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Screening of family members of patients with premature coronary heart disease
Results from the EUROASPIRE II family survey

J De Sutter, D De Bacquer, K Kotseva, S Sans, K Pyörälä, D Wood, G De Backer
DOI: http://dx.doi.org/10.1016/S0195-668X(02)00386-X 249-257 First published online: 1 February 2003

Abstract

Aims To determine whether the Joint European Societies' recommendations that first degree blood relatives of patients with premature coronary heart disease (CHD) should be screened for coronary risk factors is being followed and, if so, how effectively these relatives are being managed.

Methods and results Using a postal questionnaire, 3322 relatives (siblings and children ≥18 years of age) of 1289 index patients in the EUROASPIRE II survey who had suffered from premature CHD (men under 55 years and women under 65 years) were asked whether screening for coronary risk factors had occurred and, if so, how they were being managed in terms of lifestyle advice and drug therapies. Overall, screening for coronary risk factors because of CHD in the family was only performed in 11.1% of siblings and 5.6% of children. However, prevalences of different cardiac risk factors were high both in relatives and offspring and a clear familial clustering could be documented. Less than 50% of siblings and 25% of children were given some general lifestyle advice regarding cardiac risk factors. Moreover, active interventions such as starting antihypertensive or lipid lowering drugs were rarely carried out, particularly in children of patients with premature CHD.

Conclusions European physicians rarely screen family members of patients with premature CHD for cardiac risk factors. General lifestyle style advice or active treatment for these risk factors are also rarely given. However, since these family members have a high prevalence and familial clustering of cardiac risk factors, they form an ideal target population for primary prevention of CHD in high-risk patients.

  • Family history
  • Screening
  • Risk factors
  • Coronary heart disease

1 Introduction

Large epidemiological studies have shown that a family history of coronary heart disease (CHD) isan independent risk factor for cardiovascular disease.1–5 A history of premature paternal CHD (age <75 years) confers a greater risk of cardiovascular disease than does CHD at older ages.6–8 Also a maternal history of CHD appears to predict cardiovascular disease at least as strongly as a paternal history, and at older ages of CHD.9–12 In this respect a parental history of CHD is considered to reflect genetic, biochemical and behavioural components that may predispose an individual to be at higher risk of cardiovascular disease. While a positive family history is not modifiable, it can be used to identify individuals in whom a more intensified strategy of prevention by intervening on modifiable risk factors such as hypertension,hypercholesterolemia or smoking, should bedeveloped.13

The importance of risk factor modification in high-risk individuals was underlined in the Joint Task Force of European and other Societies on Coronary Prevention, which advised in 1994 and in 1998 that close relatives of patients with premature coronary heart disease (men <55 years and women <65 years) should be screened for coronary risk factors.14,15 In the EUROASPIRE II family survey (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) an additional enquiry was made to determine in the families (first degree blood relatives) of patients with premature CHD (men under 55 years and women under 65 years) whether this screening for risk factors had occurred and, if so, how effectively they were being managed by lifestyle and, where appropriate, drug therapies.

2 Methods

2.1 Study population

The design, protocol and main results of theEUROASPIRE II survey are described in detail elsewhere.16 Fifteen European countries were involved and 47 centres in selected geographical areas in these 15 countries participated. The participating countries were Belgium, Czech Republic, Finland, France, Germany, Greece, Hungary, Ireland, Italy, The Netherlands, Poland, Slovenia, Sweden, Spain and The United Kingdom. In total, 8181 medical records were reviewed and 5556 patients interviewed at least 6 months after one of the four following events: (i) first elective or emergency coronary bypass grafting (CABG), (ii) first elective or emergency percutaneous transluminal coronary angioplasty (PTCA) without CABG, (iii) first orrecurrent acute myocardial infarction withoutprevious CABG or PTCA, (iv) acute myocardial ischaemia without previous CABG or PTCA or acute myocardial infarction. Data collection was conducted in two stages: first, a retrospective review of hospital medical files; second, an interview and examination of patients performed at least 6 months after their admission. Trained research personnel abstracted data from patient's medical records and interviewed and examined the patients using standardized methods and instruments.Patients were invited to this interview by mail and phone and their general practitioner was informed.

