Factors related to coronary heart disease risk among men: validation of the Framingham Risk Score

A comparison of laboratory-based and office-based Framingham risk scores to predict 10-year risk of cardiovascular diseases: a population-based study

BACKGROUND

Two versions of Framingham's 10-year risk score are defined for cardiovascular diseases, namely laboratory-based and office-based models. The former is mainly employed in high-income countries, but unfortunately, it is not cost-effective or practical to utilize it in countries with poor facilities. Therefore, the present study aims to identify the agreement and correlation between laboratory-based and office-based Framingham models.

METHODS

Using laboratory-based and office-based Framingham models, this cross-sectional study used data from 8944 participants without a history of CVDs and stroke at baseline in the Fasa cohort study to predict the 10-year risk of CVDs. The laboratory-based model included age, sex, diabetes, smoking status, systolic blood pressure (SBP), treatment of hypertension, total cholesterol, and high-density lipoprotein (HDL); and the office-based model included age, sex, diabetes, smoking status, SBP, treatment of hypertension, and body mass index (BMI). The agreement between risk categories of laboratory-based and office-based Framingham models (low [< 10%], moderate [from 10 to < 20%], high [≥ 20%]) was assessed by kappa coefficients and percent agreement. Then, the correlation between the risk scores was estimated using correlation coefficients and illustrated using scatter plots. Finally, agreements, correlation coefficient, and scatter plots for laboratory-based and office-based Framingham models were analyzed by stratified Framingham risk score factors including sex, age, BMI categories, hypertension, smoking, and diabetes status.

RESULTS

The two models showed substantial agreement at 89.40% with a kappa coefficient of 0.75. The agreement was substantial in all men (kappa = 0.73) and women (kappa = 0.72), people aged < 60 years (kappa = 0.73) and aged ≥ 60 years (kappa = 0.69), smokers (kappa = 0.70) and non-smokers (kappa = 0.75), people with hypertension (kappa = 0.73) and without hypertension (kappa = 0.75), diabetics (kappa = 0.71) and non-diabetics (kappa = 0.75), people with normal BMI (kappa = 0.75) and people with overweight and obesity (kappa = 0.76). There was also a very strong positive correlation (r ≥ 0.92) between laboratory-based and office-based models in terms of age, sex, BMI, hypertension, smoking status and diabetes status.

CONCLUSIONS

The current study showed that there was a substantial agreement between the office-based and laboratory-based models, and there was a very strong positive correlation between the risk scores in the entire population as well across subgroups. Although differences were observed in some subgroups, these differences were small and not clinically relevant. Therefore, office-based models are suitable in low-middle-income countries (LMICs) with limited laboratory resources and facilities because they are more convenient and accessible. However, the validity of the office-based model must be assessed in longitudinal studies in LMICs.

The Burden of Cardiovascular Disease Attributable to Modifiable Risk Factors and Cost-effectiveness Analysis of IraPEN Program in the General Population of Iran

Background: Cardiovascular diseases (CVDs) contribute to over 30% of deaths worldwide and more than 40% in Iran in 2019. Establishing a cost-effective program to control cardiovascular diseases is essential for any country. This study aimed to estimate the cost-effectiveness of the primary prevention program (IraPEN) for cardiovascular diseases in Iran. Methods: This methodological cost-effectiveness study was performed to estimate the cost-effectiveness of the IraPEN program by modifying cardiovascular disease risk factors in the IraPEN program. We calculated the economic burden of CVDs risk factors from 2016 to 2018 in 4 pilot cities in Iran. We observed 160,833 individuals for 2 years to measure the economic burden of cardiovascular diseases. To estimate the variation of the 1-year risk of cardiovascular illnesses, and according to the study's goal of estimating the 1-year risk of cardiovascular disease, only 36,631 people remained in the study who compiled the program's instruction for 1 year. Propensity scores were used to consider the effect of those excluded from the study. The 10-year risk of CVDs was estimated by the laboratory tests and information registered in the population's electronic records. To evaluate the effect of the IraPEN program in reducing the risk factors for cardiovascular diseases, major CVD risk factors were studied by the World Health Organization formula (whocvdrisk) and cardiovascular diseases risk scoring. We used the 10-year risk for CVDs to conduct a cost-effectiveness analysis in terms of cost per disability-adjusted life-year (DALY) saved. Results: According to estimates of the 1-year relative risk reduction in cardiovascular disease, the results showed that relative risk reductions for men and women were 0.74 and 0.65, respectively. Hence, about 174,088 annual acute CVDs events reduction would be expected; this decrease is predicted for men (93,034) more than women (81,054) for the total population of Iran. The total cost of treatment for people with cardiovascular diseases was 165 USD for coronary heart disease or stroke per individual. All risk factors were further reduced in women than men, except for smoking. DALYs averted was 1057.66 for samples who were in the study for a year (36631 samples). The total cost per averted DALY was 47.16. Conclusion: Estimating the costs associated with disease prevention programs is more important in developing countries. The most cost-effective strategies have been preventive therapies that target high-risk individuals. PEN risk reduction programs for primary prevention such as Ira-pen are highly cost-effective and efficient in low- and middle-income countries.

