Cardiovascular Risk Assessments

It's always a problem taking population level data and applying it to an individual...

by crustyg - 2024-07-01 10:28:46

...and then you factor in the challenge that most (nearly all?) of us struggle with the true concept of what *risk* means to us as individuals.

I am *not* trying to squash anyone or anything here: these risk calculators are intended to be tools for health professionals to make the more obviously at-risk patients 'sit up and pay attention' as there are obvious (and perhaps 'easy') things that the patient can do to stay/become healthy or healthier.  The old style approach: 'You need to stop smoking' to a Nurse patient around 27yrs old, in the Lipid Clinic. Patient: 'what if I don't?'  'You'll have your first heart attack at 50years of age.  Result: floods of tears, nurse exited consulting room.  Turned out that smoker father had just had an MI.

I've just done the Qrisk3 for myself.  I did *not* like the answer, but it's probably a good predictor of stroke for me. Sigh.

How accurate these tools are only time will tell.  The Metropolitan Life Tables (which directly drove BMI) were good predictors of lifetime risk of death.  Over time we've become more aware of the limitations of BMI as a tool to identify 'obesity.'  Interestingly, low BMI was an accurate predictor of early death because hidden in the 'thin' population were people with as-yet undeclared cancers.  Unexpected weight loss is always a real worry...

What do we do? Wait 50years for the data to be proved reliable or be discredited?

Life is about choices.  If my EP-doc tells me that he wants me on apixaban or a beta blocker that's going to be a really short conversation.  But if my BP keeps drifting upwards, I'm going to have to do *something*.

Risk

by Amara - 2024-07-01 12:25:56

I agree it's about choices. It helps to ask your provider to explain to your actual risk in percentages so you can make a decision what risks you are willing to take. Sometimse the medications have as much or more risk than doing nothing. Since we are all different, hopefully, your physician will be willing to tell you your actual risk in a percentage over a 5-10-year period.

The BP guidelines have been updated recently. In healthcare in the US, we previously used 140/90 as a cutoff for what is considered high BP. The cardiovascular guidelines have been changed to 130/80 and higher to be considered high BP. I've read many criticisms about this in the medical community saying it's all about drug sales and increasing provider appointments for income potential. 

I don't think I can upload any documents here? I'll look for some links to post for reliable info. I do know the studies I've read refer to both the US and UK guidelines. I belong to the preventative cardiac nurses association, and they have resources, but they are in pdf format. I'll see if I can find some good links to post. 

Cardiac risk tools

by Amara - 2024-07-01 12:43:52

Here are some links to some info. You can find articles if you want the details on the same sites. 

Leading cardiologists reveal new heart disease risk calculator | American Heart Association

https://newsroom.heart.org/news/leading-cardiologists-reveal-new-heart-disease-risk-calculator

PREVENT Online Calculator - Professional Heart Daily | American Heart Association

https://professional.heart.org/en/guidelines-and-statement/prevent-calculator

High Blood Pressure  | American Heart Association

https://www.heart.org/en/health-topics/high-blood-pressure

At the end of the day, it's a personal decision when it comes to your health. It is important to keep your BP as low as possible. You also want to consider quality of life and risk vs benefit of any treatment or medication.. 

Risk prediction charts for future cardiovascular disease

by Gemita - 2024-07-01 14:04:02

Penguin what an excellent subject for discussion.  The risk calculator to determine the risk for future cardiovascular disease is a helpful guide, but not necessarily one that must be stringently followed to prevent life threatening disease.  My husband is “living” proof of that.  I tend to want to focus on the whole person, not just the areas that are covered in this risk assessment.

Before I take a new medication I have to be completely certain it is absolutely necessary (like I did with my anticoagulant for Atrial Fibrillation (AF) stroke protection).   If I am not completely satisfied that taking a new medication will be in my best interests, I won’t take it.  I may have risk factors for heart disease and stroke with a strong family history, but I can still do lots to help myself without resorting to more meds. No medication is completely without risk.

As a carer looking after someone with multiple, complex health conditions, I would be lost if I followed recommended guidelines for blood pressure control for instance and didn’t listen to the patient.  After many discussions with health professionals, it was recommended that a slightly higher blood pressure reading in the range 145 over 90 was perfectly acceptable for someone of 85 years of age, who is becoming frail and prone to falls, especially when taking high doses of certain meds which can cause instability.  The same with glucose control.  At 85, we don’t want a patient getting hypos, nor extreme spikes.  It has to be a balance and that balance can never be perfect.  A serious fall in itself could carry an enormous risk to a patient’s well being so I never follow strict guidelines to control those numbers.  I just follow the patient and step in if I feel he needs help, checking his blood pressure and glucose levels first and making sure that he is stable.

