Choosing the preventive workload in general practice: practical application of the Coronary Prevention Group guidelines and Dundee coronary risk-disk

Coronary heart disease policy models: a systematic review

BACKGROUND

The prevention and treatment of coronary heart disease (CHD) is complex. A variety of models have therefore been developed to try and explain past trends and predict future possibilities. The aim of this systematic review was to evaluate the strengths and limitations of existing CHD policy models.

METHODS

A search strategy was developed, piloted and run in MEDLINE and EMBASE electronic databases, supplemented by manually searching reference lists of relevant articles and reviews. Two reviewers independently checked the papers for inclusion and appraisal. All CHD modelling studies were included which addressed a defined population and reported on one or more key outcomes (deaths prevented, life years gained, mortality, incidence, prevalence, disability or cost of treatment).

RESULTS

In total, 75 articles describing 42 models were included; 12 (29%) of the 42 models were micro-simulation, 8 (19%) cell-based, and 8 (19%) life table analyses, while 14 (33%) used other modelling methods. Outcomes most commonly reported were cost-effectiveness (36%), numbers of deaths prevented (33%), life-years gained (23%) or CHD incidence (23%). Among the 42 models, 29 (69%) included one or more risk factors for primary prevention, while 8 (19%) just considered CHD treatments. Only 5 (12%) were comprehensive, considering both risk factors and treatments. The six best-developed models are summarised in this paper, all are considered in detail in the appendices.

CONCLUSION

Existing CHD policy models vary widely in their depth, breadth, quality, utility and versatility. Few models have been calibrated against observed data, replicated in different settings or adequately validated. Before being accepted as a policy aid, any CHD model should provide an explicit statement of its aims, assumptions, outputs, strengths and limitations.

Relation of serum cholesterol, lipid, serotonin and tryptophan levels to severity of depression and to suicide attempts

OBJECTIVE

To determine if there is a relation to low serum cholesterol, lipoprotein, serotonin or tryptophan levels in patients with depression who have recently attempted suicide.

DESIGN

Biochemical and behavioural study.

SETTING

Inpatient and outpatient treatment at the Instituto Mexicano de Psiquiatría.

PARTICIPANTS

Thirty-three patients with a diagnosis of major depressive episode. Eighteen of these patients had attempted suicide in the month before the start of the study; 15 patients had never attempted suicide.

OUTCOME MEASURES

Serum levels of total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, serotonin (5-HT) and tryptophan. Scores on Hamilton Depression Rating Scale, Carroll Depression Rating Scale, Beck Hopelessness Scale and Beck Suicide Attempt Severity Scale.

RESULTS

There were no significant differences between patients who had attempted suicide and those who had not in terms of serum cholesterol, HDL, LDL and triglyceride levels. Serum levels of 5-HT and tryptophan were significantly lower in patients with depression who had a recent suicide attempt than in those patients who had never attempted suicide. A comparison of patients not taking antidepressant medication found serum 5-HT levels to be more than 3 times lower in those patients with a recent suicide attempt than in patients with no history of suicide attempt.

CONCLUSIONS

The study found no difference in lipid profiles between patients who had attempted suicide and those who had not. Low serum levels of 5-HT may increase the risk of suicide attempt in patients who are depressed.

[Ischemic heart disease risk in the west Valladolid health area]

INTRODUCTION AND OBJECTIVES

Cardiovascular diseases, especially ischemic heart disease present a high morbidity and mortality rate in our country. The aim of this study is to estimate the average coronary risk of people living in the west Valladolid Health District.

METHODS

Cross-sectional study in a random sample of 369 people between 35 and 64 years of age from the general population, of systolic blood pressure, total serum cholesterol and cigarette smoking. With these three factors, plus sex and age, individual coronary risk was calculated through the Dundee Coronary Risk-Disk method.

RESULTS

The coronary risk in the studied district, which is to say the individual probability of suffering a coronary event within five years of life, was estimated in 5.22 (95% CL: 4.75-5.69), higher among men, 5.66 (95% CL: 4.95-6.36), than among women, 4.63 (95% CL: 4.15-5.11). A descendent trend in coronary risk as age increases was found.

CONCLUSIONS

This method is relatively easy to obtain for community studies and simple to use for individual risk. The coronary risk of a person from the studied population has similar levels to figures found in other studies from our settings. The community levels of isolated coronary risk factors do not permit the establishment the best option in coronary risk control, and only a multicausal approach will allow us to evaluate the most efficient interventions for each age group and sex.

Modelling different strategies to prevent coronary heart disease in primary care

Strategies for prevention of coronary heart disease (CHD) in primary care need to take into account the number of people who require screening, further assessment, intervention and follow-up (i.e. the patient workload generated for the general practitioner) as well as the anticipated reductions in morbidity and mortality. Risks of CHD for various risk profiles were estimated from equations produced by the Framingham study. This enabled an estimate of the number of avertable CHD events to be compared against the patient workload implications for the general practitioner when different screening and intervention strategies were used. The Framingham equations were applied to a population of 5727 men and women aged 35-64 years of age registered with general practices in the south of England. Adopting an unselective approach to screening resulted in 14.1% (n = 73) of the 517 CHD events predicted over a 10 year period being averted. A limited screening strategy, involving 25% (n = 1436) of the patients would avert 5.6% (n = 29) of the predicted CHD events, whilst more extended strategies involving between 37% (n = 2131) and 46% (n = 2660) of the practice population respectively would result in between 6.9% (n = 36) and 9.3% (n = 48) of events being averted. The marginal benefit in averting CHD events decreased as more screening criteria were included. Almost all (99%) of the people identified by the selective screening strategies would require some form of intervention, predominantly lifestyle advice. Lowering the systolic blood pressure by 15 mmHg instead of 10 mmHg was equally effective as a 5% improvement in the overall rate of smoking cessation.(ABSTRACT TRUNCATED AT 250 WORDS)