Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Timing of smoking
- Sunil Bhudia (15 July 2001)
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Why Not Weight?
- Sally Weerts (16 July 2001)
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Sense at last !
- Des Spence (17 July 2001)
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Individual cardiovascular risk cannot be predicted
- Jörgen Vesti-Nielsen (17 July 2001)
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Additional risk predictors of morbidity and mortality 0f Cardiovascular disease in adults.
- Munir E Nassar (18 July 2001)
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An Individual Profile
- Ian Niven (18 July 2001)
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The score may underestimate the risk
- Y Adi (19 July 2001)
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Importance of other risk factors
- Chng Kooi-Seng (20 July 2001)
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Further comments On Prof. Pocock 's paper and co-workers.
- Munir E Nassar (22 July 2001)
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Methodological problems in outcome prediction
- Ville Pettilä (24 July 2001)
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Which blood pressure, cholesterol, and creatinine measurements are the most appropriate
- Michael J White (3 August 2001)
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Sunil Bhudia, Cardiothoracic Research Clevelend Clinic Foundation
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This is a very useful study. Does the duration or the commencement of smoking have any any significance? From the stratification the risk is allocated to age banding. What if a 55 years old lady, previously a non-smoker, starts smoking >20 cigs/day, does her scoring change from 9 to say 13? Is the assumption in the smoking history that they have been smoking for an X number of years? What happens to people who stop smoking? |
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Sally Weerts, Associate Professor MN State Univ. Mankato
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How can height, not weight be a risk factor? AND how can BMI or some such be ignored as a risk factor? |
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Des Spence, GP Glasgow Maryhill Health Centre
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Dear Editor The 1.article is a challenge to current practice. We are very busy in General Practice but often this activity is poorly focussed and of very questionable benefit. Like many practices we run a hypertension clinic and try to follow the latest 2.Hypertension guidelines ( currently moving to multiple drug treatments in resistant cases – which is generally all of them if we use current targets ) The advent of the computer based Cardiovascular Risk calculators allows us for the first time graphically to give the patient a sense of their individual risk and what happens when the risks are modified. The average BP drop seen the trial data of ( 12.8 mmHg Systolic and 5.8 mmHg ), which anecdotally is more than I see in practice, is frankly of virtually no value when compared to other risk factor modification like smoking and cholesterol for which we do have effective interventions. Height is a different issue perhaps we should bring back the rack ! This is a call to arms that in we stop talking about the “Hypertension Clinic”, stop making people tired and impotent with our medication, give our patients a truly “informed Choice” about the benefits of treatment, stop the publication of the “ ABC of Hypertension” ! , and stop filling our surgeries with patients with borderline Hypertension with no other risk factors ( which only makes them anxious and miserable anyway ). Lets have a nurse lead “Cardiovascular Risk Clinic” and see our patients on an annual basis when we spend time looking at all the risk factors Dr Des Spence
1. “A score for predicting risk of death from cardiovascular disease in adults with raised blood pressure, based on individual patient data from randomised controlled trials”. BMJ 2001;323:75-81 ( 14 July ) 2. British Hypertension Society guidelines for hypertension management 1999: summary. BMJ 1999;319:630-635 ( 4 September ) |
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Jörgen Vesti-Nielsen, Consultant physician Dept. Med. Blenkingesjukhuset. Karslhamn. Sweden
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The article is an interesting experiment in maths but the authors cannot be serious when they suggest using this experiment for giving advice in the real world. If the rates for heart disease had been constant it would be useful in the real world instead of in the closed system of the article only, but they are not so. The authors mention the differing rates in different countries and do admit it would be difficult to predict a risk in for instance France based, as the calculations are, mainly on old American and English studies. But they forget the even larger variations over time in many parts of the world. The cardiovascular mortality rates have been falling constantly at least since 1980, in most countries (except in the former Eastern bloc) by 2-7 % yearly. (for example UK Glasgow 2.6% and UK Belfast by 6% per year, Sweden 3.8-8% in different centres per year, and so on). A third of this reduction is caused by decreasing incidence rates for coronary heart disease.