To the Editor: Dr Greenland and colleagues1 reported that both the Framingham Risk Score (FRS) and the coronary artery calcium score (CACS) were predictive of coronary artery disease. The authors also reported that across categories of FRS, CACS was predictive of risk among patients with an FRS higher than 10%, but not with an FRS less than 10%. Furthermore, the CACS was less predictive than the FRS (hazard ratio, 3.9 vs 14.3), and only added slightly to the area under the receiver operating characteristic (ROC) curve using FRS alone.
We point out that the FRS has a wide confidence interval (5.1%-6.9%) depending on the number of initial measurements in this type of patient2 and so it is possible that no significant difference exists given the size of the ROC envelope for the FRS and the small numbers of events that occurred in the study. The original cohort for the FRS included a larger proportion of smokers (40%) than is currently present in the population, and it is likely that the performance of the FRS was better than that observed now due to risk-factor drift away from smoking and toward diabetes.3 Modification of the FRS by the addition of inflammatory markers (eg, high-sensitivity C-reactive protein [hsCRP]) has been suggested as a way to improve performance,4 but this may be limited by large biological variation. While the combination of FRS and hsCRP levels might have been superior to the combination of FRS and CACS, the authors did not measure hsCRP levels.
Finally, we suspect that this study did not include patients with diabetes, given the National Cholesterol Education Program guidelines. However, the FRS used in many countries does include diabetes as a variable. The high rate of arterial calcification in this group may further confound estimates of risk determined by CACS scores.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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