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Press releases Saturday 7 July 2007

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New heart disease risk score will help minimise health inequalities

High-risk patients need better guidance on what is and isn't a heart attack

Ban on hookah smoking should stay, argue doctors

Who should ±own± genetic information?

(1)New heart disease risk score will help minimise health inequalities
(Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study
BMJ Online First

A new score for predicting the risk of heart disease gives a more accurate measure of how many UK adults are at risk of developing the disease and which adults are most likely to benefit from treatment.

The study published on bmj.com today, estimates that in the general population without pre-existing cardiovascular disease or diabetes, there are 3.2 million adults under the age of 75 in Britain at high risk of developing heart disease. This is lower than previous scores have suggested, but the researchers believe that it is a more appropriate estimate for the UK and will help minimise health inequalities.

The study comes as the government±s drugs watchdog, the National Institute for Health and Clinical Excellence, recommends that people with a 20% chance of developing heart disease over the next 10 years should be offered statins.

A person±s chance of developing heart disease is estimated using standard risk factors such as age, sex, smoking, blood pressure and cholesterol. This risk score is typically based on equations derived from the US Framingham cohort study.

But the Framingham equations tend to over-predict heart disease risk in the UK population and fail to include measures of deprivation, family history of heart disease, body mass index, and treatment with blood pressure lowering drugs, despite known links between these factors and poor health.

So a team of researchers, from Bristol PCT and the Universities of Nottingham, Bristol and Queen Mary±s, set out to derive a new cardiovascular risk score (QRISK) for the UK and test its performance against the established Framingham score and a new a score used in Scotland (ASSIGN), which includes a measure of social deprivation. The research has been conducted using data from a general practice research database called QRESEARCH (which is a joint partnership between the University of Nottingham and EMIS).

The researchers tracked the progress of 1.28 million healthy men and women, registered at 318 general practices over a period of 12 years to April 2007, recording first diagnosis of cardiovascular disease. All the participants were aged between 35 and 74 at the start of the study.

They found that the QRISK score was more accurate than either Framingham or ASSIGN. In patients aged 35-74, Framingham over-predicted cardiovascular disease risk at 10 years by 35%, ASSIGN by 36% and QRISK by 0.4%. QRISK predicted 9% of patients aged 35-74 years to be at high risk compared with 13% for the Framingham equation and 14% for ASSIGN.

Using this more focused tool for risk estimation, the research team estimate that 34% of women and 73% of men aged 64-75 would be at high risk compared with 24% and 86% according to the Framingham equation.

QRISK would also identify a different group of patients than the Framingham equation, with one in ten patients being reclassified into high or low risk, they say. QRISK is likely to provide more appropriate risk estimates of cardiovascular disease risk based on age, sex and social deprivation, write the authors. It is therefore likely to be a more equitable tool to inform management decisions and help ensure treatments are directed towards those most likely to benefit.

In people under 75 years without pre-existing cardiovascular disease or diabetes QRISK identifies 3.2 million patients at high risk in 2005, compared with 4.7 million from Framingham and 5.1 million from ASSIGN.

They suggest that QRISK should be further tested in other populations, but point out that this is the largest such study to have ever been undertaken, and the first time routine data in a UK general practice population have been used in this way.

Study leader, Professor Julia Hippisley-Cox said ±QRISK is derived from primary care data for use in primary care, and takes account of social deprivation to better identify patients most at most risk of heart disease and stroke who are most likely to benefit from treatment. We thank the many thousands of doctors who have enabled this research by freely contributing anonymised data to QRESEARCH without which this work would not have been possible.±

Contacts:
Julia Hippisley-Cox, Professor of Clinical Epidemiology and Clinical Practice, University of Nottingham, Nottingham, UK
Email: julia.hippisley-cox@nottingham.ac.uk

or Peter Brindle, General Practitioner and R&D Strategy Lead, Bristol Primary Care Trusts, Bristol, UK Tel (via Nottingham University press office)
Email: peter.brindle@nhs.net

(2) High-risk patients need better guidance on what is and isn±t a heart attack

(Editorial: Advising patients on dealing with acute chest pain)
http://www.bmj.com/cgi/content/short/335/7609/3

Varying advice means patients at high-risk of having a heart attack are unclear about when symptoms are potentially life threatening and when they should call an ambulance, argue a group of heart specialists in this week±s BMJ.

