Identification and treatment of risk factors for coronary heart disease in general practice: a possible screening model

A screening programme for the identification of risk factors for coronary heart disease in all patients aged 25-55 years in a general practice population was studied.The identification of risk factors included measurement of obesity, blood pressure, hypercholesterolaemia, and urinalysis, together with questions about family history, cigarette smoking, alcohol intake, and lifestyle. The patients with identified risk factors were invited to attend a lifestyle intervention clinic organised by the practice nurses and run by the health visitors, with the help of the local authority dietitian. Of 2646 (62%) patients who attended for screening, 78 (64%) of the 121 shown to have a high cholesterol concentration experienced a drop in cholesterol concentration. The mean fall in cholesterol concentration in the 78 patients who showed a positive response to intervention was 1·1 mmol/l.The study was intended as a possible flexible model for screening for coronary heart disease in general practice that could be complemented rather than replaced by opportunistic screening. The issues of organisation, cost, manpower, non-attendance, and effectiveness in a busy general practice environment are discussed.     

Strategies for reducing coronary risk factors in primary care: which is most cost effective?

OBJECTIVE--To examine the relative cost effectiveness of a range of screening and intervention strategies for preventing coronary heart disease in primary care. SUBJECTS--7840 patients aged 35-64 years who were participants in a trial of modifying coronary heart disease risk factors in primary care. DESIGN--Effectiveness of interventions assumed and the potential years of life gained estimated from a risk equation calculated from Framingham study data. MAIN OUTCOME MEASURE--The cost per year of life gained. RESULTS--The most cost effective strategy was minimal screening of blood pressure and personal history of vascular disease, which cost 310 pounds-930 pounds per year of life gained for men and 1100 pounds-3460 pounds for women excluding treatment of raised blood pressure. The extra cost per life year gained by adding smoking history to the screening was 400 pounds-6300 pounds in men. All strategies were more cost effective in men than in women and more cost effective in older age groups. Lipid lowering drugs accounted for at least 70% of the estimated costs of all strategies. Cost effectiveness was greatest when drug treatment was limited to those with cholesterol concentrations above 9.5 mmol/l. CONCLUSIONS--Universal screening and intervention strategies are an inefficient approach to reducing the coronary heart disease burden. A basic strategy for screening and intervention, targeted at older men with raised blood pressure and limiting the use of cholesterol lowering drugs to those with very high cholesterol concentrations would be most cost effective.     

Effectiveness of community-based comprehensive healthy lifestyle promotion on cardiovascular disease risk factors in a rural Vietnamese population: a quasi-experimental study

ABSTRACT: BACKGROUND: Health promotion is a key component for primary prevention of cardiovascular disease (CVD). This study evaluated the impact of healthy lifestyle promotion campaigns on CVD risk factors (CVDRF) in the general population in the context of a community-based programme on hypertension management. METHODS: A quasi-experimental intervention study was carried out in two rural communes of Vietnam from 2006 to 2009. In the intervention commune, a hypertensive-targeted management programme integrated with a community-targeted health promotion was initiated, while no new programme, apart from conventional healthcare services, was provided in the reference commune. Health promotion campaigns focused on smoking cessation, reducing alcohol consumption, encouraging physical activity and reducing salty diets. Repeated cross-sectional surveys in local adult population aged 25 years and over were undertaken to assess changes in blood pressure (BP) and behavioural CVDRFs (smoking, alcohol consumption, physical inactivity and salty diet) in both communes before and after the 3-year intervention. RESULTS: Overall 4,650 adults above 25 years old were surveyed, in four randomly independent samples covering both communes at baseline and after the 3-year intervention. Although physical inactivity and obesity increased over time in the intervention commune, there was a significant reduction in systolic and diastolic BP (3.3 and 4.7 mmHg in women versus 3.0 and 4.6 mmHg in men respectively) in the general population at the intervention commune. Health promotion reduced levels of salty diets but had insignificant impact on the prevalence of daily smoking or heavy alcohol consumption. CONCLUSION: Community-targeted healthy lifestyle promotion can significantly improve some CVDRFs in the general population in a rural area over a relatively short time span. Limited effects on a context-bound CVDRF like smoking suggested that higher intensity of intervention, a supportive environment or a gender approach are required to maximize the effectiveness and maintain the sustainability of the health intervention.     

