Prevalence of Emerging Cardiovascular Risk Factors in Younger Individuals with a Family History of Premature Coronary Heart Disease and Low Framingham Risk Score

Abstract

Introduction: The purpose of this study was to assess the prevalence of emerging cardiac risk factors in individuals with a family history of premature coronary heart disease (CHD) and who were predicted to be low-risk for cardiovascular (CV) disease based on their Framingham risk score. Methods: We prospectively evaluated 89 younger men and women with a family history of premature CHD and who had a low Framingham risk score. Patients with CHD or CHD equivalents were excluded. All patients were screened for emerging clinical and lipid risk factors. Results: Coronary calcium was present in 38% of patients and C-reactive protein >3 mg/dl was present in 24% of patients. Low levels of high-density lipoprotein (HDL 2 ) cholesterol were the most prevalent emerging lipid risk factor and was present in 72% of the study group. More individuals had low levels of HDL 2 than total HDL (34% versus 71%; p-value = 0.001). Triglyceride-(TG)-rich remnant lipoproteins were present in 49% of patients. Conclusions: The Framingham risk score poorly predicts CV risk in younger healthy persons with a family history of premature CHD. The prevalence of subclinical CHD and emerging clinical and lipid risk factors is high in these patients. The most prevalent lipid risk factor was low levels of HDL 2 . Individuals with a family history of premature CHD may benefit from screening for emerging risk factors to better assess their CV risk.Key words: coronary calcium, Framingham risk score, premature coronary heart disease Introduction Individuals whose parents or siblings develop coronary heart disease (CHD) at a young age are at increased risk of developing CHD themselves. A family history of premature CHD is recognized as a major risk factor for CHD in the National Cholesterol Education Program (NCEP) adult treatment panel (ATP) III guidelines, 1 and recent emphasis has been placed on screening individuals with a family history of premature CHD for established cardiovascular (CV) risk factors in order to reduce their risk of developing CHD. However, previous studies have shown that individuals with a family history of premature CHD often have normal lipid levels and few identifiable major risk factors for CHD, despite having a high prevalence of subclinical coronary artery disease (CAD). 2 -4 We hypothesized that the CV risk in the offspring of individuals with premature CHD would be underestimated by the Framingham risk score, and that their increased CV risk might be explained by factors beyond traditional CV risk factors. The NCEP ATP III guidelines have identified several emerging clinical and lipid risk factors that may contribute to CHD risk, 1 and previous studies have shown a high prevalence of these emerging risk factors in patients

Arterial stiffness is increased in families with premature coronary artery disease

“…Therefore, PWV measurements might be a practical tool for risk assessment, because the classic risk factors fail to operate in this particular high-risk subset of individuals 6. Indeed, a previous study found that a high PWV in subjects with a low SCORE risk (<5%), was a strong predictor of cardiovascular events,9 suggesting a better risk prediction by PWV in these individuals.…”

“…This emphasises the need to refine risk further among siblings in these families. Traditional risk score algorithms poorly predict cardiovascular risk in general, but even more in relatives of patients with premature CAD 6. The latter reflects the fact that these individuals are referred for cardiovascular risk evaluation at a relatively young age, whereas in the traditional risk score algorithms age is the most potent factor determining risk.…”

Asymptomatic Individuals With a Positive Family History for Premature Coronary Artery Disease and Elevated Coronary Calcium Scores Benefit From Statin Treatment

“…This emphasizes the need to further refine the risk assessment See page 261 among siblings in these families. Traditional risk algorithms poorly predict cardiovascular risk in general, but even more so in relatives of patients with premature CAD (8). This is mainly due to the fact that the question of risk mostly arises at a time when individuals are still young, whereas age is the most important risk predictor for CVD per se.…”

Role of Coronary Artery Calcium Score and Coronary CT Angiography in the Diagnosis and Risk Stratification of Individuals with Suspected Coronary Artery Disease

“…Further, these estimation tools have limited use in the elderly (>75 years of age) because most of these systems were derived primarily from middleaged cohorts. The limited use of these tools extends to the young who, even when presenting with many unfavorable risk factors, will have low risk scores [22][23][24][25][26]. Current risk assessment tools also only examine outcomes over a defined period of time rather than assess lifetime risk; it is the latter that may offer the potential benefit from earlier attempts at initiating aggressive risk factor reduction, and the failure to assess lifetime risk does not allow assimilation of the potential salutary effects of cardiac medications for reducing event rates [27,28].…”