Predicting cardiovascular disease
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2621 (Published 16 May 2016) Cite this as: BMJ 2016;353:i2621
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor,
If you have only a hammer, all your problems look like nails. This is the case with risk prediction for cardiovascular disease based on the available scores, focused on downstream risk factors.
Current scores are well designed to address the downstream prevention of vascular disease, by providing easy checks to simplify anti-hypertensive and statins prescribing, and allowing advice on lifestyle change. But they completely ignored key determinants of cardiovascular risk that act more upstream and acting at population or structural level. These are powerful and modifiable risk factors, but the key difference is that in order to improve them, changes in the dietary, fiscal, physical and regulatory environment are required. In simpler terms, these risk functions do not recognized the environment where these individuals live, and put all the responsibility on change on patients and doctors, while not exploiting the potential of determinants not considered in their equations.
For example, no risk function assess the fruit & vegetable intake of the individuals (or their price in their local economy) , or if they are exposed to salt or calorie-dense foods or trans fats in processed food. No risk function assess the actual ability of the individual to undertake physical activity. Risk functions might capture part of these effects through its impact on biological and behavioral risk factors, but offer little in terms of giving us clearer and operational insight on how to modify these causal determinants.
Risk functions are the historical product of an epidemiology focused on the biological risk factor paradigm. But this paradigm has evolved, and the modifiable upstream determinants of cardiovascular risk need to be included in the web of causation informing risk prediction, a key element in prevention strategies. But more importantly it could be a move to change the focus of prevention from individuals to whole populations, to better operate on the dietary, physical and behavioral environment surrounding them and empowering individuals to use their agency more effectively.
Competing interests: No competing interests
Re: Predicting cardiovascular disease
I whole heartedly agree with the statement that we need to translate CVD risk recognition into tangible and measurable clinical benefit for patients and the public.
There are, however, several problems requiring solutions before we can achieve this.
Many questions remain unanswered, probably most importantly: 1
How can we most accurately assess cardiac risk?
How can we best influence individuals to modify their lifestyle?
How can we ensure that the medical profession is giving optimal advice & treatment to their at-risk patients? 2
1.Lipman H M et al (2016). Preventive Cardiology: How can we reduce CVD risk?. Saarbrucken: Lambert Academic. 238.
2. Sheppard. Missed opportunities in prevention of CVD in Primary care BR J Gen Pract 2014;64:28-29
Competing interests: No competing interests