Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38555.648623.8F (Published 08 September 2005) Cite this as: BMJ 2005;331:551
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Sir,
Getz et al. [1] deserve credit for drawing attention to the unwelcome
consequences of the European guidelines for the assessment of
cardiovascular risk.[2] It is, indeed, disturbing to learn that the
application of these guidelines would result in all men over the age of 40
years in Norway being classified as at either intermediate or high risk of
a cardiovascular event.
For many years, the medical establishment accepted the validity of
cardiovascular risk based on the Framingham study only to find out
eventually that it was unreliable and produced inflated estimates when
used in populations outside of the USA. [3] Now we learn that
implementation of the European guidelines – which were published as
recently as 2003 – would result in the entire male population over the age
of 40 years in parts of Europe being subjected to medicalisation. Fit,
asymptomatic individuals labelled as being ill, chronic anxiety about
health, difficulties with employment and life insurance, everyday lives
disrupted by clinic visits, adverse drug reactions – the consequences of
injudicious guidelines are legion.
Nowadays, there is a kind of madness in medicine. And nowhere is it
more clearly observed than in the guidelines emanating from what can only
be described as an asylum of cardiovascular experts.
[1] Getz L, Sigurdsson JA, Hetlevik I, Kirkengen AL, et al.
Estimating the high risk group for cardiovascular disease in the Norwegian
HUNT 2 population according to the 2003 European guidelines: modelling
study. BMJ 2005;331;1551-4.
[2] Conroy RM, Pyorala K, Fitzgerald AP, et al. Estimation of ten-
year risk of fatal cardiovascular disease in Europe: the SCORE project.
Eur Heart J 2003;24;987-1003.
[3] Brindle P, Emberson J, Lampe F, et al. Predictive accuracy of the
Framingham coronary risk score in British men: prospective cohort study.
BMJ 2003;327;1267.
Competing interests:
None declared
Competing interests: No competing interests
As Iona Heath pointed out 'Seventy per cent of the UK population is
taking medicines to treat or prevent ill health or to enhance wellbeing.
How can this level of medicine taking be appropriate in a population
which, by all objective measures, is healthier than ever before? ' (1). At
a recent cardiology training weekend for registrars, one consultant
cardiologist when asked what tablets he would be taking when aged 70, he
replied 'Nothing I hope - I'll live a reasonably healthy life, enjoying
the more decadent things in moderation and never measure my cholesterol if
I've no other risk factors'
Mine's a glass of red at my local Italian restaurant...
1. Who needs health care—the well or the sick?
Heath BMJ.2005; 330: 954-956.
Competing interests:
None declared
Competing interests: No competing interests
Getz et al’s paper 'Estimating the high risk group for cardiovascular
disease in the Norwegian HUNT 2 population according to the 2003 European
guidelines: modelling study'(1) published as an Online First on 15th
August notes that:
‘Implementation of the 2003 European guidelines on prevention
of cardiovascular disease in a well defined Norwegian population
would class four out of 10 women and nine out of 10 men aged
50 as at high risk for fatal disease. No men aged 40 or older
would be classified as at low risk.’
Prof Ian M Graham, Prof Guy de Backer and Prof Kalevi Pyörälä claimed
in their Rapid Response of 12th July (2) that the guidelines they had
formulated would only lead to
‘the small proportion who already have established vascular disease
or are at very high multifactorial risk’ possibly receiving ‘more
intensive advice and evidence based drug therapies’
No reasonable person would describe this proportion of the population
as small. And most reasonable people would expect that the people
formulating such guidelines would have done some research before they
lumbered the long suffering public with yet more exhortations to achieve
apparently impossible goals.
Incidentally, I have been known to set off the alarm when having my
blood pressure monitored; speaking from the perspective of the hypotensive
I note that my doctors recommend that I try not to fall over and/or pass
out whilst crossing the road, waiting for a tube train or doing self-
administered intravenous antibiotics. It’s good advice, but as they
readily admit, impossible to follow…
Stevie Gamble
(1) http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38555.648623.8Fv1
(2)http://bmj.bmjjournals.com/cgi/eletters/330/7506/1461
Competing interests:
None declared
Competing interests: No competing interests
Treating Whole population!!
Now we may call it medicine and treatment but when whole male
population has to take it (40-70yr old males in Norway) can we call it a
treatment? Even calling it Primary prevention sounds strange to me. I look
after Older patients who have been started on multiple medication after
being diagnosed with angina or after MI by Cardiologist, and many of these
patient can't stand up or walk properly (their BP is in their boots), they fall
and fracture their hip, get admitted repeatedly with falls and dizzy
spells in Medical wards and rehabilitation set up. These poor souls
eventually (many of them) lose their homes and end up in institutions but
they are alive and have not ended up as Cardiovascular end point of
Mortality or reinfarct. I wish we had more Cardiologist amongst my older
patients! probably will be in next couple of decades!! Are we getting it
right at all, probably not when we talk about treating whole population
which is living longer every decade in Western world.
Competing interests:
None declared
Competing interests: No competing interests