Screening individuals and families with premature coronary heart disease: a clinical and public health challenge

C.H Hennekens

Epidemiology and Public Health, University of Miami School of Medicine, 2800 South Ocean Blvd PHA,71 3432 Boca Raton, FL, USA

Received August 26, 2002; accepted August 28, 2002

See doi:10.1016/S1095-668X(02)00386-Xfor thearticle to which this editorial refers.

In this issue De Sutter and colleagues1 make several important and timely contributions

First, they summarize the data from numerous retrospective and prospective epidemiologicstudies of family history and premature onset of coronary heart disease. The data seem to consistently show that individuals with a positive family history of premature onset of coronary heart disease have an increased risk, which is independent of other coronary risk factors. The magnitude ofthe increased risk is generally about 2-fold with somewhat higher estimates present for thosewhose first-degree relatives had earlier onset of premature coronary heart disease.

Second, they discuss why family history may be used to target populations for more intensive risk factor modification. Specifically, if a patient hasa 10-year risk of coronary heart disease of about 10% based on the existing modifiable coronary risk factors, the presence of a positive family history of premature coronary heart disease may increase that absolute 10-year risk to about 20%. Based on recently published United States federal guidelines for lipid modification,2 the goal for low density lipoprotein cholesterol for patients with 10-year risks of 20% or greater, 10–19%, or less than 10% are 100, 130, and 160mgdl, respectively.

Third, the Joint Task Force of European and other Societies on Coronary Prevention advised in 19943 as well as in 19984 screening close relatives of patients with premature coronary heart disease for risk factors. An implicit assumption underlying the concept of screening is that early detection before the development of symptoms will lead to a more favourable prognosis because treatment begun before the disease becomes clinically manifest will be more effective than later treatment. This assumption has intuitive appeal and screening has played an important role in improving public health over the years. In some circumstances, the search for early asymptomatic disease is now considered a routine and important aspect of good medical care, yet the concept of screening, including its appropriateness and evaluation, is not as straightforward as it may at first appear. To be appropriate for screening, a disease should be serious, treatment given before symptoms develop should be more beneficial in terms of reducing morbidity or mortality than that given after they develop; and the prevalence of preclinical disease should be high among the population screened.5 On all these aforementioned issues, the Joint Task Force of European and other Societies on Coronary Prevention make cogent arguments for screening for coronary risk factors of close relatives of patients with premature coronary heart disease.

Fourth, and of greatest importance and timeliness, despite several study limitations acknowledged by the authors, in the EUROASPIRE II family survey, screening is rarely performed in daily clinical practice. This situation prevails despite the fact that these individuals have a high prevalence as well as familial aggregation of coronary risk factors. Since the absolute risks of patients with multiple risk factors is far greater than the simple arithmetic sum of the individual risks,6 these patients appear to represent a high risk target population that would benefit from screening and intervention. The data from EUROASPIRE II indicate that healthcare providers rarely screen patients with a positive family history of premature onset of coronary heart disease for coronary risk factors. Overall, screening for coronary risk factors because of coronary heart disease in the family was performed in 11.1%of siblings. Further, general lifestyle advice orspecific risk factor intervention is rarely practised. Specifically, less than 50% of siblings were given some general lifestyle advice regarding coronary risk factors. With respect to children, screening for coronary risk factors because of coronary heart disease in the family was only performed in 5.6% of children and less than 25% of these 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 especially in children of patients with premature onset of coronary heart disease. Although screening for disease control in children and young adults remains controversial, the most recent guidelines from the Task Force on Prevention of the American Heart Association recommend this strategy for all individuals aged 20 and older.7 These guidelines suggest that screening, risk factor management, and promoting a healthy lifestylein young adults are, at a minimum, reasonable measures to prevent the development of future coronary heart disease.

In conclusion, the alterations in behavioursof healthcare providers recommended by theEUROASPIRE II investigators would have majorclinical impacts on individual patients as well as public health impacts on society as a whole for a disease as common and serious as coronary heart disease. Thus, the EUROASPIRE II investigatorshave provided importantly relevant and timely data that present a major clinical and public health challenge.

References

  1. De Sutter J, De Bacquer D, Kotseva K, et alon behalf ofthe EUROASPIRE study group. Screening of family membersof patients with premature coronary heart disease: results from the EUROASPIRE II family survey. Eur Heart J. 2003;24:249–257[Abstract/Free Full Text]
  2. Eidelman RS, Lamas GA, Hennekens CH. The new national cholesterol education program guidelines: clinical challenges for more widespread therapy of lipids to treat and prevent coronary heart disease. Arch Int Med. In press;:
  3. Pyorala K, De Backer G, Graham I, et al. Prevention of coronary heart disease in clinical practised: recommendations of the Task Force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J. 1994;15:1300–1331[ISI][Medline]
  4. Wood D, De Backer G, Faergeman O, et al. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. Eur Heart J. 1998;19:1434–1503[Free Full Text]
  5. Hennekens CH, Buring JE. Screening. Epidemiology in medicine. Boston: Little, Brown, and Company; 1987. p. 327–397
  6. Kannel WB. Contribution of the Framingham Heart Study to preventive cardiology: the Bishop Lecture. J Am Coll Cardiol. 1990;15:206–211[ISI][Medline]
  7. Pearson T, Blair SI, Daniels S, et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation. 2002;106:388–391[Free Full Text]

Related articles in EHJ:

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, and on behalf of the EUROASPIRE II study group
EHJ 2003 24: 249-257. [Abstract] [Full Text]