We're not identifying the hearts to watch


More people die each year from heart attack and stroke in Ireland than in any other European country. Does this mean we have some genetic predisposition for cardiovascular disease which puts us at much greater risk than our neighbours? There is little evidence that we do.

What is obvious is that we are not targeting and helping people at high risk of heart disease because we simply do not know who these people are. Despite having preventative measures and drug treatments which reduce cardiovascular risk, we have no system for dividing the population into people at low, medium and high risk.

Take Jim (55), who came for a check-up. His last medical contact was when he was in hospital for an operation to bypass a blockage in a leg artery. He had been advised then to have regular check-ups, but this was his first visit to a doctor for five years.

The check-up showed he was overweight, with high blood pressure and raised cholesterol. On the positive side, he had given up smoking and he drank alcohol in moderation.

However, when his hospital notes from five years previously were examined, his doctor discovered that Jim's high blood pressure and elevated cholesterol levels had been noted when he was in hospital. So Jim had spent five years without his high blood pressure and high cholesterol - both risk factors for heart disease - being treated. In fairness, these risk factors did not attract the same attention and treatment five years ago as they do now, but the fact remains there are many patients who, like Jim, are falling through the medical net.

One of the reasons for this is that doctors have traditionally focused on whichever body organ is causing symptoms. In Jim's case, the blockage was in an artery in his leg and treatment was directed at this. Similarly, a patient with angina may be given a heart bypass and a person who suffers a stroke caused by vascular disease will see a neurologist.

Prof Eoin O'Brien, Professor of Cardiovascular Medicine at the Royal College of Surgeons in Ireland, has come up with a model he believes can improve risk management. Over the past decade, the Blood Pressure Unit at Beaumont Hospital has used a software package, called DABL Cardiovascular TM, to divide patients into three distinct risk categories. With more than 22,000 patients on its database, the unit is currently assessing its effectiveness (by relating risk-factor modification to the person's clinical outcome).

So how does the database work? A patient's age, sex, family history, blood pressure, smoking, alcohol and salt intake, exercise habits, cholesterol level, height and weight are all entered into the computer, which produces a risk-factor indicator in the shape of a petrol gauge, divided into three areas. The green area on the left indicates low risk, the orange in the middle means medium risk, and the red area on the right signifies a high risk of having a heart attack or stroke.

This very simple visual technique has great patient impact. All the medical terminology is reduced to a simple demonstration of risk. When patients return for follow-up visits, they can see the results of their efforts to modify their risk factor, as the dial (hopefully) begins to swing towards the green zone on the left.

Prof O'Brien believes the time has come for us to consider applying this model nationally. "The national finance is there, the technology is available and we now have a level of computerisation in general practice to implement a national cardiovascular risk-stratification programme," he says.

He envisages that all patients in the low-risk category would be managed by their family doctors, as would most of those in the medium-risk group. All high-risk patients would be treated intensively, in a hospital, with the maximum resources applied to bringing about a quick reduction in their risk of heart attack or stroke.

"We could see positive results within two to three years," Prof O'Brien says. "In fact, the opportunity exists not only to reduce Ireland's own stroke and heart attack rate, but also to provide a model for other countries to follow."

Contact Dr Houston at mhouston@irish-times.ie or by leaving messages at tel: 01 6707711, ext 8511. He regrets he is unable to reply to individual medical problems.