Family history assessment: strategies for prevention of cardiovascular disease

Genetics, its role in preventing the pandemic of coronary artery disease

Epidemiologists have claimed for decades that about 50% of predisposition for coronary artery disease (CAD) is genetic. Advances in technology made possible the discovery of hundreds of genetic risk variants predisposing to CAD. Multiple clinical trials have shown that cardiac events can be prevented by drugs to lower plasma low-density lipoprotein cholesterol (LDL-C). A major barrier to primary prevention is the lack of markers to identify those individuals at risk prior to the development of symptoms of the disease. Conventional risk factors are age-dependent, occurring mostly in the sixth or seventh decade, which is less than desirable for early primary prevention. A polygenic risk score, derived from the number of genetic risk variants predisposing to CAD inherited by an individual, has been evaluated in over 1 million individuals. The risk for CAD is stratified into high, intermediate, and low. Polygenic risk scores derived from retrospective genotyping of several clinical trials evaluating the effect of statin therapy or PCSK9 inhibitors show the genetic risk is reduced 40%-50% by decreasing plasma LDL-C. Prospective randomized placebo-controlled clinical trials document a 40%-50% reduction in cardiac events in individuals at high genetic risk associated with favorable lifestyle changes and increased physical activity. The polygenic risk score is not age-dependent and remains the same throughout life. Thus, the GRS is superior to conventional risk factors in identifying asymptomatic individuals at risk for CAD early in life for primary prevention. These results indicate clinical embracement of the GRS in primary prevention would be a paradigm shift in the treatment of the number one killer, CAD.

Population attributable fraction estimates of cardiovascular diseases in different levels of plasma total cholesterol in a large-scale cross-sectional study: a focus on prevention strategies and treatment coverage

PURPOSE

Cardiovascular diseases (CVDs) are the main cause of deaths among non-communicable diseases. Arguments about the best prevention strategy to control CVDs' risk factors continue. We evaluated the population attributable fraction (PAF) of CVDs in different levels of plasma cholesterol.

METHODS

Patients' data were obtained from Iran STEPs 2016 study. In phase 0 we estimated PAF regardless of cholesterol levels and clinical factors. In phase 1 we calculated PAF based on three levels of cholesterol (<200, 200-240, ≥240 mg/dl). In phase 2 we estimated PAF in 3 groups considering lipid-lowering drugs. In phase 3 all treated participants and not treated hypercholesterolemic people were included, to evaluate the impact of treatment. Estimations were done for Ischemic heart disease (IHD) and ischemic stroke (IS), and for two sex.

RESULTS

In phase 0, the highest PAF for IHD and IS were 0.35 (95% confidence interval 0.29-0.41) and 0.22 (0.18-0.27) for females and 0.27 (0.22-0.32) and 0.18 (0.14-0.22) for males. In phase 1, the highest PAF belonged to population with cholesterol ≥240 mg/dl and IHD, as 0.90 (0.85-0.94) for females, and 0.90 (0.85-0.96) for males. In phase 2, the pre-hypercholesterolemic group had higher PAFs than the hypercholesteremic group in most of the population. Phase 3 showed treatment coverage significantly lowered fractions in all age groups, for both causes.

CONCLUSION

An urgent action plan and a change in preventive programs of health guidelines are needed to stop the vast burden of hypercholesterolemia in the pre-hypercholesterolemic population. Population-based prevention strategies need to be more considered to control further CVDs.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-020-00673-3.

Family history of pre-eclampsia and cardiovascular disease as risk factors for pre-eclampsia: the GenPE case-control study

Objective: To determine whether family history of pre-eclampsia and cardiovascular disease is consistently associated with the occurrence of pre-eclampsia sub-phenotypes and fetal growth restriction (FGR).Material and Methods: We conducted a case-control study in which cases of pre-eclampsia and healthy pregnant controls were recruited at the time of delivery from eight Colombian cities between 2000 and 2012. Odds of pre-eclampsia among women with a positive family history of pre-eclampsia or cardiovascular disease were compared to women without affected relatives (logistic regression modeling and multinomial logistic regression model [Ajusted]).Results: A total of 3510 pre-eclampsia cases and 4512 controls with data on family history of pre-eclampsia were included in analyses. A subsample of 3086 cases and 3888 controls also provided information on family history of cardiovascular disease. Women whose mothers had pre-eclampsia had 3.38 (95% CI 2.89, 3.96) higher odds than those who did not, and having an affected sister increased pre-eclampsia odds by 2.43 (95% CI 2.02, 2.93). The effect of having both mother and sister affected with pre-eclampsia was stronger than the two independent risk factors (OR 4.17 [95% CI 2.60, 6.69]). Women with parental history of cardiovascular disease also had an increased risk of pre-eclampsia (OR 1.58 [95% CI 1.24, 2.01]).Conclusions: Family history of pre-eclampsia increased the risk of PE. The impact of family history of cardiovascular disease on pre-eclampsia was more conservative, but serves to support the hypothesis that pre-eclampsia may reflect the premature exposure of underlying cardiovascular dysfunction, precipitated by the stress test of pregnancy.

Family tree database of the National Health Information Database in Korea

We constructed the family tree database (DB) by using a new family code system that can logically express interpersonal family relationships and by comparing and complementing health insurance eligibility data and resident register data of the National Health Information Database (NHID). In the family tree DB, Parents and grandparents are matched for more than 95% of those who were born between 2010 and 2017. Codes for inverse relationships and extended relationships are generated using sequences of the three-digit basic family codes. The family tree DB contains variables such as sex, birth year, family relations, and degree of kinship (maximum of 4) between subjects and family members. Using the family tree DB, we find that prevalence rates of hypertension, diabetes, ischemic heart disease, cerebrovascular disease, and cancer are higher for those with family history. The family tree DB may omit some relationships due to incomplete past data, and some family relations cannot be uniquely determined because the source data only contain relationships between head and members of the household. The family tree DB is a part of the NHID, and researchers can submit requests for data on the website at http://nhiss.nhis.or.kr. Requested data will be provided after approval from the data service review board. However, the family tree DB can be limitedly provided for studies with high public value in order to maximize personal information protection.

Prevalence and Cardiovascular Health Impact of Family History of Premature Heart Disease in the United States: Analysis of the National Health and Nutrition Examination Survey, 2007-2014

Background

Because family history is a known risk factor for heart disease, it is important to characterize its public health impact in terms of population prevalence of family history of heart disease, the burden of heart disease attributable to family history, and whether family history interacts with modifiable risk factors for heart disease.

Methods and Results

We used population data from NHANES (the National Health and Nutrition Examination Survey [2007–2014]) to measure the association of self‐reported family history of premature heart disease (FHPHD) with cardiovascular disease (n=19 253) and to examine the association between cardiovascular health metrics and FHPHD (n=16 248). Using logistic regression and multivariable adjustment, family history odds ratios were 5.91 (95% CI, 3.34–10.44) for ages 20 to 39, 3.02 (95% CI, 2.41–3.79) for ages 40 to 59, and 1.87 (95% CI, 1.54–2.28) for age ≥60 for cardiovascular disease. The prevalence of cardiovascular disease for the population with a FHPHD (15.72%; 95% CI, 13.81–17.64) was more than double the prevalence of cardiovascular disease for those without a family history (6.25%; 95% CI, 5.82–6.69). Compared with participants with optimum cardiovascular health, the prevalence ratio for FHPHD was 1.98 (95% CI, 1.40–2.79) for those with inadequate cardiovascular health.

