452 Professor Pekka Pushka, director of the North Karelia project and head of the division of health and chronic diseases at the National Public Health Institute, Helsinki. "Twenty-five years ago, Finland had a major coronary vascular disease problem, with by far the highest mortality rates in the world. Most of the coronary deaths in Finland are sudden and happen before people reach hospital, so we realised that most of the potential for solving the problem lay in primary prevention. With this in mind, we started the North Karelia project with the aim of reducing mortality from coronary heart disease, but also offering general health promotion advice.
"It is not enough just to work with chronically high-risk patients, we must also work with those who may only have moderately raised risk factors.
"Most of the reduction in mortality has tracked the reduction in risk factors - yes it has been difficult to change people's behaviour, but a comprehensive, positive programme can have meaningful effects on a population's lifestyle. The big question is not what to do but how to do it."
The epidemiologists presented the data to the people for two or three years. The media then asked the doctors what they were doing about it which created an uproar. We must make this a current affairs issue in the UK for the same thing to happen.
The North Karelia Project
454 The new (1999) WHO/ISH guidelines recommend lower levels of blood pressure in both adults and the elderly.
Hypertension is defined as a systolic (SBP) of 140mmHg or greater, and/or a diastolic (DBP) of 90mmHg or greater among those not taking hypertension medication.
Those patients with BPs in the range 130-139mmHg systolic and 85-89mmHg diastolic are now classified as having high normal BP.
Mild hypertension is classed as SBP 140-159mmHg and DBP 90-99mmHg.
Moderate hypertension is classed as SBP 160-179mmHg and DBP 100-109mmHG.
Severe hypertension is classed as SBP more than 180mmHg and DBP more than 110mmHg
The guidelines urge clinicians to consider CVS risk. A person with mild hypertension and no other CVS risk factor would be considered low risk, but someone who was a smoker with raised cholesterol would be considered a medium risk. The guidelines say trhat "it would seem desirable to achieve optimal or normal BP in young, middle-aged or diabetic subjects and at least a high normal BP in elserly patients, that is below 140/90mmHg."
455 The results of the trial of fish and of Mediterranean diet suggest that coronary patients should be advised to eat more fish, more fruit and vegetables, more bread, pasta and potatoes (in place of meat), more olive oil and mono-saturated margarine (eg rapeseed or olive oil based) in place of butter.
456 Shift work is a risk factor for myocardial infarction in both men and women. The results were not confounded by job strain, smoking or by educational attainment.
457 Alcohol consumption appears to affect survival in patients with a history of myocardial infarction. Maximum benefit was seen for light-to-moderate alcohol consumption (2-6 alcoholic drinks a week appears to be protective).
458 Albert Edge and his team. Xenotransplantation of pig liver cells for familial hypercholesterolaemia.
460 Intensive lifestyle changes significantly regressed coronary artey stenosis. Coronary arteries of control patients continued to occlude and they suffered more than twice as many cardiac events. Small study, 48 patients over 5 years.
461 A study of the accuracy of death certificates for coding coronary heart disease. Retrospective review of the community based Framingham cohort. 2683 deaths from the original study. Outcome measures were sensitivity, specificity and predictive value of the death certificate against the cause of death as judged by a panel of three independent doctors. Death certificates in the US over represent coronary heart disease as a cause of death by 24.3 per cent in this study.
463 A comment on the recent WHO recommendations. Despite the proliferation of guidelines, definitions of hypertension are still under debate.
464 A study of 4,462 Vietnam war veterans aged between 31 and 49. There was an 80 per cent increase in the risk of impotence in smokers compared with those who had never smoked. When all factors were adjusted for, a 50 per cent risk still remained.
467 Cigarette smoking remains the commonest cause of preventable mortality in the UK, accounting for about 120,000 deaths each year among people aged 35 or more.
468 Smoking related disease costs a typical health authority around £15 million a year.
469 In the UK, 29% of adults smoke cigarettes.
470 In the UK, two thirds of smokers want to stop and one third intend to give up within the year.
472 There is no French paradox. It is explained by miscoding and/or statistical variation, the French experience showing up in one corner of a scatter diagram.
473 No significant difference was found between different formulation and doses of pill and myocardial infarction among women aged 16-44 years.
A history of diabetes mellitus, angina and cigarette smoking were associated with a higher risk of myocardial infarction.
If all the women in this study had been nonsmokers it is estimated that the reduction in myocardial infarctions would be 73 per cent.
474 Raised BP should be treated to target levels of 140/85mmHg (130/80 in people with diabetes).
Moderate alcohol consumption should not be discouraged. An intake of up to three units (two units for women) per day is associated with a lower CHD risk compared with teetollaers and those who consume higher quantities of alcohol.