Cost effectiveness of lowering cholesterol concentration with statins in patients with and without pre-existing coronary heart disease: life table method applied to health authority population.

OBJECTIVES--To estimate the cost effectiveness of statins in lowering serum cholesterol concentration in people at varying risk of fatal cardiovascular disease and to explore the implications of changing the criteria for intervention on cost and cost effectiveness for a purchasing authority. DESIGN--A life table method was used to model the effect of treatment with a statin on survival over 10 years in men and women aged 45-64. The costs of intervention were estimated from the direct costs of treatment, offset by savings associated with a reduction in coronary angiographies, non-fatal myocardial infarctions, and revascularisation procedures. The robustness of the model to various assumptions was tested in a sensitivity analysis. SETTING--Population of a typical district health authority. MAIN OUTCOME MEASURE--Cost per life year saved. RESULTS--The average cost effectiveness of treating men aged 45-64 with no history of coronary heart disease and a cholesterol concentration > 6.5 mmol/l for 10 years with a statin was 136,000 pounds per life year saved. The average cost effectiveness for patients with pre-existing coronary heart disease and a cholesterol concentration > 5.4 mmol/l was 32,000 pounds. These averages hide enormous differences in cost effectiveness between groups at different risk, ranging from 6000 pounds per life year in men aged 55-64 who have had a myocardial infarction and whose cholesterol concentration is above 7.2 mmol/l to 361,000 pounds per life year saved in women aged 45-54 with angina and a cholesterol concentration of 5.5-6.0 mmol/l. CONCLUSIONS--Lowering serum cholesterol concentration in patients with and without preexisting coronary heart disease is effective and safe, but treatment for all those in whom treatment is likely to be effective is not sustainable within current NHS resources. Data on cost effectiveness data should be taken into account when assessing who should be eligible for treatment.     

Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

ObjectivesTo determine whether postal prompts to patients who have survived an acute coronary event and to their general practitioners improve secondary prevention of coronary heart disease.DesignRandomised controlled trial.Setting52 general practices in east London, 44 of which had received facilitation of local guidelines for coronary heart disease.Participants328 patients admitted to hospital for myocardial infarction or unstable angina.InterventionsPostal prompts sent 2 weeks and 3 months after discharge from hospital. The prompts contained recommendations for lowering the risk of another coronary event, including changes to lifestyle, drug treatment, and making an appointment to discuss these issues with the general practitioner or practice nurse.ResultsPrescribing of β bockers (odds ratio 1.7, 95% confidence interval 0.8 to 3.0, P>0.05) and cholesterol lowering drugs (1.7, 0.8 to 3.4, P>0.05) did not differ between intervention and control groups. A higher proportion of patients in the intervention group (64%) than in the control group (38%) had their serum cholesterol concentrations measured (2.9, 1.5 to 5.5, P<0.001). Secondary outcomes were significantly improved for consultations for coronary heart disease, the recording of risk factors, and advice given. There were no significant differences in patients’ self reported changes to lifestyle or to the belief that it is possible to modify the risk of another coronary event.ConclusionsPostal prompts to patients who had had acute coronary events and to their general practitioners in a locality where guidelines for coronary heart disease had been disseminated did not improve prescribing of effective drugs for secondary prevention or self reported changes to lifestyle. The prompts did increase consultation rates related to coronary heart disease and the recording of risk factors in the practices. Effective secondary prevention of coronary heart disease requires more than postal prompts and the dissemination of guidelines.