Conclusions

Millions of people who are at high risk of having cardiovascular disease could be identified using FHPHD. FHPHD can become an important component of public health campaigns that address modifiable risk factors that plan to reduce the overall risk of heart disease.

The Effect of Parental Medical History on the Prevalence of Cerebrovascular Diseases in Their Children in an Iranian Population

Introduction:

Still a controversial issue, family history is known as a risk factor for the development of Cerebrovascular Diseases (CVD). In this study, we aimed to evaluate the relationship between parental history and risk of CVD in their offspring in Iranian population.

Methods:

Isfahan Cohort Study (ICS) included total 6504 healthy participants which were randomly selected through a two-stage cluster sampling method from three districts. The participants were followed prospectively for 10 years. The diagnosis of CVD were confirmed by expert panelist. Clinically validated history of CVD was established for definition of parental history of CVD. Types of history were categorized into paternal, maternal, both parents, and no history.

Results:

The prevalence of CVD is generally higher among female offspring compared with male ones (P<0.001). The relative risk of CVD with maternal history was not significant (95%CI=0.95–2.29). By adjusted model analysis, history of CVD in both parents affected the risk of CVD in their male children (RR=2.13, P=0.033, 95%CI). By crude model analysis, maternal history of CVD (P=0.047), history of CVD in both parents (P=0.032), and maternal history of hypertension (P=0.005) were determined as risk factors of CVD in offspring. Indeed, the mean age of CVD in offspring decreases based on this order: history of hypertension in parents, paternal history of CVD in both parents, maternal history of CVD, and no history (P<0.001).

Conclusion:

Early and regular screening for CVD development is necessary in female offspring of the families with the present history of CVD from maternal side. This group are at risk and should be considered as the target group for screening and taking preventive measures.

Selected risk factors for atherosclerosis in children and their parents with positive family history of premature cardiovascular diseases: a prospective study

Background

The aim of the study was to evaluate serum parameters of lipid metabolism, homocysteine, soluble adhesion molecules and common carotid artery wall thickness in children from families with early symptoms of atherosclerosis.

Methods

The first stage included 137 pairs of mothers and newborns, and the second 18 children from the same group (age 18-30 months) and their parents (age 21-46 years) with a history of premature coronary artery disease (CAD), as well as 12 age- and sex-matched controls.

Results

During the first stage, inverse correlations were found between birthweight, cord blood concentrations of triglycerides (TG), VLDL cholesterol and apolipoprotein B (Apo B). Serum concentrations of total cholesterol (TC), apolipoprotein A1 (Apo A1), LDL and HDL cholesterol and were significantly higher in female than in male newborns. During the second stage, children from families with a history for premature CAD were shown to present with significantly higher serum concentrations of TG, VLDL cholesterol and lipoprotein A (Lp(a)) than the controls. Furthermore, their TC correlated positively with vascular cell adhesion molecule-1 (Rs=0.717, p<0.05) and intracellular adhesion molecule-1 (sICAM-1) levels (Rs=0.833, p<0.05). Moreover, positive correlations were found between maternal carotid intima media thickness (IMT) and TC (Rs=0.831, p<0.01), as well as between paternal IMT and Apo B (Rs=0.692, p<0.05), TG and sICAM-1 (Rs=0.912, p<0.01), TG and sE-selectin (Rs=0.678, p<0.05).

Conclusions

Serum Lp(a) may serve as a maker of cardiovascular risk in children and adolescents.

Review and Comparison of Electronic Patient-Facing Family Health History Tools

Family health history (FHx) is one of the most important pieces of information available to help genetic counselors and other clinicians identify risk and prevent disease. Unfortunately, the collection of FHx from patients is often too time consuming to be done during a clinical visit. Fortunately, there are many electronic FHx tools designed to help patients gather and organize their own FHx information prior to a clinic visit. We conducted a review and analysis of electronic FHx tools to better understand what tools are available, to compare and contrast to each other, to highlight features of various tools, and to provide a foundation for future evaluation and comparisons across FHx tools. Through our analysis, we included and abstracted 17 patient-facing electronic FHx tools and explored these tools around four axes: organization information, family history collection and display, clinical data collected, and clinical workflow integration. We found a large number of differences among FHx tools, with no two the same. This paper provides a useful review for health care providers, researchers, and patient advocates interested in understanding the differences among the available patient-facing electronic FHx tools.

Association between family history of diabetes and cardiovascular disease and lifestyle risk factors in the United States population: The 2009-2012 National Health and Nutrition Examination Survey

Family history is a well-known risk factor for diabetes and cardiovascular disease (CVD) and modification of lifestyle risk factors can significantly lessen such risk. Our aim was to assess the association between family history of diabetes and/or CVD and lifestyle behaviors and risk factors (smoking, low physical activity, excessive dietary sodium and cholesterol intake and obesity) in a nationally representative sample of U.S. adults. We conducted a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) 2009-2012. Family history, lifestyle behaviors and risk factors were defined using self-reported and physical examination data. The study sample included 10,988 participants with a mean age of 47years. Among the U.S. adult population, 29.5%, 5.7% and 6.5% had a family history of diabetes, CVD and both diseases respectively. Compared to participants with no family history, participants with a family history of diabetes, CVD and both diabetes and CVD were more likely to be current smokers (OR=1.18[95% CI, 1.03-1.35], OR=1.68[95% CI, 1.31-2.17] and OR=1.71[95% CI, 1.30-2.26] respectively). Participants with a family history of diabetes (OR=1.42[95% CI, 1.26-1.61]) and both diabetes and CVD were more likely to be overweight/obese (OR=2.06[95% CI, 1.57-2.69]). There was no association between family history and dietary factors or physical activity. In the U.S., there is a high prevalence of modifiable risk factors among persons with a family history of diabetes and/or CVD. Healthcare providers have a significant role to play in targeting these individuals for lifestyle changes.

Family health history: an essential starting point for personalized risk assessment and disease prevention

Family health history (FHH) information is well established as a basis for assessing a patient's personal disease risk, but is underutilized for diagnosis and making medical recommendations. Epidemiological and genetic information have heightened the value of FHH to an individual's health. This has motivated the development of new FHH collection tools and strategies for family members, but will require greater awareness and knowledge by both patients and practitioners. FHH will be increasingly important as genomic data become a mainstay of medical diagnostics, since in many cases, a medically important FHH results from lineage-specific genetic variants. The impact of complementary FHH and genomic information will drive the pursuit of personalized and precise targeting of treatments and interventions aimed at maintaining patient health.

Physical Activity, Parental History of Premature Coronary Heart Disease, and Incident Atherosclerotic Cardiovascular Disease in the Atherosclerosis Risk in Communities (ARIC) Study

Background

The effects of some atherosclerotic cardiovascular disease (ASCVD) risk factors vary according to whether an individual has a family history (FHx) of premature coronary heart disease (CHD). Physical activity (PA) is associated with reduced risk of ASCVD, but whether this association varies by FHx status is not well established.

