How does the Framingham Risk Score compare to established Atherosclerotic Cardiovascular Disease (ASCVD) in guiding treatment for cardiovascular disease?

From the Guidelines

The ASCVD risk calculator is generally preferred over the Framingham Risk Score for guiding cardiovascular disease treatment decisions. While the Framingham Risk Score was groundbreaking when developed, the ASCVD risk calculator (also known as the Pooled Cohort Equations) has become the standard tool recommended in current practice guidelines, as seen in the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease 1. The ASCVD calculator incorporates more diverse population data and includes additional risk factors such as diabetes status and race. For medication decisions, the ASCVD calculator helps identify patients who would benefit from statin therapy, with high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) typically recommended for those with a 10-year ASCVD risk ≥7.5% 1. Moderate-intensity statins (atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg, or pravastatin 40-80mg daily) are often appropriate for those with risk between 5-7.5%.

Some key points to consider when using the ASCVD risk calculator include:

• The calculator is best validated among non-Hispanic whites and non-Hispanic blacks living in the United States 1
• The calculator may overestimate or underestimate risk in other racial/ethnic groups or in some non-US populations 1
• Clinicians may consider the use of another risk prediction tool as an alternative to the PCE if the tool was validated in a population with characteristics similar to those of the evaluated patient 1
• The ASCVD calculator better accounts for race-specific risk factors and has been validated in more contemporary and diverse populations, making it more applicable to today's patients 1

It's also important to note that both tools have limitations and should be used alongside clinical judgment, considering factors like family history and other risk-enhancing factors when making treatment decisions, as recommended in the 2023 guidelines for major global coronary artery calcium 1. Additionally, the use of coronary artery calcium (CAC) scoring can help refine risk assessment and guide treatment decisions, particularly in intermediate-risk patients 1.

Overall, the ASCVD risk calculator is a valuable tool for guiding cardiovascular disease treatment decisions, but it should be used in conjunction with clinical judgment and other risk assessment tools to provide the best possible care for patients.

From the Research

Comparison of Framingham Risk Score and ASCVD

• The Framingham Risk Score is a widely used tool to estimate the 10-year cardiovascular risk of an individual, while ASCVD (Atherosclerotic Cardiovascular Disease) risk assessment is a more comprehensive approach that takes into account multiple risk factors, including traditional risk factors and novel biomarkers 2.
• The ASCVD risk assessment is based on global risk scores, such as the pooled cohort equations, which have been widely validated and are broadly useful for the general clinical population 3.
• However, the pooled cohort equations may systematically underestimate risk in certain populations, such as those from certain racial/ethnic groups or with chronic inflammatory diseases, and overestimate risk in others, such as those with higher socioeconomic status or who have been closely engaged with preventive healthcare services 3.

Guiding Treatment for Cardiovascular Disease

• The ASCVD risk assessment is used to guide treatment decisions, with individuals at high risk recommended for both lifestyle and pharmacologic therapy, while those at low risk are generally recommended for lifestyle management only 2.
• Additional "risk enhancing" factors, such as family history, social determinants of health, and considerations for high-risk ethnic groups, can be used to further assess ASCVD risk, especially in those at borderline or intermediate risk 2.
• The use of coronary artery calcium screening can also be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy, particularly in those with uncertain risk or who are undecided after a patient-clinician discussion 3.

Limitations of Current Risk Assessment Tools

• Current risk assessment tools, including the Framingham Risk Score and pooled cohort equations, have limitations and may not accurately estimate risk for all individuals, particularly those from diverse populations or with complex medical histories 3.
• The use of additional risk factors and biomarkers, such as non-HDL-C and LDL-C, can help to refine individual risk estimates and guide treatment decisions 4, 5.
• However, even with the use of these additional factors, the attainment of LDL-C targets recommended by current guidelines remains suboptimal, particularly in very high-risk patients with established ASCVD 6.