The Diagnosis and Management of Cardiometabolic Risk and Cardiometabolic Syndrome after Spinal Cord Injury

Individuals with spinal cord injuries (SCI) commonly present with component risk factors for cardiometabolic risk and combined risk factors for cardiometabolic syndrome (CMS). These primary risk factors include obesity, dyslipidemia, dysglycemia/insulin resistance, and hypertension. Commonly referred to as “silent killers”, cardiometabolic risk and CMS increase the threat of cardiovascular disease, a leading cause of death after SCI. This narrative review will examine current data and the etiopathogenesis of cardiometabolic risk, CMS, and cardiovascular disease associated with SCI, focusing on pivotal research on cardiometabolic sequelae from the last five years. The review will also provide current diagnosis and surveillance criteria for cardiometabolic disorders after SCI, a novel obesity classification system based on percent total body fat, and lifestyle management strategies to improve cardiometabolic health.

Visual functions and disability in Iranian adults: a population-based study

Background

Vision-related quality of life is related to severity of visual impairments and show the impact of eye diseases on daily activities. This study aims to assess visual functions and disability and its association with age, gender, education, marital status, and economic status in adults aged 45–69 years.

Methods

Data in this population-based study were from the second phase of the Shahroud eye cohort study and collected by using a Short-Form Visual Functioning Scale. The scores of visual function and disability were calculated based on Rasch-transformed scores of the National Eye Institute visual functioning questionnaire, where a more negative score indicates a better situation. Multiple linear regression was used to investigate the factors associated with visual functions.

Results

Among 4737 participants the visual function data for 4715 people were analyzed. The visual function of 75.3, 17.1 and 7.5% of participants were “ideal and good”, “moderate”, and “bad and very bad”, respectively, while 0.06% were unable for vision. The running mean of the visual function was calculated to be − 3.95 ± 0.02. The visual performance was worse in females than the males (β = 0.14, p = 0.005). Visual function improved with increasing levels of education (β = − 1.06, p < 0.001). It was worse in low-economic (β = 0.016, p = 0.005) and moderate-economic (β = 0.28, p < 0.001) participants than high-economic ones.

Conclusion

The visual function of Iranian adults aged 45–69 years was moderate. The male gender, higher education and the higher economic status had a better visual function.

Food Access and Cardiovascular Outcomes in Metropolitan Atlanta Census Tracts With Residents at Low Risk and High Risk of Cardiovascular Disease: The Morehouse-Emory Cardiovascular Center for Health Equity Study

Introduction

Perceived and actual access to healthy foods may differ in urban areas, particularly among Black people. We assessed the effect of objective and perceived neighborhood food access on self-reported cardiovascular disease (CVD) among Black people living in areas of high risk and low risk for the disease in Atlanta, Georgia. We hypothesized that perceived and objective food access would independently predict self-reported CVD.

Methods

We used survey data from the Morehouse–Emory Cardiovascular (MECA) Center for Health Equity Study. Study participants consisted of 1,402 Black adults, aged 35 to 64, residing in urban Atlanta census tracts with high rates or low rates of CVD. We assessed perceived neighborhood healthy food access by self-reported selection and quality of produce and low-fat food options. We assessed objective food access by the 2015 US Department of Agriculture Food Access Research Atlas. Low access was defined as census tracts with at least 500 people living more than 1 mile from a large food retailer. Self-reported CVD included related conditions and/or procedures. We used multilevel logistic models adjusted for demographic characteristics to examine the association between objective and perceived food access and self-reported CVD.

