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3. Calculate 10-Year Risk for CHD or Add Up Cardiac Risk Factors

The National Cholesterol Education Program Adult Treatment Panel III (ATP III) defines high risk as a net of two or more (CHD) risk factors, which leads to more vigorous intervention (National Cholesterol Education Program, 2001 [R]).  Identified risk factors are:

  • Age 45 years or older for men; age 55 years or older for women. CHD rates are higher in the elderly than in the young, and in men more than in women of the same age.

  • A family history of premature CHD, defined as definite myocardial infarction (MI) or sudden death before age 55 in the father or a male primary relative, or before age 65 in the mother or a female primary relative.

  • Currently smoking.

  • Hypertension, defined as blood pressure greater than 140/90 mmHg (confirmed by measurement on several occasions) or current use of any antihypertensive medication.

  • Low HDL-cholesterol level (less than 40 mg/dL).
Emerging non-traditional risk factors such as C-reactive protein (CRP) and total homocysteine have been shown to have some predictive values in screening vascular disease. The value of screening for these risk factors is not yet known.

A cardiac risk calculator based on the Framingham study can be accessed through the following Web site:


Obesity and physical inactivity are not listed as risk factors, but should be considered as targets for intervention. Obesity operates through other risk factors (hypertension, hyperlipidemia, decreased HDL-cholesterol and diabetes mellitus).  

If HDL-cholesterol is 60 mg/dL or higher, one risk factor may be subtracted because high HDL-cholesterol levels decrease CHD risk. (For example, if a patient has three risk factors but his or her HDL-cholesterol level is 60 mg/dL or higher, one risk factor is subtracted, leaving a total of two risk factors.)

Family history

Family history of coronary artery disease was identified as a risk factor by the National Cholesterol Education Program (NCEP) in an attempt to screen for heterozygous familial hypercholesterolemia, as well as other genetically predisposed populations to coronary disease. Heterozygous familial hypercholesterolemia affects 1 in 500 persons in the United States, with the risk of death from coronary artery disease increased almost fourfold between the ages of 20 and 74. (Myocardial infarction leading to sudden death often occurs in these men in their 30s or 40s, and by age 50, 80 percent of males have ischemic heart disease.) Without intervention, approximately 50%-75% of men with heterozygous familial hypercholesterolemia will have a myocardial infarction by age 60. Thompson showed the prevalence of coronary disease in men at age 35 equalled that in women at age 40 in contrast to the typical 10-year lag between men and women. 

(Bild, 1993 [R]; Goldstein, 1989 [R]; Scientific Steering Committee on behalf of the Simon Broome Register Group,1991 [R]; Thompson, 1989 [R]; Williams, 1986 [D]; Yamamoto, 1989 [D])  

C-reactive protein (CRP), if measured by high-density lipoprotein, may have an independent value as a predictor of cardiovascular disease risk and independent value in identifying patients with normal lipids who could benefit from treatment (Albert, 2002 [C]).