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A more obvious target for cardiovascular prevention
- Tom P Marshall (7 September 2007)
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Should primary care target relatives in other cardiovascular diseases?
- Nigel D Hart, Margaret E. Cupples, M. Ivan Wiggam, Chris C. Patterson, John W. G. Yarnell (13 September 2007)
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Role of subclinical hypothyroidism
- P B S Fowler (18 September 2007)
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Targeting at risk families for cardiovascular primary prevention
- Martha J Wrigley, Peter Wilkinson, Consultant Cardiologist (7 October 2007)
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Tom P Marshall, Senior Lecturer in Public Health University of Birmingham, B15 2TT
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It is correct that first degree relatives of patients with coronary heart disease are at higher risk than the general population. Screening first degree relatives would be an improvement on unselected screening. However family history is only one of a number of risk factors for cardiovascular disease. Selecting patients on the for screening on basis of multiple risk factors is better than selecting patients on the basis of one risk factor. For most patients, many risk factors are known. All patients have an electronic record of their age and sex. Most patients have an electronic record of their smoking status and blood pressure and some have a cholesterol level. If diagnosed, patients with diabetes have an electronic record of this diagnosis. And of course, if they have a family history of premature coronary heart disease, some patients have a record of this fact. Earlier in 2007 I collected electronic data from three large general practices. Of 19,552 patients aged 35 and over, 35% had full risk factor information and 76% lacked only a cholesterol level. Of these, 2.2% (437) were aged 35 to 74, untreated but at greater than 20% ten-year cardiovascular risk and hence eligible for treatment. Including patients whose cholesterol levels were not known 6.7% (1307) were untreated high- risk patients. Only 14% (181) of these patients had a record of a family history of premature coronary heart disease. These figures are consistent with the results from similar data extraction exercises in eight different practices at various times over the past few years. Since patients over 35 are about half the practice population, this means that in a typical practice about 3% to 4% of their population are currently untreated but have recorded risk factors indicating they are high-risk. These patients are identifiable by searching the practice database, without the need to need to wait until their relatives present to secondary care with heart disease. Yours sincerely Tom Marshall The most efficient strategy for CVD prevention Competing interests: None declared |
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Nigel D Hart, Clinical Research Fellow Queen's University Belfast, BT9 7HR, Margaret E. Cupples, M. Ivan Wiggam, Chris C. Patterson, John W. G. Yarnell
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Chow et al's1 excellent analysis of family history of premature coronary heart disease (CHD) and strategies for primary prevention have prompted us to report on our recent work exploring the possible value of targeting the offspring of people with stroke for risk factor screening in general practice. Similar to CHD there is good evidence that a family history of stroke is itself an important risk factor for stroke.2, 3 Chow et al suggest that primary prevention of CHD should be targeted by identifying first degree relatives at the time when the ‘index patient’ presents to hospital. Several years ago staff in a local hospital stroke unit began ‘screening’ family visitors for stroke risk factors but, whilst this seemed to be an intuitive step in delivering effective primary prevention, it was not clear whether there was evidence to justify the strategy.
To address this question we conducted a case-control study from 11 GP surgeries in Northern Ireland to compare stroke risk factor prevalence between those with (cases, 199) and those without (controls, 199) a parental history of stroke, matched on age, gender and socioeconomic status. Participants answered questions about their medical history, smoking and alcohol habits. Diet and exercise habits were assessed using validated questionnaires and height, weight, blood pressure, serum lipids and glucose were measured. Mean systolic and diastolic blood pressures were significantly higher in cases than in paired controls (systolic 146.3 vs 140.6 mmHg (p<0.01); diastolic 87.7 vs 85.0 mmHg (p=0.014)). Although not attaining statistical significance, more of the cases, including those already on hypertensive medication, had a blood pressure greater than 140/90 mmHg (67% v 58%, a difference of 9% (95% CI -1%,19%)). Cases consumed more alcohol than their paired controls (13.8 vs 10.1 units/wk (p<0.01)) but for BMI, lipids, diabetes, diet and exercise cases and controls did not differ significantly. The debate about targeted screening for primary prevention of cardiovascular disease may appear redundant since the current NHS General Medical Services contract for general practice4 encourages recording of relevant risk factors for the population. However, the uptake of this is far from complete. In addition previous work has shown that there is a low yield from inviting unselected people for primary care screening.5 Hence, it may seem an intuitive step to pro-actively seek to screen the offspring of stroke patients in order to implement effective risk reduction. Our work suggests that most of the benefit is likely to be from detecting raised blood pressure. Give the relationship between blood pressure and stroke risk, this may provide a useful opportunity for effective primary prevention. References: 1. Chow CK, Pell AC, Walker A, O'Dowd C, Dominiczak AF, Pell JP. Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention. BMJ 2007; 335(7618):481-5. 2. Jousilahti P, Rastenyte D, Tuomilehto J, Sarti C, Vartiainen E. Parental history of cardiovascular disease and risk of stroke. A prospective follow-up of 14371 middle-aged men and women in Finland. Stroke 1997; Jul;28(7):1361-6. 3. Polychronopoulos P, Gioldasis G, Ellul J, Metallinos IC, Lekka NP, Paschalis C, et al. Family history of stroke in stroke types and subtypes. J Neurol Sci 2002;195(2):117-22. 4. NHS Confederation, British Medical Association. New GMS contract 2003 : investing in general practice. London: British Medical Association / NHS Confederation; 2003. 5. Wonderling D, McDermott C, Buxton M, Kinmonth AL, Pyke S, Thompson S, et al. Costs and cost effectiveness of cardiovascular screening and intervention: the British family heart study. BMJ 1996; 312(7041):1269-73. Competing interests: None declared |
