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PAPERS: Tim C Clayton, Jacobus Lubsen, Stuart J Pocock, Zoltán Vokó, Bridget-Anne Kirwan, Keith A A Fox, Philip A Poole-Wilson on behalf of the ACTION investigators Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomised trial cohort of patients BMJ 2005; 331: 869 [Abstract] [Full text]

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Epidemiologists and researchers continue to overlook the obvious

Stephen J Bunker, Andrew Tonkin, Ian Hickie, David Colquhoun, Sami Heistaro, James Dunbar.   (21 October 2005)

A comparison of Clayton and Pocock scores

Ioan A. Gutiu, Laurentiu Gutiu   (21 October 2005)

Re: Authors reply: Epidemiologists and researchers continue to overlook the obvious & A comparison of Clayton & Pocock scores

Tim C Clayton, Jacobus Lubsen, Stuart J Pocock   (3 November 2005)

Epidemiologists and researchers continue to overlook the obvious 21 October 2005
Stephen J Bunker, Manager, Psychosocial Risk Factor Program National Heart Foundation of Australia, West Melbourne, 3003., Andrew Tonkin, Ian Hickie, David Colquhoun, Sami Heistaro, James Dunbar. Send response to journal: Re: Epidemiologists and researchers continue to overlook the obvious	Observational studies showing the influence of psychosocial factors on outcomes of people with coronary heart disease (CHD) have been appearing in the scientific literature for decades (1). The magnitude of the increased risk afforded by depression following acute myocardial infarction (MI), for example, was shown to be comparable to that of left ventricular dysfunction and prior MI (2). There is also strong evidence for a number of underlying behavioural and pathophysiological mechanisms linking psychosocial factors to both the onset and prognosis of CHD (3,4). The work of Clayton, et al., on behalf of the ACTION Investigators, in developing a risk prediction algorithm in patients with stable angina, is yet another example of epidemiologists and researchers continuing to focus solely on clinical and biomedical variables to calculate risk scores, thereby overlooking the obvious and substantial contribution to risk afforded by well-established psychosocial risk factors (5). Inexplicably, psychosocial variables, particularly depression, continue to be routinely excluded from studies by cardiovascular epidemiologists and researchers. This is despite the availability of a number of simple, robust, well-established screening instruments. Until the clinical significance of psychosocial factors is recognised and incorporated into risk factor equations and analysis, current models for CHD risk prediction will continue to significantly underestimate true risk in at least 30% of patients with CHD who have depression or depressive symptoms. It is no longer acceptable to ignore psychosocial risk factors when assessing CHD risk. 1. Ruberman W, Weinblatt E, Goldberg JD, Chaudhary BS. Psychosocial influences on mortality after myocardial infarction. NEJM 1984;311:552- 559. 2. Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6 month survival. JAMA 1993;270:1819- 1825. 3. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol. 2005;45:637-51. 4. Carney RM, Freedland KE, Miller GE, Jaffe AS. Depression as a risk factor for cardiac mortality and morbidity: a review of potential mechanisms. J Psychosom Res. 2002;53:897-902. 5. Bunker SJ, Colquhoun DM, Esler MD, Hickie IB, Hunt D, et al. “"Stress" and coronary heart disease: psychosocial risk factors. National Heart Foundation of Australia position statement update. Med J Aust 2003;178:272-276. Competing interests: None declared
A comparison of Clayton and Pocock scores 21 October 2005
Ioan A. Gutiu, Professor of Medicine, University of Medicine and Pharmacy Dpt of Medical Emergencies, Bucharest, ROMANIA, Laurentiu Gutiu Send response to journal: Re: A comparison of Clayton and Pocock scores	Dear Editor, Clayton and his team have formed a risk score for predicting death, myocardial infarction and stroke in patients with stable angina. [1] The score seems be useful in identification of the groups of patients for divers treatment orientations. We are studying a group of patients with cardiovascular disease and we used, for grading of cumulating atherosclerosis risk factors, the Pocock’s score (published in B.M.J.) for predicting the risk of death by