Assessing family history of heart disease in primary care consultations: a qualitative study

BACKGROUND: Current primary prevention guidelines recommend the assessment of family history of coronary heart disease (CHD) to identify at-risk individuals. OBJECTIVE: To examine how clinicians and patients understand and communicate family history in the context of CHD risk assessment in primary care. METHODS: A qualitative study. Patients completed a validated family history questionnaire. Consultations with clinicians were video recorded, and semi-structured interviews conducted with patients after consultation. The participants were 21 primary care patients and seven primary care clinicians (two practice nurses, five GPs). Four practices in South West England. RESULTS: Patients and clinicians usually agreed about the patient's level of risk and how to reduce it. Patients were mostly satisfied with their consultations and having their family history assessed. However, three issues were identified from the consultations which contributed to concerns and unanswered questions for patients. Problems arose when there were few modifiable risk factors to address. Firstly, patients' explanations of their family history were not explored in the consultation. Secondly, the relationship between the patient's family history and their other risk factors, such as smoking or cholesterol, was rarely discussed. Thirdly, clinicians did not explain the integration of family history into the patient's overall cardiovascular disease risk. CONCLUSIONS: Clinicians appeared to lack a rhetoric to discuss family history, in terms of capturing both genetic and environmental factors and its relation to other risk factors. This created uncertainties for patients and carries potential clinical and social implications. There is a need for better guidance for primary care clinicians about family history assessment.     

疾病家族史与冠心病发生风险的关联研究

目的 分析疾病家族史对急性冠心病事件（MCE）及缺血性心脏病（IHD）发病风险的影响。方法 研究对象来自中国慢性病前瞻性研究,剔除基线时患有恶性肿瘤、心脏病及脑卒中的个体,纳入485 784人进行分析。统计分析采用Cox比例风险模型。结果 研究人群随访M=7.2年,随访期间新发MCE 3 934例,IHD 24 537例。与无家族史者相比,有家族史者发生MCE及IHD的风险均较高,HR值（95% CI）分别为1.41（1.19~1.65）和1.25（1.18~1.33）。与双亲型家族史相比,同胞型家族史与早发MCE的关联更强（HR=2.97,95% CI：1.80~4.88）;超重/肥胖者中家族史与MCE、IHD的关联更强;吸烟者中家族史与MCE的关联更强。结论 有家族史者发生MCE及IHD的风险较高。结果提示应鼓励个体根据疾病家族史信息,及早开展生活方式干预和相关基础疾病的治疗管理。     

Coronary risk appraisal for primary prevention of coronary heart disease in a community

PURPOSE: In discussion on application of "National Health Promotion Toward 21st Century in Japan" in Kanagawa prefecture, it was noted that the age-adjusted mortality rate of death from ischemic heart disease in this part of Japan was higher than that for the whole nation in 1996. To facilitate development of a strategy for primary prevention of coronary heart disease (CHD), the present study was conducted to predict 2-yr incidence of CHD and decrease with simulations assuming improvement in CHD risk factors. METHODS: Using CHD risk prediction algorithm; the Weibull accelerated failure regression model based on the Framingham Heart Study, a 2-yr incidence of CHD was predicted for 1652 residents (515 male, 1137 female) on the basis of results of a health check up in 1998. We then estimated the probable decrease in CHD recalculated assuming decrease in total cholesterol (TC), increase in HDL-cholesterol (HDL-C), decrease in systolic blood pressure (SBP), or quitting the smoking habit. RESULTS: 1. The 2-yr probability of developing CHD for men free of heart disease was 2.79 +/- 2.17%, and that for men who had heart disease was 10.25 +/- 2.17%. The 2-yr probability for women free of heart disease was 16.80 +/- 14.40%, and that for women who had heart disease was 3.66 +/- 1.09%. As the reported probability of developing CHD in the U.S.A. is remarkably higher than in Japan, the fact that the present model was based on American data explains why these predicted probabilities are higher than values reported from Japanese cohort studies. 2. For men free of heart disease, a strategy for high risk case such as a decrease in TC and an increase in HDL-C, or quitting the smoking habit, was more effective than a population-based strategy. For women free of heart disease, the population-based strategy was more effective. 3. Women more than 60-yrs old who had a high 2-yr probability of developing CHD were divided into three groups; high, middle, and low risk. The mean body weight, mean body mass index, mean diastolic blood pressure, and mean blood glucose in the high risk group were significantly higher than the values in the other groups. Decrease in systolic blood pressure was a more effective strategy for decrease in CHD incidence in the high risk group than in the other groups. CONCLUSIONS: CHD risk prediction of this type may be considered useful for setting target CHD risk factors and for focusing interventions to prevent CHD effectively.     

