Background-Separate multivariable risk algorithms are commonly used to assess risk of specific atherosclerotic cardiovascular disease (CVD) events, ie, coronary heart disease, cerebrovascular disease, peripheral vascular disease, and heart failure. The present report presents a single multivariable risk function that predicts risk of developing all CVD and of its constituents. Methods and Results-We used Cox proportional-hazards regression to evaluate the risk of developing a first CVD event in 8491 Framingham study participants (mean age, 49 years; 4522 women) who attended a routine examination between 30 and 74 years of age and were free of CVD. Sex-specific multivariable risk functions ("general CVD" algorithms) were derived that incorporated age, total and high-density lipoprotein cholesterol, systolic blood pressure, treatment for hypertension, smoking, and diabetes status. We assessed the performance of the general CVD algorithms for predicting individual CVD events (coronary heart disease, stroke, peripheral artery disease, or heart failure).

The impact of nonrheumatic atrial fibrillation, hypertension, coronary heart disease, and cardiac failure on stroke incidence was examined in 5,070 participants in the Framingham Study after 34 years of follow-up. Compared with subjects free of these conditions, the age-adjusted incidence of stroke was more than doubled in the presence of coronary heart disease (/?< 0.001) and more than trebled in the presence of hypertension (p<0.001). There was a more than fourfold excess of stroke in subjects with cardiac failure (/><0.001) and a near fivefold excess when atrial fibrillation was present (/»<0.001). In persons with coronary heart disease or cardiac failure, atrial fibrillation doubled the stroke risk in men and trebled the risk in women. With increasing age the effects of hypertension, coronary heart disease, and cardiac failure on the risk of stroke became progressively weaker (p<0.05). Advancing age, however, did not reduce the significant impact of atrial fibrillation. For persons aged 80-89 years, atrial fibrillation was the sole cardiovascular condition to exert an independent effect on stroke incidence (/><0.001). The attributable risk of stroke for all cardiovascular contributors decreased with age except for atrial fibrillation, for which the attributable risk increased significantly (/><0.01), rising from 1.5% for those aged 50-59 years to 23.5% for those aged 80-89 years. While these findings highlight the impact of each cardiovascular condition on the risk of stroke, the data suggest that the elderly are particularly vulnerable to stroke when atrial fibrillation is present The powerful independent effect of atrial fibrillation reported here is in accord with the findings of recent randomized clinical trials in which >50% of stroke events were prevented by warfarin anticoagulation. (Stroke 1991^2:983-988)A lthough hypertension is the strongest risk fac-/ \ tor for stroke, age and the presence of other J. \ . risk factors may modify or enhance the effect of increased blood pressure on stroke occurrence. Impaired cardiac function, overt or occult, increases stroke incidence at all levels of blood pressure. In hypertensive persons coronary heart disease, cardiac failure, and particularly atrial fibrillation are associated with increased stroke risk. 5 -7 Atrial fibrillation, which is frequently associated with hypertension, coronary heart disease, and cardiac failure, becomes increasingly prevalent among persons aged >70 years.8 It has been suggested that Received December 21, 1990; accepted April 23, 1991. atrial fibrillation is a risk "marker" for stroke and that the increased stroke incidence in persons with this arrhythmia is a result of age and associated cardiovascular abnormalities. 910 To help address this issue, we have extended our previous study and examined in detail the relative impacts of hypertension, coronary heart disease, cardiac failure, and atrial fibrillation on the incidence of stroke in the Framingham Study. 8 We took advantage of the 110 additional initial stroke events, a...

In subjects from the original cohort of the Framingham Heart Study, AF was associated with a 1.5- to 1.9-fold mortality risk after adjustment for the preexisting cardiovascular conditions with which AF was related. The decreased survival seen with AF was present in men and women and across a wide range of ages.

An increased plasma homocysteine level is a strong, independent risk factor for the development of dementia and Alzheimer's disease.