cardiovascular disease based on data from randomized controlled trials [2] After reading of Clayton’s and all paper, we tried to compare Clayton’s score with older Pocock’s score. On a little number of patients who fulfilled all conditions for the both scores calculations, we stated a very good correlation between Pocock’s and Clayton’s scores: r=0.617, p<0.0001 (Pearson correlation), number of cases - 66. This high significant correlation coefficient shows that both scores have very close values in predicting of death, stroke, or myocardial infarction. Practically, we think that all these works on the role of atherosclerosis risk factors in prognosis appreciation of cardiovascular disease have importance and must be continued. On the other hand, we sustain that, in analysis of atherosclerosis risk factors, is necessary to retain for analysis the “new” atherosclerosis risk factors such as: low level non specific inflammation (with markers C reactive protein, fibrinogen, 6-interleukine, etc.) and dental state appreciation. These “new” risk factors may intervene in atherogenesis and may have weight in any prognostic score.[3.4.5] In Clayton’s score, the authors mention that they have retained white blood cells number only, not C reactive protein or others. We think any risk score in predicting death, coronary obstruction or stroke must use the “new” atherosclerosis risk factors, too. References: 1.Clayton TC, Lubsen J, Pocock SJ et al: Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomized trial cohort of patients. BMJ 2005;331:869- 872. 2. Pocock SJ, McCormack V, Gueyffier F et al: A score for predicting risk of death from cardiovascular disease in adults with raised blood pressure, based on individual patient data from randomized controlled trials. BMJ 2001;323:75-81. 3. Hansson GK: Mechanisms of Disease: Inflammation, Atherosclerosis, and Coronary Artery Disease. N Engl J Med 2005; 352:1685-1695. 4. Janket SJ, Qvarnstroem M, Meurman JK, et all: Asymptotic Dental Score and Prevalent Coronary Heart Disease. Circulation 2004;109:1095- 1109. 5. Desvariuex M, Demmer RT, Rundek T, et all: Relationship Between Periodontal Disease, Tooth Loss, and Carotid Artery Plaque. The Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 2003;34:2120-2125. Competing interests: None declared
Re: Authors reply: Epidemiologists and researchers continue to overlook the obvious & A comparison of Clayton & Pocock scores 3 November 2005
Tim C Clayton, Medical Statistician London School of Hygiene & Tropical Medicine, WC1E 7HT, Jacobus Lubsen, Stuart J Pocock Send response to journal: Re: Re: Authors reply: Epidemiologists and researchers continue to overlook the obvious & A comparison of Clayton & Pocock scores	Author’s reply: We agree with Dr. Bunker that psychosocial factors may contribute to long-term risk. The main reason we could not include them in our risk score is that we used data from one large multi-national clinical trial and the database of that trial does not contain any information relevant to psychosocial factors. It is not customary to collect such information in large scale trials involving many different countries. In addition, although psychosocial factors may indicate increased risk in stable angina patients this does not mean such factors would necessarily be selected in a multivariate model after inclusion of variables that are themselves associated to psychosocial factors, such as smoking, severity of angina and history of myocardial infarction. Finally, the risk score is intended to incorporate readily available standard risk factors and to incorporate psychosocial factors requires a simple, reliable method to measure them, and that is not easily done in practice. Dr. Gutio’s observation that our risk score and the earlier Pocock score are correlated shouldn’t be a surprise as the scores partly overlap as regards included variables. Hence, a person having a high value of one score is also liable to have a high value of the other. What matters is how the score value translates to absolute risk. This question isn’t addressed by the correlation analysis that was performed. Lastly, readers might like to know that our website www.anginarisk.org is now up and running, and should help to make our risk score more user-friendly. Tim Clayton, Jacobus Lubsen & Stuart Pocock Competing interests: None declared