Copyright © 2004 by the European Society of Cardiology.
Letter to the Editor
Principles of prevention of cardiovascular disease: Reply
Department of Epidemiology, Public Health Medicine, Royal College of Surgeons in Ireland, Dublin 2, Ireland
* Tel.: +353-1-402-2434; fax: +353-1-402-2329
E-mail address: ian.graham{at}amnch.ie
Dear Sir
We note the statement by Dr. Greten on behalf of the International Atherosclerosis Society regarding the Systematic COronary Risk Evaluation (SCORE) Project1. It is important because it illustrates some fundamental misconceptions about both risk prediction and the practical prevention of cardiovascular diseases.
(1) The SCORE Project1 describes a simple method of predicting the risk of atherosclerotic cardiovascular diseases. It does not offer advice with regard to prevention of cardiovascular diseases. This is given in the guidelines of the Third Joint European Societies Task Force on Cardiovascular Disease Prevention in Clinical Practice2, which includes the European Atheroesclerosis Society. It is not clear to us why the International Atherosclerosis Society chose not to refer to these agreed European Guidelines.
(2) The Joint European Task Force Recommendations2 use the SCORE risk algorithm to predict risk of atherosclerotic cardiovascular diseases, not just coronary heart disease. This acknowledges the importance of manifestations of atherosclerosis other than coronary heart disease, such as stroke and peripheral vascular disease.
(3) Dr. Greten and the International Atherosclerosis Society apparently fail to understand that a high risk of cardiovascular diseases mortality also denotes a high risk of morbidity. In no way will this approach "shift the balance in public health policy more to secondary prevention and away from primary prevention". Further, it is scientifically incorrect to state that the association between risk factors and mortality is weaker then the association with morbidity.
(4) Dr. Greten and colleagues also fail to understand the statistical methods of elaboration of the cardiovascular risk algorithm. The relations of risk factors to CVD in high or low risk regions are not outcome of weighting but the result of what is naturally occurring in different populations of Europe.
(5) The SCORE Project Group is indeed addressing the issue of the prediction of morbid events, as well as cardiovascular diseases mortality. This issue requires rigorous scientific examination, and is not as simple as many would appear to believe, for several reasons:
(5.1) The definitions of morbid events vary considerably in different cohort studies
(5.2) It is likely the level of ascertainment also varies considerably in different studies
(5.3) Newer diagnostic techniques such as troponin are likely to have altered the spectrum of morbidity
(5.4) Similarly, newer treatments such as thrombolysis and acute percutaneous interventions as well as lifestyle changes would be expected to have modified the natural history of coronary disease and stroke.
It follows that both the number of morbid events and their character may show considerable secular changes. It is not clear to us whether these issues have been fully addressed in either Framingham or PROCAM
(6) It is true that the SCORE paper does not address the issue of risk in older people, all of whom are at increasing, and eventually inevitable risk of death. Such issues are much better dealt with in agreed recommendations on prevention 2.
Finally, we would suggest to Dr.Greten and the International Atherosclerosis Society the distinction between primary and secondary prevention is neither watertight nor particularly helpful. Prevention activities span a spectrum rather than being neatly divisible into two categories.
(7) As is implicit in Dr. Greten’s letter, the risk of atherosclerotic cardiovascular disease is continuously distributed, and we would suggest that our efforts should be devoted to identifying both the level of risk, and the most appropriate strategies to reduce this level of risk in individuals as well as in populations as a whole.
Yours sincerely,
Ian M. Graham, F.R.C.P.I., F.E.S.C.
Project Leader, SCORE Project
Ronan Conroy, B.Mus
Principal Investigator, SCORE Project
Kalevi Pyörälä, MD. FESC
Chairman, Scientific Committee, SCORE Project
References
- Conroy R, Pyörälä K, Fitzgerald AP et al. The SCORE (Systemic COronary Risk Evaluation) manuscript. Prediction of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. European Heart Journal. 2003;24(11):987–1003.
[Abstract/Free Full Text] - De Backer G, Ambrosioni E, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts). European Heart Journal. 2003;24:1601–1610.
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