(1) People simply are getting healthier. The calculations in the article have a built-in blemish in that they are based on older studies in populations with substantially higher basic rates for cardiovascular disease. The logic in itself is flawless but the arguments do not hold. It is impossible, based on old studies, to predict in figures the absolute risk of cardiovascular death for a person living today, since the rates in the future are unknown, and whatever drives the changing rates is unknown as well. Perhaps the relative risks are the same, which I seriously doubt, but the absolute risks, necessary to advise a patient, have changed substantially. 1. Tunstall-Pedoe H, Kuulasmaa K, Mähönen M, Tolonen H, Ruokoski E,Amouyl P. Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA Project populations. The Lancet 1999; 353:1547-57 |
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Munir E Nassar, Consultant 17 Cobblefield Way, Pittsford, NY USA 14534
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Sir: Permit me to add some important risk factors that impact on morbidity and /or death from cardiovascular disease in adults. Obesity is well recognized as an independent risk factor in the pathogenesis of coronary artery disease (Ref. The Framingham Heart Study, Circ. 1983). The finding of a carotid bruit on physical exam in an otherwise asymptomatic adult correlates with likelyhood of presence of coronary artery disease. Sedentary life style with job related stress has been described to enhance coronary artery disease, and thus are risk factors (Ref. Clinical Evidence BMJ 4th and 5th editions) Family history of heart disease,(Acute MI, compared to absence of AMI, increases the likelyhood of CAD in siblings. (ref. Heart Disease, White P.) Undetected atrial septal defect or patent Foramen ovale in adults, with potential paradoxical embolisation is a risk factor for stroke. The presence of atrial fibrillation of rheumatic origin or otherwise or syphilitc aortitis are other risk factors. Hence for the sake of better accuracy in assessing the score of risk factors implicated in morbidity and mortality of coronary artery disease, the physician may have to be more inclusive of CAD risk factors. Munir E Nassar, M.D. |
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Ian Niven, Chiropractor, Private Practice Melbourne, Australia
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Thanks for your work in putting together and publishing the profile.1 I have found combining a general risk profile such as you describe and individual risk factors usually brings a greater involvement of patients in their vascular health. Other factors I have found to have powerful educative value are homocysteine, CRP, fibrinogen, glucose and the lipid and apolipoprotein profiles along with changing fat:muscle ratios. I've found the lifestyle changes resulting from this combined approach are both effective and satisfying. And while this more detailed approach takes more time the maturing relationship that develops as factors are monitored and (hopefully) change over time has well-documented outcomes.2. 1.A score for predicting risk of death from cardiovascular disease in adults with raised blood pressure, based on individual patient data from randomised controlled trials Stuart J Pocock, Valerie McCormack, François Gueyffier, Florent Boutitie, Robert H Fagard, and Jean-Pierre Boissel BMJ 2001; 323: 75-81 2. Love and Survival. Ornish,D. HarperCollins, NY, 1998 |
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Y Adi, Systematic Reviewer Department of Public Health & Epidemiology, University of Birmingham
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"Lack of exercise" and "weight" are more important risk factors than height. It is hard to imagine that these two factors were not assessed in the primary trials. For a man who is 55 years old, non-smoker, whose height is 175 cm with no other serious conditions, this patient according to this score will be in a low risk category, whether he exercises regularly and has an ideal weight or can hardly walk and is grossly overweight. |
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Chng Kooi-Seng, Family physician Johor Bahru, Malaysia.
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The article by Prof. Pocock et al. though potentially useful has caused me some confusion. For some years doctors have been counselling their hypertensive patients to loose weight. Now it would seem that weight is not important as a predictor of future death. What do I tell my patients now? Recent reviews on hypertension have stressed the importance of pulse pressure in assessing future risks. This has also been considered unimportant. Perhaps Prof Pocock would like to explain why weight(or BMI),pulse pressure and diastolic pressure are unimportant predictors of future risks. |
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Munir E Nassar, Consultant 17 Cobblefield Way, Pittsford, NY USA 14534
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Sir: After another careful review of the scoring method and responses
to the paper of Prof. Pocock and colleagues,permit me to voice the
following remarks: It is not clear what is meant by raised B P in adults.
