UF cardiologists develop heart disease risk score for women with chest pain

A new risk assessment score designed to pinpoint the likelihood a woman with early signs of heart disease will eventually experience a bad outcome such as heart attack, stroke or death appears to determine a patient’s prognosis more effectively than standard methods alone, University of Florida cardiologists will report today at the American Heart Association’s Scientific Sessions 2004 in New Orleans.

Coronary heart disease is the leading cause of death and disability among U.S. women, yet the tools cardiologists use to assess cardiovascular risk in women with chest pain are inadequate, say UF researchers who developed the score.

The new approach — called the WISE score — takes into account 10 factors, traditional ones such as age, smoking, diabetes and hypertension and those increasingly recognized as playing a role in heart disease development and progression. These include elevated levels of inflammatory markers and low levels of the oxygen-carrying molecule hemoglobin. Other aspects are blood vessels that malfunction in response to exercise or blood flow-regulating chemicals in the body, and the presence of metabolic syndrome, characterized by a constellation of symptoms, including obesity.

The WISE score builds upon the renowned Framingham risk score, the standard in cardiovascular disease risk assessment since the mid-1990s.

“One of the challenges in managing women with chest pain is determining what their risk of future cardiovascular events is,” said Christopher B. Arant, M.D., a cardiologist at the University of Florida College of Medicine and the lead author of the research abstract to be presented today. “But the Framingham risk score is traditionally used for asymptomatic patients, and it also doesn’t look at other risk factors such as inflammatory markers, which are becoming increasingly recognized as important risk factors for heart disease. Data suggest women may have more inflammation as the underlying root of their coronary disease. That’s partly why the WISE score may be useful.

“When we used traditional and novel risk factors, we were able to add to the Framingham risk score as far as our ability to predict adverse outcomes,” Arant added. “It appears that by looking at our risk score you gain more prognostic information than just by looking at the Framingham risk score.”

These findings stem from an analysis that showed traditional risk scores poorly predict future cardiovascular complications in patients enrolled in the Women’s Ischemia Syndrome Evaluation — a multicenter National Heart, Lung and Blood Institute-sponsored study of women with suspected reduced blood flow to the heart. WISE aims to evaluate more than 900 women with chest pain to better define the prevalence, severity and complexity of heart disease in women. It also seeks to identify ways of predicting heart disease, in part by finding ways to eliminate risk factors for heart disease as early as possible, before arteries begin to clog.

The WISE score was developed after UF researchers studied 510 women enrolled in WISE for an average of three years. All women underwent comprehensive tests that included coronary angiography to assess whether they had blocked arteries, a cholesterol screening, and blood work to measure hemoglobin levels and inflammatory markers such as C-reactive protein.

UF researchers then tracked the women to see how many suffered a heart attack, congestive heart failure or stroke, or died. Overall, 14 percent died or were hospitalized for heart attack, heart failure or stroke. In addition, an individual woman’s risk rose the more risk factors she had, Arant said. Twenty percent of those with six risk predictors experienced an adverse cardiovascular event, as did 36 percent of those with seven factors and 53 percent of those with eight or more, he said.

“Cardiologists traditionally use the Framingham risk score to assess the risk of future problems,” said Carl J. Pepine, M.D., chief of cardiovascular medicine at UF’s College of Medicine. “The problem is when you apply the Framingham risk score to women it performs very poorly. Part of the reason is it doesn’t have a provision for metabolic syndrome, which is increasingly prevalent among women. But there also are other things wrong with it. It’s been looked at in Europe and not found to be predictive of disease because of other limitations. The other problem with the Framingham risk score is it was not derived in the minority population that we’re seeing; 14.5 percent of the population is now Hispanic and growing rapidly. Our study shows some additional evidence that there is something that can provide additional information.”

UF researchers plan to further test the WISE risk score’s usefulness by studying an additional 1,000 women and evaluating their health over time. For now, Arant said, “in women presenting with chest pain, the WISE risk score appears to be a better tool for predicting adverse events than the Framingham risk score.”

“This is clearly a significant advance in our ability to predict risk in women, whose cardiovascular risk is harder to stratify compared with men,” said Noel Bairey Merz, M.D., medical director and endowed chair of the Women’s Health Program and the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles. “For example, the majority of women will be low risk until very advanced ages, and yet cardiovascular disease kills more young and middle-age women than breast cancer. So we clearly have to do a better job with risk prediction so we can find those women who need and would benefit from treatment.

“The critically important next steps are to do further research to translate this into clinical practice,” added Merz, WISE study scientific chairwoman. “We need to make it user-friendly, and we need to validate it in a real-world situation as rapidly as possible to try to get this in the hands of practicing doctors so they can use it and do a better job of risk assessing and treating women.”