Results

Overall, self-reported CVD was not significant for perceived (odds ratio = 0.87; 95% CI, 0.59–1.29) or objective (odds ratio = 0.74; 95% CI, 0.48–1.12) healthy food access. Similar results were obtained among adults living in areas with higher-than-expected rates of CVD.

Conclusion

Results of this study suggest the odds for self-reported CVD events were not significantly affected by perceived or objective access to healthy foods.

Cardiovascular risk factors among adult patients with haemophilia

Since the introduction of episodic and prophylactic treatments with safer factor concentrates, the life expectancy of people with haemophilia (PwH) has improved considerably. Ageing-related diseases such as cardiovascular disease (CVD) have also become more prevalent in PwH. This cross-sectional study aimed to evaluate CVD risk factors and estimate 10-year risk for CVD events among PwH. Male patients ≥ 30 years were interviewed and examined. Blood tests were performed at the local laboratory. Eighty-two patients were included, of whom 83% had haemophilia A and half had severe disease. Median age at study entry was 43.0 years (interquartile range [IQR], 36.0-51.3). Prevalence of obesity, systemic arterial hypertension (SAH) and diabetes mellitus were 16%, 60% and 16%, respectively. Hypertriglyceridaemia, hypercholesterolaemia and low HDL blood levels were present in 18%, 41% and 30% of patients, respectively. Metabolic syndrome was found in 37%. The Framingham Risk Score showed that 39% of PwH had a high risk of developing cardiovascular events in the following 10 years. We conclude that, in this cohort, PwH have a higher prevalence of SAH when compared with Brazilian men without haemophilia and about two-fifths have a high risk of developing a CVD event in the following 10 years.

Waist circumference does not improve established cardiovascular disease risk prediction modeling

Despite considerable evidence demonstrating that waist circumference (WC) is independently associated with cardiovascular disease (CVD) and/or all-cause mortality, whether the addition of WC improves risk prediction models is unclear. The objective was to evaluate the improvement in risk prediction with the addition of WC, alone or in combination with BMI, to the Framingham Risk Score (FRS) and a population specific model. 34,377 men and 9,477 women aged 20 to 79 years who completed a baseline examination at the Cooper Clinic (Dallas, TX) during 1977–2003 and enrolled in the Aerobics Center Longitudinal Study (ACLS). WC was measured at the level of the umbilicus and expressed as a continuous variable. Deaths among participants were identified using the National Center for Health Statistics National Death Index. A total of 728 fatal cardiovascular disease (CVD) events occurred over a mean follow-up period of 13.1 ± 7.5 years. WC was significantly higher in CVD decedents (P = .002). The FRS C-statistic for fatal CVD in men was 0.836 (0.816–0.855) and 0.883 (0.851–0.915) in women. The addition of WC did not improve the C-statistic in men (0.831 (0.809–0.853)) or women (0.883 (0.850–0.916)). Similar findings were observed for non-fatal CVD and all-cause mortality, and when WC was added to a population specific model. Upon adding WC, the net-reclassification index was 0.024 with an integrated discrimination improvement of -0.0004. The addition of WC, alone or in combination with BMI, did not substantively improve risk prediction for CVD or all-cause mortality compared to the Framingham Risk Score or a population specific model.

Classification of obesity, cardiometabolic risk, and metabolic syndrome in adults with spinal cord injury

Objective: To describe and compare (1) classification of obesity using clinical proxies of body composition that are easily accessible in the outpatient clinic setting, (2) cardiometabolic risk using existing screening tools and staging systems, and (3) the presence of metabolic syndrome (MetS) using four commonly-used definitions in adults with spinal cord injury (SCI). Design: Retrospective chart review Setting: Outpatient Veterans Affairs (VA) SCI Annual Evaluation Clinic Participants: Patients who attended an annual evaluation appointment with demographic, anthropometric, and biochemical data documented in their medical records as part of routine medical care. Outcome measures: Obesity classification (body mass index, waist circumference, ideal body weight percentage), cardiometabolic risk scores (Framingham Risk Score, Cardiometabolic Disease Staging System, Edmonton Obesity Staging System), and MetS classification (using four commonly-used definitions) were described and compared. Results: Of the 155 veterans included in this analysis, 93% were considered "at risk" by at least one of the measurements studied. However, there was considerable variation between the different screening tools. The κ-agreement between various definitions of MetS ranged from fair to moderate. Conclusion: Screening tools that were developed for the non-SCI population produced variable assessments of risk when applied to veterans with SCI. Due to the fair to moderate inter-rater agreement between MetS definitions, it is unknown which definition is superior to identify MetS in the SCI population. An SCI-specific screening tool is needed to accurately classify obesity, cardiometabolic risk, and MetS in order to provide timely education and intervention.