475 A UK study. Examines the risk of heart attacks from cigarette smoking in women aged under 45. The increase in risk was two and a half times in women smoking 1 to 5 cigarettes a day. It rises to 74.6 times in those smoking more than 40 a day. The risk was not increased by the contraceptive pill but was increased by the presence of diabetes or hypertension. It is a shame that young women seem more resistant to anti-smoking propaganda than anyone else.
476 Nearly 400 women, aged 40-79, attending breast clinics in the Leeds area took part in a case-control study.
Those patients who were diagnosed with breast cancer were no more likely to have experienced one or more stressful life events in the past few years than those who had benign breast lumps.
"We believe that women with breast cancer can be told that life stresses are unlikely to have played an important part in the development of their disease".
478 Large clinical trials have demonstrated that lipid-lowering therapy reduces cardiovascular morbidity and mortality, and overall mortality, in both patients with established coronary heart disease and those at high risk of developing it. The debate about cholesterol lowering has, therefore, moved from the questions of efficacy and safety to those of cost, cost-effectiveness and patient selection.
The dietary recommendations made by the Committee on Medical Aspects of Food panel on diet and cardiovascular disease, intended for the population as a whole, state that total dietary fats should be reduced to 35% or less of the total energy intake, saturated fat intake no more than one third of fat intake, and cholesterol intake to less than 300mgs daily. Early trials of diet in patients with CHD utilising reduced saturated fat intake did not give convincing results. More recent trials, utilising diets low in saturated fat and supplemented with polyunsaturated fatty acids, mainly from omega-3 fatty acids (three helpings of oily fish per week, fish oil capsules and alpha-linoleic acid margarine have shown significant reductions in coronary mortality and improved survival.
479The incidence of coronary heart disease is very high in the United Kingdom, but elsewhere in the world it is often much lower. Epidemiological studies show a strong correlation between the average serum cholesterol of a population and its rate of CHD.
481 Study to determine whether oral Vit E is associated with lower risk of CHD.
Double blind, randomised trial with 4.5 yr follow up.
9541 high-risk patients alocated to 400IU daily of vit E or placebo.
No significant difference in number of deaths from cardiovascular disorders, MI or stroke.
482 MONICA study looked at 38 popupations (more than 100,000 heart disease "events") and found that where there was a reduction of risk factors there was less heart disease.
Professor Hugh Tunstall-Pedoe quoted in Medical Monitor "The best advice to the general public is to take care of your risk factors whether or not you have heart disease."
483 Plant stanols & sterols (found in Benecol etc) lower levels of LDL cholesterol enough to reduce heart disease by up to a quarter.
484 Worldwide estimate of 3,000,000 deaths annually caused by tobacco smoking. Alcohol misuse responsible for a further 2,000,000 deaths per year.
485 The BMJ of 11/3/2000 has as its theme "Risk in cardiovascular disease". Guidelines. Validation of the new Sheffield table. Using the Framingham model to predict heart disease in the UK. Computer based decision support. Randomised comparison of risk assessment scoring methods.
487, 488 Rehabilitation should be an intrinsic part of the management of all forms of cardiac disease and should cross traditional boundaries. Virtually all patients are suitable for rehabilitation. Programmes need to be based on the assessment of the individual needs rather than a regimented process of attending a fixed number of talks and exercise sessions. One in four patients will manifest either anxiety or depresion at a level that would benefit from treatment. Exercise should be moderate and regular; brisk walking, gradually increasing up to thirty minutes five times per week.
489 "When an investigator has a financial interest in or funding by a company with activities related to his or her research, the research is lower in quality, more likely to favor the sponsor's product, less likely to be published and more likely to have publication delayed."
490 "Smoking is the cause of a third of all cancers."
491 Exercise is of benefit in the prevention and treatment of cardiovascular disease, non-insulin-dependent diabetes, osteoporosis and obesity, as well as producing a reduced risk of falling and improved mental health. The most striking evidence is in relation to cardiovascular disease where the decreased risk attributable to regular physical activity is similar to other risk factors such as not smoking.
496Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk greater than or equal to 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year. Advice on aspirin for primary prevention requires formal accurate estimation of absolute coronary event risk.
497A new scoring system using 11 risk factors, which is based on a large cohort of participants in controlled trials of antihypertensive drugs, can quantify an adult's five year risk of death from cardiovascular disease, including stroke and coronary heart disease. An individual's risk can therefore be readily assessed as high or low compared with others of the same age and sex; and the web site http://www.riskscore.org.uk is available for users of the risk score. This new scoring system adds objectivity when assessing patients' needs for antihypertensive drugs and other health management strategies.
498 Based on the list of standards in the National Service Framework, the researchers estimate that in an average practice of 10,000 patients, over 900 items will need recording and over 2,000 disease control measures will be needed, with profound implications for primary care. Study limitations mean that these estimates are conservative.
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