Methods and Results

We evaluated 9996 participants free of ASCVD at baseline. FHx of premature CHD was defined as CHD occurring in a father before age 55 or mother before age 60. PA, assessed by a Baecke questionnaire, was converted into minutes/week of moderate or vigorous exercise and categorized per American Heart Association guidelines as recommended, intermediate, or poor. Incident ASCVD was defined as incident myocardial infarction, fatal CHD, or stroke. Multivariable‐adjusted Cox hazard models were used. The mean age was 54±6 years, 56% were women, and 21% of black race. Participants with and without a FHx of premature CHD reported similar levels of PA at baseline (423 versus 409 metabolic equivalents of task×min/week, respectively, P=0.852), and ≈40% of both groups met American Heart Association recommended PA levels. Over a mean follow−up of 20.9 years, there were 1723 incident ASCVD events. Compared to those with poor PA adherence to American Heart Association guidelines, participants who reported PA at recommended levels had significantly lower risk of incident ASCVD after adjustment for demographics and lifestyle factors (hazard ratio 0.84, 95% CI 0.74–0.94), but this association was not modified by FHx status (P−interaction=0.680).

Conclusions

PA was associated with a reduced risk of ASCVD among individuals with and without a FHx of premature CHD.

Can the cardiovascular family history reported by our patients be trusted? The Norwegian Stroke in the Young Study

Background and purpose

Family history (FH) is used as a marker for inherited risk. Using FH for this purpose requires the FH to reflect true disease in the family. The aim was to analyse the concordance between young and middle‐aged ischaemic stroke patients' reported FH of cardiovascular disease (CVD) with their parents' own reports.

Methods

Ischaemic stroke patients aged 15–60 years and their eligible parents were interviewed using a standardized questionnaire. Information of own CVD and FH of CVD was registered. Concordance between patients and parents was tested by kappa statistics, sensitivity, specificity, predictive values and likelihood ratios. Regression analyses were performed to identify patient characteristics associated with non‐concordance of replies.

Results

There was no difference in response rate between fathers and mothers (P = 0.355). Both parents responded in 57 cases. Concordance between patient and parent reports was good, with kappa values ranging from 0.57 to 0.7. The patient‐reported FH yielded positive predictive values of 75% or above and negative predictive values of 90% or higher. The positive likelihood ratios (LR+) were 10 or higher and negative likelihood ratios (LR−) were generally 0.5 or lower. Interpretation regarding peripheral arterial disease was limited due to low parental prevalence. Higher age was associated with impaired concordance between patient and parent reports (odds ratio 1.05; 95% confidence interval 1.01–1.09; P = 0.020).

Conclusions

The FH provided by young and middle‐aged stroke patients is in good concordance with parental reports. FH is an adequate proxy to assess inherited risk of CVD in young stroke patients.

Improving assessment of cardiovascular disease risk by using family history: an integrative literature review

BACKGROUND

Cardiovascular disease (CVD) is the number one killer in the United States. Although the causes of CVD are multifactorial, including genetic and environmental influences, it is largely a preventable disease. The cornerstone of CVD prevention is accuracy in risk prediction to identify patients who will benefit from interventions aimed at reducing risk. Nurse practitioners commonly perform CVD risk assessments and are well positioned to impact preventive therapy. Cardiovascular disease risk scoring systems currently in use substantially underestimate risk in large part because these do not include family history of premature CVD as a high-risk factor.

PURPOSE

We sought to examine the state of evidence for the use of family history as a predictor in CVD risk stratification.

CONCLUSIONS

A comprehensive literature search using the Medical Subject Headings terms of family history of CVD, family history of premature CVD, risk assessment, and risk estimation displayed 416 articles; a review of the titles and subsequent evaluation of the articles eliminated 392 references, leaving 24 for review. By incorporating family history in risk assessment, categorization of CVD risk improves substantially. The evidence demonstrates that family history is an independent contributor to risk appraisal and unequivocally supports its incorporation to improve accuracy in global CVD risk estimation.

CLINICAL IMPLICATIONS

Underestimation of CVD risk leaves patients and providers misinformed, promoting the ongoing epidemic of chronic disease. Translating this evidence into practice by establishing a clinical algorithm that incorporates family history into risk prediction will standardize CVD risk assessment, improve the identification of high-risk patients, and provide the indicated aggressive care to prevent CVD.

Effect of an intervention to improve the cardiovascular health of family members of patients with coronary artery disease: a randomized trial

BACKGROUND

Family members of patients with coronary artery disease (CAD) have higher risk of vascular events. We conducted a trial to determine if a family heart-health intervention could reduce their risk of CAD.

METHODS

We assessed coronary risk factors and randomized 426 family members of patients with CAD to a family heart-health intervention (n = 211) or control (n = 215). The intervention included feedback about risk factors, assistance with goal setting and counselling from health educators for 12 months. Reports were sent to the primary care physicians of patients whose lipid levels and blood pressure exceeded threshold values. All participants received printed materials about smoking cessation, healthy eating, weight management and physical activity; the control group received only these materials. The main outcomes (ratio of total cholesterol to high-density lipoprotein [HDL] cholesterol; physical activity; fruit and vegetable consumption) were assessed at 3 and 12 months. We examined group and time effects using mixed models analyses with the baseline values as covariates. The secondary outcomes were plasma lipid levels (total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol and triglycerides); glucose level; blood pressure; smoking status; waist circumference; body mass index; and the use of blood pressure, lipid-lowering and smoking cessation medications.

RESULTS

We found no effect of the intervention on the ratio of total cholesterol to HDL cholesterol. However, participants in the intervention group reported consuming more fruit and vegetables (1.2 servings per day more after 3 mo and 0.8 servings at 12 mo; p < 0.001). There was a significant group by time interaction for physical activity (p = 0.03). At 3 months, those in the intervention group reported 65.8 more minutes of physical activity per week (95% confidence interval [CI] 47.0-84.7 min). At 12 months, participants in the intervention group reported 23.9 more minutes each week (95% CI 3.9-44.0 min).

INTERPRETATION

A health educator-led heart-health intervention did not improve the ratio of total cholesterol to HDL cholesterol but did increase reported physical activity and fruit and vegetable consumption among family members of patients with CAD. Hospitalization of a spouse, sibling or parent is an opportunity to improve cardiovascular health among other family members.

TRIAL REGISTRATION

clinicaltrials.gov, no NCT00552591.

Public health action in genomics is now needed beyond newborn screening

For decades, newborn screening was the only public health program in the US focused on reducing morbidity, mortality and disability in people affected by genetic conditions. The landscape has changed, however, as evidence-based recommendations are now available for several other genomic applications that can save lives now in the US. Many more such applications are expected to emerge in the next decade. An action plan, based on evidence, provides the impetus for a new paradigm for public health practice in genomics across the lifespan using established multilevel processes as a guide. These include policy interventions, education, clinical interventions, and surveillance. Applying what we know today in hereditary breast/ovarian cancer, Lynch syndrome and familial hypercholesterolemia has the potential to affect thousands of people in the US population every year. Enhanced partnerships between genetic and nongenetic providers of clinical medicine and public health are needed to overcome the challenges for implementing genomic medicine applications both now and in the future.

