes of Health, including the National Institute of
Nursing Research and the National Heart, Lung and Blood Institute, the
Johns Hopkins General Clinical Research Center and the Maryland Athletic
Club Charitable Foundation.
Other researchers involved in the two studies were
Khurram Nasir, M.D., M.B.A.; Joel Braunstein, M.D.; John Rumberger,
M.D.; Matthew Budoff, M.D.; Wendy Post, M.D.; Chandra Vasamreddy, M.D.;
Diane Becker, M.P.H., Sc.D.; Lisa Yanek, M.P.H.; Taryn Moy, M.S.; Elliot
Fishman, M.D.; and Lewis Becker, M.D.
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