CARDIOVASCULAR DISEASE RISK SCORE FOR THE UK
DEPRIVATION, FAMILY HISTORY AND CARDIOVASCULAR RISK
NEW GUIDELINES ON PREVENTING CARDIOVASCULAR DISEASE
PATIENTS WITH CHD AND SERIOUS MENTAL HEALTH PROBLEMS
PERINDOPRIL IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE
DRUG COMBINATIONS AND THE RECURRENCE OF MI
LEFT VENTRICULAR HYPERTROPHY IN ARTERIAL HYPERTENSION
Primary prevention of cardiovascular disease is predicated on the availability of calculation tools to estimate an individual's risk of CHD. Current tools are based on equations developed from the Framingham study in the US 30 years ago.
The authors of this study have attempted to derive a new cardiovascular disease risk score for the UK, QRISK, and to validate its performance against the Framingham equation and the recently developed Scottish score (ASSIGN).
They report that the Framingham equation overpredicted cardiovascular disease risk at 10 years by 35 per cent, ASSIGN by 36 per cent and QRISK by 0.4 per cent. Measures of discrimination tended to be higher for QRISK than for the Framingham equation and it was better calibrated to the UK than the Framingham equation and ASSIGN. Using QRISK, 8.5 per cent of patients aged 35-74 are at high risk (20 per cent risk or higher over 10 years), compared with 13 per cent with the Framingham equation and 14 per cent with ASSIGN.
The researchers conclude that using QRISK, 53,668 patients in the validation dataset (9 per cent of the total) would be reclassified from high to low risk or vice versa, compared with the Framingham equation.
These results indicate that QRISK outperforms the older US risk tool and may be a better tool for the UK. QRISK is sensitive to patients' socioeconomic status, which is included as a variable, thus addressing an important additional risk factor and the health inequalities that follow. However, further validation is needed to demonstrate QRISK's advantages.
- Dr Rubin Minhas is a GPSI in cardiology in Gillingham, Kent, and Medway PCT CHD lead
Recognising that conventional risk factors do not explain the burden of cardiovascular disease, these authors have attempted to improve cardiovascular disease prevention by developing a risk score that includes social deprivation and family history.
The ASSIGN score was derived from cardiovascular outcomes in the Scottish Heart Health Extended Cohort (SHHEC). The participants were initially free from cardiovascular disease, ranked for social deprivation by postcode using the Scottish Index of Multiple Deprivation and followed for cardiovascular mortality and morbidity through 2005.
Participants qualified for analysis if they had risk-factor data, permitted follow-up, were aged 30-74 years, reported neither CHD nor stroke and had no prevous hospital discharge diagnoses of these or TIA.
Classic risk factors, including smoking, plus deprivation and family history (but not obesity), were significant factors in constructing ASSIGN scores for each sex. Discrimination of risk in the SHHEC population was significantly, but marginally, improved overall by ASSIGN.
However, the social gradient in cardiovascular event rates was inadequately reflected by the Framingham score, leaving a large social disparity in future events among patients not identified as high risk. ASSIGN classified more people with social deprivation and positive family history as high risk, anticipated more of their events and abolished this gradient.
The authors conclude that conventional scores fail to target social gradients in disease and that by including unattributed risk from deprivation, ASSIGN shifts preventive treatment towards the socially deprived. RM
NEW GUIDELINES ON PREVENTING CARDIOVASCULAR DISEASE
European Guidelines on Cardiovascular Disease Prevention: European Society of Cardiology, Sophia Antipolis, France, 2007. Available online at http://www.escardio.org/
The latest edition of the European guidelines on cardiovascular disease prevention aim to support a reduction in CHD, stroke, peripheral artery disease and associated complications.
The task force members who developed the guidelines are based in countries across Europe, including the UK, reflecting the consensus arising from a multidisciplinary partnership between the major European professional bodies represented in the group.
The guidelines cover when and how to assess cardiovascular risk, lifestyle recommendations and drug treatment. They divide Europe into two regions for assessing risk: high-risk, including the UK, and low-risk, including France and Spain.