Of the 5556 interviewed patients, 2843 (51%) had premature CHD at the time of their first clinical manifestation of CHD (men under 55 years and women under 65 years). Permission was asked to send a postal questionnaire to first-degree relatives (siblings and children ≥18 years of age) of these patients. If permission was given, a questionnaire with an accompanying letter of information was sent to the close relatives who could return the form in a self-addressed, stamped envelope. The relatives who answered and returned the questionnaire are the study population of the EUROASPIRE II family survey.

2.2 Data collection

The postal questionnaire contained questions on personal characteristics and on a personal history of coronary heart disease. Questions were asked regarding previous examinations to check the risk of a heart attack and regarding smoking status and advice to stop smoking. Self-reported weight and length were used to calculate body mass indexand to assess the presence of overweight and obesity. Relatives were also asked whether blood pressure or blood cholesterol had been measured within the past 5 years, whether the results were reported as normal or high and whether they took drugs to lower blood pressure or blood cholesterol levels. They were asked if they had ever been told by a doctor that they had diabetes and if so, how they were treated (diet only, oral antidiabetic drugs, insulin, oral antidiabetic drugs and insulin). Finally, the relatives were asked whether they had received advice from a doctor or nurse within the past 5 years on any of the following: eating a low fat diet, eating a diet high in fruit and vegetables, eating a low salt diet, avoiding overweight, not drinking too much alcohol and being physically active.

2.3 Statistical analysis

All statistical analyses were undertaken using SAS statistical software in the Department of Public Health, Ghent University, Belgium. A priori sample size calculation proved that data from 400 siblings and 400 children were sufficient to estimate prevalences with a precision of at least 5%, with a confidence interval of 95%. As this was a descriptive survey with emphasis on estimation of prevalences, no formal hypothesis testing was done. Only for comparison between patients with and without relatives in the study (Table 1), were chi-squared tests used and a P-value <0.05 considered asstatistically significant.

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Table 1

Characteristics of premature CHD patients with and without relatives contributing to the study

Patients with no relatives in study (n=1554)Patients with relatives in study (n=1289)Significance
Men (%, n)66.7% (1037/1554)63.9% (824/1289)
Women (%, n)33.3% (517/1554)36.1% (465/1289)P=0.12
Age <45 years (%, n)10.8% (169/1554)10.3% (133/1289)
Age 45–54 years (%, n)43.2% (671/1554)51.4% (663/1289)
Age 55–64 years (%, n)32.3% (502/1554)30.1% (388/1289)
Age ≥65 years (%, n)13.6% (212/1554)8.1% (105/1289)P<0.001
CABG (%, n)25.0% (389/1554)22.6% (292/1289)
PTCA (%, n)28.6% (445/1554)30.2% (390/1289)
AMI (%, n)25.0% (389/1554)26.2% (338/1289)
Ischaemia (%, n)21.3% (331/1554)20.9% (269/1289)P<0.43
Smoking (%, n)30.3% (470/1550)23.9% (308/1289)P<0.001
Overweight (%, n)79.9% (1235/1545)80.5% (1035/1286)P<0.72
Obese (%, n)35.2% (544/1545)34.6% (445/1286)P=0.70
High cholesterol (%, n)90.4% (1359/1503)91.1% (1159/1272)P=0.53
Hypertension (%, n)66.4% (1027/1546)65.6% (844/1287)P=0.63
Diabetes (%, n)17.4% (270/1549)18.5% (239/1289)P=0.44

3 Results

3.1 Study population

In total, 1289 patients with premature CHD in the EUROASPIRE II survey gave permission to send a postal questionnaire to 5391 first-degree relatives (siblings and children). Of the 1289 index patients, 465 were women (36.1%). Premature atherosclerosis at an even earlier age (men <45 years, women <55 years) was noted in 28.3% of those 1289. Table 1 compares the group of patients with premature CHD Math whose relatives were not contacted with the patients with premature CHD who gave permission to send a postal questionnaire to their relatives Math. Patients who gavepermission were slightly younger and were less frequently smokers but did not differ from the other group in gender, diagnostic categories or other risk factors. The latter were also similar after adjustment for age.

