(307) "No-one can take away from doctors the fact that they have the ultimate responsibility for their actions with their patients. No-one can take away from the suppliers and developers the fact that they have an obligation to provide an effective and a reliable tool. The encapsulation of medical knowledge within such tools raises a different question. It imposes obligations on the user to understand the validity of the knowledge and to control its use. It imposes obligations on the supplier to ensure that the user has the relevant facilities that give him the best possible chance of providing good patient care."
(308) "In this group of stably employed middle aged men loss of employment was associated with an increased risk of mortality even after adjustment for background variables, suggesting a causal effect. The effect was non-specific, however, with an increased mortality involving both cancer and cardiovascular disease". (the increase was times two for both cancer and cardiovascular disease). The British Regional Heart Study.
(309) "General checks by nurses are ineffective in helping smokers to stop smoking, but they help patients to modify their diet and total cholesterol concentration. The public health importance of this dietary change depends on whether it is sustained".
(310) "As most general practices are not using such an intensive programme the changes in coronary risk factors achieved by the voluntary health promotion package for primary care are likely to be even smaller. The government's screening policy cannot be justified by these results".
(311) More than 250 per 100,000 women in Glasgow have coronary heart disease - the worst rate in 21 countries. Second were Belfast women with a rate of 197. Glaswegian men 823, surpassed only by men in Finland. HT-P tracked 75,000 heart attacks.
(312) Quoted in "GP". Background quit rate 0.5% per year
Patches + Counselling 11.7%
General practitioner advice alone 2.7%
Nicotine gum + counselling 5.3%
Sheffield Centre for Health and Related Research
(313) Blood pressure. Hypertension leads to excess mortality and morbidity, particularly heart disease and stroke unless actively treated, and would attract an excess premium for both types of insurance according to the level of blood pressure.
It is the level achieved on treatment that determines mortality rather than pretreatment levels. When levels on treatment are consistently within the normal range no extra premium would be charged.
Cholesterol. The Framingham follow-up study of male non-smokers had mortality ratios consistently below 100% for levels of total cholesterol up to 7.8. Applicants for life and disability insurance with levels up to 7.8, but who have no other cardiac risk factors, my therefore be accepted at standard rates. Male smokers had increased mortality with levels of 5.9 and above, mortality increasing with the number of cigarettes smoked. Such men would be rated appropriately.
(315) David Pickersgill explains how the British Medical Association committee on Private Practice and Professional Fees comes to the conclusion that a general practitioner's time is worth £97.50 an hour.
(316) A crushing condemnation of smoking. 34,500 doctors monitored from 1951 over 40 years, 20,000 deaths. Half of all regular cigarette smokers will be killed by the habit, the hazards are even greater than we thought. If you stop before the age of 35 your survival pattern will be the same as a previous non-smoker. Survival prospects significantly improved by stopping, even in the 70s.
(317) Confirms other reports that drinking 1 - 2 units alcohol per day reduces the risk of death from ischaemic heart disease and other causes. Above 3 units a day there is progressive increase in many causes of death. Current guidelines appear correct.
(318) A Scandinavian study (Simvastatin Survival Trial) of 4,444 patients shows that two fifths of coronary deaths in high risk patients could be prevented by treating raised cholesterol.
(319) From America. High density lipid estimation does not need fasting blood. Measure it at same time as total cholesterol.
(320*) "Many people are aware of healthy eating advice but are unclear how to put it into practice. Fat intake, particularly saturated fat, can be reduced by opting for reduced fat products, avoiding frying and roasting, and limiting consumption of cakes, biscuits and creamy sauces. Eating fruit & vegetables and more starchy foods reduces fat intake, controls weight and increases intake of NSP and antioxidants. While individuals are advised to moderate their intakes of salt and alcohol, extreme measures are not necessary for most people."
(322) An overview of many of the controversial aspects of screening and treatment. An important introduction.
(323*) The first conclusive evidence that HMG CoA reductase inhibitors decrease mortality in patients at risk. The 4,444 patients with existing cardiovascular disease and elevated serum cholesterol received simvastatin or placebo. For the patients on simvastatin the relative risks were 0.7 for death and 0.66 for coronary events compared with controls.
(324) A 15 year study on 22,432 people in Finland showing that cholesterol concentration was not related to deaths from violent causes.
(325) This short chapter is well worth looking at for an overview with commentary of the trials that have been done and evidence for prevention.
