Preventive cardiology
Central Obesity and Multivariable Cardiovascular Risk as Assessed by the Framingham Prediction Scores

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To evaluate the role of measurements of central obesity in the multivariable prediction of cardiovascular risk using the Framingham risk scores, we studied 4,175 representative men from Australian cities, free of heart disease, stroke, and diabetes in 1989, and followed the cohort for mortality to 2004. Baseline lipids, blood pressure, and current cigarette smoking were recorded. Obesity was assessed by body mass index, waist circumference (WC), and waist-to-hip ratio (WHR) by strictly standardized methods. The Framingham equations were strong predictors of coronary heart disease (CHD) and cardiovascular disease (CVD) deaths. Of the obesity measurements, WHR and WC predicted deaths using Cox proportional hazards regression but body mass index did not. In the multivariable analyses, WHR was an independent predictor of CHD deaths, and WHR and WC were independent predictors of CVD deaths. There was little or no attenuation of hazard ratios for WHR and WC after correction for the Framingham scores. The 2 measurements of central obesity were more strongly predictive of CHD and CVD deaths in subjects at the lower levels of Framingham risk. In contrast, cigarette smoking risk appeared to contribute more in the higher Framingham risk categories. In conclusion, central obesity significantly and independently contributes to cardiovascular outcomes and to residual risk after accounting for the Framingham equations.

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Methods

Baseline data of 4,175 men from an age- and gender-stratified sample of adults in Australian capital cities (Australian Risk Factor Prevalence Survey, 1989) with no previous diabetes, heart attack, or stroke were linked with the National Death Index to determine the causes of death for the 346 subjects who had died by December 31, 2004. The sample of voters 42.3 ± 13.1 years of age had their fasting serum lipid levels, blood pressure, smoking, and obesity measured. Registration for voting is

Results

Baseline characteristics for the 4,175 subjects who had no history of angina, heart attack, stroke, or diabetes are presented in Table 1. Framingham predicted risks of 15-year CHD and CVD deaths are also presented. During 15 years of follow-up (1989 to 2004) there were 346 deaths due to all causes, 88 deaths due to CVD, and 64 deaths due to CHD.

Actual CHD and CVD deaths were compared with Framingham predicted risk for CHD and CVD deaths, respectively, in 10% class intervals of increasing risk (

Discussion

This study shows that measurements of central obesity predict CVD and CHD risk independently from the multivariable Framingham score in a representative sample of men of European descent free of previous CHD, stroke, and diabetes. The Framingham risk score is the most common way to predict cardiovascular risk and is recommended for providing a reliable simple tool for stratifying a patient's risk status.7, 8 It was developed from a U.S. population cohort with a high prevalence of CVD, and it

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This work was supported by a grant-in-aid from Merck, Sharp and Dohme (Australia) Pty. Ltd., South Granville, NSW 2142, Australia.

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