In total, 3696 relatives of 1289 index patients who had suffered from premature CHD in theEUROASPIRE II survey replied. This represents a response rate of 69%. The percentage of returned questionnaires varied widely between the different countries.

Of the 3696 returned questionnaires, 374 were excluded because their index relative had passed the predefined age limit for premature CHD. The total number of valid questionnaires varied widely: from 44 in Hungary to 613 in Spain. Thus, in total 3322 relatives were included, consisting of 1687 siblings (50.8%) (763 brothers and 924 sisters) and 1635 children (49.2%) (805 sons and 830 daughters). In total, 1568 men (47.2%) and 1754 women (52.8%) were included. The average age of the siblings was 51.1 years (brothers 51.0 years, sisters 51.1 years) and the average age of the children was 29.1 years (sons 29.0 years, daughters 29.2 years).

3.2 Prevalence of CHD and cardiac risk factors in relatives

The prevalence of CHD was 9.9% (166/1681) in siblings and 1.5% (24/1634) in the children (24/1634). This prevalence was higher in male siblings (104/762 or 13.6%) compared to female siblings (62/919 or 6.8%). Table 2 shows the prevalence and reasons for screening for CHD risk factors in siblings and children who were free of CHD at the moment of interview. 53.9% of all siblings and 70.9% of all children were never screened for CHD risk factors. If screening was performed the most frequentreason was for a general health check-up and only 11.1% of siblings and 5.6% of children were screened because of CHD in the family. Since there were important differences in the contribution of each centre towards the total number of observations, these results were weighted for centres. This did not change significantly the overall frequency of screening because of CHD in the family forsiblings (10.5%) and children (6.8%). The gender of the index patient was not related to the prevalence of screening for CHD risk factors because of CHD in the family (9.8% of siblings and 5.8% of children if the index patient was male vs 10.2% of siblings and 5.1% of children if the index patient was female). Regarding the diagnostic category of the eventof the index patient, the highest prevalence of screening a relative was if the index patient had undergone CABG (16.5% of siblings and 8.6% of children). The prevalence of screening was lower if the index patient had undergone PTCA (9.9% of siblings and 4.1% of children), had suffered anAMI (7.5% of siblings and 6.2% of children) or an ischaemic event without revascularization (5.9% of siblings and 3.4% of children).

View this table:
Table 2

Reasons for screening for risk factors in relatives of patients with premature CHD

SiblingsChildren
Index mean <55 years and index women <65 years
Because of CHD in the family11.1% (166/1496)5.6% (89/1598)
Men11.3% (74/655)5.1% (40/782)
Women10.9% (92/841)6.0% (49/816)
For general health check-up35.0% (523/1496)23.5% (375/1598)
Men39.4% (258/655)24.6% (192/782)
Women31.5% (265/841)22.4% (183/816)
No screening53.9% (807/1496)70.9% (1134/1598)
Men49.3% (323/655)70.3% (550/782)
Women57.6% (484/841)71.6% (584/816)
Index mean <45 years and index women <55 years
Because of CHD in the family13.0% (65/499)5.9% (22/373)
Men10.8% (24/223)5.4% (9/166)
Women14.9% (41/276)6.3% (13/207)
For general health check-up30.3% (151/499)23.1% (86/373)
Men33.6% (75/223)22.3% (37/166)
Women27.5% (76/276)23.7% (49/207)
No screening56.7% (283/499)71.0% (265/373)
Men55.6% (124/223)72.3% (120/166)
Women57.6% (159/276)70.0% (145/207)