(326) Smith's meta-analysis showed currently evaluated treatments, including diet, fibrates, cholestyramine and the statins improved mortality in only a small proportion of high risk patients. These included patients who had already had a myocardial infarct and those who smoked, had diabetes, hypertension or peripheral vascular disease.
(328) In people over 45 systolic pressure is a better predictor of risk of heart attack and stroke than the diastolic.
(329) Multiple Risk Factor Intervention Trial. Systolic pressure a better predictor of risk than diastolic for coronary heart disease.
(330) Medical Research Council trial. 25% reduction in strokes, 19% reduction in coronary events treating isolated systolic raised blood pressure in the elderly.
(331) "It seems reasonable to recommend that a threshold pressure of 160 should be considered an indication for treatment in younger patients irrespective of diastolic".
(332) A review of trials of lipid lowering therapy. Results of the Scandinavian Simvastatin Survival Study published last year suggest we should probably use simvastatin as routinely as aspirin in patients with coronary heart disease whose cholesterol remains above 5.5. This could prevent four out of every nine deaths in these patients. More trials are needed.
(333) 28 year study of 3,313 Helsinki businessmen. Smoking, cholesterol and systolic blood pressure all predictors of overall death rate. Cholesterol up by 1 mmol/l mortality up by 11%. No relation between cholesterol, violent death or cancer. Lowest coronary heart disease risk also lowest cancer.
(334) "70% of women remain unaware that heart disease is the single largest risk to their well being."
(335) "The first sign of coronary heart disease for many women is sudden death or fatal heart attack." "After the age of 45 women's average blood pressure is higher than men's." "Every year in the United Kingdom 5 times as many women die from coronary heart disease as of breast cancer."
(339*) Tom Stuttaford writing about the Scandinavian Simvastatin Survival Study. The progress of 1,111 patients between 65 & 70 who were known to have coronary heart disease was followed for 10 years. Treatment with cholesterol lowering drugs improved their chances of survival by a third and cut the coronary death rate by 43%. Age is no bar to treating raised cholesterol.
(340) One year follow up of 1,632 workers showed health checks failed to lead to changes in diastolic blood pressure, body mass index or self reported levels of smoking and exercise. Informing workers of their cholesterol level and cardiac risk score produced no improvements compared with controls.
(341*) "With more than 35 million working days lost through coronary heart disease in England each year, there is a clear incentive for employers to promote the health of their workforce" Chief Medical Officer, Department of Health.
(342) Research involving 43,757 men aged 40-75. Diets high in fibre, especially from cereals, reduced the risk of coronary heart disease by 29% for every 10g increase in cereal fibre. This was independent of fat intake.
(343-5) There was a reduction in serum cholesterol, beneficial dietary change and a reduction in the long term risk of myocardial infarction by 5-12% in men and 13-20% in women. Oxcheck costs about £30 and the BFH £63 per patient. Only likely to be cost effective if effects last for 5 years in Oxcheck or 10 years in BFH. The effect on coronary risk of a nurse led cardiovascular screening and intervention scheme in general practice may not be sufficient to justify the costs involved.
(346) Prevalence of obesity increased from just over 14% in 1991 to 16% in 1994 for women. Slight increase also for men.. 31% men and 29% of women cholesterol < 5.2 (15,809 adults). Mean adult blood pressure 139 in 1991 136 in 1994.
(347) Plasma cholesterol positively related to coronary heart disease mortality in both sexes absolute risk of coronary death was so much less in women that a woman with high cholesterol (>7.2) was at less risk than a man with <5.
(348) "Women develop coronary heart disease later, while men die of it younger. The burden of coronary heart disease is equal between men and women. Diabetes is a more powerful risk factor for coronary heart disease in women. Loss of ovarian function increases risk of coronary heart disease at any age. Hormone replacement therapy reduces risk by up to 44%. After diagnosis of coronary heart disease fewer women stop smoking. Women less likely to be referred for investigation/surgery. Diagnostic testing is less accurate in women. Perceptions of coronary heart disease are wrong."
(349) Rule of halves. 10% adults have HBP. In half those who did it went undetected. Half of those with known hypertension were not being treated, while half those treated were poorly controlled.
(350) 5mm to 6mm reduction in diastolic blood pressure (10 in systolic) reduced the risk of coronary events by one sixth..
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