MDCalc

Framingham Risk Score for Hard Coronary Heart Disease

Estimates 10-year risk of heart attack in patients 30-79 years with no history of CHD or diabetes.

There are several distinct Framingham risk models. MDCalc uses the 'Hard' coronary Framingham outcomes 10-year risk model, which is intended for use in adults aged 30–79 years with without diabetes, prior coronary heart disease (CHD), or intermittent claudication. This version was selected because it is the most widely applicable to patients without previous cardiac events. See the official Framingham website for additional risk models.

While historically the standard for cardiovascular risk assessment in North America, the FRS has largely been superseded by newer risk calculators, such as the ACC/AHA Pooled Cohort Equations (2013) and PREVENT equations (2024), in contemporary guidelines. 

years
Sex
Smoker
mm Hg
Blood pressure being treated with medicines

Result:

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Advice
  • Consider this score as one component of a comprehensive risk assessment rather than the sole determinant of treatment decisions. 
  • Use the score to facilitate shared decision-making about the benefits and risks of preventive therapies.
  • Reassess risk at regular intervals and after significant changes in the patient’s risk factor profile.
  • Recognize that this tool was developed primarily in non-Hispanic white populations; performance may vary in other ethnic groups.
  • Do not use this score for patients with established cardiovascular disease, as these individuals require intensive risk factor modification regardless of calculated risk.
Management

Consider risk-based treatment recommendations based on the clinical context and FRS categories:

  • Low risk (<10%):
    • Emphasize lifestyle modification, including diet, physical activity, weight management, and smoking cessation.
    • Statin therapy is generally not indicated unless other high-risk features are present.
  • Intermediate risk (10%–20%):
    • Moderate-intensity statin therapy is reasonable, particularly when risk-enhancing factors are present.
    • Consider coronary artery calcium scoring or other biomarkers (e.g., hs-CRP, Lp[a]) to further refine risk and guide treatment decisions.
    • Intensive lifestyle modifications.
  • High risk (>20%):
    • Consider high-intensity statin therapy with a goal of ≥50% LDL cholesterol reduction.
    • Aggressively manage all modifiable risk factors, including blood pressure and tobacco use.
    • Consider additional lipid-lowering therapy if LDL goals are not achieved with statins alone.

Always refer to the most current guidelines to guide treatment decisions.

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