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EDUCATION AND DEBATE: Josipa Kern, Marija Strnad, Tanja Coric, and Silvije Vuletic Cardiovascular risk factors in Croatia: struggling to provide the evidence for developing policy recommendations BMJ 2005; 331: 208-210 [Full text]

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Clarification needed for useful interpretation of Croatian CVS risk study

Christopher Bell   (29 July 2005)

Clarification needed for useful interpretation of Croatian CVS risk study 29 July 2005
Christopher Bell, Professor of Physiology Cardiovascular Health Unit, Dept of Physiology, Trinity College Dublin Send response to journal: Re: Clarification needed for useful interpretation of Croatian CVS risk study	The dramatic incidence of cardiovascular disease in the European transitional countries is a serious concern and Kern et al's study is a useful step towards better understanding of the underlying processes. However, interpretation of their findings would be facilitated greatly by provision of additional information. First, some of the risk factor criteria reported differ from those in common use and have the potential to confuse the literature. Setting a blood pressure threshold of 130/85 matches accepted international guidelines for the upper limit of desirable pressures (1-3) but it is misleading to refer to values above this as hypertension; doing so may mask other clinically significant variations. Daily ingestion of any amount of alcohol is stated to be used as a criterion of high alcohol consumption; a classification that ignores international evidence that regular low intakes may be cardioprotective (4) and the fact that this has been built into recent algorithms showing benefits of a Mediterranean diet (5). Classification as smokers of individuals who quit up to 10 years ago, apparently without regard to age, and not providing data on pack years, limits the usefulness of data on incidence of smoking. Second, the primary object of the survey was to define the incidence of risk factors by geographical region of Croatia, on the basis that diet and lifestyle differ substantially between continental and coastal areas. For this reason, useful interpretation of the findings depends entirely on knowing how the regional incidence of cardiovascular morbidity compares with the risk factor distributions described. Given the size of this survey, the nature of the information sought and the fact that the regional breakdown corresponds with that defined by the Croatian Central Bureau of Statistics, it seems likely that at least most of this missing information could be made available. This would greatly enhance the resource value of the study, both for policy making in Croatia and neighouring countries, and as a contribution to our knowledge of global cardiovascular disease. 1 Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, Sever PS, Thom S McG. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Human Hypert 20004;18:139-185. 2 Guidelines Submittee. 1999 World Health Organization-International Society of Hypertension guidelines for the management of hypertension. J Hypert 1999;17:151-183. 3 Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology Guidleines for the management of arterial hypertension. J Hypert 2003;21:1149-1158. 4 Gronbaek M, Becker U, Johansen D, Gottschau A, Schnohr P, Hein HO, Jensen G, Sorensen TI.Type of alcohol consumed and mortality from all causes, coronary heart disease, and cancer. Ann Intern Med. 2000;133:411 -9. 5 Trichopoulou A, Costacou T, Bamia C, Trichopoulou D. Adherence to a Mediterranean diet and survival in a Greek population. New Engl J Med 2003; 348:2599-2608. Competing interests: None declared