GP Dr David Archer tries out an innovative tool for assessing cardiovascular risk based on routinely available information
A recent article in the BMJ1 discussed a new risk score system for predicting risk of death from cardiovascular disease within 5 years. The system involves the use of a matrix set up on the website www.riskscore.org.uk (Figures 1 and 2, below). GPs can use this as a starting point when discussing risk factors with patients.
Our practice currently uses EMIS, and we were interested to compare the different components of this tool against the 'gold standard' Framingham risk score.
We have always entered values for cholesterol, HDL, blood pressure taken during routine surgery consultations, and blood results. Smoking status, diabetic status, and the presence of left ventricular hypertrophy are already noted on the database.
The Framingham risk score can therefore be calculated rapidly during the consultation when patients enquire about their latest cholesterol or blood pressure result.
It is used to demonstrate to the patient that it is not a particular figure that is important, but that cardiovascular risk is a more generalised problem involving more than one area of risk.
The Cardiovascular Risk Assessment Tool is very useful in this regard as it clearly demonstrates the modifiable risks to patients. For patients who are really interested in reducing risk, the suggestions are clearly spelt out in bold type.
This is a considerable advantage, as recent evidence in the BMJ suggests that patients are not influenced by cold circulars from GP practices, but are motivated to modify their lifestyle when they are personally interested in their own results.
We currently give each patient a 10-minute appointment, but found it extremely difficult to access the Net and enter all the parameters into the Risk Assessment Toolbox in this time. The EMIS system has been set up to calculate the Framingham score within a few seconds of HDL, cholesterol, or blood pressure being entered, but the time taken to access the Net and enter the 11 criteria, even if they are already on the EMIS database, means constant changing of pages. Eye contact with the patient is lost and is potentially a disadvantage.
One suggestion would be to place the Cardiovascular Risk Assessment Test in the computer via disk so that all results would be in place when the patient's screen is accessed, avoiding the necessity for double entry or accessing the Net.
Another problem is that if the patient's risk score is only slightly above the average for that age range, the predicted risk is often considerably higher than one would expect. Although that is mathematically demonstrable from the graphs, some patients have great difficulty in understanding the implication of the steep curve of the graph shown.
I suspect that we will continue to use the Framingham score as it is easier to access and probably easier to understand for patients who wish to know their risk over the next 10 years.
Furthermore, the evidence suggests that patients with a risk of >30% over the next 10 years should be treated with lipid-lowering agents, and unfortunately the Cardiovascular Risk Assessment Tool does not produce a figure on which the clinician has confidence to initiate treatment.
However, this is an innovative way of enabling patients to calculate their own cardiovascular risk, and will be invaluable for 'the worried well'. Any tool that enables patients to take more responsibility for their own health care must be welcomed. I suspect that many patients would value this information if they knew that it was available and could access it.
|Figure 1: Extract from the website www.riskscore.org.uk|
|Figure 2: Risk scores for cardiovascular disease in men and women|
- Pocock SJ, McCormack V, Gueyffier F et al on behalf of the INDANA project steering committee. A score for predicting risk of death from cardiovascular disease in adults with raised blood pressure, based on individual patient data from randomised controlled trials. Br Med J 2001; 323: 75-80.
- Little P, Somerville J, Williamson I et al. Randomised controlled trial of self management leaflets and booklets for minor illness provided by post. Br Med J 2001; 322: 1214-17.