CORONARY RISK SCORING

DR. S. KARTHICK PRABHU

WHY

Clinical, non-invasive & invasive tools are useful in refining the estimate of risk for the individual pt with angina.
Non-invasively acquired information is valuable in identifying the candidates for cardiac catheterization. Risk scoring is an instrument to assess both the relative risk & absolute risk of developing CV disease & mortality in an individual.

RISK SCORING

There are different methods of risk scoring -Some use mathematical model,others use charts or computer programmes. Few methods are 1. TIMI risk scoring 2. Framingham risk scoring 3. GRACE- Global Registry of Acute Coronary Events 4. Joint British chart 5. The New Zealand chart 6. The Sheffield tables

TIMI Risk scoring

Have 7 independent risk factors -Age, >65y -At least 3 risk factors for CAD :( like f/h of CAD,SHT,dyslipidemia, DM,or current smoker) -Signi coronary stenosis : (eg, prior coronary stenosis >50%) -ST deviation >0.5mm - >2 anginal events in last 24h -Use of aspirin in last 7days -Elevated S.Cardiac markers Total possible points are 14.

TIMI

Use of this scoring system was able to risk-stratify patients across a 10 fold gradient of risk. Predicts the response to the therapies in UA / NSTEMI. Patients with higher TIMI risk scores signi reductions in events when treated with enoxaparin~unfractionated heparin, GP IIb/IIIa inhibitor~placebo & invasive vs conservative strategy.

FRAMINGHAM RISK SCORING

Risk scoring- essential for planning the line of management. This is the 1st such method-took 6 variables to predict the 10 & 20y risk of CAD. This algorithm provides estimates of total CHD risk (developing either angina, MI or coronary disease death) over 10 yrs. Relative risk for CHD is estimated by comparison to low risk participants.

Separate score sheets are used for men & women.

Factors used to estimate risk include age , T.cholesterol, HDL, BP, smoking, & DM.

FRAMINGHAM-sample score sheet

Consider a 55y old man, T.ch-250mg%, HDL-39mg%, BP-146/88, DM+, & non-smoker.

1 2 3 4 5 6

Age HDL BP DM -

yes

55y 39mg%

4 2 1 2 2 0 11 31%

T. Cholesterol -250mg% - 146/88mm Hg no

Cig smoker Total point

Estimated 10y CHD Risk

Low 10y CHD Risk

Relative risk

7%
31/7 = 4.4

FRAMINGHAM Cont

Low risk derived by using persons of the same age, optimal BP, T.cho-160-199, HDL- 45 for men or 55 for women, non-smoker & no DM.
Relative risk 4.4, means that coronary risk for this person is approximately 4 times that of a man the same age with a low risk profile.

FRAMINGHAM cont

Limitations :
-Only for persons without heart disease. -Study population is almost all Caucasian. -Estimates the risk of developing CHD within a 10y

time.

For the Indians, the cut-off point for cholesterol level, wt, waist-hip ratio underestimate the risk of CHD.

GLOBAL REGISTRY OF AC. CORONARY EVENTS

Collects clinical data in pts with UA / NSTEMI / STEMI, from 245 hospitals in 30 countries on current practices of care provided .

GRACE risk model identified factors associated independently with increased mortality were increased age, Killip class, increased HR, lower SBP, ST segment deviation, cardiac arrest at presentation, & elevated S.creatinine or cardiac enzymes.

Joint British chart/New Zealand/Sheffield table

All included factors are age, sex, smoking, DM status, BP, & ratio of T.cholesterol to HDL as part of their risk assessment.

Isles et al (BMJ july 2000)- studied all 3 & compared them .

Sensitivity & specificity of Sheffield & Jt British are nearer & that of NZ are least. Jt British chart not appropriate for pts with established CAD, familial hyperlipidemia, CKD or DM.

Sheffield
Joint British New Zealand

98%
91% 83%

91%
98% 89%

REYNOLDS RISK SCORE

Provides a greater accuracy for assessment of cardiovascular risk in women.

-Other alternative scoring systems are The Heart score, Prospective cardiovascular Munster study, etc.

Conclusion

Most of the risk scoring algorithms focus on 5y or 10y absolute risks for developing CHD, which is helpful in a high risk individual.

It is also essential to identify the long-term risks, because even a single elevated risk factor can lead to signi risks for CHD in future.