A review of family history of cardiovascular disease: risk factor and research tool

Family history (FH) studies have been used to quantify the heritable component of diseases for centuries. Genome-wide association studies (GWAS) in both coronary artery disease (CAD) and stroke have implicated several gene loci in these diseases and have shed light on biological mechanisms, but have not yet yielded fruit in terms of clinical application, partly because of the complexity of gene-gene and gene-environment interactions. Family history studies remain the most accessible way of measuring the inherited component of a disease and they represent the overall interaction between environmental and genetic factors. The current knowledge base for FH of stroke and CAD and disease correlates are evaluated. FH of stroke and CAD are inconsistently recorded in clinical practice, partly because of lack of data regarding family history of stroke and CAD in prospective population studies. Future FH studies are necessary to characterise the role of FH in prognosis and risk prediction of contemporary populations, but also to guide future studies of genetics and epigenetics. In this article, the study design and methodology of family history studies are reviewed. The Oxford Vascular Study (OXVASC) is an ongoing prospective, population-based study of CAD and stroke with very high levels of clinical ascertainment, which allows detailed study of FH, and has already shown important new findings. Such data may help to formulate improved risk prediction tools and to inform future GWAS.

Current priorities for public health practice in addressing the role of human genomics in improving population health

In spite of accelerating human genome discoveries in a wide variety of diseases of public health significance, the promise of personalized health care and disease prevention based on genomics has lagged behind. In a time of limited resources, public health agencies must continue to focus on implementing programs that can improve health and prevent disease now. Nevertheless, public health has an important and assertive leadership role in addressing the promise and pitfalls of human genomics for population health. Such efforts are needed not only to implement what is known in genomics to improve health but also to reduce potential harm and create the infrastructure needed to derive health benefits in the future.

A Family History Intervention

This article describes the effect of individualized counseling using family history data and objective cardiovascular risk factors on intent to change and actual exercise behavior in a diverse sample of working adults. Using a longitudinal, quasi-Bxperimental, crossover design, objective data (blood lipids, glucose, blood pressure, and body mass index) and subjective data (awareness of heart disease risk, depression, spirituality, and knowledge of family history) were collected from 91 (mostly female and with a mean age of 45 years) primary and secondary teachers in a southwestern city. The Transtheoretical Model of Change guided the study and measured intent to exercise. Objective risks in this sample mirrored national indices of risk for obesity and abnormal lipids. Although some participants increased their exercise, no significant differences were found between the groups in exercise behavior at 6 and 12 months. Using knowledge of family history to raise awareness and encourage lifestyle changes related to cardiovascular risk warrants further study.

Validation of My Family Health Portrait for six common heritable conditions

PURPOSE

To assess the ability of My Family Health Portrait to accurately collect family history for six common heritable disorders.

BACKGROUND

Family history is useful to assess disease risk but is not widely used. We compared the pedigree from My Family Health Portrait, an online tool for collection of family history, to a pedigree supplemented by a genetics professional.

METHODS

One hundred fifty volunteers collected their family histories using My Family Health Portrait. A genetic counselor interviewed the volunteers to validate the entries and add diagnoses, as needed. The content and the affection assignments of the pedigrees were compared. The pedigrees were entered into Family Healthware to assess risks for the diseases.

RESULTS

The sensitivity of My Family Health Portrait varied among the six diseases (67-100%) compared to the supplemented pedigree. The specificities ranged from 92 to 100%. When the pedigrees were used to generate risk scores, My Family Health Portrait yielded identical risks to the supplemented pedigree for 94-99% of the volunteers for diabetes and colon, breast, and ovarian cancer. The agreement was lower for coronary artery disease (68%) and stroke (83%).

CONCLUSIONS

These data support the validity of My Family Health Portrait pedigrees for four common conditions--diabetes and colon, breast, and ovarian cancer. The tool performed less well for coronary artery disease and stroke. We recommend that the tool be improved to better capture information for these two common conditions.

The importance of the family history in caring for families with long QT syndrome and dilated cardiomyopathy

In potentially inherited cardiac diseases, the family history is of great importance. We looked at the way cardiologists take a family history in patients with idiopathic dilated cardiomyopathy (DCM) or long QT syndrome (LQTS) and whether this led to screening of relatives or other follow-up. We performed retrospective cross-sectional analyses of adult index patients with DCM or LQTS in a general hospital (GH) or a University Medical Center (UMC). We identified 82 index patients with DCM (34 GH; 48 UMC) and 20 with LQTS (all UMC) between 1996 and 2005. Mean follow-up was 58 months. A family history was recorded in 90% of both LQTS and DCM patients most of the cases restricted to first-degree family members. The genetic aspects, counseling and screening of family members was discussed significantly more often with LQTS than DCM patients (all P < 0.05). Also follow-up (screening of family members, DNA analysis and referral) was performed significantly more often in LQTS than DCM patients. Cardiologists in the UMC referred DCM index patients for genetic counseling more often than those in the GH (25% vs. 6%; P < 0.05). Only a few index patients with DCM were referred to a clinical genetics department. One-third of DCM cases and nearly all LQTS cases are familial. Since early recognition and treatment may reduce morbidity and mortality we recommend cardiologists take a more thorough family history and always consider referring to a clinical genetics department in such index patients.

Strategies to improve detection of hypertension genes

Multiple factors contribute to the development of hypertension, including genetic factors and environmental exposures. Various pathophysiological mechanisms are at play in the pathogenesis of hypertension and this pathogenesis, by necessity, exhibits substantial variation at the level of the individual, as it depends on the relative contribution of inherited genes and individual lifetime environmental exposures. Over time, long-term compensatory mechanisms, including responses to either chronic hypertension or to therapeutic intervention, can only obscure the initiating mechanisms of disease. Acute compensating mechanisms can also mask initiating gene effects during or after an intervention, so that early phenotype assessments during the intervention may be more likely to detect the genetic initiators. Compensatory mechanisms, working over days, weeks or even years, will likely be variably effective in minimizing the expected blood pressure rise, making it difficult to detect genetic initiating mechanisms in cross-sectional, 'steady state', or 'in balance' studies. If the lifetime risk of hypertension indeed approaches 90%, the power to identify genetic factors can only decrease with duration of disease and treatment, and prediction of hypertension becomes of vanishing significance. With multiple factors at play, we cannot expect that all causes are mutually exclusive, but it is reasonable to assume that one of these mechanisms is predominant in the initiation of the disease in any one individual. Given the heterogeneity of essential hypertension argued above, it becomes evident that the chance of identifying genetic factors that contribute to disease development will be greatest if study subjects at highest genetic predisposition are observed during age ranges when heritability is at a maximum, using the correct phenotypes, measured in the correct tissues, during the correct time window. Genes found to be significant in such studies should be densely typed in clinical trials and large population studies to assess public health and clinical applications of the findings.

Decisions to seek healthcare based on family health history among urban Appalachian women

Family health history (FHH) is a valuable health promotion tool that can be used to assess disease risk and make lifestyle and screening recommendations. However, few FHH resources exist for medically underserved populations such as the urban Appalachian community in Cincinnati Ohio. Women of Appalachian heritage with less than a college education who did and did not participate in a prior FHH education session were interviewed by phone in a semi-structured format. Interviewees were asked to discuss their understanding of FHH and the role FHH played in seeking (or not seeking) medical care. Analysis of their discussion identified four overarching themes as well as a model identifying conditions that facilitated or impeded the choice to seek medical care based on FHH. Findings from this study may be used to develop targeted FHH educational interventions in the urban Appalachian and other communities.