Key messages

• Postal prompts to patients and their general practitioners about effective secondary prevention after a myocardial infarction did not improve the prescribing of cholesterol lowering drugs and β blockers
• The prompts did improve general practice recording of cardiovascular risk factors and lifestyle advice given to patients, but they made no difference to patients’ reports of changes to lifestyle
• Other methods are needed to improve the quality of secondary prevention of coronary heart disease in general practice

     

Impact of treating hyperlipidemia or hypertension to reduce the risk of death from coronary artery disease

OBJECTIVE: To compare the prevalence of modifiable risk factors for cardiovascular disease among hypertensive and nonhypertensive adults and to estimate the effect of treating hyperlipidemia or hypertension to reduce the risk of death from coronary artery disease. METHODS: The authors evaluated a sample of 7814 subjects aged 35-74 years free of clinical cardiovascular disease from the Canadian Heart Health Surveys to estimate the prevalence of cardiovascular risk factors. They identified hyperlipidemic subjects (ratio of total cholesterol to high-density lipoprotein cholesterol [total-C/HDL-C] 6.0 [corrected] or more for men and 5.0 [corrected] or more for women) and hypertensive subjects (systolic or diastolic blood pressure 160/90 mm Hg or greater, or receiving pharmacologic or nonpharmacologic treatment). A life expectancy model was used to estimate the rate of death from coronary artery disease following specific treatments. RESULTS: An elevated total-C/HDL-C ratio was significantly more common among hypertensive than nonhypertensive men aged 35-64 (rate ratio [RR] 1.56 for age 35-54, 1.28 for age 55-64) and among hypertensive than nonhypertensive women of all ages (RR 2.73 for age 35-54, 1.58 for age 55-64, 1.31 for age 65-74). Obesity and a sedentary lifestyle were also more common among hypertensive than among nonhypertensive subjects. According to the model, more deaths from coronary artery disease could be prevented among subjects with treated but uncontrolled hypertension by modifying lipids rather than by further reducing blood pressure for men aged 35-54 (reduction of 50 v. 29 deaths per 100,000) and 55-64 (reduction of 171 v. 104 deaths per 100,000) and for women aged 35-54 (reduction of 44 v. 39 deaths per 100,000). Starting antihypertensive therapy in subjects aged 35-74 with untreated hypertension would achieve a greater net reduction in deaths from coronary artery disease than would lipid lowering. Nonetheless, the benefits of lipid therapy were substantial: lipid intervention among hypertensive subjects aged 35-74 represented 36% of the total benefits of treating hyperlipidemia in the total hyperlipidemic population. INTERPRETATION: The clustering of hyperlipidemia and the potential benefits of treatment among hypertensive adults demonstrate the need for screening and treating other cardiovascular risk factors beyond simply controlling blood pressure.     

What can be concluded from the Oxcheck and British family heart studies: commentary on cost effectiveness analyses.

OBJECTIVES--To provide a commentary on the economic evaluations of the Oxcheck and British family heart studies: direct comparison of their relative effectiveness and cost effectiveness; comparisons with other interventions; and consideration of problems encountered. DESIGN--Modelling from cost and effectiveness data to estimate of cost per life year gained. SUBJECTS--Middle aged men and women. INTERVENTIONS--Screening for cardiovascular risk factors followed by appropriate lifestyle advice and drug intervention in general practice, and other primary coronary risk management strategies. MAIN OUTCOME MEASURES--Life years gained; cost per life year gained. RESULTS--Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranged from 34,800 pounds for a 1 year duration to 1500 pounds for 20 years for the British family heart study and from 29,300 pounds to 900 pounds for Oxcheck. These figures exclude broader net clinical and cost effects and longer term clinical and cost effects other than coronary mortality. CONCLUSIONS--Despite differences in underlying methods, the estimates in the two economic analyses of the studies can be directly compared. Neither study was large enough to provide precise estimates of the overall net cost. Modelling to cost per life year gained provides more readily interpretable measures. These estimates emphasise the importance of the relatively weak evidence on duration effect. Only if the effect lasts at least five years is the Oxcheck programme likely to be cost effective. The effect must last for about 10 years to justify the extra cost associated with the British family heart study.     