No abstract

No abstract

A health risk appraisal function has been developed for the prediction of stroke using the Framingham Study cohort. The stroke risk factors included in the profile are age, systolic blood pressure, the use of antihypertensive therapy, diabetes mellitus, cigarette smoking, prior cardiovascular disease (coronary heart disease, cardiac failure, or intermittent claudication), atrial fibrillation, and left ventricular hypertrophy by electrocardiogram. Based on 472 stroke events occurring during 10 years' follow-up from biennial examinations 9 and 14, stroke probabilities were computed using the Cox proportional hazards model for each sex based on a point system. On the basis of the risk factors in the profile, which can be readily determined on routine physical examination in a physician's office, stroke risk can be estimated. An individual's risk can be related to the average risk of stroke for persons of the same age and sex. The information that one's risk of stroke is several times higher than average may provide the impetus for risk factor modification. It may also help to identify persons at substantially increased stroke risk resulting from borderline levels of multiple risk factors such as those with mild or borderline hypertension and facilitate multifactorial risk factor modification. (Stroke 1991;22:312-318) S troke is the third leading cause of death in the United States and is a major source of disability in persons older than age 60 years. In the face of an elderly population of increasing size, stroke is likely to be responsible for even greater disability and death. Epidemiologic study has identified key risk factors for stroke and has provided an estimate of the relative impact of these factors. Using data collected over 36 years of follow-up in the general population sample at Framingham, Mass., a stroke risk profile or health risk appraisal function has been developed. This profile contains a number of ingredients not available at the time of the previous stroke risk handbook, which was based on 16 years of follow-up. 1 The inclusion of previously diagnosed cardiovascular disease (coronary heart disease Received October 15, 1990; accepted November 27, 1990. [includes history of myocardial infarction, angina pectoris, and coronary insufficiency], cardiac failure, and intermittent claudication), atrial fibrillation, and left ventricular hypertrophy by electrocardiogram as ingredients in the profile has improved the efficiency of the risk prediction and gives a more realistic assessment of the importance of the stroke risk factors. Key to the usefulness of determining the likelihood of stroke by means of a risk profile is evidence that modification of several potent risk factors will reduce stroke probability. Epidemiologic study and clinical trial results have shown that reduction of elevated blood pressure and cessation of cigarette smoking can reduce stroke incidence. Warfarin (and perhaps aspirin) therapy in persons with atrial fibrillation, reversal of left ventricular hypertrophy by electroca...

Background-Atrial fibrillation (AF) and congestive heart failure (CHF) frequently occur together, but there is limited information regarding their temporal relations and the combined influence of these conditions on mortality. Methods and Results-We studied participants in the Framingham Study with new-onset AF or CHF. Multivariable Cox proportional hazards models with time-dependent variables were used to evaluate whether mortality after AF or CHF was affected by the occurrence and timing of the other condition. Hazard ratios (HRs) were adjusted for time period and cardiovascular risk factors. During the study period, 1470 participants developed AF, CHF, or both. Among 382 individuals with both conditions, 38% had AF first, 41% had CHF first, and 21% had both diagnosed on the same day. The incidence of CHF among AF subjects was 33 per 1000 person-years, and the incidence of AF among CHF subjects was 54 per 1000 person-years. In AF subjects, the subsequent development of CHF was associated with increased mortality (men: HR 2.7; 95% CI, 1.9 to 3.7; women: HR 3.1; 95% CI, 2.2 to 4.2). Similarly, in CHF subjects, later development of AF was associated with increased mortality (men: HR 1.6; 95% CI, 1.2 to 2.1; women: HR 2.7, 95% CI, 2.0 to 3.6). Preexisting CHF adversely affected survival in individuals with AF, but preexisting AF was not associated with adverse survival in those with CHF. Conclusions-Individuals with AF or CHF who subsequently develop the other condition have a poor prognosis.Additional studies addressing the pathogenesis, prevention, and optimal management of the joint occurrence of AF and