alvina


27

ABSTRACT

Cardiovascular disease (CVD) risk factors, such as diabetes, hypertension,
hypercholesterolemia,  smoking, and obesity tend to occur together in the general
population. Increasing prevalence of multiple CVD risk factors has been related
to increased risk of death from coronary heart disease and stroke. Studies have
suggested that people with several risk factors of CVD may have impaired health-
related quality of life. The objective of this study was to assess the association
of CVD risk factors with quality of life (QOL) among adults aged 40 to 65
years. A cross-sectional study was conducted involving  220 subjects 40 - 65
years of age at a health center. The CVD risk factors were assessed using the
Framingham risk score that is the standard instrument for assessment of the risk
of a first cardiac event. The risk factors assessed were age, smoking, blood
pressure, total cholesterol and high density lipoprotein cholesterol concentrations.
QOL was assessed by means of the WHOQOL-BREF instrument that had been
prevalidated. The results of the study showed that 28.2% of subjects were
smokers, 56.4% had stage 1 hypertension, 42.8% high total cholesterol and
13.6% low HDL cholesterol. The high risk group amounted to 45.5% and 42.3%
constitued an intermediate risk group. High CVD risk scores were significantly
associated with a low QOL for all domains (physical, psychological, social and
environment) (p=0.000). Preventing or reducing the multiple CVD risk factors
to improve QOL is necessary among adults.

Keywords: Framingham risk score, quality of life, adult

*Medical Profession Study
Program, Medical Faculty,
Trisakti University

Correspondence
aChristian Yosaputra
Medical Profession Study
Program, Medical Faculty,
Trisakti University
Jl. Kyai Tapa No.260
Grogol - Jakarta 11440

Univ Med 2010;29:27-33

High Framingham risk score decreases
quality of life in adults

Christian Yosaputra*a, Erica Kholinne*, and Erick Susanto Taufik*

January-April, 2010January-April, 2010January-April, 2010January-April, 2010January-April, 2010              Vol.29 - No.1             Vol.29 - No.1             Vol.29 - No.1             Vol.29 - No.1             Vol.29 - No.1

UNIVERSA MEDICINA

INTRODUCTION

Chronic diseases are considered major
threats to the quality of life (QOL). Prevalence
rates of most chronic diseases increase with
age and a substantial part of the elderly
population suffers from more than one chronic

disease. Since chronic diseases and conditions
a r e  p a r t  o f  t h e  e v e r y d a y  l i f e  o f  a  l a rg e
proportion of the population, it is considered
important to do research on their QOL. One of
the frequently encountered chronic diseases is
cardiovascular disease (CVD). CVD has
become the leading cause of morbidity and



28

Yosaputra, Kholinne, Taufiq

m o r t a l i t y  f o r  m e n  a n d  w o m e n ,  b o t h  f o r
developed and developing countries and rates
are expected to rise further over the next few
decades.(1-3) The prevalence and incidence of
cardiovascular disease increases exponentially
with age.(4) Despite the fact that over the
lifespan, approximately the same proportion of
the female population as the male population
dies of complications resulting from CVD, it
has been traditionally considered as a middle-
age disease. The increasing burden of CVD has
important economic implications. CVD occurs
typically at a younger age in developing as
c o m p a r e d  t o  d e v e l o p e d  c o u n t r i e s ,  w i t h
i m p o r t a n t  c o n s e q u e n c e s  s u c h  a s  l o s s  o f
r e v e n u e  a t  h o u s e h o l d  l e v e l  a n d  l o s s  o f
productivity at macroeconomic level.(5)

In Indonesia, the results of the Basic
Health Research Survey (Riset Kesehatan
D a s a r )  o f  t h e  y e a r  2 0 0 7 ,  s h o w e d  t h e
prevalence of CVD to be 7.2%.(6) CVD is
inseparable from an individual’s unhealthy
lifestyle in consequence of changes in patterns
of living. The Framingham heart study has
d e v e l o p e d  m a t h e m a t i c a l  f u n c t i o n s  f o r
predicting risk of clinical coronary heart
disease (CHD) events, viz. multivariable
mathematical functions that assign weights to
major CHD risk factors such as sex, age, blood
pressure (BP), total cholesterol (TC), low-
density lipoprotein cholesterol (LDLC), high-
density lipoprotein cholesterol (HDL-C),
smoking behavior, and diabetes status.(7) These
mathematical functions are known as the
Framingham risk score (FRS), on the basis of
which the risk of CVD for a given individual
may be predicted.

