Being smarter about preventing heart diseaseBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7236.0 (Published 11 March 2000) Cite this as: BMJ 2000;320:0
Some theme issues are planned by us. Others assemble themselves. This is one that has come together naturally, which presumably means that there is widespread interest in assessing risk of heart disease and responding as intelligently as possible. And so there should be. Heart disease is the commonest cause of death in most developed countries and is increasing in poor countries. Yet with the wisdom of hindsight much of our response looks unintelligent: treating people, regardless of their absolute risk, when they cross a particular magic line of blood pressure or lipid concentration.
Now we know better, even if we don't necessarily practise what we know. There is rich debate in this issue, but all agree that clinicians should treat on the basis of absolute, not relative, risk of heart disease and should concentrate on those at highest risk (p 659). New Zealand authors use a model to show that targeting patients at high risk can greatly increase the efficiency of treatment—more “disease events” are prevented for the same number of patients treated (p 680). Between the intent and the action, however, falls the shadow—a Bristol group finds that providing general practices with computer based decision support systems does not make treatment smarter (p 686). (This is a small setback for the British prime minister, who this week hosted a lecture that pinned great hope on decision support systems to “modernise” the NHS.)
UK readers of the BMJ may assume that we have tremendous timing because this issue on preventing heart disease is published in the week that Alan Milburn, the health secretary, has announced a “national service framework” to cut deaths from heart disease in England by 40% by 2010 (by which time Milburn will be something much more senior or languishing in the same obscurity as most of his predecessors) (p 665). In fact this is coincidence, not least because both we and the government have been “faffing around” for a long time with our respective ventures. The government wants to ensure that 80% of patients discharged from hospital after heart attacks are prescribed aspirin, βblockers, or statins and that thrombolytic drugs are made available to patients within one hour of calling for help. These are noble intentions, but readers might worry that the politicians are not entirely in touch with the difficulties of implementing such top-down commands.
Finally, a book review (another coincidence) reminds us that the British government is by no means the first to declare war on a disease (p 721). The Nazis did the same in prewar Germany.
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