Comparison of family history measures used to identify high risk of coronary heart disease

We examined 15 published continuous family history measures (scores) as well as two new formulations in terms of several desirable properties. We applied the scores to sample pedigrees and found that some systematically increase with family size. In contrast to aggregate scores, non-aggregate scores are sensitive to the age, sex, and covariate status of individual relatives but are unstable when the families are small. We also applied these scores to our own population case-control data, characterised by a high proportion of missing and false-negative responses. In these small families, all scores provided significant discrimination between CHD cases and controls beyond the usual categorical definition of positive family history, but appeared no better than detailed categorical definitions or even simple counts. Our new formulations offer no solution to the problems of few data; most scores apply asymptotic approximations to differences between observed and expected number of affected relatives and are not suited to small families. All scores would be improved by ruling out families with only one affected relative, as is being done in the NHLBI Family Heart Study. We recommend that researchers, when using a family history measure, consider the number of informative families and other characteristics of their data prior to choosing any particular formulation.     

Interactions between diabetes and family history of coronary heart disease and other risk factors for coronary heart disease among adults with diabetes in Utah

We used a unique data base containing medical family history information from representative Utah families to investigate interactions between diabetes and family history of coronary heart disease and other risk factors for coronary heart disease. We compared nonrelated individuals reported to have had diabetes mellitus diagnosed over the age of 19 (948) with 2150 nondiabetic individuals. Among both men and women, diabetes and family history of early coronary heart disease magnified the risk for coronary heart disease, so that in diabetic individuals with a positive family history of coronary heart disease, about 74% of the coronary heart disease could be attributed to interaction. Relative to nondiabetics without a family history of early coronary heart disease, nondiabetics with family history had a relative risk of 4.5 (2.3-8.7), diabetics without a family history had a relative risk of 2.8 (1.6-4.9), and diabetics with a family history had a relative risk of 21.3 (9.1-50.0). Smoking also interacted with diabetes; among smoking diabetics, 47% of early heart disease may be attributable to interaction between smoking and diabetes. Smoking entailed the highest risk for diabetic women. Hypertension and diabetes appeared to act additively, with little interaction. Among women, family history of diabetes was a risk factor for coronary heart disease with a relative risk of 2.5 (1.0-6.4), whereas for men the relative risk was estimated to be 0.4 (0.2-1.1).     

Pharmacological trials: primary and secondary prevention of coronary heart disease

This brief overview of outcome in studies on the primary and secondary prevention of CHD with drugs influencing cholesterol-lipid-lipoprotein metabolism or with platelet-influencing drugs indicates the following conclusions: (1) The central finding of the European trial on primary prevention with clofibrate—significant adverse effects on long-term mortality from all causes—compels the conclusion that this drug has no place in the broad effort to reduce CHD risk by lowering plasma lipids-lipoproteins. (2) No other disease endpoint data are as yet available on lipid reduction by other drugs for primary prevention; data from a U.S. cholestyramine trial are due in 1983 or 1984. (3) Results of the Coronary Drug Project with lipid-influencing drugs for secondary prevention in middle-aged post-MI men were negative for 5.0 and 2.5 mg/day mixed conjugated equine estrogens, and for dextrothyroxine, with early termination of all three of these regimens because of possible adverse effects. At the scheduled end of the trial, clofibrate showed no evidence of benefit and some signs of adverse effects. Nicotinic acid showed no evidence of benefit in regard to the primary CDP endpoint, all causes mortality, but it yielded a significant reduction in rates of nonfatal MI, nonfatal MI + CHD death, and stroke events. (4) Combined therapy with resin + nicotinic acid has a much greater capacity—over and above diet—than any single lipid-lowering drug to reduce markedly all atherogenic lipids-lipoproteins, while simultaneously raising HDL, but no disease endpoint data are available on benefit/risk ratio with this regimen. (5) Eight secondary prevention trials with platelet—influencing drugs indicate encouraging but not statistically significant results in five of six aspirin trials, in a trial with aspirin + dipyridamole, and in a trial with sulfinpyrazone. (6) Viewed in perspective, these discouraging data on lipid—influencing drugs for the primary and secondary prevention of CHD, and these equivocal data with platelet-influencing drugs for secondary prevention reinforce the fundamental conclusion that the main strategic thrust for the control of epidemic premature CHD must be primary prevention by nutritional-hygienic means, i.e., avoidance and correction of the lifestyles—especially “rich” diet and cigarette smoking, also sedentary living and incongruent behavior—that are the cause of the mass problem.     