General practitioners' attitudes to assessment of genetic risk of common disorders in routine primary care

In 2003, the UK Department of Health set out the genetics white paper, a plan for action and investment with particular emphasis on integration of genetic health care into primary care. Since the delivery of the genetics white paper, there has been little exploration of UK primary care doctors' attitudes towards extending their role to include provision of routine genetics services. We explored explore general practitioners' (GPs) attitudes towards provision of genetic health care including routine family history screening and familial risk assessment for common disorders in primary care using a quantitative, evaluative postal survey. Only 25% (797 of 3160) of the GPs returned a completed questionnaire. Although 32% of GPs supported collection of family history information and 41.5% familial risk assessment, 18% were not willing to offer these services even if training is provided. Of the GPs, 50% stated they recognized when referral to genetics services is appropriate, although 43% felt unprepared to collect family history or assess familial risk. Lack of training within the last 3 years was a significant predictor of feeling unprepared to undertake these activities (OR = 2.53,p = 0.012). A substantial group of GPs remain unprepared or unwilling to provide genetic health care. GPs' attitudes to delivery of genetic health care are significantly influenced by factors such as a lack of evidence of the direct benefits to patients, local guidelines and specialist services. These factors need addressing if delivery of genetic health care is to be incorporated into routine primary care.

Familial risk for common diseases in primary care: the Family Healthware Impact Trial

CONTEXT

Family history is a risk factor for many common chronic diseases, yet it remains underutilized in primary care practice.

BACKGROUND

Family Healthware is a self-administered, web-based tool that assesses familial risk for CHD; stroke; diabetes; and colorectal, breast, and ovarian cancer, and provides a personalized prevention plan based on familial risk. The Family Healthware Impact Trial evaluated the tool.

DESIGN

In this cluster RCT, participants completed baseline and 6-month follow-up surveys. The intervention group used Family Healthware directly after the baseline survey. Controls used the tool after completing the follow-up survey.

SETTING/PARTICIPANTS

Patients aged 35-65 years with no known diagnosis of these six diseases were enrolled from 41 primary care practices.

MAIN OUTCOME MEASURES

The prevalence of family-history-based risk for coronary heart disease (CHD); stroke; diabetes; and colorectal, breast, and ovarian cancer was determined in a primary care population.

RESULTS

From 2005 to 2007, 3786 participants enrolled. Data analysis was undertaken from September 2007 to March 2008. Participants had a mean age of 50.6 years and were primarily white (91%) women (70%). Of the 3585 participants who completed the risk assessment tool, 82% had a strong or moderate familial risk for at least one of the diseases: CHD (strong=33%, moderate=26%); stroke (strong=15%, moderate=34%); diabetes (strong=11%, moderate=26%); colorectal cancer (strong=3%, moderate=11%); breast cancer (strong=10%, moderate=12%); and ovarian cancer (strong=4%, moderate=6%). Women had a significantly (p<0.04) higher familial risk than men for all diseases except colorectal and ovarian cancer. Overweight participants were significantly (p<or=0.02) more likely to have a strong family history for CHD, stroke, and diabetes. Older participants were significantly (p<or=0.02) more likely to report a strong family history for CHD and stroke as well as colorectal and breast cancer.

CONCLUSIONS

This self-administered, online tool delineated a substantial burden of family-history-based risk for these chronic diseases in an adult, primary care population.

TRIAL REGISTRATION

NCT00164658.

Sibling and parental history in type 2 diabetes risk among ethnic Chinese: the Chin-Shan Community Cardiovascular Cohort Study

BACKGROUND

This study aims to compare various family history profiles as predictors of diabetes in a community-based prospective cohort because few prospective studies have examined the association of family history with diabetes risk in ethnic Chinese populations.

METHODS

Among 2960 participants free from baseline diabetes through the Chin-Shan Community Cardiovascular Cohort Study, there were 548 cases that developed diabetes after a median 9 years of follow-up.

RESULTS

After multivariate adjustment, sibling history was associated with diabetes [Relative risk (RR): 2.08, 95% confidence interval (CI): 1.42-3.06, P=0.0002]. Both maternal and paternal histories had similar effects (RR: 1.62, 95% CI: 1.04-2.51 for paternal history, RR: 1.36, 95% CI: 0.98-1.89 for maternal history). Obese participants with sibling history increased the risk of diabetes by 4.6-fold (RR: 4.61, 95% CI: 2.93-7.26), compared with those with neither obesity nor family history.

CONCLUSION

The findings support the hypothesis that sibling history is more important than parental history for diabetes risk.

Family history of cardiovascular disease does not predict risk-reducing behavior

BACKGROUND

Family history is one of the main risk factors for cardiovascular disease, especially in the younger population. These individuals, being closely related to young symptomatic patients, are anticipated to have a high rate of risk factors but also to control them aggressively. The aim of the study was to evaluate the association between family history of cardiovascular disease and risk factors that control as well as reduce risk-reducing behavior among young, healthy adults.

DESIGN AND METHODS

Demographic, clinical and lifestyle parameters of career service personnel of the Israeli Defense Forces, who were checked at the staff periodic examination center, were evaluated. Behavioral and clinical parameters of participants, with and without cardiovascular family history, were compared.

RESULTS

The study cohort comprised 41,099 patients (36,236 men and 4863 women). Of those, 3802 men and 628 women with a family history of cardiovascular disease were identified. Male individuals had a higher rate of treatable risk factors like, obesity (P<0.0005), high blood pressure (P<0.0005), high plasma glucose (P<0.0005) and dyslipidemia (P<0.0005) than individuals without a family history. Among the women, the rate of these risk factors was higher than in the control groups but was statistically significant only for obesity, high blood pressure and high glucose levels. Risk-reducing behavior like regular physical activity and nonsmoking status in both the sexes did not differ between the groups.

CONCLUSION

Members of the young population with a family history of cardiovascular disease is easily identified but remains largely uncontrolled. Special attention and continued education are required to modify their behavioral and medical parameters.

Gene-environment interactions in the development of complex disease phenotypes

The lack of knowledge about the earliest events in disease development is due to the multi-factorial nature of disease risk. This information gap is the consequence of the lack of appreciation for the fact that most diseases arise from the complex interactions between genes and the environment as a function of the age or stage of development of the individual. Whether an environmental exposure causes illness or not is dependent on the efficiency of the so-called “environmental response machinery” (i.e., the complex of metabolic pathways that can modulate response to environmental perturbations) that one has inherited. Thus, elucidating the causes of most chronic diseases will require an understanding of both the genetic and environmental contribution to their etiology. Unfortunately, the exploration of the relationship between genes and the environment has been hampered in the past by the limited knowledge of the human genome, and by the inclination of scientists to study disease development using experimental models that consider exposure to a single environmental agent. Rarely in the past were interactions between multiple genes or between genes and environmental agents considered in studies of human disease etiology. The most critical issue is how to relate exposure-disease association studies to pathways and mechanisms. To understand how genes and environmental factors interact to perturb biological pathways to cause injury or disease, scientists will need tools with the capacity to monitor the global expression of thousands of genes, proteins and metabolites simultaneously. The generation of such data in multiple species can be used to identify conserved and functionally significant genes and pathways involved in gene-environment interactions. Ultimately, it is this knowledge that will be used to guide agencies such as the U.S. Department of Health and Human Services in decisions regarding biomedical research funding and policy.