When premature CHD was defined more strictly (men <45 years and women <55 years) prevalence of CHD was 9.2% (51/553) in siblings and 1.1%(4/379) in the children. Table 2 shows that the prevalence and reasons for screening in siblings and children who were free of CHD at the time of the survey did not change substantially when using this definition. Cardiac risk factors in the relatives are shown in Table 3. 56.8% of all siblings and 48.3% of all children were former or currentsmokers. Overweight and obesity were frequently reported both in siblings and in children of the index patients. In contrast to the frequency of blood pressure measurements, cholesterol had been measured in only 68.6% of siblings and 37.37% of the children.

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Table 3

Prevalence of cardiac risk factors in siblings and children of patients with premature coronary heart disease

SiblingsChildren
Smoking status
Never smoked43.3% (709/1639)51.7% (831/1606)
Former smoker26.8% (439/1639)13.2% (212/1606)
Current smoker30.0% (491/1639)35.1% (563/1606)
Overweight (BMI ≥25kgm−2)59.6% (988/1657)35.2% (565/1605)
Obesity (BMI ≥30kgm−2)19.6% (324/1657)10.2% (163/1605)
Hypertensive status
BP measured91.6% (1522/1661)82.7% (1303/1575)
BP high (self reported)23.4% (345/1471)8.3% (104/1248)
Hyperlipidaemic status
Chol measured68.6% (1119/1631)37.7% (579/1537)
Chol high (self reported)34.9% (380/1089)19.6% (110/560)
Diabetes (self-reported)7.8% (132/1681)1.0% (17/1631)
  • BMI=body mass index, based on self-reported height and weight; BP=blood pressure measured during the past 5 years; Chol=cholesterol measured during the past 5 years.

3.3 Lifestyle advice and interventions for cardiac risk factors in relatives

As can be seen in Table 4, life style advice was given during the past 5 years to less than 50% of siblings and less then 25% of the children.

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Table 4

Lifestyle advice given during the past 5 years to siblings and children of patients with premature coronary heart disease

SiblingsChildren
Eating low fat diet46.5% (764/1644)21.7% (350/1612)
Eating more fruit and vegetables40.1% (654/1632)23.0% (371/1610)
Eating a low salt diet34.2% (559/1632)13.9% (223/1604)
Avoiding overweight41.8% (685/1638)21.0% (337/1608)
Alcohol restriction23.2% (379/1632)10.7% (171/1601)
Being physically active43.5% (714/1642)27.9% (448/1605)

Interventions for cardiac risk factors in siblings and children are shown in Tables 5 and 6. Lifestyle advice regarding a low fat or low salt diet, alcohol restriction, physical activity and overweight was more frequently given in siblings than in children. However, even in siblings who were overweight, hyperlipidaemic or hypertensive such lifestyleadvice was generally given in less then 60% of the cases, except for the advice of eating a low fat diet in siblings with hyperlipidaemia (Table 5).

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Table 5

Lifestyle advice given during the past 5 years to relatives according to the presence of overweight, hyperlipidaemia or hypertension

SiblingsChildren
No overweight
Eating low fat diet35.2% (230/653)15.2% (156/1028)
Avoiding overweight19.8% (128/647)9.9% (101/1023)
Being physically active33.4% (218/652)23.5% (241/1024)
Overweight
Eating low fat diet54.4% (526/966)34.5% (192/556)
Avoiding overweight56.8% (547/963)42.0% (234/557)
Being physically active50.6% (488/964)36.9% (204/553)
Not hyperlipidaemic (self-reported)
Eating low fat diet46.6% (324/695)27.4% (122/446)
Avoiding overweight47.6% (329/691)26.6% (119/448)
Being physically active50.2% (348/693)33.9% (151/446)
Hyperlipidaemic (self-reported)
Eating low fat diet77.3% (289/374)70.6% (77/109)
Avoiding overweight59.5% (220/370)47.2% (50/106)
Being physically active58.4% (218/373)50.0% (53/106)
Not hypertensive (self-reported)
Eating a low salt diet28.5% (309/1085)12.6% (142/1126)
Not drinking too much alcohol22.8% (248/1089)10.8% (122/1124)
Hypertensive (self-reported)
Eating a low salt diet57.8% (196/339)34.3% (34/99)
Not drinking too much alcohol31.2% (104/333)20.4% (20/98)
View this table:
Table 6