Score charts then enable a clinician to assess cardiovascular disease in asymptomatic patients. Interestingly, the guidelines provide a relative-risk chart, which can be used to show a younger person at low risk that, relative to others in their age group, their risk may be many times higher than necessary. This could prove very useful in motivating patients' decisions to adjust to a healthier lifestyle at an earlier stage.
Many epidemiological studies have confirmed that the prevalence of CHD varies with ethnicity and deprivation. Recent studies in the US reported that black patients were less likely to undergo revascularisation than white patients. These results remained constant even after adjustments for sociodemographics, illness severity and comorbidity.
It is known that CHD risk factors, such as smoking, obesity and diabetes, are more common in people with schizophrenia and bipolar disorder. A patient with serious mental health problems will consult their GP four times more often than a member of the general population. This study explored whether patients with CHD and schizophrenia and bipolar disorder were less likely to receive good quality care.
The authors conclude that for the majority of CHD care indicators, such as achievement of target BP or cholesterol levels, there was no significant difference between patients with schizophrenia and bipolar disorder and those without.
However, the authors also found that patients with schizophrenia showed a significant deficit in the recording of cholesterol values and the prescribing of statins. Furthermore, the authors refer to the differential use of exception codes, which remove patients with mental illness from consideration.
We will hear more about patient and clinician factors, which influence the structure, process and outcome of care for those patients who are most at risk, but fail to benefit most from interventions. So the inverse care law still applies, but perhaps only for a few more years.
- Dr Vasa Gnanapragasam is a GP with an interest in cardiology in Sutton, Surrey.
The drug reps who used to wax lyrical about ACE inhibitors in the 1990s have long departed from the local postgraduate centre. Nobody now recalls the Heart Outcomes Prevention Evaluation (HOPE) study, which confirmed that ACE inhibitors were effective in reducing cardiovascular events in patients who did not have heart failure.
The talk now is all about the 'added value' of angiotensin-II receptor antagonists. So I was surprised to come across an article that mentioned the ACE inhibitor perindopril.
EUROPA, the EUropean Trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease, confirmed that use of perindopril resulted in a 20 per cent relative risk reduction in cardiovascular death, MI or cardiac arrest.
It is not easy to follow all of the clinical, social, financial and economic arguments required in determining cost-effectiveness. The paper concludes by stating the obvious - cost-effectiveness varies with risk characteristics. I was surprised to read that 97 per cent of patients randomised to EUROPA would have an incremental cost per quality-adjusted life year of less than £30,000. I hope the falling price of generic perindopril makes ACE inhibitors even more cost-effective in future. VG
This innovative case-controlled study reviewed the medical notes for 3,513 patients in the Netherlands who had an MI between 1991 and 2000. The incidence of a recurrent myocardial event was then compared to the number of cardioprotective drugs each patient was taking.
Patients had to be taking their medication for at least 70 per cent of the time and should not have had existing heart failure or have received CABG or percutaneous transluminal coronary angioplasty (PTCA) before the first coronary event.
Those taking one of an antiplatelet agent, a statin, a beta-blocker or an ACE inhibitor corresponded to a 6 per cent odds reduction for an acute event. The confidence interval, however, was a 30 per cent reduction to a 28 per cent increase in events. Patients who used two drugs had an odds reduction of 26 per cent (CI 47 per cent reduction to 3 per cent increase in events) while those who took three cardioprotective agents benefited from a 41 per cent reduction in events (CI 6-63 per cent reduction).
It is clear that irrespective of drug class, the greater the number of cardioprotective drugs taken, the lower the risk of recurrent MI.
- Dr Raj Thakkar is a GP in Wooburn Green, Buckinghamshire, and a hospital practitioner in echocardiography at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust.
In the context of hypertension, left ventricular hypertrophy (LVH) significantly increases the risk of cardiovascular events, up to 10-fold according to some literature. As such, aggressive risk management is required in these patients. No less than 30 different ECG-based criteria exist for the diagnosis of LVH. Many GPs use ECG as a screening tool for LVH in the community, but how accurate is it? Studies comparing ECG to echocardiographical findings in hypertensive patients were sought and 21 studies, with a total of 5,608 cases, were included in this research. In the primary care setting, 33 per cent of patients were found to have LVH. The authors concluded that despite testing six of the commonly used ECG-based criteria, ECGs should not be used to rule out a diagnosis of LVH. RT