Genetics of premature myocardial infarction

Common multigene disorders account for 80% of deaths in the world and all have significant genetic predisposition. Coronary artery disease and myocardial infarction (MI) account for more than 40% of these deaths. The genetic component is due to multiple genes, each contributing only minimally to the phenotype. Linkage analysis, which has been successful in identifying rare disorders that cause MI, is not sensitive for multigene disorders. The recent candidate case-control approach has been equally unsuccessful. Multigene disorders require genome-wide association studies involving genotyping hundreds of thousands of DNA markers in thousands of individuals with replication in independent populations. Platforms with 500,000 and 1 million single nucleotide polymorphisms provide the necessary high-throughput genotyping for genome-wide association. The first confirmed common locus, 9p21, is independent of conventional risk factors. Identifying the 9p21 gene will elucidate novel mechanisms responsible for MI. Comprehensive prevention of MI based on individual genetic variants (personalized medicine) is expected in the next decade.

Family history: value-added information in assessing cardiac health

The purpose of this study was to describe family health history profiles and objective indices of cardiac health among ethnically diverse working adults. Family history of disease is an important predictor of individual health, yet is underused by clinicians. Participants were staff in an elder-care facility and completed a web-enabled program capturing family history, objective cardiovascular measures (blood lipids, blood pressure, height, weight, and waist-to-hip ratio), and subjective measures (anxiety, spirituality, and health status appraisal). Of the 44 participants, 89% were unable to provide complete information about their family health and mortality for the three-generation genogram; 25% had one or more first-degree relatives with cardiac disease; and more than two thirds had first-degree relatives with diabetes. More than 80% of the sample exhibited objective indices of risk including body mass indexes in the overweight or obese categories. Family history information was incorporated into health screening and enabled more appropriate health counseling for these employees.

When the third degree is necessary: do pediatricians obtain enough information to detect patients at risk for HCM?

This study was designed to see if pediatricians are collecting sufficient data in family histories to be able to ascertain whether children are at risk for hypertrophic cardiomyopathy (HCM). Surveys were returned by 326 general pediatricians who were members of the Second Chapter of the American Academy of Pediatrics. The majority of pediatricians (98.2%) reported taking family histories; however, only 51.2% reported that this information was updated on a regular basis. Only 29.8% of the pediatricians reported including all five risk factors for HCM in a medical family history. Although almost all of the pediatricians reported including first-degree relatives in medical family histories, only 40.5% reported including all second-degree relatives. Female physicians were found to take more thorough medical family histories than male physicians, and foreign medical school graduates were found to take more thorough medical family histories than US medical school graduates. Additionally, graduates of foreign medical schools reported updating medical family histories more often than graduates of US medical schools. This study suggests that pediatricians might not be identifying risks pertinent to the identification of HCM.

Personalized medicine: a reality within this decade

Personalized medicine is defined as individualized treatment based on the individual's genetic variants. Such treatment has the potential to enable pharmacogenetics, such as the prevention of 100,000 deaths per year in the USA because of adverse drug reactions or specify treatment in heart failure such at the beta 1 adrenergic receptor polymorphisms. It is claimed that coronary artery disease (CAD) is at least 50% because of genetic predisposition. Identification of the genes predisposing to CAD would greatly facilitate prevention, early treatment, and more specific therapies. The arrival of the multimillion single nucleotide polymorphism (SNP) array provides the high throughput genotyping required to perform genome-wide Association (GWA) studies. These studies require markers (SNPs) at intervals of 6,000 bp and sample size of several thousands. Platforms are available to genotype and process millions of genotypes per day. The GWA performed by the Ottawa Heart Genomic Study identified the first deoxyribonucleic acid region (9p21) predisposing to CAD after replication in six independent populations totaling 23,000. This was subsequently confirmed in several independent studies totally more than 45,000 individuals. The region confers a risk for CAD independent of known risk factors. 9p21 occurs in heterozygous form in 40 to 50% of Caucasians with increased risk of 15 to 20% and in homozygous form in 25% of Caucasians with increased risk of 40%. Identification of the genes predisposing to CAD is a prerequisite for personalized care of these patients. It is anticipated that most of the genes predisposing to CAD will be identified in the next 5 to 8 years. The 9p21, in addition to conferring increased risk, provides the bonus of being independent of known risk factors. Thus, 9p21 is likely to provide the impetus and nidus for a major research effort over the next few years. It has the potential to not only provide for early genetic screening but also as a target for novel therapy.

Identifying genes for coronary artery disease: An idea whose time has come

BACKGROUND

Coronary artery disease (CAD) remains the number one killer in the western world. Genetics accounts for greater than 50% of the risk for CAD. Genetic screening and early prevention in individuals identified as being at increased risk could dramatically reduce the prevalence of CAD, thus necessitating the identification of genes predisposing to CAD. Studies of genes identified by the candidate gene approach have not been replicated due, in part, to inadequate sample size. Genome-wide scan association studies have been limited by the use of thousands of markers rather than the hundreds of thousands required, and by the use of hundreds of individuals rather than the thousands required. Replication of positive findings in an independent population is essential. To detect a minor allele frequency of 5% or greater with an odds ratio for risk of 1.3 or greater and 90% power, an estimated 14,000 (9000 affected and 5000 control) subjects are required.

METHODS

The Affymetrix GeneChip Human Mapping 500K Array Set (Affymetrix Inc, USA) provides a marker every 6000 base pairs as required, and is being used to genotype 1000 cases of premature CAD and 1000 normal subjects, followed by replication in 8000 affected individuals and 4000 control subjects. The phenotype is confirmed or excluded by coronary arteriograms by catheterization or multislice computed tomography.

RESULTS

Since 2005, more than 800 million genotypes have been performed and analyses performed on 500 control subjects and 500 affected individuals. Several thousand significant single nucleotide polymorphisms and 130 clusters associated with CAD have been identified.

CONCLUSIONS

This is the first genome-wide scan using the 500,000 marker set in a case-control association study for CAD genes. Several genes associated with CAD appear promising.

Research review: DSM-V conduct disorder: research needs for an evidence base

This article charts a strategic research course toward an empirical foundation for the diagnosis of conduct disorder in the forthcoming DSM-V. Since the DSM-IV appeared in 1994, an impressive amount of new information about conduct disorder has emerged. As a result of this new knowledge, reasonable rationales have been put forward for adding to the conduct disorder diagnostic protocol: a childhood-limited subtype, family psychiatric history, callous-unemotional traits, female-specific criteria, preschool-specific criteria, early substance use, and biomarkers from genetics, neuroimaging, and physiology research. This article reviews the evidence for these and other potential changes to the conduct disorder diagnosis. We report that although there is a great deal of exciting research into each of the topics, very little of it provides the precise sort of evidence base required to justify any alteration to the DSM-V. We outline specific research questions and study designs needed to build the lacking evidence base for or against proposed changes to DSM-V conduct disorder.

Cholesteryl ester transfer protein B1B1 genotype is associated with a parental history of cardiovascular diseases in Taiwanese people

OBJECTIVE

To investigate the association between family history of cardiovascular disease (CVD) and cholesteryl ester transfer protein (CETP) TaqIB polymorphism in Taiwanese subjects.

