Preventive cardiology in practice: a device for risk estimation and counseling in coronary disease

Hypercholesterolemia and 5-year risk of development of coronary heart disease among university and school workers in Jeddah, Saudi Arabia

BACKGROUND

A study was performed among university and school employees as a step in detecting the prevalence of coronary heart disease (CHD) risk factors among school and university staff and the relation of the various risk factors to hypercholesterolemia and to predict the 5-years probability of development of CHD.

METHODS

All university staff and a sample of school workers in Jeddah were included in the study. Data were collected by interview and self-administered questionnaires, as well as by direct observation and measurement of weight, height, blood pressure, and total blood cholesterol. Logistic regression analysis was performed to identify the impact of various risk factors on hypercholesterolemia. The 5-year risk of development of CHD was calculated to identify the proportion at highest risk.

RESULTS

Some CHD risk factors were detected among the participants as 18.8% were current cigarette smokers, around half were classified as overweight, and 19.9% were classified as hypertensive. Hypercholesterolemia was present in 10.1% and was significantly related to older age (40 years and over) and place of work. The estimated risk of CHD in the coming half-decade for those classified in the fifth quintile was 0.068. The Q(5)/Q(1) ratio has shown that those classified in the fifth quintile were at 3.6 times more risk of developing CHD in the coming 5 years than those classified in the first quintile.

CONCLUSION

CHD risk factors are becoming prevalent in our society. The risk of development of CHD in the coming decades is not trivial. Short- and long-term health strategies are recommended to decrease the risk of CHD and improve the quality of life.

Multivariate risk estimation for coronary heart disease: the Busselton Health Study

Coronary heart disease (CHD) is a multifactorial disease and CHD risk should be estimated by assessing all cardiovascular risk factors simultaneously. Simply adding up the number of factors with 'at risk' values fails to identify high-risk subjects with multiple risk factors at moderately elevated values. A more efficient approach is to use a quantitative multivariate risk score. A number of overseas studies have produced CHD risk scoring systems for men. There are few risk scores developed for women and no CHD risk scores have been developed from Australian data. This study used data on CHD risk factors and morbidity/mortality follow-up for the 1978 Busselton Health Survey participants to provide age-specific estimates of absolute risk of CHD hospitalisation or death, and to develop multivariate CHD risk scoring systems for men and women. The scores are based on age, blood pressure, anti-hypertensive medication, total and HDL cholesterol, smoking, diabetes, left ventricular hypertrophy and previous history of CHD. The generalisability and applicability of these risk estimation systems to Australian populations in the late 1990s is discussed.

Prediction of coronary heart disease mortality in Busselton, Western Australia: an evaluation of the Framingham, national health epidemiologic follow up study, and WHO ERICA risk scores

STUDY OBJECTIVES

To evaluate the performance of the Framingham, national health epidemiologic follow up study, and the WHO ERICA risk scores in predicting death from coronary heart disease (CHD) in an Australian population.

DESIGN

Cohort follow up study.

SETTING AND PARTICIPANTS

The cohort consisted of 1923 men and 1968 women who participated in health surveys in the town of Busselton in Western Australia over the period 1966-81. Baseline assessment included cardiovascular risk factor measurement. Mortality follow up to 31 December 1994 was used.

MAIN RESULTS

Risk scores for death from CHD within 10 years based on age, systolic blood pressure, cholesterol, smoking, and BMI were derived from the Busselton study data using logistic regression analysis. Similar risk scores developed from the Framingham, the national health epidemiologic follow up study, and the WHO ERICA cohorts were found to perform just as well in Busselton as the Busselton-derived scores, both before and after controlling the effect of age. There was considerable overlap across the different risk scores in the identification of individuals in the highest quintile of risk. Those in the top 20% of scores included about 41% of deaths from CHD among men and about 63% of deaths from CHD among women.

CONCLUSION

Although there is variation in risk score coefficients across the studies, the relative risk predictive performance of the scores is similar. The use of Framingham and other similar risk scores will not be misleading in white Australian populations.

Major differences in cardiovascular risk indicators by educational status. Results from a population based screening program

All people aged 30-59 years living in one primary health care center's catchment area were invited to participate in a population based screening program. A total of 2642 people (68%) participated. An overall risk index for having a heart attack within 5 years (Ps) was calculated based on diastolic BP, smoking status, total cholesterol, and age. Other risk indicators registered were Body Mass Index, and physical activity. A highly significant association between education level and age-adjusted overall risk index for both men (p = 0.001) and women (p < 0.001) was found. Also Body Mass Index, total cholesterol, smoking status, and, for women, diastolic blood pressure showed similar significant variation with education level with higher education associated to lower risk. These findings imply the possibility of a great variation in the "risk" of receiving pharmacological treatment for one's CVD risk factors.

