Your doctor told you your Framingham risk score and the number was higher than you expected. Maybe you were told you have a 20% chance of a heart attack or stroke in the next 10 years. That is alarming to hear, but it also means you have a real opportunity, because most of the factors driving that number are things you can change.
The Framingham risk score estimates your 10-year risk of a cardiovascular event based on age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure treatment status, smoking status, and diabetes status. Some of these you cannot change. Most of them you can.
Understanding Your Risk Category
Framingham risk scores are grouped into three categories:
- Low risk (below 10%): Less than 10% chance of a cardiovascular event in the next 10 years. Lifestyle measures are the primary focus
- Intermediate risk (10% to 20%): Moderate risk. Aggressive lifestyle changes are recommended, and medication may be discussed depending on individual factors
- High risk (above 20%): Significant risk. Both lifestyle changes and medication are typically recommended. This risk level is treated similarly to having existing heart disease
Modifiable Risk Factors: What You Can Change
1. Quit Smoking
Smoking is the single most impactful modifiable risk factor in the Framingham score. Quitting smoking can reduce your 10-year cardiovascular risk by 30 to 50% within just a few years.
Within 1 year of quitting, your excess heart disease risk drops by about half. Within 5 to 15 years, your stroke risk drops to that of a nonsmoker. If your Framingham score is high and you smoke, quitting will move that number more than almost any other single change.
Talk to your doctor about cessation aids. Nicotine replacement therapy, bupropion, and varenicline all significantly improve quit rates. You can assess your nicotine dependence level with our nicotine dependence test.
2. Lower Your Blood Pressure
Systolic blood pressure is one of the most heavily weighted factors in the Framingham calculation. Reducing systolic blood pressure by just 10 mmHg lowers cardiovascular risk by about 20%.
Evidence-based strategies for lowering blood pressure:
- Reduce sodium intake: Aim for less than 2,300 mg per day. Most Americans consume over 3,400 mg daily
- DASH diet: This eating pattern, rich in fruits, vegetables, whole grains, and low-fat dairy, can lower systolic blood pressure by 8 to 14 mmHg
- Exercise: Regular aerobic exercise lowers systolic blood pressure by 4 to 9 mmHg
- Weight loss: Each kilogram (2.2 pounds) lost reduces systolic blood pressure by approximately 1 mmHg
- Limit alcohol: More than two drinks per day for men or one for women raises blood pressure
- Medication: If lifestyle measures are insufficient, several classes of blood pressure medications are highly effective
Monitor your progress with our blood pressure calculator to understand where your readings fall.
3. Improve Your Cholesterol
The Framingham score uses both total cholesterol and HDL (good) cholesterol. You want your total cholesterol lower and your HDL higher.
To raise HDL cholesterol:
- Exercise: Aerobic exercise for 30 or more minutes, 5 times per week, can raise HDL by 5 to 10%
- Lose excess weight: For every 6 pounds lost, HDL may increase by 1 mg/dL
- Choose healthy fats: Olive oil, avocados, nuts, and fatty fish raise HDL while lowering LDL
- Quit smoking: Quitting can raise HDL by up to 10%
To lower total and LDL cholesterol:
- Reduce saturated fat: Limit to less than 7% of daily calories. Replace with unsaturated fats
- Increase soluble fiber: Oats, beans, lentils, and psyllium lower LDL by 5 to 10%
- Statins: When prescribed, statins typically lower LDL by 30 to 50% and are one of the most evidence-backed medications in all of cardiology
4. Manage Diabetes
Having diabetes roughly doubles your cardiovascular risk. If you have diabetes, keeping your A1C below 7% and maintaining good blood sugar control reduces the cardiovascular complications of diabetes.
Newer diabetes medications like SGLT2 inhibitors and GLP-1 receptor agonists have been shown to reduce cardiovascular events independently of their blood sugar effects. Ask your doctor if these might be appropriate for you.
5. Lose Excess Weight
Weight is not directly in the Framingham formula, but it affects nearly every variable that is: blood pressure, cholesterol, and diabetes risk. Losing 5 to 10% of your body weight can improve all of these simultaneously.
Non-Modifiable Risk Factors
Some factors in the Framingham score cannot be changed:
- Age: Risk increases with age. This is the strongest factor in the score
- Sex: Men generally have higher cardiovascular risk than premenopausal women, though women’s risk increases after menopause
You cannot change these factors, but understanding them helps explain why your score may be higher than expected even with healthy habits. A 60-year-old with perfect cholesterol will still have a higher score than a 30-year-old with mediocre cholesterol, simply because of age.
How Much Can You Actually Lower Your Score?
The potential reduction depends on your starting point and which factors are driving your score. Realistic examples:
- A smoker who quits and adopts the DASH diet might see their 10-year risk drop from 22% to 12%
- Someone who starts a statin, lowers blood pressure with medication, and begins exercising might see their risk drop from 18% to 9%
- A person who loses 30 pounds, bringing blood pressure and cholesterol into normal range, might see their risk drop from 15% to 8%
These are illustrative, not guaranteed. Your actual results depend on your specific numbers and how much room there is for improvement.
When Medication Is Recommended
For people with a 10-year risk above 20%, or between 10% and 20% with additional risk factors, medication is often recommended in addition to lifestyle changes:
- Statins for high LDL cholesterol. The benefit is well-established for anyone with a 10-year risk above 10%
- Blood pressure medications if lifestyle changes do not bring blood pressure below 130/80
- Low-dose aspirin may be considered for some high-risk patients, though this recommendation has narrowed in recent years. Discuss with your doctor
Frequently Asked Questions
How often should I recalculate my Framingham score?
Annually is typical, ideally at your yearly physical when you have fresh cholesterol and blood pressure numbers. More frequent calculation can be motivating if you are actively working to improve your risk factors.
Is the Framingham score accurate for everyone?
The Framingham score was developed in a predominantly white population and may underestimate risk in some groups and overestimate it in others. The ACC/AHA Pooled Cohort Equations, developed from more diverse populations, are now more commonly used in clinical practice. Both tools assess similar risk factors.
My score is high mostly because of my age. What can I do?
Focus on the factors you can control. Even if your absolute risk number remains above 10% due to age, improving your cholesterol, blood pressure, and other modifiable factors still meaningfully reduces your actual risk of a cardiovascular event.