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P B S Fowler, Formerly Senior Physician, Charing Cross Hospital Gerrards Cross SL9 8HN
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Articles in two current issues of important medical journals deal with risk factors for coronary heart disease (CHD) (1, 2) but neither mentions the role of subclinical hypothyroidism (SCH) as a risk factor for CHD. My late colleague, John Swale, and I reported the association between minimal thyroid insufficiency with CHD in 1967 (3) and I have continued this work for 30 years (4). If one wants to keep a secret, publish it - no one reads. The Rotterdam Study showed conclusively that subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women. A study done of the general population would not show the results found in one done on elderly women because of the mortality effect on the data. Men in mortuaries cannot stand up to be counted. John Lykoudis (6) showed that the bacteria in peptic ulcers are a cause and not a result of the disease. It was about 50 years before infection was rediscovered as a cause of peptic ulcers. The long delay in the acceptance of an infection for peptic ulcers suggests that it might take longer for the association of SCH with CHD to be accepted. 1. CK Chow and colleagues. Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention. BMJ 2007; vol 335, pp 481-485. 2. T. Zornitzki and colleagues. Diabetes, but not the metabolic syndrome, predicts the severity and extent of coronary artery disease in women. QJ Med 2007; 100:575-581. 3. Fowler PBS, Swale J. Premyxoedema and coronary artery disease. Lancet 1967;1:1077-9. 4. Fowler PBS. The thyroid, blood flow and atheroma. QJM 2000;93:477- 485. 5. Hak AE, Pols HA, Visser TJ, et al. Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: the Rotterdam Study. Ann Intern Med 2000;132:270–278. 6. Rigas B, Feretis C, Papavassiliou ED. John Lykoudis: an unappreciated discoverer of the cause and treatment of peptic ulcer disease. Lancet 1999;354:1634-5. Competing interests: None declared |
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Martha J Wrigley, Cardiac Research Coordinator Ashford & St Peter's Hospitals NHS Trust, Chertsey, Surrey KT16 0PZ, Peter Wilkinson, Consultant Cardiologist
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In their article discussing the opportunity for targeting families with a history of premature coronary heart disease, Chow and colleagues 1 conclude that research is needed to identify barriers and determine the most effective approach. Over the past three years we have undertaken a single centre case study looking at primary prevention for the first degree relatives of patients diagnosed with premature coronary heart disease (CHD) 2. The study was undertaken in a district general hospital, when their relative, sibling or parent, was initially diagnosed with premature CHD on our coronary care unit. The participants were invited to participate in a two year health promotion programme where a nursing assessment of their lifestyle risk factors was evaluated, discussed and they were encouraged and supported to make behavioural changes. The final results are being analysed, so we are unable at present to comment on the outcome of the study; but can reflect upon certain demographics which provide valuable insight regarding the participants who completed the study. We used purposive sampling and within a year recruited 28 participants, from 14 families; 21 of these completed the study. We invited first degree relatives of any age and gender to participate in the study, excluding those with a diagnosis of cardiovascular disease. The age range of our population varied from 19 to 58 years; 4 of the participants were less than 25 years, while 7 where between 26 and 35 years of age. A third of our participants, 7, lived within 5 miles of the hospital but 8 travelled over ten miles to attend the study. For 13 of our participants their relative had been diagnosed with CHD in the preceding year; however for 8, the diagnosis had been made between one and 14 years previously. The points of interest arising from this study is that firstly people of all age ranges are interested in participating. It is important that young people are involved in prevention studies, when the atherosclerotic process can start in childhood 3 and influencing behavioural change is often easier when people are younger and less established in their lifestyle practices. We know that attendance at a cardiac rehabilitation programme is influenced by distance, where the distance that patients travel to the classes can affect adherence to the programme 4. Yet here we show that people were willing to travel to receive comprehensive lifestyle assessment and advice. Even those for whom the diagnosis of their relative occurred over a year ago, again they are still willing to attend five visits, in a hospital setting, over a two year period. Perhaps instead of looking for barriers to prevention we should be encouraged that people of all ages are actively interested and will travel to participate in a health promotion research study. Reflecting upon our own experience with this cohort we can illustrate that the sustained enthusiasm and interest from these people, to receive professional advice, encouragement and support, may not be as problematic at one might assume. We would regard the model of cardiac rehabilitation classes to be suitable for patients to bring their relatives to receive appropriate assessment, advice and support; where integration of primary, secondary and tertiary prevention can occur. References 1. Chow CK, Pell ACH, Walker A, O'Dowd C, Dominiczak AF. Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention. British Medical Journal 2007;335:481-5. 2. Wrigley MJ, Pakrashi T, Maslin-Prothero S, Watkinson G. Primary Prevention for Coronary Heart Disease: past evidence, present measures and future challenges. British Journal of Cardiac Nursing 2006;1(6):294-304. 3. Hayman Laura L, Meininger JC, Daniels Stephen R, McCrindle Brain W, Helden Liz, Ross Joyce, et al. Primary Prevention of Cardiovascular Disease in Nursing Practice: Focus on Children and Youth. Circulation 2007;116:344-57. 4. Campbell N, Grimshaw J, Rawles J, Ritchie L. Cardiac Rehabilitation: the agenda set by post-myocardial-infarction patients. Health Education Journal 1994;53:409-20. Competing interests: None declared |
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