SUBJECTS AND METHODS

In this cross-sectional study, 240 subjects (115 men and 125 women) were divided into two groups based on whether or not they had a parental history of CVD. Polymerase chain reaction/restriction fragment length polymorphism was used to analyze the genotype of the subjects for the TaqIB polymorphism of CETP in intron 1.

RESULTS

The frequency of the B1B1 genotype was significantly higher in Taiwanese subjects with a family history of CVD than in those without it (31.2 vs. 18.8%, odds ratio = 1.97, 95% confidence interval = 1.084-3.579, p = 0.035). Siblings with the B1B1 genotype had lower levels of serum high-density lipoprotein cholesterol (HDL-C) than siblings with either B1B2 (46.7 +/- 11.0 vs. 52.5 +/- 11.1 mg/dl, p = 0.034) or B2B2 genotypes (46.7 +/- 11.0 vs. 55.2 +/- 9.6 mg/dl, p = 0.01).

CONCLUSION

CETP TaqIB polymorphism is associated with plasma HDL-C levels. The CETP B1B1 genotype may influence the susceptibility to CVD in Taiwan.

Predicting prognosis for the conduct-problem boy: can family history help?

OBJECTIVE

Many children with conduct disorder develop life-course persistent antisocial behavior; however, other children exhibit childhood-limited or adolescence-limited conduct disorder symptoms and escape poor adult outcomes. Prospective prediction of long-term prognosis in pediatric and adolescent clinical settings is difficult. Improved prognosis prediction would support wise allocation of limited treatment resources. The purpose of this article is to evaluate whether family history of psychiatric disorder can statically predict long-term prognosis among conduct-problem children.

METHOD

Participants were male members of the Dunedin Study, a birth cohort of 1,037 children (52% male). Conduct-problem subtypes were defined using prospective assessments between ages 7 and 26 years. Family history interviews assessed mental disorders for three generations: the participants' grandparents, parents, and siblings.

RESULTS

Family history of externalizing disorders distinguished life-course persistent antisocial males from other conduct-problem children and added significant incremental validity beyond family and child risk factors. A simple three-item family history screen of maternal-reported alcohol abuse was associated with life-course persistent prognosis in our research setting and should be evaluated in clinical practice.

CONCLUSIONS

: Family history of externalizing disorders distinguished between life-course persistent versus childhood-limited and adolescent-onset conduct problems. Brief family history questions may assist clinicians in pediatric settings to refine the diagnosis of conduct disorder and identify children who most need treatment.

Is family history a useful tool for detecting children at risk for diabetes and cardiovascular diseases? A public health perspective

Several studies indicate that the risk for type 2 diabetes or cardiovascular disease is detectable in childhood, although these disorders may not emerge until adulthood. In addition, type 2 diabetes and cardiovascular disease seem to share risk factors, including obesity and dyslipidemia, and might even share etiology, which has important implications for screening and prevention strategies for both diseases. Primary prevention, in particular, has gained importance because the results of major randomized, controlled trials strongly suggest that, at least in high-risk adult groups, type 2 diabetes can be prevented or delayed. Furthermore, some intervention studies indicate that the risk factors for diabetes and cardiovascular disease can be reduced in children. A simple way to detect risk for either diabetes or cardiovascular disease is to examine the family history. Numerous studies have shown that adults who have 1 or more first- or second-degree relatives affected with diabetes or cardiovascular disease are at high risk of having or developing these diseases. Currently, there are no overall screening strategies recommended for either diabetes or cardiovascular disease among children and adolescents. The evidence is strong, however, that youth with a positive family history already show signs of increased risk for these conditions. Family history can be part of the approach to screening for children at risk of diabetes and cardiovascular disease and should be part of prevention campaigns aimed at reducing the burden of these diseases and their risk factors in children.

The use of family health histories to address health disparities in an African American community

African Americans continue to suffer from health disparities. The Center for Minority Health (CMH) within the University of Pittsburgh has the mission to eliminate racial and ethnic health disparities. CMH has designed and implemented the Family Health History (FHH) Initiative. The FHH Initiative places genetic-counseling graduate students in the African American community to provide risk assessments and emphasize the importance of family history as it pertains to disease prevention. The FHH Initiative also allows participants to enroll into the Minority Research Recruitment Database (MRRD). This enables CMH to alert individuals to available research participation opportunities. In the first year of this program, 225 African Americans completed their family health histories. More than 60% of individuals enrolled in the MRRD. The authors report their initial successes and challenges of an initiative that incorporates awareness of family history information, proper screening guidelines, behavior-modification recommendations, and support for participation in clinical research.

Genetics and hypertension

Although it has long been appreciated that there is a genetic component to hypertension, it is only recently that specific genes are being identified. This progress is part of a general advancement of our understanding of common, genetically complex human diseases. This understanding will eventually affect clinical practice.

Food preference questionnaire as a screening tool for assessing dietary risk of cardiovascular disease within health risk appraisals

OBJECTIVE

Nutrition components of health risk appraisals (HRAs) aim to rapidly and accurately assess dietary behaviors that increase disease risk. Because cognitive research suggests that recalling food likes/dislikes may be simpler and more accurate than recalling intake, we tested whether a preference measure was predictive of cardiovascular disease risk factors within an HRA.

METHODS

HRA participants (422 primarily non-Hispanic white men, mean age 46+/-10 years) from a manufacturing company completed surveys to assess fat and sweet food/beverage preference; frequency of consuming fat and sweet foods/beverages, alcoholic beverages, fiber-rich foods (whole grains, fruits, and vegetables); and physical activity. Per measured risk factors, 34% had central obesity (waist circumference>or=102 cm), 32% had hypertension (>or=140 and/or>or=90 mm Hg), 52% had prehypertension (>or=120 to 139 and/or>or=80 to 89 mm Hg), and 52% had an elevated total cholesterol level (>or=200 mg/dL [5.2 mmol/L]).

STATISTICAL ANALYSES

Multiple linear regression models explaining variability in waist circumference, blood pressure, and serum lipids were tested.

RESULTS

Although preference and intake pairs for fat and sweets were significantly correlated, intake of fat and sweets failed to associate significantly with any risk factor. Significant variance in waist circumference was explained by age, fat preference, fiber intake, and physical activity. Those with greater circumferences liked fat more, consumed less fiber, and exercised less. Waist circumference in turn contributed significantly to models predicting serum lipid levels and blood pressure. Alcohol intake explained variability in serum lipid levels-higher intakes were associated with higher high-density lipoprotein cholesterol levels. The models predicting risk were generally more explanatory in younger (<50 years) than in older men.

CONCLUSIONS

Including a preference measure within an HRA appears to enhance cardiovascular disease risk factor assessment. Fat preference, intake of fiber-rich foods, and alcohol proved the best dietary determinants of cardiovascular disease risk factors.