Physical conditions such as high BP or
body mass index (BMI) as well as risk behaviors
(such as smoking, alcohol drinking and poor
nutritional habits) have been recognized as risk
factors for cardiovascular diseases. In addition,
psychosocial factors have been suggested as risk
factors for atherosclerotic disease.(8)

It is known that health is one of the
significant factors that influence a person’s

QOL. Chronic diseases are considered major
threats to the QOL of western populations.(9)

Prevalence rates of most chronic diseases
increase with age and a substantial part of the
elderly population suffers from more than one
chronic disease.

The goal of a health service is not only
viewed from the aspect of an individual’s
survival rate, but also from his/her QOL. The
World Health Organization (WHO) generally
evaluates an individual’s QOL by means of
multi-dimensional parameters, comprising
physical, psychological, environmental and
social functions, which affect the well being
of an individual’s life. (10) The WHO has
recently developed a generic profile subjective
QOL instrument, the WHOQOL-100, and its
brief version, the WHOQOL-BREF.(11) This
instrument may be used for assessing an
individual’s quality of life. If an individual has
many risk factors for CVD, his/her QOL will
decline. In the physical dimension the lowered
health status will be clearly seen,  the more so
if the parameters of lipid and BP levels are at
least borderline (threshold). (12) It may be
hypothesized that a high FRS may lower an
individual’s QOL, which naturally has to be
proven. The aim of this study was to investigate
the associations between the cardiovascular
risk factors as measured by FRS and the level
of QOL in adult subjects in primary care.

METHODS

Study setting and design
T h e  p r e s e n t  s t u d y  w a s  a n a l y t i c a l -

observational with cross-sectional approach
performed at one of the South Jakarta districts
in November 2007.

Subjects of study
The study subjects were patients visiting

the district health center selected according to
the following inclusion criteria: aged between
40 and 65 years, able to communicate verbally
a n d  w i l l i n g  t o  p a r t i c i p a t e  i n  t h e  s t u d y.



29

Exclusion criteria were past history of stroke
and coronary heart disease based on the
information provided by their physician. The
age range of 45 to 65 years constitutes the
r e p r o d u c t i v e  a g e  a n d  i s  a s s o c i a t e d  w i t h
substantially better health-related QOL and
less illness in older age.(13)

Demographic variables and history of CVD
The collected variables were age, sex,

occupation, and educational attainment. The
educational level was categorized as no
education, not finishing elementary school,
elemenrary school graduate, junior high school
graduate, senior high school graduate, college
or university graduate. A history of CVD was
determined by an affirmative answer to the
question, “Has a doctor, nurse, or other health
professional ever told you that you had any of
the following: (a) a heart attack, also called a
myocardial infarction; (b) angina or coronary
heart disease; or (c) a stroke?”

Cardiovascular risk factors
The Framingham Risk score (FRS) is the

standard instrument used to assess the risk of
a first cardiac event and to guide the institution
of primary preventive therapy in individuals
at risk of CVD.(8,14) On the basis of the FRS,
the risk of CVD is categorized as (i) low: score
= 0; (ii) intermediate: score = 1-10; (iii) high:
score =11-20;and (iv) very high: score ≥ 20.
In this study, the CVD risk factors collected
comprised total and HDL-C, hypertension and
smoking.

Total and HDL-C
After the subjects had fasted overnight,

venous blood samples were drawn to measure
T C  a n d  H D L - C  i n  w h o l e  p l a s m a .
Hiperlipidemia is the condition of high blood
lipid levels. The normal TC concentration is
140-200 mg/dL or less. The normal HDL-C
concentration is more than 40 mg/dl. Thus a
HDL-C concentration of < 40 mg/dL is a risk
factor for CVD. The ratio of TC to HDL-C

should be < 4.6 in males and < 4.0 in females.
The risk for CHD increases proportionally with
TC: HDL-C ratio. According to the FRS, the
lipid profile affecting CHD risk comprises total
a n d  H D L - C . ( 7 , 1 5 ) T h e  l i p i d  p r o f i l e s  w e r e
determined at the Pramita Utama Laboratory.