I do not believe we can safely use these measurement tools and apply them to everyone within a specific age group.  For example with all the risk factors my husband has - history of heart disease, of strokes, diabetes, high blood pressure, high triglycerides, to name but a few, he really should be on maximum medical therapy, but he isn’t and has his cardiologist’s blessing because he is doing okay.  In fact he surprises his doctors who see him looking so well.  His quality of life is better off a Statin, ACE inhibitor, and several recommended heart failure meds than on them, so why take them at 85 when quality of life is more important than quantity?

The cardiovascular risk chart is a useful way of assessing the likelihood of experiencing a first major cardiovascular event (myocardial infarction or stroke) over the following ten years, when the values of six risk factors - gender, history of diabetes, smoking, age, systolic blood pressure and total serum cholesterol – are known.  However, calculation of risk factors for cardiovascular disease should be made on an individual basis, looking at many factors like exercise, lifestyle, diet, quality of sleep, stress, weight, age, other health problems like COPD, kidney disease, depression, anxiety and social isolation in the elderly and I could go on and on.  For that reason alone, I do not pay a great deal of attention to these risk assessment calculators.  Treatment of the “whole” person is what is required since stress and emotional well being can impact physical health

Wisdom!

by Penguin - 2024-07-01 16:25:22

Thank you CrustyG, Amara and Gemita for your wise words.  I'm in agreement with what you all say and would like to thank Amara for the excellent links that I will read. 

  I was inspired to open the thread after reading the responses to Gemita's thread following her recent blood test results and after trying to understand the science behind cholesterol management, women's CVD risk after menopause and the value of cholesterol in good health (raised by SeenBetterDays - very wisely!).

I wondered how easy other people were finding it to lower their risk assessment scores without medication and how many seemingly fit / healthy people of a certain age on this forum are affected by the new guidelines.

I'll keep the thread open for other experiences and opinions. Keep 'em coming!

Amara

by Penguin - 2024-07-01 18:12:15

Thank you for the links again. The first and third links are very relevant and interesting!

I couldn't get the second link to work.  Perhaps it is restricted to professionals?

I clicked on the link which provides the funding statement for the AHA. 

$42 million donated to the AHA collectively by pharmaceutical companies, device companies etc. Wow - that's a lot of money! I note that there are regulations so that donations  don't influence advice. 

Re: BP

Normal BP = below 120/80 - that's gone down (I think!)

Elevated is up to 129 systolic and below 80 diastolic.

New assessment guidelines take account of kidney function, heart failure, metabolic syndrome and are geared towards a wider age range with children mentioned and young adults.  The approach is preventative e.g. to assess early before CVD, kidney disease, heart failure and metabolic diseases develop. 

Hopefully this is advice based if there's no disease.  I hope that someone has analysed what is driving the earlier onset of these diseases. That's probably very important!

Significant changes indeed! I understand the forces behind the changes a little more now.  It's encouraging to me to read that factors such as socio-economic groups (affecting spend on diet perhaps?), female sex etc are being thought about.   

My Pleasure and Happy to Contribute

by Amara - 2024-07-02 00:55:54

For some reason, the link directly to the calculator won't work. If you use the link, then go to the menu on the top, and to guidelines & statements, you will see a link for the PREVENT calculator. 

That is a lot of money, goodness! Hopefully, it's helping us all in the research they do for heart health.

Yes, the BP has gone down for a normal reading. That's why the strutiny in the medical community. That puts more than half of all adults into the high BP arena. I don't personally agree with that, but it does put an emphasis on the importance of our BP in the scope of our health. We can certainly be more attentive to our vital signs in general.

I also like that they've included kidney function, heart failure, and metabolic syndrome. That's at least closer to the whole person :)

I agree prevention starts way before someone is using a risk calculator. 

Even though the guidelines are not perfect, we sure can learn a lot by studying how they work and why each element is in the calculation.

I'm not a fan of all the pharmaceutical drug pushing that goes on in the industry. I'm also not against medications when they're needed. 

I agree with a lot of what you wrote Gemita as well. Great points. It sure helps to look at ourselves as a whole person and how we feel and function. Every part of our health affects the rest of our health. Gemita you certainly have a lot of knowledge most people don't. 

What makes it difficult is that there are so many opinions out there and most people struggle with understanding what to believe and follow. The AHA has good info in general and is a good resource in my opinion. No matter where you get info, you have to use your discretion on what to follow and believe. 

Sometimes we need to just try different strategies and see what works for us. 

Thanks Penguin

by piglet22 - 2024-07-03 06:28:10

Thanks for raising this.

I was browsing through my full medical record, as you do, and I noticed this strange figure, a percentage, a risk factor, and didn't give it a lot of thought at the time.