Importance of Family History in Lifestyle Management

Families affect the health of their members by transmitting genetic predisposition to wellness and illness. Families also model and teach health beliefs, attitudes, and behaviors. Eliciting an individual's family history can identify potential genetic vulnerabilities to disease and lifestyle influences. This review explores the implications of family history for patient education about lifestyle. Family history is particularly useful for helping health care providers be effective with individuals who have strong family patterns of atherosclerotic cardiovascular disease, major risk factors (dyslipidemia, hypertension, diabetes, and tobacco use), and related factors (obesity, poor nutrition, physical inactivity, and alcohol excess). Gathering and recording family history information can be problematic, even with an electronic medical record (EMR). The genogram (expanded genetic pedigree) is an efficient way to record and display family history data. Family history data in genogram format can be used as a versatile patient education tool. Despite its clinical utility, the genogram has been used more for teaching than for patient care. Thus far, the genogram has not been integrated into the EMR. Adding relevant cultural information to the conventional genogram might increase its utility for helping health care providers encourage lifestyle changes that promote wellness and prevent disease, disability, and premature death in ethnically diverse populations.

Personalized genomic medicine: a future prerequisite for the prevention of coronary artery disease

Within the next 10-15 years, medicine will be personalized in large part on the basis of the individual's genomic variants. Coronary artery disease remains the number one cause of morbidity and mortality in the Western world and is predicted to become the number one cause worldwide by 2010. It has been stated that treating the risk factors of coronary artery disease has made it a preventable disease that should be eliminated in the 21st century. It is postulated that about 50% of susceptibility to coronary artery disease is genetic, involving known and occult risk factors. Thus, comprehensive prevention will require identification of genetic susceptibility. The recent technology of a chip with 500,000 DNA markers makes genome-wide scanning to identify the genes contributing to coronary artery disease possible. Multislice CT will provide the high-throughput coronary arteriograms required for this research and for prevention in asymptomatic individuals with a family history of heart disease.

Harnessing the power of the pedigree

Primary care providers are in an ideal position to practice genomic-based medicine. Family history data can be used to assess reproductive risks or determine an individual's risk for developing specific diseases. The US Department of Health and Human Services has recently launched the US Surgeon General's Family History Initiative, a national public health campaign designed to encourage Americans to learn more about their family health histories. Furthermore, several national associations now recommend that primary care providers collect family history data to identify patients at risk for these diseases. Ideally, family history data should be ascertained, documented, and analyzed in a standardized manner. Graphic representation of a family history in the form of a pedigree may be preferable to a text format, but further research will clarify this issue. Family history tools are now being developed and studied to identify which methods are most beneficial in different clinical settings.

Family history of type 2 diabetes: a population-based screening tool for prevention?

PURPOSE

To evaluate the use of self-reported family medical history as a potential screening tool to identify people at-risk for diabetes.

METHODS

The HealthStyles 2004 mail survey comprises 4345 US adults who completed a questionnaire to ascertain personal and family history of diabetes, perceived risk of diabetes, and practice of risk-reducing behaviors. Using number and type of affected relatives, respondents were ranked into three familial risk levels. Adjusted odds ratios (AORs) were obtained to evaluate associations between familial risk and prevalent diabetes, perceived risk of disease, and risk-reducing behaviors. Validity of family history as a screening tool was examined by calculating sensitivity, specificity, and positive and negative predictive values.

RESULTS

Compared to those of average risk, people with moderate and high familial risk of diabetes were more likely to report a diagnosis of diabetes (AOR: 3.6, 95% CI: 2.8, 4.7; OR: 7.6, 95% CI: 5.9, 9.8, respectively), a higher perceived risk of diabetes (AOR: 4.6, 95% CI: 3.7, 5.7; OR: 8.5, 95% CI: 6.6, 17.7, respectively), and making lifestyle changes to prevent diabetes (AOR: 2.2, 95% CI: 1.8, 2.7; OR: 4.5, 95% CI: 3.6, 5.6, respectively). A positive familial risk of diabetes identified 73% of all respondents with diabetes and correctly predicted prevalent diabetes in 21.5% of respondents.

CONCLUSION

Family history of diabetes is not only a risk factor for the disease but is also positively associated with risk awareness and risk-reducing behaviors. It may provide a useful screening tool for detection and prevention of diabetes.

Do we need genomic research for the prevention of common diseases with environmental causes?

Concerns have been raised about the value of genomic research for prevention and public health, especially for complex diseases with risk factors that are amenable to environmental modification. Given that gene-environment interactions underlie almost all human diseases, the public health significance of genomic research on common diseases with modifiable environmental risks is based not necessarily on finding new genetic "causes" but on improving existing approaches to identifying and modifying environmental risk factors to better prevent and treat disease. Such applied genomic research for environmentally caused diseases is important, because 1) it could help stratify disease risks and differentiate interventions for achieving population health benefits; 2) it could help identify new environmental risk factors for disease or help confirm suspected environmental risk factors; and 3) it could aid our understanding of disease occurrence in terms of transmission, natural history, severity, etiologic heterogeneity, and targets for intervention at the population level. While genomics is still in its infancy, opportunities exist for developing, testing, and applying the tools of genomics to clinical and public health research, especially for conditions with known or suspected environmental causes. This research is likely to lead to population-wide health promotion and disease prevention efforts, not only to interventions targeted according to genetic susceptibility.

Family history of heart disease and cardiovascular disease risk-reducing behaviors

BACKGROUND

Family history is an important cardiovascular disease (CVD) risk factor. Preventive behaviors, including lifestyle modifications, can attenuate CVD risk. We studied the association between family history-based heart disease (HD) risk and CVD risk-reducing behaviors.

METHODS

Using data from the 2001 Healthstyles survey, we compared frequencies of CVD risk-reducing behaviors among adults without known CVD in categories defined by family history-based HD risk. We classified respondents' HD risk as average (no first-degree relatives with HD), moderate (one relative), or high (> or = two relatives). Behaviors studied included lifestyle modifications, cholesterol measurement, and aspirin use.

RESULTS

Of 3383 respondents without known CVD, 28% were classified as being at moderate risk and 15% as being at high risk for HD based on family history. Adjusted odds ratios indicated that moderate- and high-risk respondents were more likely to report having cholesterol measured within the previous 5 years (OR = 1.39, 95% Confidence Interval [CI] = 1.16-1.67 and 1.29, 95% CI = 1.01-1.64, respectively), and aspirin use to reduce CVD risk (OR = 1.49, 95% CI = 1.23-1.79 and 1.67, 95% CI = 1.33-2.09, respectively) than average-risk respondents.

CONCLUSION

Almost one half of respondents reported a family history of HD. Aspirin use and cholesterol measurement (i.e., behaviors that health-care providers might suggest) were more likely to be reported by moderate- and high-risk respondents than were lifestyle changes. Family history merits further investigation as a public health tool to identify persons with increased HD risk who might benefit from enhanced prevention strategies.

Current and future applications of genetics in primary care medicine

Individualized medical treatment and prevention based on one's genetic makeup are promises likely to be fulfilled over decades. Already family history is taking a more prominent role in preventive care. Primary care clinicians and geneticists will increasingly collaborate to diagnose and manage genetic conditions: both single-gene disorders and multifactorial diseases such as infections,cancers, cardiovascular disease and mental illness. This will require society, with primary care clinicians in the forefront, to implement means for efficient family history-taking; maintaining private, personally accessible genetic health records; safeguarding people from genetic discrimination; distributing access to scarce genetic specialists and expensive technologies; rectifying lay misconceptions about inheritance; managing emotional responses and family dynamics related to genetic diagnosis; and motivating people at increased familial risk to take preventive action.