Aspirin use for the primary prevention of coronary heart disease: a population-based study in Switzerland

OBJECTIVE: To determine the patterns of aspirin use for the primary prevention of coronary heart disease (CHD). Aspirin for primary prevention has a more favorable risk/benefit profile among adults with high CHD risk than among low-risk adults. METHOD: We studied 5725 adults aged 35-75 without cardiovascular disease in a population-based study in Switzerland in 2003-2006. We examined regular aspirin use for cardiovascular prevention according to 10-year CHD risk and other cardiovascular risk factors. RESULTS: One hundred seventy-four participants used aspirin. Aspirin use increased with 10-year CHD risk, from 2.6% in persons with risk <6% (low risk) to 9% in those with risk 6-20% (intermediate risk, p=0.001), but no adults with risk >or=20% used aspirin. Participants with cardiovascular risk factors were more likely to use aspirin. However, 1.9% adults with risk <6% and no diabetes used aspirin. Using a population perspective, a more appropriate aspirin use would reduce up to 2,348/24,310 CHD deaths expected over 10 years in Switzerland, and avoid about 700 gastrointestinal bleedings and hemorrhagic strokes among those not eligible. CONCLUSION: Individuals at intermediate CHD risk and diabetics are more likely to take aspirin, but there are significant opportunities for improvement. The underuse of aspirin for those at risk coexists with an overuse among those at low risk.     

Cholesterol-based personal risk assessment in coronary heart disease

Using data from the National Health and Nutrition Examination Survey (NHANES II) 1976-1980, we demonstrate how cross-sectional total serum cholesterol surveillance data can be used by an individual to assess current and future personal cholesterol risk status. We propose statistical models, based on a person's current measured cholesterol level and the relationship between cross-sectional age and cholesterol percentile estimates, that will allow prediction of future cholesterol levels or the age at which specified cholesterol risk levels will be reached if no cholesterol-altering intervention is taken. These models incorporate the observed variation in the NHANES II data and expected intraperson biological variation and intralaboratory analytical variation. We illustrate the adequacy of the models using data from the longitudinal Framingham Study.     

Family history and the risk of coronary heart disease: comparing predictive models

Family history is commonly used when evaluating coronary heart disease (CHD) risk yet it is usually treated as a simple binary variable according to the occurrence or non-occurrence of disease. This definition however fails to consider the potential components of a family history which may in fact exert different degrees of influence on the overall risk profile. The purpose of this paper is to compare different predictive models for CHD which incorporate family history as either a binary variable or different types of family risk indices in terms of their predictive ability. Models for estimating CHD risk were constructed based on usual risk factors and different family history variables. This construction was accomplished using logistic regression and RECursive Partition and AMalgamation (RECPAM) trees. Our analyses demonstrate the importance of using more sophisticated definitions of family history variables compared to a simple binary approach since this leads to a significant improvement in the predictive ability of CHD risk models.     

Prevalence and management of coronary heart disease in primary care: population-based cross-sectional study using a disease register

BACKGROUND: Patients with coronary heart disease are at high risk of further coronary events. Hence, one of the main priorities in the National Service Framework for Coronary Heart Disease strategy is the identification and treatment of patients with pre-existing coronary heart disease. We aimed to determine the prevalence of established coronary heart disease in a large primary care population and to compare the management of risk factors in these patients with the standards given in the National Service Framework. METHODS: A population-based cross-sectional study was carried out using data collected from primary care. Sixty-three general practices (total list size 378,021) in four primary care groups in SW London took part. Data collection was confined to 103,613 patients over 44 years of age. We calculated age- and sex-specific and age-standardized prevalence rates, and age-adjusted relative risks for men and women. RESULTS: A total of 6,778 patients with coronary heart disease were identified (8 per cent of men and 5 per cent of women over 44 years of age). There was a history of myocardial infarction in 30 per cent (1204/3991) of men and 22 per cent (613/2787) of women (relative risk 1.57; 1.37-1.81). Coronary revascularization procedures had been performed in 27 per cent (1068/3991) of men and 11 per cent (312/2787) of women (2.02; 1.73-2.35). Most patients had been assessed for hypertension (89 per cent (3538/3991) of men; 90 per cent (2500/ 2787) of women), but in many patients blood pressure was poorly controlled (26 per cent (902/3538) of men; 27 per cent (678/2500) of women). Total cholesterol had been recently measured in 51 per cent (2018/3991) of men and 44 per cent (1218/2787) of women and was elevated in 44 per cent (881/ 2018) of men and 59 per cent (716/1218) of women (0.74; 0.69-0.79). Statins were prescribed to 49 per cent (1967/3991) of men and 38 per cent (1064/2787) of women (1.06; 1.00-1.12). Aspirin was prescribed to 65 per cent (2586/3991) of men and 59 per cent (1631/2787) of women (1.08; 1.03-1.14). Beta-blockers were prescribed to 20 per cent (181/913) of men and 15 per cent (72/499) of women with a history of myocardial infarction (1.11; 0.85-1.44). CONCLUSIONS: Most patients with coronary heart disease in primary care were being treated with aspirin but less than half with statins or beta-blockers. More men than women were treated with aspirin and statins, even though women had higher cholesterol levels than men. Men were also more likely to have a confirmed diagnosis and to have undergone a coronary revascularization procedure. There is considerable scope for improving the secondary prevention of coronary heart disease and addressing gender inequalities in primary care.     