Interventions for cardiac risk factors in siblings and children of patients with premature coronary heart disease

SiblingsChildren
Smoking
Current smokers
Advice to stop smoking48.1% (233/484)30.5% (170/558)
Use of NRT12.5% (60/480)9.2% (51/557)
Use of antihypertensive drugs
Overall21.3% (356/1674)3.1% (50/1620)
BP high (self reported)65.6% (225/343)26.2% (27/103)
Use of lipid-lowering drugs
Overall13.2% (221/1670)1.4% (22/1612)
Chol high (self-reported)41.9% (157/375)15.4% (17/110)
Diabetes
Diet41.9% (52/124)53.3% (8/15)
Oral AD drugs40.5% (51/126)20.0% (3/15)
Insulin21.4% (27/126)33.3% (5/15)
Oral AD drugs and insulin4.8% (6/124)0.0% (0/15)
  • NRT=nicotine replacement therapy; AD=antidiabetic; BP=blood pressure measured during the past 5 years; Chol=cholesterol measured during the past 5 years.

Less than half of the siblings who were current smokers and less than one third of the children who were current smokers was given advice to stop smoking (Table 6). Both antihypertensive drugs and lipid lowering drugs were not frequently used in siblings and children who were told that their blood pressure or cholesterol level was high.

3.4 Prevalence of cardiac risk factors and lifestyle advice in relatives according to the status of the index patient

In further analyses the risk factor status of siblings and offspring was examined according to the status in the index patient. No major differences in age distribution were observed in relatives of index patients with and without the respective riskfactors. For instance, relatives of obese indexpatients had a similar age distribution as relatives of non-obese index patients. Table 7 shows the prevalence of different cardiac risk factors in relatives according to the status of the index patient for these risk factors. Overweight, obesity, smoking as well as hypertension and hypercholesterolemia were more frequently found in siblings and in children if the index patient had these risk factors him or herself.

View this table:
Table 7

Prevalence of different cardiac risk factors in relatives according the status of the index patient (IP) for these risk factors

SiblingsChildren
If no overweight49.1% (169/344)28.4% (83/292)
Overweight10.5% (36/344)8.2% (24/292)
IP overweight
Overweight62.4% (819/1313)36.7% (481/1311)
Obesity21.9% (288/1313)10.5% (138/1311)
IP no obesity
Overweight54.6% (601/1101)28.7% (293/1022)
Obesity15.5% (171/1101)7.1% (73/1022)
IP obesity
Overweight69.6% (387/556)46.6% (271/581)
Obesity27.5% (153/556)15.3% (89/581)
IP not smoking
Current smoking25.7% (312/1216)32.7% (419/1280)
IP smoking
Current smoking42.3% (179/423)44.2% (144/326)
IP not hypertensive
BP measured91.9% (555/604)80.8% (375/464)
BP high (self-reported)16.0% (85/531)5.4% (19/355)
IP hypertensive
BP measured91.3% (936/1025)83.7% (907/1084)
BP high (self-reported)27.8% (253/911)9.4% (82/872)
IP not hyperlipidaemic
Chol measured62.5% (85/136)40.7% (59/145)
Chol high (self-reported)17.9% (15/84)10.5% (6/57)
IP hyperlipidaemic
Cholesterol measured69.3% (1026/1480)37.4% (513/1373)
Cholesterol high (self-reported)36.5% (364/997)20.8% (103/496)
IP no diabetes
Diabetes (self-reported)5.2% (71/1374)0.3% (4/1293)
IP diabetes
Diabetes (self-reported)19.9% (61/307)3.8% (13/338)
  • Hypertension in the index patient is defined as systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg and/or using antihypertensive medication for lowering blood pressure. Hyperlipidaemia in the index patients is defined as total cholesterol ≥5mmoll−1and/or using lipid-lowering drugs.