Central obesity and health-related factors among middle-aged men: a comparison among native Japanese and Japanese-Brazilians residing in Brazil and Japan

The objective of this study was to investigate the influence of different cultural environments on the development of obesity by examining the association of central obesity, lifestyle, and selected coronary risk factors among people with identical Japanese genetic backgrounds living in Japan and Brazil. One hundred and four native Japanese and 286 Japanese-Brazilians residing in Brazil and Japan aged 35 years or over were studied. Obesity, metabolic risk factors for coronary disease, and history of regular sports activity, daily physical activity, and eating habits were assessed. The results showed Japanese-Brazilians residing in Brazil with significantly higher waist circumference values, and greater prevalence of central obesity compared to native Japanese and Japanese-Brazilians residing in Japan. The risk of developing central obesity was found to be 2.8 times higher among Japanese-Brazilians residing in Brazil. However, this association was no longer found to be significant after adjusting for lifestyle factors in the logistic model. Additionally, waist circumference was found to be significantly associated with metabolic risk factors for coronary disease. These findings suggest substantial variation in measures of central obesity among the three groups of Japanese ancestry, and underscore the heterogeneity of risk factors among communities of Japanese ancestry living in different cultural environments. The results also suggest that immigrant men exposed to the Brazilian cultural environment are more susceptible to the development of central obesity, and it seems to be associated with various lifestyle items and metabolic risk factors for coronary disease.     

“Unwarranted survivals” and “anomalous deaths” from coronary heart disease: prospective survey of general population

ObjectivesTo assess survival in people who are at apparent high risk who do not develop coronary heart disease (“unwarranted survivals”) and mortality in people at low risk who die from the disease (“anomalous deaths”) and the extent to which these outcomes are explained by other, less visible, risk factors.DesignProspective general population survey.SettingRenfrew and Paisley, Scotland.Participants6068 men aged 45-64 years at screening in 1972-6, allocated to “visible” risk groups on the basis of body mass index and smoking.ResultsVisible risk was a good predictor of mortality: 13% (45) of men at low risk and 45% (86) of men at high risk had died by age 70 years. Of these deaths, 12 (4%) and 44 (23%), respectively, were from coronary heart disease. In the group at low visible risk other less visible risk factors accounted for increased risk in 83% (10/12) of men who died from coronary heart disease and 29% (84/292) of men who survived. In the high risk group 81/107 who survived (76%) and 19/44 (43%) who died from coronary heart disease had lower risk after other factors were considered. Different risk factors modified risk (beyond smoking and body mass index) in the two groups. Among men at low visible risk, poor respiratory function, diabetes, previous coronary heart disease, and socioeconomic deprivation modified risk. Among men at high visible risk, height and cholesterol concentration modified risk.ConclusionsDifferences in survival between these extreme risk groups are dramatic. Health promotion messages would be more credible if they discussed anomalies and the limits of prediction of coronary disease at an individual level.

What is already known on this topic

People pay attention to visible risk factors, such as smoking and weight, in explaining or predicting coronary events but are aware that these behavioural risk factors fail to explain some early deaths from coronary heart disease (in those with “low risk” lifestyles) and long survival (in those with “high risk” lifestyles)Such violations to notions of coronary candidacy undermine people''s belief in the worth of modifying behavioural risk factors for coronary heart disease

What this study adds

Visible risk status was a good marker for other coronary risk factors at the extremes of the risk distributionMost men at low visible risk (slim, never smoked) who died prematurely from coronary heart disease had poorer risk profiles on other less visible risk factors; similarly, men at high visible risk (obese, heavy smokers) who survived often had more favourable profiles on other risk factors     

Debate: at what level of coronary heart disease risk should a statin be prescribed?