At least 70% of people who die from coronary heart disease have had previous heart problems.

Yet recent data from the British Heart Foundation shows that 40% of the general population would not immediately call an ambulance during a suspected heart attack and the greatest delays in calling 999 are among the high-risk group.

This implies, say Dr Khavandi and colleagues, that high-risk patients do not seem to be receiving clear effective guidance from their doctors.

One of the symptoms of a heart attack is angina. Yet angina can also be a stable condition which lasts only a few minutes and can be controlled by medication. The writers say ideally they would like patients to be able to tell the difference between the two types but in reality they do not.

In particular, high-risk patients with ischaemic heart disease (IHD) - which causes a reduction in the blood supply to the heart, usually felt as angina - are given varying advice from doctors, health organisations and drug manufacturers about how to use the drugs (sublingual nitrate GTN sprays) prescribed to relieve the condition.

The advice also varies on when they should call an ambulance.

The British Heart Foundation advises patients with known IHD to call an ambulance if chest pains last longer than 15 minutes and to use their spray three times during that period.

The American College of Cardiology recommends one spray and 5 minutes before calling an ambulance.

Manufacturer±s instructions are sometimes non-specific, for example, recommending no more than 3 doses and 15 minutes between treatments ± leaving it to the prescribing doctor to guide the patient.

Waiting 15 minutes, say the writers, could be too long for some patients. One study has shown that the median time from onset of symptoms to cardiac arrest is ten minutes.

They recommend patients and their relatives should be explicitly primed to recognise high-risk features of chest pain. They advise patients at high-risk or with IHD to carry a GTN spray with them at all times, to take two metered doses immediately if they get chest pain and to wait 5 minutes before calling an ambulance. They should not waste time by calling a friend or relative first and should not drive themselves to hospital.

Contacts:
Dr Ali Khavandi, Specialist Registrar, Cardiology, North Bristol NHS Teaching Trust, Bristol, UK
Email: khavandi@hotmail.com

or Paul Walker, Consultant Cardiologist, Southmead Hospital, North Bristol NHS Teaching Trust, Bristol, UK

(3) Ban on hookah smoking should stay, argue doctors

(One last puff)
http://www.bmj.com/cgi/content/short/335/7609/20

(Clinical Review: Managing smoking cessation)
http://www.bmj.com/cgi/content/short/335/7609/37

Campaigners are trying to get hookah smoking exempted from England±s smoking ban for cultural reasons. Despite there being little research into the health effects, doctors writing in this week±s BMJ say the ban should stay in place.

A hookah is a glass based waterpipe used for smoking. It is commonly used in Arabic communities for smoking herbal fruits after meals, but it is becoming increasingly popular among young adults in Western Europe for smoking tobacco, massel (aromatic tobacco), cannabis and bango (an intoxicating plant leaf), write Dr Rashid Gatrad and colleagues.

It is thought that around 100 million people use a hookah daily worldwide.

Reports suggest that family attitudes towards children smoking tobacco in waterpipes are far more permissive than attitudes to cigarette smoking.

There has been little research into the health effects of waterpipe smoking, but data show that rising numbers of children in the UK are being exposed to and experimenting with smoking hookah products, write the authors. Children as young as 10 years old are known to smoke fruit flavoured aromatic tobacco in areas with large minority ethnic communities such as Leicester and London.