4 Discussion

A family history of premature CHD is widely recognized as a strong risk factor of CHD. In 1994 and again in 1998, the Joint Task Forces of European and other Societies on Coronary Prevention advised screening close relatives of patients with premature coronary heart disease (men <55 years and women <65 years) for coronary risk factors.14,15 The results of this survey show, however, that this screening is rarely performed in daily clinical practice. Indeed, only 11% of siblings and 6% of children of patients with premature CHD were screened because of CHD in the family. Even if premature CHD was defined more strictly (man <45 years and women <55 years) screening was not more frequently performed in family members. Only if the index patient had undergone CABG was screening somewhat more frequently carried out (17% of siblings and 9% of children). These results are comparable to those of the recently published American College of Cardiology Evaluation of Preventive Therapeutics (ACCEPT) survey.17 Similar to theEUROASPIRE II study, the ACCEPT study included 5553 patients with either first CABG, first PTCA, an AMI or myocardial ischaemia admitted to 53 hospitals throughout the United States. A total of 2772 patients were interviewed 6 months after discharge. Less than 1% of inpatient medical records contained a discharge plan by the physician recommending screening family members of patients younger than age 55 and 6 months after discharge, and only 17.8% of patients with premature CHD were advised to have their family screened. The number of family members that were actually screened was, however, not assessed in this survey. Taken together these results indicate that physicians are not surveying relatives of patients with premature CHD for cardiac risk factors in Europe or the United States.

As is shown in Table 3, prevalences of different classic cardiac risk factors were high in relatives and offspring of patients with premature CHD. A comparison with the general population or previous studies on patients with premature CHD is difficult since we used self-reported risk factors and since age and gender matched groups of patients are not easily found in literature. Strikingly, also in the children of patients with premature CHD the prevalence of cardiac risk factors such as smoking, overweight and hypercholesterolemia was high. Almost 20% of the children of patients with premature CHD whose cholesterol levels were checked reported high cholesterol levels. This is in agreement with other studies showing that dyslipidaemia is very common in the offspring of patients with premature atherosclerosis. Rallidis et al.18 reported for example that 32% of the offspring (age 6–25 years) of young Greek coronary patients had elevated total cholesterol levels. Also in EARS I and II(European Atherosclerosis Research Studies) levels of total cholesterol were significantly higher (5–6%) in university students aged 18–26 years with documented premature paternal histories of CHD as compared to controls.19,20 Since it is known that atherosclerosis begins at early age and since preventive measures aim to reduce the incidence of cardiovascular disease later in life, our resultsindicate that screening of family members ofpatients with premature CHD should not be limited to brothers or sisters but should certainly include the children of these patients.

Our results also indicate that a clear familial clustering of coronary risk factors exists in family members of patients with premature CHD. Indeed for all risk factors studied, an almost doubling of prevalence was noted in family members (both siblings and children) of index patients with acertain risk factor as compared to index patients without this risk factor (see Table 7). Whether genetic or environmental factors, or both, explain this association is difficult to be determinedbecause blood relatives share the same familyenvironment for at least the first part of their lives. However, the latter certainly contributes to a greater prevalence of CHD risk factors, as shown in different studies that have examined spouse concordance for CHD risk factors where genetics have no influence. For example, the Framingham study, which is the largest population survey to report on this subject, found significant correlations between 1259 pairs for smoking, blood pressure, lipid levels and relative weight in cross-sectional analyses.21,22 Also in women married to men with myocardial infarction under 65 years, Wood et al.23 reported a higher frequency of CHD risk factors compared with married women in the general population. Regarding genetic factors, several studies have evaluated, often with conflicting results, different genetic polymorphisms for different cardiac risk factorsin families of patients with premature CHD. For example, conflicting results have been reported regarding certain gene polymorphisms that may affect the observed higher apo B levels in young men and women with a paternal history of CHD.24–26 From their results the EARS investigators (European Atherosclerosis Research Studies groups) therefore concluded that, using the genetic probes currently available, one can only incompletely distinguish the offspring of patients with premature CHD from controls drawn from the same population.20 At the present time it is accepted that the most important mode of action of certain genetic factors is through interaction with environmental factors. Whatever the explanation is for the observed familial clustering of cardiac risk factors, our results clearly show that the detection of one or more risk factors in a patient with premature CHD, should trigger further familial screening because of the high prevalence of the same risk factors in family members.