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are effective treatments for the primary and secondary prevention of coronary heart disease, but an outstanding issue is determining who should have such treatment. The benefit from treatment with statins appears to be proportional to the underlying risk of coronary heart disease and independent of the factors increasing risk. Most benefit will therefore be achieved by treating people at increased risk of coronary heart disease. Statins reduce coronary morbidity even when the risk of coronary heart disease is relatively low (6% over 10 years), but reduction in all-cause mortality, the true measure of safety has been shown only when the risk of a major coronary heart disease event is 15% over 10 years or greater. At this level of risk patients appear willing to take treatment to gain the benefit expected from statin treatment, and the cost effectiveness of statin treatment is within the range accepted for other treatments. The major impediments to the systematic introduction of statin treatment at this level of risk are the very high overall cost and the large workload in countries like Britain, where the population risk of coronary heart disease is high. For this reason, recent British guidelines correctly advise statin treatment for secondary prevention and primary prevention when the 10 year coronary heart disease risk is 30% or greater as the first priority, moving to a lower coronary heart disease threshold for primary prevention only when resources permit.     

How can we best prolong life? Benefits of coronary risk factor reduction in non-diabetic and diabetic subjects.

OBJECTIVE--To compare the theoretical benefits of different approaches to reduce risk factors for coronary heart disease in subjects at risk. DESIGN--The results of findings from meta-analyses of intervention studies on cause specific mortality and of observational studies on smokers and ex-smokers were applied to observational data on 10 year cause specific mortality derived from the multiple risk factor intervention trial. Lifetable analyses were used to estimate gains in life expectancy. SUBJECTS--Diabetic and non-diabetic men initially 35-57 years of age. MAIN OUTCOME MEASURES--10 year mortality from coronary heart disease, 10 year total mortality, man years of intervention to prevent one death and one death from coronary heart disease, gain in life expectancy, and drug costs per year of additional life in diabetic and non-diabetic men of 45. RESULTS--In non-diabetic men a 10 year mortality from coronary heart disease of 14.4 per 1000 would be reduced by a mean of 0.58, 0.82, 2.64, and 2.74 per 1000 by antihypertensive treatment, lowering cholesterol concentration, taking aspirin, and stopping smoking respectively; a 10 year total mortality of 44.1 per 1000 would fall by a mean of 1.06, 5.16, and 8.65 per 1000 with antihypertensive and aspirin treatment and stopping smoking respectively and increased by a mean of 0.07 per 1000 with the lowering of cholesterol concentration. In diabetic men the reductions in mortality from coronary heart disease would be between three and five times greater, and total mortality would show mean reductions of 5.81, 0.56, 16.17, and 20.84 per 1000 respectively, with all interventions of significant benefit except the lowering of cholesterol concentration. Between 2400 and 3800 man years of pharmacological intervention were calculated as being necessary to prevent one death from coronary heart disease in a non-diabetic man, and between 800 and 1200 man years in a diabetic man. The loss of life expectancy associated with smoking and hypertension is greater than that accruing from hypercholesterolaemia, but stopping smoking would prolong life by a mean of around four years in a 45 year old non-diabetic man and three years in a diabetic man, whereas aspirin and antihypertensive treatment would provide approximately one year of additional life expectancy in both categories. CONCLUSIONS--Studies to date have shown little impact of drugs that lower cholesterol concentration and blood pressure on either coronary heart disease or total mortality. Although new treatments for hypercholesterolaemia and hypertension might help prevent coronary heart disease, other approaches to reduce the burden of premature death are required.     

Prevention of coronary heart disease by raising high-density lipoprotein cholesterol?

Consistent with several potentially anti-atherogenic activities of high-density lipoproteins in vitro, low plasma levels of high-density lipoprotein cholesterol are associated with an increased risk of coronary heart disease. In addition to genes, lifestyle factors (e.g. smoking, being overweight and physical inactivity) strongly affect plasma high-density lipoprotein cholesterol levels. Moreover, a low level of high-density lipoprotein cholesterol interacts with other risk factors. Raising of high-density lipoprotein cholesterol by either adjustments of lifestyle or drug intervention as well as elimination of additional risk factors are thus thought to affect coronary risk. Here, we summarize the outcomes of observational and interventional studies as well as genetic and experimental research which have recently much advanced our understanding of the function and regulation of high-density lipoprotein metabolism. We conclude from the data that changes in the kinetics and functionality of high-density lipoprotein rather than changes in plasma high-density lipoprotein cholesterol levels per se will affect the anti-atherogenicity of therapeutic interference with high-density lipoprotein metabolism.     

Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study.

OBJECTIVE--To measure the costs and cost effectiveness of the Oxcheck cardiovascular risk factor screening and intervention programme. DESIGN--Cost effectiveness analysis of a randomised controlled trial using clinical and economic data taken from the trial. SETTING--Five general practices in Luton and Dunstable, England. SUBJECTS--2205 patients who attended a health check in 1989-90 and were scheduled for re-examination in 1992-3 (intervention group); 1916 patients who attended their initial health check in 1992-3 (control group). Participants were men and women aged 35-64 years. INTERVENTION--Health check conducted by nurse, with health education and follow up according to degree of risk. MAIN OUTCOME MEASURES--Cost of health check programme; cost per 1% reduction in coronary risk. RESULTS--Health check and follow up cost 29.27 pounds per patient. Estimated programme cost per 1% reduction in coronary risk per participant was between 1.46 pounds and 2.25 pounds; it was nearly twice as much for men as women. CONCLUSIONS--The cost to the practice of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be 47,000 pounds, a proportion of which could be paid for through staff pay reimbursements and Band Three health promotion target payments. This study highlights the considerable difficulties faced when calculating the costs and benefits of a health promotion programme. Economic evaluations should be integrated into the protocols of randomised controlled trials to enable judgments to be made on the relative cost effectiveness of different prevention strategies.     

Short-term versus long-term risk for coronary artery disease: implications for lipid guidelines

PURPOSE OF REVIEW: The aim of this article is to describe recent advances in our understanding of lifetime risks for cardiovascular disease and their implications for lipid guidelines. RECENT FINDINGS: Recent studies have indicated that, among younger and middle-aged adults, there is a large subset with low 10-year risk but high lifetime risk for cardiovascular disease. Individuals with high lifetime risks can be identified on the basis of single adverse risk factors or on the basis of overall risk factor burden. For example, using the ATP-III online risk estimator, a 45-year-old obese, nonsmoking, nondiabetic man with total cholesterol of 200 mg/dl, HDL-cholesterol of 40 mg/dl, and untreated systolic blood pressure of 135 mmHg has an estimated 10-year risk for hard coronary heart disease of 3%. In contrast, recent data indicate that his predicted remaining lifetime risk for cardiovascular disease is 50% and his predicted median survival is over 10 years shorter than a man at the same age with optimal risk factors. SUMMARY: Lifetime risk estimation for cardiovascular disease may be an important adjunct to short-term (10-year) risk estimation that may help identify more treatment-eligible individuals at risk for cardiovascular disease, improve risk communication, motivate changes in lifestyle and behaviors, and promote adherence to therapy.     

Using nurses for preventive activities with computer assisted follow up: a randomised controlled trial.

OBJECTIVE--To assess whether an organised programme of prevention including the use of a health promotion nurse noticeably improved recording and follow up of cardiovascular risk factors and cervical smears in a general practice that had access to computerised cell and recall. DESIGN--Randomised controlled trial. SETTING--General practice in inner London. PATIENTS--All 3206 men and women aged 30-64 registered with the practice. INTERVENTION--The intervention group had their risk factors ascertained and followed up by the health promotion nurse and the general practitioner, whereas those in the control group were managed by the general practitioner alone. END POINT--Recording and follow up of blood pressure and cervical smears after three years. Recording of smoking, family history of ischaemic heart disease, and serum cholesterol concentrations were also examined. MEASUREMENTS and MAIN RESULTS--When the trial was stopped after two years the measurements of blood pressure in the preceding five years were 93% (1511/1620) v 73% (1160/1586) (95% confidence interval for difference 17.5 to 22.7%) for intervention and control groups respectively. For patients with hypertension the figures were 97% (104/107) v 69% (80/116) (18.2 to 38.2%). For women the proportion who had had a cervical smear in the preceding three years were 76% (606/799) v 49% (392/806) (22.5 to 31.9%). Recording of smoking, family history of ischaemic heart disease, and serum cholesterol concentrations was also higher in the intervention group compared with the control group. CONCLUSION--An organised programme, which includes a nurse with specific responsibility for adult prevention, is likely to make an important contribution to recording of risk factors and follow up of those patients with known risks.     

Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease.

OBJECTIVE: To assess the effectiveness of multiple risk factor intervention in reducing cardiovascular risk factors, total mortality, and mortality from coronary heart disease among adults. DESIGN: Systematic review and meta-analysis of randomised controlled trials in workforces and in primary care in which subjects were randomly allocated to more than one of six interventions (stopping smoking, exercise, dietary advice, weight control, antihypertensive drugs, and cholesterol lowering drugs) and followed up for at least six months. SUBJECTS: Adults aged 17-73 years, 903000 person years of observation were included in nine trials with clinical event outcomes and 303000 person years in five trials with risk factor outcomes alone. MAIN OUTCOME MEASURES: Changes in systolic and diastolic blood pressure, smoking rates, blood cholesterol concentrations, total mortality, and mortality from coronary heart disease. RESULTS: Net decreases in systolic and diastolic blood pressure, smoking prevalence, and blood cholesterol were 4.2 mm Hg (SE 0.19 mm Hg), 2.7 mm Hg (0.09 mm Hg), 4.2% (0.3%), and 0.14 mmol/l (0.01 mmol/l) respectively. In the nine trials with clinical event end points the pooled odds ratios for total and coronary heart disease mortality were 0.97 (95% confidence interval 0.92 to 1.02) and 0.96 (0.88 to 1.04) respectively. Statistical heterogeneity between the studies with respect to changes in mortality and risk factors was due to trials focusing on hypertensive participants and those using considerable amounts of drug treatment, with only these trials showing significant reductions in mortality. CONCLUSIONS: The pooled effects of multiple risk factor intervention on mortality were insignificant and a small, but potentially important, benefit of treatment (about a 10% reduction in mortality) may have been missed. Changes in risk factors were modest, were related to the amount of pharmacological treatment used, and in some cases may have been overestimated because of regression to the mean, lack of intention to treat analyses, habituation to blood pressure measurement, and use of self reports of smoking. Interventions using personal or family counselling and education with or without pharmacological treatments seem to be more effective at reducing risk factors and therefore mortality in high risk hypertensive populations. The evidence suggests that such interventions implemented through standard health education methods have limited use in the general population. Health protection through fiscal and legislative measure may be more effective.     

Secular decline in mortality from coronary heart disease in adults with diabetes mellitus: cohort study

Objective To examine trends in fatal coronary heart disease in adults with and without diabetes.Design Cohort study.Setting Two surveys of the Nord-Trøndelag health study (HUNT), a population based study in Norway.Participants 74 914 men and women from the first survey (1984-6) and 64 829 from the second survey (1995-7).Main outcome measure Age specific mortality from coronary heart disease among adults with and without diabetes during two consecutive nine year follow-up periods.Results A total of 2623 men and 1583 women died from coronary heart disease. Mortality rates were substantially lower during the most recent follow-up period: among men aged 70-79 without diabetes, deaths per 1000 person years declined from 16.38 to 8.79 (reduction 48%, 95% confidence interval 39% to 55%) and among women aged 70-79 from 6.84 to 2.68 (62%, 52% to 70%). Among the same age group with diabetes, deaths per 1000 person years in men declined from 38.97 to 17.89 (54%, 32% to 69%) and in women from 28.15 to 11.83 (59%, 37% to 73%). The reduction was more noticeable in age groups younger than 70 at baseline, and less pronounced among people aged 80 or more. Mortality from coronary heart disease was more than twofold higher in people with than without diabetes, with a slightly stronger association in women. The difference in mortality by diabetes status remained almost unchanged from the first to the second survey.Conclusion The strong general reduction in mortality rates from coronary heart disease from the first to the second follow-up period also benefited people with diabetes, but the more than twofold higher mortality from coronary heart disease associated with diabetes persisted over time.     

