VIII CONGRESSO SINV (Societą Interdisciplinare NeuroVascolare) RAPALLO (GE) 26-27 Novembre 1999
The Multidisciplinary approach to the ischaemic cerebrovascular pathology
"THE
QUANTITATIVE
DISPLAY
OF
CARDIAC
AND
CEREBROVASCULAR
RISK
FACTORS:
PRACTICAL
CONSIDERATIONS
REGARDING
THE
COMPUTERIZATION
IN
PRIMARY
PREVENTION"
Francesco Piruzza, General Practitioner, A.S.S. no. 4 "Medio Friuli", Castions di Strada, UDINE, ITALY
Scientific
research
has
identified
and
quantified
risk
factors
basing
itself
on
results
of
random
trials
on
a
vast
scale.
In
reality,
however,
the
doctor
has
the
difficulty
of
quantifying
the
individual
risk
for
one
specific
patient
and
chosing
the
preventive
pharmacological
treatment
on
a
long
term
basis,
which
should
be
all
based
on
the
evaluation
of
the
probable
benefit
related
to
the
reduction
of
this
risk.
A
practical
instrument
for
the
quantification
and
the
display
of
the
risk
has
been
achieved
by
the
researchers
of
the
Canadian
Medical
Association:
the
researchers
after
having
re-elaborated
the
data
from
the
Framingham
Study
gave
a
score
to
the
various
risk
factors
and
have
inserted
them
into
two
gradient
charts.(see
James
McCormack,
Pharm
D;Levine,;
Rangn.
Primary
prevention
of
heart
disease
and
stroke:
a
simplified
approach
to
estimating
risk
of
event
and
making
drug
treatment
descisions.
CMAJ
1997;
157:422-8)
PROCEDURE:
1)Consult
the
chart
with
the
PAS,
col-tot,
HDL,
smoke,
diabetes,
IVS,
FA
scores.
2)Single
out
the
patient's
age
on
the
scale
for
men
and
women.
3)
Trace
a
vertical
line
which
intersects
the
relative
risk
curve.
The
value
on
the
y-axis
corresponds
to
the
risk
only
according
to
age
and
sex.
4)
In
order
to
add
the
other
risk
factors,
identify
the
value
for
each
risk
factor.
If
the
number
is
positive
move
the
previously
identified
point
towards
the
right
according
to
the
number
of
spaces
indicated
by
the
final
number,
towards
the
left
if
the
number
is
negative.
The
percentage
of
risk
evaluation
is
purely
indicative
since
it
doesn't
take
other
factors
such
as
family
history,
sendentary
way
of
life
and
body
weight
into
account.
In
spite
of
these
limits
the
method
remains
a
valid
one
for
primary
prevention.
The
procedure
is
quite
simple
but
rather
laborious:
for
obvious
logistic
reasons,
the
practical
application
in
the
GP's
studio
proves
to
be
far
from
easy.
The
author
has
computerized
the
Canadian
researcher's
methods
inserting
bars
into
the
original
charts
which
automatically
show
the
percentage
of
risk
and,
with
the
aid
of
a
paticular
device,
displays
the
benefits
in
risk
reduction,
after
a
period
of
time,
produced
by
preventive
therapeutical
measures.
Furthermore,
he
has
elaborated
another
chart
to
identify
the
level
of
risk
regarding
the
BMI
(chart
no.
3)
and
an
accompanying
analysis
of
other
risk
factors
so
as
to
obtain
a
more
meaningful
prognostic
value.
The
software
has
been
set
out
on
one
screen
so
as
to
have
an
overall
picture
of
the
patient's
problems
thus
translating
the
important
and
innovative
concept
of
"GLOBAL
RISK"
proposed
by
the
Task
Force
for
Prevention
of
Coronary
Heart
Disease
in
cooperation
with
the
Atherosclerosis
Society.
(Nutrition
1998):
it
stresses
the
importance
of
considering
all
the
known
variables
as
a
whole
in
order
to
distinguish
the
cardiovascular
risk
profile
in
each
individual.