For anyone who's interested, it was less than 50%. Better odds than the Conservative party being in office on Friday.

So this is what goes on behind the scenes.

No-one at the surgery has ever mentioned it, and drilling down through layers of menus to find it, probably means that quite a few people are going to be "scored" and be none the wiser.

Since my GP surgery was swallowed up into a conglomerate of four existing functioning surgeries with high hopes of building a health hub/polyclinic - nice website, shame about the empty building site - there has been a plethora of "systems" to cope with, and I suspect that a fair few patients will feel even more cut off.

A non-computer neighbour using the traditional means of accessing the surgery was 52 in the phone queue recently. She would be absolutely unaware of being scored like this.

Is this scoring a means of prioritising patients for care, or simply a big number that comes up every time you contact them?

I've noticed more terseness creeping into conversations with clinicians and notes now have coded entries. These might be a forerunner to an AI web med? There are things like “he denied” written in, more like a police witness statement.

I was appalled 10 days ago when visiting the surgery with a chest infection and mentioning what a struggle physically it had been to get there, thinking it might be something to do with the infection.

The GP, probably a locum in for the day, said "I haven't got time for that, you'll have to make another request".

Maybe surgeries are adopting stricter working methods and systems and scoring is something patients will have to get used to, but I think it's a move in the wrong direction.

As for being abl to reduce risks without medication, all my efforts to get cholesterol down or keep BP under control, or reduce blood glucose, have mainly failed.

For the Brits here, a far more worrying thing that might affect your overall health and well-being, is what we will wake up to on Friday morning.

The country trashed by politicians and a health service on its knees.

Piglet

by Penguin - 2024-07-04 04:37:15

Hi Piglet, 

The QRisk3 tool (I think that's the name of it?) calculates your estimated risk of a cardiovascular event e.g. a heart attack or stroke and in doing so it pulls together a lot of known data about your health - whether you smoke, your BMI, blood pressure, diabetes score, cholesterol levels as examples. I don't know which data precisely, but it's online here: https://www.qrisk.org/ 

It wouldn't be used to prioritise your treatment in a GP appointment system.  Your locum's reaction to the chest infection might be because you made a single appointment for 2 separate issues.  They only have time to deal with one issue in 10 minutes if they're really busy I suspect.  Getting a double appointment can be difficult though! 

Re: Reducing cholesterol. I've been doing a lot of reading around this and there's a lot of conflicting information regarding 'the worth' of reducing it.  Diabetes prevention is a related topic and you might be helped by reading a straightforward book like Dr Aseem Malhotra's 'A Statin Free Life'.  It's very easy to understand and it explains diabetes / insulin resistance and the relationship to statins / cholesterol management.  It's changed my view on lowering cholesterol, but has made me much more aware of insulin resistance / diet / lifestyle and what I can do to help myself as I age and risk scores increase. 

In the current climate and with the political factors you allude to affecting healthcare, it seems very wise to educate ourselves so that we can have informed discussions with our doctors and get straight to the point in a 10 min appointment. 

Penguin

by piglet22 - 2024-07-04 09:41:49

It wasn't so much the telling of how busy she was, but the manner.

None of the partner GPs would speak to a patient the way she did.

The surgery I went to is an old building, a school, and has four floors served by a spiral staircase.

The patient before me, a neighbour, can hardly put one foot in front of the other and uses a stick.

The consultation room was right at the top.

The locum called out his name then stood and watched from the top while he laboured up the stairs.

No offer of help.

This probably put her behind and didn't improve her mood.

The way the appointment system works, Anima, only allows for one request and rapidly closes after 8 am owing to demand.

After the physical struggle to get there, and  having a lung infection to deal with, I didn't think it unreasonable to mention it.

Reply to Angry Sparrow

by Penguin - 2024-07-08 06:44:14

Hi Angry Sparrow, thank you for contributing your personal feelings about risk assessments to the thread. It's always good to hear your perspective.

Your experiences suggest that - like many people - you resent being put in a box and labelled using what may seem like arbitrary criteria at times.  Our bodies are indeed remarkable considering what gets thrown at them. Your spirit is certainly remarkable too and that's inspiring.

The point of the thread was to question the reasons behind new criteria, to discover how they’d changed and how they work for us as individuals. You've explained some situations which get through the net. I suppose one size will never fit everyone as Crusty remarks further up the thread.

We’re told that any target needs to be realistic and achievable to mean something and to be motivational. I was therefore concerned to hear that the calculation might be skewed in terms of age. If older people can't achieve the targets set, they may just accept what they are told, but is it fair to use statistics / averages to judge us all?  I wanted to know how the other boundaries / criteria had changed and whether they were achievable too and to hear other peoples' experiences.  Thank you for sharing yours.