Systolic and diastolic blood pressure
Single systolic BP measurements were

performed with a mercury sphygmomanometer,
with the cuff placed on the right brachial artery
at the upper arm 2 cm proximal to the cubital
fossa in seated non-smoking subjects. BP
categories were defined on the basis of the
S e v e n t h  R e p o r t  o f  t h e  J o i n t  N a t i o n a l
Committee (JNC VII).(16)

Smoking
All participants were interviewed about

present and past smoking habits. Current and
past smokers of cigarettes and cigars were
judged to have a history of smoking.

QOL assessment
QOL was assessed using the Indonesian

version of the WHOQOL-BREF questionnaire.
This questionnaire is made up of 26 items
which assess the following four domains: (i)
physical domain, consisting of 7 items, (ii)
psychological domain, with 6 items, (iii) social
r e l a t i o n s  c o m p r i s e s  3  i t e m s ,  a n d  ( i v )
environment, with 8 items. The WHOQOL-
BREF also measures 2 facets of general QOL:
(i) overall QOL and (ii) general health. Each
item is given a score of 1–5, and a higher score
indicates a better QOL. Scores for each domain
are calculated by multiplying the average score
of each facet by 4. A domain is not given a
score if ≥ 20% items have been left unanswered
by the respondent. The WHOQOL-BREF
instrument has been validated and has shown
a high validity and reliability for assessment
of the QOL of the elderly.(17) Calculations of
high and low QOL categories in each domain
are based on the highest and lowest scores for
the respective domains according to the

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30

Yosaputra, Kholinne, Taufiq

responses of the respondents. The highest and
lowest scores are totaled and then divided by
2. The value obtained by this division is taken
as the cut-off point for separating the group
with a high QOL and that with a low QOL.

Data analysis
For every participant, we calculated the

FRS using the classic Framingham equation,
and participants were assigned to high risk,
intermediate risk, and low risk groups. The
distributions of several major factors of CVD
and the QOL domains were analyzed by means
of percentage analysis. The Pearson correlation
analysis was used for determining a correlation
between CVD risk factors (according to FRS)
and QOL. The analyses were done using SPSS
for Windows version 15. A p-value < 0.05 was
considered statistically significant.

RESULTS

A total of 220 study subjects participated
in this study with an age range of 40 - 65 years.
More than half of the subjects (58.6%) were
females, while males accounted for 41.4%,
Eighty percent of the subjects had a low
educational level (uneducated and not passing
e l e m e n t a r y  s c h o o l )  a n d  5 5 . 9 %  w e r e
housewifes. The distribution of cardiovascular
risk is presented in Table 2. Some 28.2% of
subjects were smokers, 56.4% had stage 1
hypertension, 42.8% high TC and 13.6% low
HDL-C.

Of all of the individual risk factors
included in the FRS calculation, approximately
45.5% was in the high risk category, 42.3%
was categorized as intermediate risk and 8.6%
as low risk (Table 3).

From Table 4, it is apparent that in the
physical domain subjects with a good QOL
a m o u n t e d  t o  4 0 . 5 % ,  w h e r e a s  i n  t h e
psychological domain good QOL subjects
totaled 51.8%. In the social domain good QOL
s u b j e c t s  a c c o u n t e d  f o r  5 5 %  a n d  i n  t h e
environmental domain 55.5% of subjects had
a good QOL.

Table 2. Distribution of cardiovascular risk
for all subjects (n=220)

Table 1. Classification of blood pressure for adults(16)

Note: BP= blood pressure; SBP= systolic blood pressure; DBP= diastolic blood pressure

Table 3. Cardiovascular risk for all subjects
based on Framingham risk score



31

The results of the Pearson correlation test
demonstrated the presence of a statistically sig-
nificant inverse correlation between FRS and
QOL in the physical (r = -0.491; p = 0.000),
psychological (r = -0.52; p = 0.000), social (r =
-0.496; p = 0.000), and environmental domains
(r = -0.512; p = 0.000) (Table 5). High FRS val-
ues indicate a poor QOL in each domain.