A Brief Review of Cardiovascular Diseases, Associated Risk Factors and Current Treatment Regimes

Cardiovascular diseases (CVDs) are the leading cause of premature death and disability in humans and their incidence is on the rise globally. Given their substantial contribution towards the escalating costs of health care, CVDs also generate a high socio-economic burden in the general population. The underlying pathogenesis and progression associated with nearly all CVDs are predominantly of atherosclerotic origin that leads to the development of coronary artery disease, cerebrovascular disease, venous thromboembolism and, peripheral vascular disease, subsequently causing myocardial infarction, cardiac arrhythmias or stroke. The aetiological risk factors leading to the onset of CVDs are well recognized and include hyperlipidaemia, hypertension, diabetes, obesity, smoking and, lack of physical activity. They collectively represent more than 90% of the CVD risks in all epidemiological studies. Despite high fatality rate of CVDs, the identification and careful prevention of the underlying risk factors can significantly reduce the global epidemic of CVDs. Beside making favorable lifestyle modifications, primary regimes for the prevention and treatment of CVDs include lipid-lowering drugs, antihypertensives, antiplatelet and anticoagulation therapies. Despite their effectiveness, significant gaps in the treatment of CVDs remain. In this review, we discuss the epidemiology and pathology of the major CVDs that are prevalent globally. We also determine the contribution of well-recognized risk factors towards the development of CVDs and the prevention strategies. In the end, therapies for the control and treatment of CVDs are discussed.

Factors influencing left ventricular ejection fraction in patients with coronary microvascular disease and obstructive coronary artery disease

Objective

The aim of our research was to evaluate the relationship involving left ventricular ejection fraction, low density lipoprotein, B-type natriuretic peptide, Troponin I and coronary flow reserve, and to determine the predictors of left ventricular ejection fraction in patients with coronary microvascular disease and obstructive coronary artery disease, and in patients with coronary microvascular disease.

Results

The mean age was 58.5 ± 12.5 years. In patients with obstructive coronary disease and coronary microvascular disease we found low density lipoprotein-c had significant inverse relationship with left ventricular ejection fraction, left ventricular ejection fraction also had significant negative relationship with B-type natriuretic peptide, and Troponin-I. While a significant direct relationship turned out to be observed linking left ventricular ejection fraction with coronary flow reserve. Left ventricular ejection fraction had significant negative relationship with low density lipoprotein, and B-type natriuretic peptide in patients with obstructive coronary artery disease only. Age, blood pressure, lipid levels, red cell distribution width, glycated hemoglobin, symptoms, New York heart association classification, alcohol drinking, hypertension, diabetes mellitus, troponin levels and B-type natriuretic peptide were the predictors for left ventricular ejection fraction in coronary microvascular disease patients.

Assessing the performance of genome-wide association studies for predicting disease risk

To date more than 3700 genome-wide association studies (GWAS) have been published that look at the genetic contributions of single nucleotide polymorphisms (SNPs) to human conditions or human phenotypes. Through these studies many highly significant SNPs have been identified for hundreds of diseases or medical conditions. However, the extent to which GWAS-identified SNPs or combinations of SNP biomarkers can predict disease risk is not well known. One of the most commonly used approaches to assess the performance of predictive biomarkers is to determine the area under the receiver-operator characteristic curve (AUROC). We have developed an R package called G-WIZ to generate ROC curves and calculate the AUROC using summary-level GWAS data. We first tested the performance of G-WIZ by using AUROC values derived from patient-level SNP data, as well as literature-reported AUROC values. We found that G-WIZ predicts the AUROC with <3% error. Next, we used the summary level GWAS data from GWAS Central to determine the ROC curves and AUROC values for 569 different GWA studies spanning 219 different conditions. Using these data we found a small number of GWA studies with SNP-derived risk predictors that have very high AUROCs (>0.75). On the other hand, the average GWA study produces a multi-SNP risk predictor with an AUROC of 0.55. Detailed AUROC comparisons indicate that most SNP-derived risk predictions are not as good as clinically based disease risk predictors. All our calculations (ROC curves, AUROCs, explained heritability) are in a publicly accessible database called GWAS-ROCS (http://gwasrocs.ca). The G-WIZ code is freely available for download at https://github.com/jonaspatronjp/GWIZ-Rscript/.