Population based CVD health risk appraisal. A method to create a "critical mass" of health-conscious people

This study used a population based screening procedure as a means for a combined strategy for targeting individuals at high risk of cardiovascular disease while aiming for a low-risk population. During a five month period 68% of the total target population (2642 out of 3880) men and women attended the screening. We found, 1) that a broad population based health risk appraisal activity, supported by a personal computer as an educational tool and as a means to speed up the handling of each test, was feasible, 2) that it was easy to identify high risk individuals, to be able to offer them further follow-up, and 3) that there is evidence supporting the view that reaching a large proportion of the population in a limited time period, a "critical mass", will contribute to a growing health awareness not only among participants but also among the general population in the actual area.

The Dundee coronary risk-disk for management of change in risk factors

OBJECTIVE

To devise a simplified system for grading and monitoring modifiable coronary risk in primary care, to be used with an action plan.

METHODS

The risk equation came from 5203 men aged 40-59 in the United Kingdom heart disease prevention project, who had 331 coronary events over five years; the population rank (reading 1-100) was obtained by scoring 10,359 participants in the Scottish heart health study. Calculation of rank was embodied in the Dundee coronary risk-disk; the formula was tested against the Whitehall study; disk and action plan were evaluated in primary care.

RESULTS

The system measures modifiable coronary risk from smoking, blood pressure, and blood cholesterol concentration by a sex and age related rank running from 1 (high risk, priority action) to 100 (low risk, general advice). The formula predicted outcome acceptably in the Whitehall study and is built into a circular slide rule. Only eight (11%) of 76 general practitioners and practice nurses surveyed already used risk factor scores. After evaluation most thought they should use one and proposed to incorporate the Dundee coronary risk-disk and the associated action plan into their routines.

CONCLUSION

The Dundee coronary risk-disk readout of Dundee rank, standardised on a scale of 1 to 100 by age and sex, is a simple, valid means of assessing and monitoring modifiable coronary risk. It puts single risk factors (such as cholesterol concentration) in perspective and can aid selective testing. Understood by medical staff and patients, it should improve the efficiency and effectiveness of the high risk approach to coronary prevention.

Perceived cardiac risks and beliefs about health and running in elite older runners

Beliefs about the perceived health benefits of exercise of 24 elite runners were compared on an objective measure of risk for coronary heart disease. Results showed a 4- to 6-fold increase in estimates of perceived risk as compared to the objective estimate of risk, suggesting that these runners held somewhat exaggerated beliefs about the health benefits of running. In addition, these beliefs remained stable over time.

Lipids and hypertension. Implications of new guidelines for cholesterol management in the treatment of hypertension

The approach to management of cardiovascular risk factors has been greatly enhanced by the recent publication of results from several large intervention studies. This increased knowledge has led to rapid changes in perspective and to some controversies regarding cardiovascular risk management. The major cardiovascular disease risk factors are high blood pressure, elevated serum cholesterol, and cigarette smoking. In the past, physicians have paid little attention to the latter two factors, focusing primarily on severe hypertension. Initially, the pharmacologic treatment of hypertension consisted mostly of thiazide diuretics, since they were the only agents generally available that were well-tolerated by most patients. Over the past decade, however, new data from large-scale intervention studies and the development of many new classes of antihypertensive agents have considerably improved the approach to managing all three primary risk factors. Recently published results of major clinical trials are likely to further alter physicians' perspectives and influence their practice habits. This article proposes an approach to comprehensive risk management that simultaneously involves all the major risk factors, with emphasis on blood pressure and lipids. The rationale for this integrated approach is based on the following facts: Hypertension trials have not convincingly demonstrated that lowering blood pressure alone reduces the risk for coronary heart disease; Cholesterol lowering has been shown conclusively to reduce the risk of coronary heart disease; Several classes of antihypertensive agents have now been found to significantly affect blood lipids, either adversely or beneficially; and Past observational epidemiologic studies have shown a positive association between blood lipids (cholesterol and triglycerides) and blood pressure, implying that these two conditions commonly occur together. The background supporting these facts, as well as a practical approach to the treatment of hypertension that takes into consideration the management of blood lipids, is provided in this article.

Development and validation of a self-scoring test for coronary heart disease risk

Self-administered tests to assess an individual's coronary heart disease risk are common in the popular press. However, delusion and inaccuracy in self-scoring may impair their utility as educational tools. Self-assessment questions concerning dietary cholesterol, weight, cigarette smoking, and blood pressure were administered several days prior to risk measurement to 246 randomly selected adults aged twenty-five to sixty-four. A standard risk score combining measured blood pressure, cigarette smoking on blood cholesterol level was calculated for each participant using a multiple logistic equation. The self-scoring test was derived by multiple regression, using the standard risk score as the dependent variables and the self-assessment responses, age, and sex as independent variables. The multiple R2 of the resulting equation was 0.48. For 86 percent of the participants, the decile of self-assessed risk was within two deciles of the decile of risk calculated from logistic equation. We tested the validity of the self-scoring test in a separate and independent population (n-247) with comparable results. We conclude that the test indicated risk status and sources of elevated risk for many individuals. Such a test can be a valid health education tool.