Less then 50% of siblings of patients with premature CHD reported that they were given some general lifestyle advice such as eating a low fat diet, avoiding overweight or being physically active. Moreover, these recommendations were given to less then 25% of the children of these patients. Even when risk factors were detected in family members, general lifestyle advice was given in less then 60% of siblings or children (Table 5). Less than 50% of active smokers were given the advice to stop smoking and nicotine replacement therapy was rarely used. Also, the use of antihypertensive drugs and lipid-lowering drugs was low, especially in children with documented hypertension (antihypertensive drugs in only 26%) or hypercholesterolemia (lipid lowering drugs in only 15%) (Table 6). Taken together, our results suggest that general lifestyle advice regarding cardiac risk factors is not frequently given and active interventions to prevent these cardiac risk factors are rarely carried out in family member of patients with premature CHD. There is, however, evidence in the literature that intervention in families can be successful. TheBritish Family Heart Study, for example, demonstrated that in primary prevention a clear concordance between middle-aged couples for coronary risk factors exists and that an equally strong concordance for change in coronary risk factors in these couples can be achieved after a 1-year lifestyle intervention programme.27 In the Tromso Family Study, high-risk men without CHD and their families were randomly assigned to a control group or to a group given advice on different cardiac risk factors. After 6 years follow-up, men in the intervention group as well their wives and children showed greater reductions in cardiac risk factors as compared to the control group. No differences were found for smoking rates and physical activity between the control and active treated group.28 Also, active involvement of nurses in the management of lipids29 or parents in teaching their children how to reduce their CHD risk30 has been shown in some studies to be effective in improving primary prevention in high-risk individuals.

4.1 Study limitations

Some study limitations need to be considered. First our results are only applicable in relatives who had a family member with premature CHD who agreed to participate in the EUROASPIRE II survey and whose relatives, in turn, agreed to participate in the postal questionnaire survey. Also, we onlystudied relatives of patients who survived their coronary event at least 6 months, as defined in EUROASPIRE II. Secondly, results of this survey are based on self-reported and not on directly measured behaviour, cardiac risk factors and medication intake. Finally, the large differences in participation rate of family members across the different European countries, makes a comparison between the different countries difficult. Therefore these data were not incorporated in the results.

5 Conclusions

The Joint European Societies recommend screening of first degree relatives of patients with premature CHD, yet the results of the EUROASPIRE II family survey show that physicians rarely screen family members of such patients for cardiac risk factors. Furthermore, general lifestyle style advice oractive treatment for these risk factors are rarely given. However since these family members havea high prevalence and familial clustering of cardiac risk factors, they form an ideal target population for primary prevention of CHD in high-risk patients.

Acknowledgments

EUROASPIRE II Group is grateful to all the hospitals in which the study was carried out. (for a complete list of the study centres, see reference.16 Their administrative staff, physicians, nurses and other personnel helped us in many ways and we very much appreciate this. We are also grateful to the patients and relatives who participated in the study. This EUROASPIRE II Study was supported by unrestricted educational grants to the Europeans Society of Cardiology from Astra Zeneca, Bristol-Myers Squibb, Merck, Sharp & Dohme and Pfizer.

References

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