DISCUSSION

T h e  p r e s e n t  s t u d y  e x a m i n e d  t h e
association between CVD risk and QOL.
According to FRS values, 45.5% of subjects
in the age range of 40 to 65 years were at high
risk of CVD. Subjects with a high FRS had a
correspondingly high risk of CVD. FRS is used
for predicting the occurrence of CVD after 10
years (10-year risk prediction) in individuals
aged 30 to 74 years who have not suffered from
CVD. A prospective study in subjects aged >45

years without any complaints of CVD and were
followed-up for approximately 8.5 year,
indicated that the risk of CHD death or nonfatal
MI for participants in the highest FRS group
was 4.3 higher that of participants in the lower
FRS group (p=0.009).(18) Our study determined
that only 8.6% of subjects were at low risk of
CVD. Similar results were obtained in a cohort
study of subjects in the age range of 36-64
years, indicating that only a small minority of
t h e  c o h o r t  ( < 1 0 %  o f  t h e  e n t i r e  3 9 5 2 2
participants) met the criteria for low risk at the
baseline examination in 1967-1973. Of note,
participants with 0 risk factors also had better
outcomes than those with 1 or more high risk
factors.(19) Subjects at high risk of CVD should
attempt to reduce their risk factors, as most of
them are amenable to modification. Smokers
should stop this habit. Our study showed that
the prevalence of main risk factors was: 56.4%
for stage I hypertension (140-159 mmHg);
42.8% for high TC (≥240 mg/dL); 13.6% for
low HDL-C (<40 mg/dL); and 28.2% for
s m o k i n g .  A d d i n g  a l r e a d y  r e c o g n i z e d
cardiovascular risk factors in this group may
put them in a challenged life situation. They
are a vulnerable population subgroup that
needs puhlic health attention. The three major
coronary risk factors, viz. serum cholesterol,
BP, and cigarette smoking, are important
because of their high prevalence and impact
on risk, and their prevention could have a great
influence on longevity, health care costs and
QOL. Assessing effects of cardiovascular risk
profile, rather than individual risk factors, is
also of public health importance.

Table 5. Correlation between Framingham risk score and respective QOL domains

* r = Pearson correlation coeficient

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Table 4. Distrbution of each domain of QOL



32

Yosaputra, Kholinne, Taufiq

Our study indicates that high CVD risk
tend to significantly lower the QOL in subjects
aged 40-65 years for all four domains (physical,
psychological, social and environmental).
Several previous studies obtained results
consistent with ours, in that higher CVD risk (a
combination of hypertension, hyperlipidemia,
and smoking) had an adverse impact on
HRQOL.(20-22) The influence of increasing
numbers of risk factors, was generally additive.
Thus accumulation of more CVD risk factors
may be associated with a more substantial
impairment of QOL.(23) However, no causality
can be drawn from the presented results and
therefore prospective studies are needed to
allow causal inferences to be drawn.

Actually the three major coronary risk
factors (serum cholesterol, BP, and cigarette
s m o k i n g )  a r e  v a r i a b l e s  a m e n a b l e  t o
intervention. A study has demonstrated that
p r i m a r y  p r e v e n t i o n  t h r o u g h  l i f e s t y l e
i n t e r v e n t i o n  i n  p r i m a r y  h e a l t h c a r e  h a s
favourable effects on several cardiovascular
risk factors in moderate to high risk patients,
and the improvements can persist for up to one
year.(24) Subjects in the high CVD risk group
should be motivated to complete such an
intervention program.

A weakness of our study would be the
limited number of CVD biomarkers selected
for investigation. Other biomarkers such as
diabetes, low density lipoprotein cholesterol,
and obesity should also have been included. A
second limitation of our study is that the
majority of subjects were female with a low
level of education, so that the study results
cannot be generalized to populations with
differing characteristics.

CONCLUSIONS

A high prevalence of major risks factors
was found in our study. The majority of
subjects were in the groups of intemediate and
high risk CVD, as assessed by the FRS. The
data in this study support the hypothesis that

an individual with a high risk of CVD at 10-
years prediction will experience a lowered
QOL. These findings stress the need for
affordable, cost-effective treatment strategies
and the critical importance of public health
strategies aimed at reducing risk factors in the
entire population.

ACKNOWLEDGEMENTS

We are deeply indebted to all respondents
who participated in this study. We are also
g r a t e f u l  f o r  h e l p f u l  c o m m e n t s  f r o m  t h e
reviewers of this paper.

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