Knowing heart health risk scores can change patient behaviour

Rosanne Barrett

11/03/2021 3:11:42 PM

Patients at an Australian chest-pain clinic reduced their cardiovascular absolute risk score by an average of 2.4% after learning their rating.

Stethoscope on heart
The findings validate the absolute risk approach promoted in Australia’s national guidelines.

Providing a heart-health score can lead patients to reduce their risk factors, according to new Australian research.
The study of 189 Tasmanian chest-pain patients found that providing a cardiovascular absolute risk score made patients more likely to take steps to reduce risk factors, including quitting smoking and improving blood pressure and cholesterol levels.
Published in the Medical Journal of Australia, the study revealed an overall reduction in the intervention group’s average absolute risk score of 2.4%, compared to an increase of 0.4% in the control group.
Cardiologist and staff specialist at Royal Hobart Hospital, Dr Andrew Black, said patients who attended the clinics had many risk factors for heart disease, but these preventable changes were ‘rarely explicitly discussed’.
‘Absolute risk scores may be useful for educating patients and encouraging engagement with strategies for improving cardiovascular health,’ he said.
‘The absolute-risk-based approach recognises the synergism of risk factors and the greater overall benefit of directing preventive measures to patients at greater risk.
‘Risk score calculation is designed to assist clinical decision-making, but providing risk scores to patients may also help improve risk perception and promote engagement with strategies for reducing risk.’
The research tracked patients who attended the rapid access chest-pain clinic of Royal Hobart Hospital between mid-2014 and the end of 2017. It excluded people who had high-risk coronary ischaemia, reduced blood flow and oxygenation to the heart.
Patients aged 35–74 were screened and their five-year risk of heart, stroke and blood vessel diseases was assessed using the Australian absolute risk calculator, which calculates an overall risk score using the combination of risk factors, instead of assessing each factor in isolation.
Patients in the intervention group were told of their risk score and their risk factors were discussed in detail. This included medications if necessary, which were prescribed in the clinic. People who smoked were guided to a quit service, and a registered nurse offered lifestyle advice.
Patients were also all ‘strongly encouraged’ to talk about their risk management with their GPs.
The patients were followed up a year later. Research nurses checked cholesterol levels, blood pressure, smoking status, weight, physical activity and any major cardiovascular events.
GP and senior lecturer in the University of Western Australia’s School of Medicine, Dr Brett Montgomery, told newsGP the finding is important because it validates the absolute risk approach promoted in Australia’s national guidelines.
‘The absolute risk approach makes good intuitive sense. It should get therapies to the people who need them most, and hopefully help motivate people most in need of behavioural change,’ he said.
‘But despite its face validity, as the authors state, this absolute-risk-oriented strategy hasn’t been studied very much – even though the many therapies it helps to target have separately been studied very rigorously.
‘I think it helps to reassure us that our guidelines take the right approach to primary prevention of cardiovascular disease.’
Dr Montgomery was surprised the practice of providing absolute-risk scores was not already in place in the chest-pain clinic at which the study was conducted, but said it demonstrated the ‘slow road of translation of guidelines into practice’.
He also pointed to recent research that suggested fewer than one in 10 Australians aged 35–74 had had an absolute risk score done.
The same review of MedicineInsight data found almost half of Australians aged over 45 had not had a cholesterol check in the past five years, and one-third of people went without a blood pressure check in the previous two years.
Dr Montgomery said medical students were now taught to use absolute risk calculators in a general practice setting.
‘We’re seeing a slow culture change from thinking in terms of individual risk factors to multifactorial risk, which is complicated,’ he said.
Professor Mark Nelson, a co-author on the study and Professorial Research Fellow at the University of Tasmania’s Menzies Institute for Medical Research, said the absolute risk score is a better indicator of the overall potential for future disease than single inputs of blood pressure and other factors.
He cited a potential patient with a blood pressure reading of 139 mm Hg, when the threshold for treatment is 140 mm Hg.
‘The resistance is, a lot of GPs will say you can’t treat blood pressure at 139 mm but you must treat it above 140 mm,’ he said.
‘You do have thresholds for treatment based on absolute risk as well, but you have multiple inputs.’
Professor Nelson said the move to a preventive health model from the historical role of treating disease means ‘medicalising the people most likely to benefit from treatment’ – before they have the disease.
He referred to a previous Heart Foundation campaign for everyone to know their number, but said it should include the absolute risk score.
‘The number that you need to know is your absolute risk,’ he said.
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