https://escholarship.org/content/qt02t0p1vw/qt02t0p1vw.pdf?t=nvz9j2

Coronary calcium and atherosclerosis by ultrafast computed tomography in asymptomatic men and women: Relation to age and risk factors

The National Heart, Lung, and Blood Institute sponsored national telephone surveys of practicing physicians in 1983 (N = 1610) and 1986 (N =1277) to assess attitudes and practices regarding elevated serum cholesterol levels. The 1983 survey was conducted just before the release of the results of the Lipid Research Clinics Coronary Primary Prevention Trial, which showed that a reduction in the blood cholesterol level reduced coronary heart disease. In 1986, 64% of physicians thought that reducing high blood cholesterol levels would have a large effect on heart disease, up considerably from 39% in 1983. Whereas in 1983, physicians attributed considerably less preventive value to reducing the cholesterol level than to reducing blood pressure or smoking, this disparity was substantially smaller in 1986. The median range of blood cholesterol at which diet therapy was initiated was 6.21 to 6.70 mmol/L (240 to 259 mg/dL) in 1986, down from 6.72 to 7.21 mmol/L (260 to 279 mg/dL) in 1983; the median for drug therapy was 7.76 to 8.25 mmol/L (300 to 319 mg/dL) in 1986 and 8.79 to 9.28 mmol/L (340 to 359 mg/dL) in 1983. In 1986, 87% of physicians surveyed felt that medical evidence warranted the recommended treatment levels set forth in the 1984 National Institutes of Health Consensus Conference on Lowering Blood Cholesterol. These changes indicate that by 1986, physicians were more convinced of the benefit of lowering high blood cholesterol levels and were treating patients accordingly. The data also suggest areas for continued educational initiatives. (JAMA1987;258:3521-3526)

Change in Physician Perspective on Cholesterol and Heart Disease: Results From Two National Surveys

Q uantifying severity of coronary artery stenosis is becoming increasingly important for many reasons, including evaluation of interventions such as cholesterol control, stress management, pharmacological agents, percutaneous transluminal coronary angioplasty, thrombolysis, and bypass surgery; clinical decisions on medical versus mechanical treatment of coronary artery stenoses; judgment of adequacy of noninvasive diagnostic techniques; understanding the role of fluid dynamics in localizing atheroma at specific sites of an artery exposed to the same risk factors throughout its length; and in silent coronary artery disease, as the only basis for choosing medical or mechanical intervention to prevent sudden death or acute myocardial infarction. There are two fundamental ways of describing stenosis severity based on anatomic and physiological approaches.1 These anatomic and physiological methods are related but provide independent complementary data; each is essential forjudging severity and regression or progression or for making clinical decisions and will be briefly reviewed.

Identifying and measuring severity of coronary artery stenosis: quantitative coronary arteriography and positron emission tomography

A strategy was devised for identifying men at high risk of acute myocardial infarction or sudden ischaemic death A risk score was devised using cigarette smoking, mean blood pressure, recall of ischaemic heart disease or diabetes mellitus diagnosed by a doctor, history of parental death from "heart trouble," and the presence of angina reported on a questionnaire The top fifth of the score distribution identified 53% of ischaemic heart disease cases--that is, men who subsequently experienced major ischaemic heart disease over the next five years The addition of serum total cholesterol concentration and electrocardiographic evidence only slightly improved prediction (to 59%) and would have considerably increased the cost and effort of screening Using this risk score on an opportunistic basis could be particularly valuable in general practice Management of this high risk group is regarded as appropriate medical care and is complementary to the population approach to preventing ischaemic heart disease Such a strategy for reducing the incidence of and mortality from ischaemic heart disease in men at high risk would also increase professional and public awareness of the need for preventive action

https://www.bmj.com/content/bmj/293/6545/474.full.pdf

Identifying men at high risk of heart attacks: strategy for use in general practice.

Dietary lipids and coronary heart disease: old evidence, new perspective.

Intervention in the whole population in order to reduce the risk of coronary heart disease through altering lifestyles and specific intervention in individuals with identified high risk are complementary and not opposing strategies. Yet they are valid alternatives in that they present society with different choices and uses of its limited resources. To community health educators-and evidently to epidemiologists-mass intervention is to be preferred. To many physicians and cardiologists, the high risk strategy is likely to be more attractive. In the best of all possible worlds we should be able to afford both policies if they truly benefit society. But, so far, the results of investment in mass intervention trials have not been impressive-with a very considerable outlay and little or no yield (see later). It is argued that such trials are unnecessary because the cost of changing lifestyle on a mass population basis is really negligible and it is not expensive to promote campaigns to tell people to stop smoking, change their diet, or take more exercise: such advice is bound to do more good than harm, it is said. Yet improved health is not the only need of the population. Simply to argue that cigarette smoking should be eliminated without taking into account the repercussions on economy and employment is a narrow medical view. Similarly, to recommend changes in farming policy and farming economy leading to reductions in dairy farming by a quarter or a third needs much more consideration than it usually gets from the health education enthusiasts. Reduction in milk production and the requirement for less carcass fat imply a substantial reduction in animal food, of which barley is the major component. I Land will be released for other purposes but perhaps more than is needed for fruit and vegetables. The case for making large changes in agricultural strategy, with all its

https://heart.bmj.com/content/heartjnl/54/1/1.full.pdf

M F Oliver

Papers

Strategies for preventing and screening for coronary heart disease.