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Primary prevention of coronary heart disease - Unevaluated screening inhibits informed consenthttp://bmj.com/cgi/content/full/325/7355/56
EditorialsPrimary prevention of coronary heart diseaseUnevaluated screening inhibits informed consent
Population screening for individuals at high risk of getting coronary heart disease is an explicit objective in primary care. The national service framework for coronary heart disease recommends that general practitioners and primary healthcare teams should identify all people at significant risk of cardiovascular disease, but who have not yet developed symptoms, and offer them appropriate advice and treatment to reduce their risk.1 In contrast to the current policy of maximising participation, Marteau and Kinmonth in this issue suggest that helping individuals to become involved in making informed choices may increase their motivation to make changes.2 When the introduction of a national screening programme is being considered, a proper scientific evaluation should occur. Wilson and Jungner's criteria are a yardstick against which a screening programme can be judged (see box).3 Apart from the recognition that coronary heart disease is an important health problem little evidence exists that any of the other criteria are adequately met. The "significant risk of cardiovascular disease" to which the national
service framework refers equates to a risk of coronary heart disease
of more than 30% over 10 years. It is advocated that risk assessment
should be performed by using one of several clinical decisions aids
that are based on a Framingham risk equation.4
Although mortality due to coronary heart disease has declined
considerably since the 1970s, and evidence has shown that the
Framingham risk equation overestimates risk in populations of low
prevalence of coronary heart disease, we do not know the sensitivity
and specificity of this equation in a British population. 5
6 Further, the collection of the necessary
information about risk factors is inadequate and user accuracy only
moderate even when all the information is present. Wide variation
also exists between the clinical decision aids with respect to the
numbers of individuals identified as being at high risk.
7 8
Even if the Framingham equation is assumed to be accurate, an estimated 3.4% of the population aged between 35 and 69 years would be identified as having a risk of coronary heart disease of greater than 30% over 10 years. Moreover, the threshold of 15% for consideration of treatment with aspirin and antihypertensives would entail identifying and treating 25% of the population.9 Only very few patients' records contain all the necessary data on risk factors, and this reflects that primary care is struggling with the workload associated with identifying the patients at high risk.7 More conservative and practicable approaches have been suggested, which entail restricting the measuring of total and high density lipoprotein cholesterol to patients who are among the 5% of the population (based only on their age, sex, smoking, and blood pressure) with a risk of 30% or more over 10 years.10 As yet, no consensus has been reached. Difficulties in risk assessment aside, once an estimate has been made of a
patient's risk of coronary heart disease, a dialogue needs to be
started between clinician and patient to enable an informed decision
about possible interventions. The language used by the clinician The presence of the national service framework has undoubtedly resulted in
concentrating the efforts of primary care practitioners on the
prevention of coronary heart disease. Risk assessment combining
multiple risk factors is preferable to focusing on arbitrary thresholds
of single risk factors. But practical issues remain concerning
the estimation of risk of coronary heart disease and sharing the
decisions on treatment with patients. These difficulties, combined
with the disappointing results of the trials of multiple risk factor
interventions, question how informed the clinician or the patient can
be.12 Until scientific evaluation catches up with
political expediency, the goal of involving patients in making
genuinely informed choices about coronary heart disease screening
seems a long way off. Department of Social Medicine, University of Bristol, Bristol BS8 2PR (peter.brindle@bristol.ac.uk) Tayside Centre for General Practice, University of Dundee, Dundee DD2 4AD
Rapid Responses:Read all Rapid Responses
Other related articles in BMJ:
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PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS
OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
DISCLAIMER: All information, data, and material contained, presented, or provided here is for general information purposes only and is not to be construed as reflecting the knowledge or opinions of the publisher, and is not to be construed or intended as providing medical or legal advice. The decision whether or not to vaccinate is an important and complex issue and should be made by you, and you alone, in consultation with your health care provider.
Copyright 2012 by Vaccination News, A Non-Profit Corporation. All Rights Reserved. This content may not be copied unless permission in writing from Sandy Gottstein has been obtained. 
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 "A foolish faith in authority is the worst enemy of truth." -- Albert Einstein, letter to a friend, 1901 "I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education." -- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820 "What's the point of vaccination if it doesn't protect you from the unvaccinated?" -- Sandy Gottstein "Who gets to decide what the greater good is and how many will be sacrificed to it?" -- Sandy Gottstein |
for
example, the use of words such as "rare" or "probable"