Certain adults may have a temporary raised B P just by being monitored for
B P. Whereas, established raised B P has to be labelled as such, after 2-3
months of observed readings.
It is not clear that such a process was done to include adults with
"raised B P "
As has been mentioned in rapid responses, there are several risk factors
that were not included in the study that certainly may affect the outcome
of the scoring technique used making the limited risk factors in the study
incomplete and thus partially valid.Several responses were quite critical
and justifiably so. However, from a different perspective, it puts such
knowledge of risk factors within reach of general readers who would jump
on the occasion that such factors are the ultimate answer to risk of
death, especially when as one response suggested that combining it with
hyperlipemia and elevated homocysteine
would be of educative, informative value. Here again, though
elevated blood level of homcysteine is an independent risk
factor, any study that would include such a parameter in a study of risk
factors, needs to know an accurate dietary history the intake of the
essential amino acid methionine and folic acid, B6, and B12, from day
today in the adults being studied to ba able to say that truly
homocysteine levels are high.One should be precise before conducting such
research of risk factors, or cost effective medical practice would be
unreasonable, let alone Chiropractors assessing C-V Risk factors.
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Ville Pettilä, Senior consultant Intensive Care Unit, Helsinki University Hospital
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Sir-The paper of Pocock et al (1)provides us detection of several risk factors of death in adults with raised blood pressure by Cox proportional hazards model. The relation of the created new risk score and probability of dying was clearly shown in the development set. However, their paper is flawed by the lack of validation in an independent sample of patients- a basic methodological principle of any predictive model(2).Therefore, it would be of outmost importance to test the discrimination by ROC analysis and calibration (3) of this suggested new risk model, especially when their calculations are based on older study populations, as previously pointed out(4).Assessment of usefulness of the model of Pocock et al. will be possible only after this mandatory validation process. 1. A score for prediction risk of death from cardiovascular disease in adults with raised blood pressure, based on individual patient data from randomised controlled trials. BMJ 2001;323:75-81 2. Randolph AG, Guyatt GH, Calvin JE, Doig G, Richardson WS. Understanding articles describing clinical prediction tools. Evidence Based Medicine in Critical Care Group. Crit Care Med 1998;26:1603-1612 3. Ruttimann UE. Statistical approaches to development and validation of predictive instruments. Crit Care Clin 1994;10:19-36 4. Vesti-Nielsen J. Independent cardiovascular risk cannot be predicted. Electronic response. |
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Michael J White, General Practitioner Stakes Lodge Surgery, Waterlooville, Hampshire
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Dear Editor I would like to predict the risk score for all patients in my practice aged 35 years or older as so clearly described in this article. My enthusiasm invariably turns to disappointment when using risk scores, for the following reasons: 1. Age: most of these studies stop at the age of 74. As a significant proportion of my patients are aged 75 and over, I feel cheated. Is there any possibility of extrapolating the risk scores to an older age? 2. Tobacco: should I include ex-cigarette smokers who have only recently stopped smoking, recent being, for example, during the last year. 3. Blood pressure: which measurement do I use?
4. Which cholesterol measurement is the most appropriate?
5. Which creatinine measurement is the most appropriate?
6. Left ventricular hypertrophy: how should it be defined? Echocardiogram evidence only ECG evidence Ideally I would like to be able to discuss with a patient their current risk score, and be able to compare with their previous risk scores, since when they have stopped smoking, blood pressure has been reduced and their hypercholesterolaemia has been treated. Likewise on a practice basis, I would like to be able to produce a “before and after” risk score to assess the effectiveness of the various treatments, which my practice has implemented often at great expense, time, and energy. I am disappointed that the above points are not specifically addressed in this and other similar risk score assessments as to which are the most appropriate blood pressure, cholesterol and creatinine measurements to use for the purpose of risk score assessment. Yours faithfully Michael J White MB BS MRCGP DCH DRCOG
No competing interests |
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