Development of a validated risk score for interstage death or transplant after stage I palliation for single-ventricle heart disease

OBJECTIVE

To develop a risk score to predict mortality or transplant in the interstage period.

BACKGROUND

The "interstage" period between the stage 1 and stage 2 palliation is a time of high morbidity and mortality for infants with single-ventricle congenital heart disease.

METHODS

This was an analysis of patients with single-ventricle congenital heart disease requiring arch reconstruction who were enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from 2008 to 2015. The primary composite endpoint was interstage mortality or transplant. Multivariable logistic regression and classification and regression tree analysis were performed on two-thirds of the patients ("learning cohort") to build a risk score for the composite endpoint, that was validated in the remaining patients ("validation cohort").

RESULTS

In the 2128 patients analyzed in the registry, the overall event rate was 9% (153 [7%] deaths, 42 [2%] transplants). In the learning cohort, factors independently associated with the composite endpoint were (1) type of Norwood; (2) postoperative ECMO; (3) discharge with Opiates; (4) No Digoxin at discharge; (5) postoperative Arch obstruction, (6) moderate-to-severe Tricuspid regurgitation without an oxygen requirement, and (7) Extra Oxygen required at discharge in patients with moderate-to-severe tricuspid regurgitation. This model was used to create a weighted risk score ("NEONATE" score; 0-76 points), with >75% accuracy in the learning and validation cohorts. In the validation cohort, the event rate in patients with a score >17 was nearly three times those with a score ≤17.

CONCLUSIONS

We introduce a risk score that can be used post-stage 1 palliation to predict freedom from interstage mortality or transplant.

Addition of estimated cardiorespiratory fitness to the clinical assessment of 10-year coronary heart disease risk in asymptomatic men

The Framingham Risk Score (FRS) was developed to quantify a patient's coronary heart disease (CHD) risk. Non-exercise estimated CRF (e-CRF) may provide a clinically practical method for describing cardiorespiratory fitness. We computed e-CRF and tested its association with the FRS and CHD.

Male participants (n = 29,854) in the Aerobics Center Longitudinal Study (ACLS) who completed a baseline examination between 1979–2002 were followed for 12 years to determine incident CHD defined by self-report of myocardial infarction, revascularization, or CHD mortality. e-CRF was defined from a 7-item scale and categorized using age-specific tertiles. Multivariable survival analysis determined associations between FRS, e-CRF, and CHD. Interaction between e-CRF and FRS was tested by stratified analysis by ‘low’ and ‘moderate or high’ 10-year CHD risk.

Men with high e-CRF were significantly (p-value < 0.0001) younger, and less likely to be smokers, compared to men with low e-CRF. Multivariable survival analysis reported men with high e-CRF were 29% (HR = 0.71; 95% 0.56, 0.88) less likely to experience a CHD event compared to men with low e-CRF. Stratified analyses showed men with ‘low’ 10-year FRS predicted CHD risk and high e-CRF had a 28% (HR = 0.72; 95% CI 0.57, 0.91) lower CHD-mortality risk compared to men with low e-CRF, no association was found in this group and men with moderate e-CRF. Men who were more fit had a decreased risk for CHD compared to men in the lowest third of fitness. Estimated CRF may add clinical value to the FRS and help clinicians better predict long-term CHD risk.

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Men with low e-CRF had a higher proportion of CHD events compared to high-fit men.

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E-CRF was a protective factor of CHD in crude and adjusted analysis.

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E-CRF could be used to capture patient CRF during clinic visits.

A discriminant analysis prediction model of non-syndromic cleft lip with or without cleft palate based on risk factors

BACKGROUND

A risk prediction model of non-syndromic cleft lip with or without cleft palate (NSCL/P) was established by a discriminant analysis to predict the individual risk of NSCL/P in pregnant women.

METHODS

A hospital-based case-control study was conducted with 113 cases of NSCL/P and 226 controls without NSCL/P. The cases and the controls were obtained from 52 birth defects' surveillance hospitals in Hunan Province, China. A questionnaire was administered in person to collect the variables relevant to NSCL/P by face to face interviews. Logistic regression models were used to analyze the influencing factors of NSCL/P, and a stepwise Fisher discriminant analysis was subsequently used to construct the prediction model.