Since
a
number
of
preset
factors
can
coexist
in
the
same
person,
in
this
case,
they
can
interact
multiplying
the
cardiovascular
risk
and
this
obviously
has
a
particular
importance
in
determining
the
prognosis,
the
choice
of
an
appropriate
therapy
andthe
desirable
levels
to
reach
for
the
reduction
of
the
risk
factors.
The
Boolean
data
processing
automatically
gives
a
detailed
report:
a)
of
the
patient's
risk
in
percentage
in
5
and
10
years,
b)
the
diagnosis
of
the
risk
level
(slightly
increased,
moderately
increased
or
elevated)according
to
the
global
risk
criteria
published
by
Nutrition.
c)
of
the
alterable
F.R.,
d)
of
the
therapeutical
and/or
diagnostic
measures
to
adopt,
e)
the
print-out
of
a
report,
for
the
patient's
use,
to
make
him
aware
of
his
own
responsabilities
with
regards
to
the
risk
factors.
EVIDENCE-BASED-MEDICINE
There
are
NON
Modifyable
risk
factors
(
age,
sex,
family
history
and
race)
and
Modifyable
risk
factors
(
diabetes,
hypertension,
peripheral
vascular
diseases,
smoke,
alcohol,
obesity,
a
sedentary
way
of
life,
cholesterol,
hyperuricemia,
prothrombotic
factors,
hyperomocystinemia,
menopause,
PCR,
personality
type,
stress,
migrane,
CHD,
IVS,
F.
arterial
and
socio-environmental
situations.)
Here
is
an
example
that
describes
the
above
:
consider
a
50
year-old
man,
1,75m
tall,
weighing
95Kg
(IMC=31),
smoker,
with
PAS
160
mmHg,
Col-tot
292
mg/dl,
HDL
33
mg/dl,
non-diabetic
and
without
IVS
electrocardiographic
signals.
His
cardiovascular
risk
is
13%
in
5
years
and
23%
in
10
years.
After
6
months'
diet
and
the
changes
in
life-style
the
physical
and
ematochemical
values
have
been
normalized:
(IMC=27,
PAS
135
mmHg,
Col-tot
200
mg/dl,
HDL
48
mg/dl,
smoking
forbidden).
His
cardiovascular
risk
has
diminished
sensibly
in
5
and
10
years
positioning
itself
in
the
lower
most
part
of
the
risk
curve.
Absolute risk and Relative risk
According
to
the
Framingham
Study,
about
17%
of
the
vascular
events
in
men
are
represented
by
heart
attack
or
death
caused
by
coronary
heart
disease,
while
in
women
the
percentage
increases
to
40%.
Therefore,
returning
to
our
previous
example,
the
patient's
risk
in
a
5
year
period
of
myocardio
heart
attack
or
death
due
to
coronary
heart
disease
is
9.1%
(70%
of
13%)
and
at
10
years
16.10%.
The
risk
of
cardiovascular
events
in
10
years
can
be
calculated
the
same
way
using
the
second
chart.
After
adding
up
all
the
risk
factors,
the
percentage
of
absolute
risk
for
the
same
patient
is
equal
to
12%.
According
to
the
Framingham
Study,
the
ischaemic
attacks
represent
about
25%
(20%
for
women)
of
the
cerebrovascular
events.
Therefore,
this
patient
has
a
9%
probability
of
being
the
victim
of
a
fatal
or
non-fatal
stroke
in
the
next
10
years.
The strong point of the evaluation, apart from reducing the under-estimation of the risk factors and the potential beneficial therapies, is definitely the support given to evidence-based-medicine.
The computerization of the method, removing the logistic problems (ease of use and rapid execution) would allow the wide-scale use in GP's studios: primary prevention would become routine and one could automatically have a constantly up-dated map of the patients with a high risk factor at one's disposal, together with the consequent positive implications regarding the rationalization of the resources
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