|Smoking years||× 5,|
|Systolic blood pressure||× 3 (NB not the mean BP)|
|Total cholesterol||× 51|
|Ischaemic heart disease||+ 170|
|Parental death||+ 50|
(11) Large multicentre screening in general practice using micros. Included cholesterol using Reflotron. 19 health centres involved Reflotron. Framingham Pooling score. Microcomputer to store and analyse data. Opportunistic approach. 40,000+ patients "The patient has immediate feedback of his level of risk, which is achieved without a formal interview with the doctor. Such a procedure may circumvent many of the problems, expectations and misconceptions that this interaction implies."
|cholesterol > 7||15%|
|cholesterol > 9||2%|
|Diastolic blood pressure > 95||10%|
|Systolic blood pressure >165|
18 Health centres throughout the United Kingdom (centred on Glasgow)
|Blood pressureP under 40yrs and less than 150/90||no action|
|Blood pressure under 40yrs and 150/90 - 170/105||repeat|
|Blood pressure over 40yrs and less than 155/95||no action|
|Blood pressure over 40yrs and 155/95-170/105||repeat|
|High - Less than 30yrs||6·0||6·5|
|High - More than 30yrs||6·5||7·0|
|Moderate - Less than 30yrs||5·5 - 6·0||6·0 - 6·5|
|Moderate - More than 30yrs||6·0 - 6·5||6·5 - 7·0|
|Normal||20 - 24||20 -23|
|Overweight||25 - 29||24-27|
|Obese||30-34||28 - 31|
(22) Can health promotion and screening damage your health?
People labelled as hypertensives show more absenteeism and more depressive symptoms
(23) The finding of mean cholesterol concentrations of 5·9 and 5·8 in British men and women aged 25-59 suggests that little or no change in plasma cholesterol levels in the population has occurred during the past 12 years (written in 1988). This finding is disappointing in view of the attempts that have been made to encourage the population to adopt dietary changes to lower blood cholesterol content.
Strategies for preventing coronary heart disease - 2 main approaches. The population strategy aims at reducing the prevalence of risk factors in the community, many cases occur in those with only moderately raised cholesterol. The high risk strategy is aimed at people who are at a particularly high risk.
Both should be applied in countries at high risk such as the United Kingdom
(Secondary prevention is the third strategy and is unequivocally effective - GMC)
Clearly in Britain Health Education has had little impact on plasma lipids (little change in 12 years).
The complementary role of the high risk strategy.
5% of the population have cholesterol greater than 7·8 and 25% greater than 6·5.
(24) Authors caution about the anxiety and confusion which may result when abnormalities are found in random screening of healthy people leading healthy life styles. The other worry is the "certificate of health" effect on the young men with no risk factors detected - this group were not leading significantly healthier life styles than the rest of the men in terms of exercise, smoking, diet and so on yet the results of the screening may give them a false reassurance that they do not need to be concerned about their life style.
(26) Who should be screened? All patients who attend their general practitioner, patients who want to know their lipid levels, relations of patients with known cardiovascular disease or hyperlipidaemia, children of patients with a family history.
(27) The fundamental dietary principle remains moderation in all things.
(29) Phase one cardiovascular mortality studied in 253 towns.
Phase two (current) a clinical survey of middle aged men in 25 towns.
Phase three prospective study of (2) to determine which personal risks are most strongly related to cardiovascular events.
(1) Associations (on a town basis) include mean systolic blood pressure, heavy cigarette smoking and heavy alcohol consumption. No correlation with body mass index, serum cholesterol or high density lipid cholesterol. Water hardness regularly associated with stroke and ischaemic heart disease.
(2) 300 middle aged men from each of 25 towns studied in depth. About a quarter of them showed evidence of coronary heart disease.
(34) A cigarette smoker has 2 or 3 times the risk of a coronary attack than a non-smoker.
A doctor who can persuade 5% of his patients to stop smoking each year is likely to be more effective in reducing the burden of coronary disease in the community than are the therapeutic efforts of many cardiologists and thoracic surgeons.
(35) About half of all strokes and a quarter of deaths from coronary heart disease in people under 70 are probably preventable by the application of existing knowledge.
Quoted in 10
Leaflets:- Flora, Heartbeat Wales, Look after yourself.
Life-style intervention clinics
(39) This is a letter from the chemical pathologist at the Norfolk & Norwich hospital discouraging the general practitioner from random cholesterol measurements. "the department's budget will not allow us to measure fasting lipids unless a clear medical indication is given".
(43) As the risk of coronary heart disease is comparatively low at concentrations less or equal to 5·2 this value should be taken as the optimal value for subjects in the general population.
All adults should have blood lipids measured at least once before the age of 30. Those with levels of 5·2 - 6·5 should receive general dietary counselling and advice on other risk factors. Those with levels greater than this should receive clinical care.
(50) General practitioners and their practice staff need have no fear when using sophisticated equipment as long as standard safety and quality control procedures are followed carefully.
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