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The Framingham prediction rule is not valid in a European population of treated hypertensive patients

Bastuji-Garin, Sylviea; Deverly, Annec; Moyse, Dominiqued; Castaigne, Alainb; Mancia, Giuseppef; de Leeuw, Peter W.g; Ruilope, Luis M.h; Rosenthal, Talmai; Chatellier, Gilleseon behalf of the INSIGHT committees and investigators

Origianl Papers: Epidemiology: Original article

Background  Stratification of population groups according to cardiovascular risk level is recommended for primary prevention.

Objective  To assess whether the Framingham models could accurately predict the absolute risk of coronary heart disease (CHD) and stroke in a large cohort of middle-aged European patients with hypertension, and rank individual patients according to actual risk.

Design  A prospective cohort study comparing the actual risk with that predicted by either the Framingham equations or models derived from the INSIGHT study.

Patients and setting  From the INSIGHT prospective trial, conducted in eight countries of Western Europe and Israel, we selected 4407 European patients younger than 75 years without previous cardiovascular events.

Interventions  None.

Main outcome measures  Major cardiovascular events.

Results  In this population (45% men, mean age 64.1 years), 124 (2.8%) patients had CHD and 96 (2.2%) had strokes after a median follow-up of 3.7 years. Overestimation of absolute CHD risk by the Framingham equation was observed in all countries (from 2% in the UK to 7% in France), whereas predicted risk of stroke was close to the actual risk. However, patients in the highest risk quintile within each country had a threefold greater risk of a cardiovascular event than those in the lowest quintile.

Conclusions  The Framingham models should not be used to predict absolute CHD risk in the European population as a whole. However, these models may be used within each country, provided that cut-off points defining high-risk patients have been determined within each country.

Departments of aPublic Health and bCardiology, Henri-Mondor Hospital, (AP-HP), Paris XII University, Créteil, cBayer, Puteaux, dDMSA, Paris and eDepartment of Medical Informatics, Hôpital Européen Georges Pompidou, (AP-HP), Paris, France, fCattedra di Medicina Interna, University of Milan, Milan, Italy, gUniversity of Maastricht, Maastricht, The Netherlands, hNephrology Department, Hospital 12 de Octobre, University of Madrid, Madrid, Spain and iHypertension Unit, The Chaim Sheba Medical Centre, University of Tel Aviv, Tel Aviv, Israel.

Note: This work was presented in part at the XXIIIth Congress of the European Society of Cardiology (Stockholm, September 2001) and at the 21st Journées de l'Hypertension Artérielle (Paris, December 2001).

Correspondence and requests for reprints to Sylvie Bastuji-Garin MD, PhD, Département de Santé Publique, Hôpital Henri Mondor, 94010 Créteil Cedex, France. Tel: +33 1 49 81 37 06; fax: +33 1 49 81 36 97; e-mail:

Received 6 March 2002

Revised 13 June 2002

Accepted 1 July 2002

See editorial commentary page 1937

© 2002 Lippincott Williams & Wilkins, Inc.