Comparison of estimates and calculations of risk of coronary heart disease by doctors and nurses using different calculation tools in general practice: cross sectional study

EDITOR – McManus and colleagues report on estimating the risk of
coronary heart disease among ‘high risk’ patients without coronary heart
disease in primary care (1). They rightly point out that the information
necessary to calculate patient risk, using most of the currently available
equations and tables, is often not available in GP records.

However, their paper does not address the even more important issue
of secondary prevention, arguing that more emphasis has already been
placed on this category of patients, and that those most likely to benefit
are identified relatively easily. Patients with known CHD are clearly a
high-risk group, but how best to identify them in general practice has
been hotly debated (2). Even assuming they are identified, the critical
issue is the level of interventions they actually receive.

We have recently reviewed the available data from England and Wales
on secondary prevention in order to populate a CHD mortality model.
Information on the effectiveness of various interventions was relatively
easily obtained from meta-analyses and randomised controlled trials,
likewise information about the numbers of hospital admissions with
coronary heart disease was available online from Public Health Common
Dataset/Hospital Episode Statistics. Actual details of hospital
interventions, and any changes over time, were however very limited. For
treatment at primary care level, limited prescription and uptake data were
available from PACT, audits and a few studies (3,4,5).

In general, data for women and the elderly (over 65) were
particularly scarce. Systematic information on prescribing and uptake of
secondary prevention treatments for coronary heart disease was virtually
absent among the older age groups who are most at risk of coronary heart
disease. Data on many AMI treatments in hospital such as aspirin,
thrombolysis, beta-blocker prescribing was lacking, particularly for those
aged over 75 years.

Every year in Britain, CHD causes over 120,000 deaths and costs over
£10 billion (British Heart Foundation). However, information on CHD is
fragmented, patchy and mixed in quality. Future CHD disease monitoring and
evaluation requires comprehensive and accurate population-based
information on trends in treatment uptake. Regular and comprehensive
surveys (including women and elderly people), using standardised
methodology will be essential to evaluate future interventions.

References:

1-McManus RJ, Mant J, Meulendijks CFM, Salter RA, Pattison HM, Roalfe
AK, Hobbs FDR. Comparison of estimates and calculations of risk of
coronary heart disease by doctors and nurses using different calculation
tools in general practice: cross sectional study. BMJ 2002; 324: 459-464

2-Gray J, Majeed A, Kerry S, Rowlands G. Identifying patients with
ischaemic heart disease in general practice: cross sectional study of
paper and computerised medical records. BMJ 2000; 321: 548-550.

3-Ryan R, Majeed A. Prevalence of ischaemic heart disease and its
management with statins and aspirin in general practice in England and
Wales, 1994-98. Health Statistics Quarterly 12, 2001;34-39

4-Whitford DL, Southern AJ. Audit of secondary prophylaxis after
myocardial infarction. BMJ 1994;309:1268-69.

5-EUROASPIRE II Study Group. Lifestyle and risk factor management and use
of drug therapies in coronary patients from 15 countries; principal
results from EUROASPIRE II Euro Heart Survey Programme. European Heart
Journal,2001;22(7):554-72.