一、二级预防中冠状动脉心脏病风险的评估

目的 通过经济发达地区社区人群冠状动脉心脏病(CHD)风险评估，筛选CHD一、二级预防的对象。方法 以中国心血管健康多中心合作研究中苏南经济发达地区城市和农村两社区人群中心血管危险因素资料，引入美国胆固醇教育计划第3次报告(ATPⅢ)对CHD危险状态的评估和胆固醇处理的原则和方法。结果 根据CHD危险因素数量，将危险状态分为3类。城市、农村社区中，CHD等危症组分别占14．32％和7．70％；2个及以上危险因素组的对象通过Framindham积分，分别有62．44％和51．58％的患者10年风险超过10％。在CHD等危症组，城市和农村社区分别有62．50％和43．75％患者高于低密度脂蛋白胆固醇(LDL-C)标准值(LDL-C≥2．59mmol／L)；2个及以上危险因素组中，分别有24．17％和10．41％的患者超过目标值(LDL—C≥3．36mmol／L)；0～1个危险因素组分别有5．25％和5．82％的患者超过目标值(LDL—C≥4．14mmol／L)。此外，城市和农村社区代谢综合征的患病率分别有30．40％和18．11％。结论 经济发达地区城市、农村社区人群通过ATPⅢ的评估，有一定比例的人口具有较高的CHD风险，代谢综合征患病率也处于较高的水平。鉴于ATPⅢ是一份以大量科学事实、临床试验证据为依据的科学报告，在完善我国的CHD一、三级预防中，应将其作为借鉴。     

Family history,longevity, and risk of coronary heart disease: the PRIME Study

BACKGROUND: To assess the contribution of family history of coronary heart disease (CHD) and longevity in parents to 5-year incidence of coronary events in middle-aged men. METHODS: A prospective study in men from Northern Ireland and the French cities and environs of Lille, Strasbourg, and Toulouse. A total of 10 600 men aged 50-59 years were examined between 1991 and 1994 and followed annually by questionnaire for incident cases of coronary disease. A detailed family history was taken and a quantitative family risk score for CHD was calculated for each subject. Five-year follow-up is complete; all coronary events (coronary deaths, myocardial infarction, and angina) documented by clinical records were reviewed by an independent medical committee. RESULTS: At screening, 9758 subjects were free of clinical and historical evidence of CHD; in this group there were 317 coronary events by 5 years of follow-up. Subjects whose parents had both survived until >/=80 years showed a relative odds of 0.49 (95% CI: 0.31-0.77) for risk of a coronary event compared with subjects whose parents had not survived until >/=80 years old with adjustment for age and nine other risk factors including family history. The pattern of results was similar in France and Northern Ireland, although parental survival was longer in France. Likewise, subjects with a strong family history showed a relative odds of 1.93 (95% CI: 1.25-3.00) compared with subjects without such a history, after adjustment for age and the nine risk factors including parental longevity. The pattern of results was similar in France and Northern Ireland. CONCLUSIONS: These results indicate that a family history of coronary disease and parental longevity, although related, act independently of one another and of other major cardiovascular risk factors in predicting 5-year risk of subsequent coronary events.     

Compliance and exercise in primary and secondary prevention of coronary heart disease: A review

Compliance with exercise programs in the primary and secondary prevention of coronary heart disease is reviewed. The evidence suggests that compliance with health behavior changes such as exercise is necessary for potential benefits to become apparent. However, the compliance rate with exercise programs is low and particular care must be taken in the interpretation of exercise studies as well as clinical trials because of self-selection bias. There appear to be certain characteristics that may help to identify the potential dropout; there are also certain programmatic features which should be considered in designing compliance-improving strategies to reduce dropout. Behavior modification techniques appear to have significant potential in reducing program dropout; however, there is a need to carefully investigate compliance-improving strategies before recommendations for a particular approach can be made.