Effects of Lifestyle Modification Programs on Cardiac Risk Factors

Medicare conducted a payment demonstration to evaluate the effectiveness of two intensive lifestyle modification programs in patients with symptomatic coronary artery disease: the Dr. Dean Ornish Program for Reversing Heart Disease (Ornish) and Cardiac Wellness Program of the Benson-Henry Mind Body Institute. This report describes the changes in cardiac risk factors achieved by each program during the active intervention year and subsequent year of follow-up. The demonstration enrolled 580 participants who had had an acute myocardial infarction, had undergone coronary artery bypass graft surgery or percutaneous coronary intervention within 12 months, or had documented stable angina pectoris. Of these, 98% completed the intense 3-month intervention, 71% the 12-month intervention, and 56% an additional follow-up year. Most cardiac risk factors improved significantly during the intense intervention period in both programs. Favorable changes in cardiac risk factors and functional cardiac capacity were maintained or improved further at 12 and 24 months in participants with active follow-up. Multivariable regressions found that risk-factor improvements were positively associated with abnormal baseline values, Ornish program participation for body mass index and systolic blood pressure, and with coronary artery bypass graft surgery. Expressed levels of motivation to lose weight and maintain weight loss were significant independent predictors of sustained weight loss (p = 0.006). Both lifestyle modification programs achieved well-sustained reductions in cardiac risk factors.     

Cardiovascular disease risk prediction using genetic information (gene scores): is it really informative?

PURPOSE OF REVIEW: DNA-based tests for assessment of genetic predisposition to coronary heart disease need to provide information over and above that of conventional risk factors. The efficacy of selected 'candidate' gene loci in risk algorithms, to improve the predictive accuracy for coronary heart disease, remains to be demonstrated. RECENT FINDINGS: Although many candidate genes for coronary heart disease have been tested, the optimal set of risk genotypes has yet to be identified. There is only a relatively modest risk to be expected in association with any single genotype, published estimates are in the range of 1.12-1.73. Thus the risk associated with any one genotype is modest, but, in combination, selected genotypes may be associated with a clinically significant risk. Since the allele frequency for many of these variants is high, many individuals will carry several 'risk alleles'. A small number of selected single nucleotide polymorphisms should complement the conventional risk factors to identify high-risk individuals in whom correction of 'modifiable risk factors' through lifestyle interventions or medication would be most beneficial. SUMMARY: As our understanding of how genetic variation impacts on common diseases advances, the novel loci identified by genome-wide association scans associated with disease risk will rapidly improve these risk algorithms.     

The University of Manitoba Follow-up Study. A Prospective Investigation of Cardiovascular Disease: Part II. Build,Blood Pressure and Electrocardiographic Factors Possibly Associated with the Development of Coronary Heart Disease

The relationship of selected physical and electrocardiographic factors to the occurrence of coronary heart disease was examined in a cohort of 3983 healthy North American males followed up for 15 years. Variations in build or mean heart rate were not found to be related to the occurrence of coronary heart disease. The risk of coronary heart disease rose progressively as blood pressure increased. With readings of 160/95 mm. Hg or higher the risk was 1.77 times that of the population as a whole. Non-specific S-T and/or T wave changes in the electrocardiogram were associated with three times the risk of developing coronary heart disease. Individuals with the combination of a blood pressure of 160/95 mm. Hg and nonspecific T wave changes exhibited an augmented susceptibility to coronary heart disease, the risk being four times that of the whole population.