Validity of the Framingham point scores in the elderly: results from the Rotterdam study

Am Heart J. 2007 Jul;154(1):87-93. doi: 10.1016/j.ahj.2007.03.022.


Background: The National Cholesterol Education Program recommends assessing 10-year risk of coronary heart disease (CHD) in individuals free of established CHD with the Framingham Point Scores (FPS). Individuals with a risk >20% are classified as high risk and are candidates for preventive intervention. We aimed to validate the FPS in a European population of elderly subjects.

Methods: Subjects free of established CHD at baseline were selected from the Rotterdam study, a population-based cohort of subjects 55 years or older in The Netherlands. We studied calibration, discrimination (c-index), and the accuracy of high-risk classifications. Events consisted of fatal CHD and nonfatal myocardial infarction.

Results: Among 6795 subjects, 463 died because of CHD and 336 had nonfatal myocardial infarction. Predicted 10-year risk of CHD was on average well calibrated for women (9.9% observed vs 10.1% predicted) but showed substantial overestimation in men (14.3% observed vs 19.8% predicted), particularly with increasing age. This resulted in substantial number of false-positive classifications (specificity 70%) in men. In women, discrimination of the FPS was better than that in men (c-index 0.73 vs 0.63, respectively). However, because of the low baseline risk of CHD and limited discriminatory power, only 33% of all CHD events occurred in women classified as high risk.

Conclusions: The FPS need recalibration for elderly men with better incorporation of the effect of age. In elderly women, FPS perform reasonably well. However, maintaining the rational of the high-risk threshold requires better performing models for a population with low incidence of CHD.

Publication types

  • Validation Study

MeSH terms

  • Aged
  • Body Mass Index
  • Calibration
  • Cholesterol, HDL / blood
  • Comorbidity
  • Coronary Disease / blood
  • Coronary Disease / classification*
  • Coronary Disease / epidemiology*
  • Coronary Disease / prevention & control
  • Discriminant Analysis
  • Electrocardiography
  • False Positive Reactions
  • Female
  • Humans
  • Hypertension / epidemiology
  • Male
  • Middle Aged
  • Models, Statistical*
  • Myocardial Infarction / mortality
  • Netherlands / epidemiology
  • Predictive Value of Tests
  • Primary Prevention / statistics & numerical data
  • Reproducibility of Results
  • Risk Assessment / standards*
  • Smoking / epidemiology
  • Survival Rate


  • Cholesterol, HDL