Wells Susan, Kerr Andrew, Broad Joanna, Riddell Tania, Kenealy Tim, Jackson Rod
Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland.
N Z Med J. 2007 Sep 7;120(1261):U2712.
Current New Zealand cardiovascular (CVD) risk management guidelines advocate targeting treatment to patients with a high 5-year CVD risk assessed using a calculator derived from the Framingham Heart Study. For some high-risk population subgroups, a 5% upward adjustment to their calculated 5-year CVD risk is recommended. We estimated the impact of these adjustments on eligibility for treatment in a primary care setting.
Between 2002 and 2006, 23,709 patients visiting their primary care provider in Auckland, New Zealand had CVD risk assessments as part of an opportunistic screening programme using PREDICT, a web-based clinical decision support system. We calculated their baseline CVD risk with and without the 5% upward adjustment for family history of premature ischaemic CVD or for being of Maori, Pacific or Indian subcontinent ethnicity.
A baseline CVD risk could be calculated for 23,693 (99.9%) patients of whom 90% were between ages 35 and 74 years. Unadjusted risk scores classified the majority (70%) below the 10% 5-year risk threshold for specific individualised treatment. A further 11% were between 10 to 15% risk (recommended to receive individualised lifestyle counselling in general practice) and 19% had a greater than 15% risk ( recommended for drug treatment and referral to a dietician in addition to individualised lifestyle counselling). Over a quarter of patients were recorded as having a premature family history of CVD; 21% were Maori, Pacific, or Indian subcontinent and thus met the criteria for a single 5% upward adjustment. This increased the number of people eligible for drug treatment, intensive lifestyle management, and dietician referral by approximately 20% and individualised lifestyle assessment and counselling by 50%.
The upward adjustments to the calculated CVD risk recommended by the New Zealand CVD risk management guidelines has the potential to substantially increase resource requirements for CVD preventive services in primary care. Moreover the true impact is likely to be underestimated given other adjustment factors related to diabetes risk that were not available in this dataset. Given the impact of these relatively small changes to the CVD risk calculator, locally developed and validated risk equations are urgently needed.
新西兰当前的心血管疾病（CVD）风险管理指南主张，针对使用源自弗雷明汉心脏研究的计算器评估出5年CVD风险较高的患者进行治疗。对于一些高危人群亚组，建议将其计算出的5年CVD风险上调5%。我们估计了这些调整对初级保健环境中治疗资格的影响。
2002年至2006年间，新西兰奥克兰的23709名患者前往其初级保健提供者处就诊，作为使用基于网络的临床决策支持系统PREDICT的机会性筛查项目的一部分，接受了CVD风险评估。我们计算了他们在有和没有因早发性缺血性CVD家族史或属于毛利人、太平洋岛民或印度次大陆族裔而向上调整5%的情况下的基线CVD风险。
可为23693名（99.9%）患者计算基线CVD风险，其中90%的患者年龄在35至74岁之间。未经调整的风险评分将大多数（70%）患者归类为低于特定个体化治疗的10% 5年风险阈值。另有11%的患者风险在10%至15%之间（建议在全科医疗中接受个体化生活方式咨询），19%的患者风险大于15%（除个体化生活方式咨询外，建议进行药物治疗并转诊至营养师处）。超过四分之一的患者记录有CVD早发家族史；21%为毛利人、太平洋岛民或印度次大陆族裔，因此符合单次上调5%的标准。这使得有资格接受药物治疗、强化生活方式管理和转诊至营养师处的人数增加了约20%，个体化生活方式评估和咨询的人数增加了50%。
新西兰CVD风险管理指南建议对计算出的CVD风险进行上调，这有可能大幅增加初级保健中CVD预防服务的资源需求。此外，鉴于该数据集中没有与糖尿病风险相关的其他调整因素，实际影响可能被低估。鉴于对CVD风险计算器的这些相对较小的改变所产生的影响，迫切需要本地开发和验证的风险方程。