RESULTS

In the univariate analysis, 13 influencing factors were related to NSCL/P, of which the following 8 influencing factors as predictors determined the discriminant prediction model: family income, maternal occupational hazards exposure, premarital medical examination, housing renovation, milk/soymilk intake in the first trimester of pregnancy, paternal occupational hazards exposure, paternal strong tea drinking, and family history of NSCL/P. The model had statistical significance (lambda = 0.772, chi-square = 86.044, df = 8, P < 0.001). Self-verification showed that 83.8 % of the participants were correctly predicted to be NSCL/P cases or controls with a sensitivity of 74.3 % and a specificity of 88.5 %. The area under the receiver operating characteristic curve (AUC) was 0.846.

CONCLUSIONS

The prediction model that was established using the risk factors of NSCL/P can be useful for predicting the risk of NSCL/P. Further research is needed to improve the model, and confirm the validity and reliability of the model.

Milk Consumption and Framingham Risk Score: Analysis of the Korea National Health and Nutrition Examination Survey Data (2008-2011)

PURPOSE

The benefit of milk intake remains controversial. The association between milk consumption and Framingham Risk Score (FRS) in a population consuming relatively low amounts of dairy products is undetermined.

MATERIALS AND METHODS

A total of 13736 adults (5718 male and 8018 female) aged 20-80 years from the Korea National Health and Nutrition Examination Survey (2008-2011) were divided into groups according to milk consumption (rarely, monthly, weekly, and daily) and compared according to FRS after relevant variable adjustments.

RESULTS

The mean FRS in males and females were 6.53 and 5.74, respectively. Males who consumed milk daily (15.9%) had a significantly lower FRS than males having milk rarely (31.6%) or monthly (17.4%; p=0.007). Females who consumed milk daily (22.3%) also had significantly lower FRS than rarely (29.8%), monthly (13.8%), or weekly (34%; p=0.001) consumers. In particular, males ≥60 years old who consumed milk daily had a significantly lower FRS than males who consumed less milk (p<0.001). The odds ratio in this age group showed a significant and gradual increase in the weekly [OR=2.15; 95% confidence interval (CI) 1.14-4.03], monthly (OR=2.29; 95% CI 1.15-4.54), and rarely (OR=3.79; 95% CI 2.01-7.14) milk consumption groups when compared with the daily milk consumption group.

CONCLUSION

Milk consumption was associated with a lower FRS in a low milk-consuming population. In particular, daily milk consumption in males over 60 years old may be beneficial for those at risk for cardiovascular disease.

Association of Cardiorespiratory Fitness With Coronary Heart Disease in Asymptomatic Men

OBJECTIVE

To examine the association of cardiorespiratory fitness (CRF) with risk of coronary heart disease (CHD) while controlling for an individual's Framingham Risk Score (FRS)-predicted CHD risk.

PATIENTS AND METHODS

The study included 29,854 men from the Aerobics Center Longitudinal Study, who received a baseline examination from January 1, 1979, to December 31, 2002. Coronary heart disease events included self-reported myocardial infarction or revascularization or CHD death. Multivariable survival analysis investigated the association between CRF, FRS, and CHD. Cardiorespiratory fitness was analyzed as both a continuous and a categorical variable. The population was stratified by "low" and "moderate or high" risk of CHD to test for differences in the FRS stratified by CRF.

RESULTS

Compared with men without incident CHD, men with incident CHD were older (mean age, 51.6 years vs 44.6 years), had lower average maximally achieved fitness (10.9 metabolic equivalent of tasks vs 12.0 metabolic equivalent of tasks [METs]), and were more likely to have moderate or high 10-year CHD risk (P<.001). Cardiorespiratory fitness, defined as maximal METs, exhibited a 20% lower risk of CHD (hazard ratio, 0.80; 95% CI, 0.77-0.83) for each 1-unit MET increase. Among men in the low CRF strata, individuals with moderate or high 10-year CHD risk, according to the FRS, had a higher CHD risk (hazard ratio, 6.55; 95% CI, 3.64-11.82) than men with low CHD risk according to the FRS.

CONCLUSION

Clinicians should promote physical activity to improve CRF so as to reduce CHD risk, even to patients with otherwise low CHD risk.