The nicotine content in hookah tobacco seems to be the same as in cigarettes, but the authors warn that hookah smoking carries a greater risk of carbon monoxide poisoning than cigarette smoking, particularly if smaller hookah pipes and ±quick lighting± commercial charcoal are used. There is also some evidence that hookah smoking causes chromosomal damage.

When used for smoking tobacco, the hookah is included in the legislation that came into force in England on 1 July 2007 banning smoking in public places.

The authors believe that including the hookah in the legislation is appropriate since the exposure of non-smokers to tobacco fumes is considerably higher than for cigarette smoking because of the large plume of smoke that the hookah generates.

However, it remains to be seen what effect the legislation will have on smoking non-tobacco containing products that still generate a large amount of smoke, they conclude.

A separate review article also published in this week±s BMJ highlights the importance of helping patients to stop smoking as young as possible. It points to evidence that, beyond 40, people lose three months of life expectancy for every further year of smoking.

Contact:
Rashid Gatrad, Consultant Paediatrician, Manor Hospital, Walsall, UK Tel (via Emma Dickinson, BMJ Press Office):
Email: edickinson@bmj.com

(4) Who should ±own± genetic information?

(Head to Head: Should families own genetic information?)
http://www.bmj.com/cgi/content/short/335/7609/22

We all share our genetic make up with relatives, but should we also share ownership of the results of DNA analysis or should this knowledge be considered private? Two experts give their views in this week±s BMJ.

Dr Anneke Lucassen, a clinical geneticist at the University of Southampton, believes that if anyone is to own genetic information, it has to be all those who have inherited it and, more importantly, it must be available to all those who might be at risk.

The question, she says, is how to balance a right to privacy with disclosing risks to others.

Patient confidentiality is of course one of the most important cornerstones of medical practice, she writes. Nevertheless, confidentiality is rarely seen as absolute, and there are both statutory and professional guidelines on exceptions to the duty of confidentiality.

The Human Genetics Commission±s 2002 report suggested that ±genetic solidarity± and altruism should be promoted, while UK guidelines state that where there is a serious preventable harm, confidentiality may be breached.

Methods for sharing information need to be sensitive and relevant, she says, but today±s increasingly individualistic modern medicine must find ways of facilitating this. It should not be denied because of a narrow view of information ownership, she concludes.

But Professor Angus Clarke at the Institute of Medical Genetics in Cardiff argues that genetic information should be regarded as private and personal.

To treat it as if it were owned in common by a body as vague and ill defined as ±the family± is flawed, he says.

He concedes that there are occasions when genetic information does belong intrinsically to the family. For example, in a genetic linkage study looking at the pattern of sharing of DNA sequences.

While he does not deny that family members should be prepared to share important medical information with their relatives, two particular problems arise, he says.

The first occurs when an individual fails to pass potentially important information to their relatives. He argues that genetic disorders are not sufficiently similar to infectious diseases such as gonorrhoea, syphilis and HIV, that doctors have a duty to enforce disclosure by patients or clients to other members of their family.

The harm done by a failure to disclose will usually not entail an immediate and grave form of damage, he writes.

The second problem is when an individual forbids health professionals to release or to use genetic test results to provide more accurate or relevant medical advice to their relatives.

Once family members know that a relative has been diagnosed with a particular genetic condition, Professor Clarke argues that the more detailed, technical information (such as the precise mutation causing the disease in the family) belongs to the laboratory or the health service that generated it and not to either the individual or the family.

Contacts:
Anneke Lucassen, Consultant, Wessex Clinical Genetics Service, Princess Anne Hospital, University of Southampton, UK
Email: annekel@soton.ac.uk

Angus Clarke, Consultant Clinical Geneticist, Institute of Medical Genetics, University Hospital of Wales, Cardiff, Wales NB. Prof Clarke is out of the office on Thurs and Fri, but can be contacted via Emma Dickinson, BMJ Press Officer
Email: clarkeaj@cardiff.ac.uk

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