21 February 2012

Family History May Be Key in Heart Risk

First appeared in the Wall Street Journal

Ecorse Heart Doctors often gloss over a key question for assessing a person's risk for coronary heart disease, according to a new study: What is the patient's family history of cardiovascular illness?

The study suggests some doctors may not be capturing the full extent of many patients' chances of developing heart disease. Detailed family information could help doctors better predict who is at risk and more accurately target patients for preventive care that may help avert the disease altogether, according to the study, due to be published Tuesday in the Annals of Internal Medicine. Routinely tracking family history sharply boosted the number of people in the study considered at high risk for heart disease.

A widely used scorecard for measuring heart risk, the Framingham Risk Score, fails to take family history directly into account. And while many doctors currently collect some information about the health of their patients' families, the data often lack the detail to be clinically useful for assessing risk and prescribing care.

Family history remains one of the most important predictors of an event for an individual. Still, most of the family history that experts are collecting is just the presence or the absence of heart disease, not the age of onset or the type of disease, according to Northville Cardiologists.

Guidelines for heart-risk screening, issued by the heart association in late 2010, encouraged doctors to take family histories into account. Doctors sometimes make judgment calls to treat people as high risk because of family history, even if it isn't part of the patient's risk score.

The study, funded by the United Kingdom Department of Health, included 748 patients aged 30 to 65. Up to 13% of patients were found to be at high risk of coronary heart disease using traditional assessment tools. After patients filled out enhanced questionnaires that sought more complete information, the percentage considered at high risk jumped to 18%. The traditional assessment could include general information, such as blood pressure, cholesterol level and basic information about whether a family member had a history of heart disease. The enhanced survey would identify, for instance, that a patient's mother had a heart attack at age 50.

It's a low cost way to target people who are at high risk for cardiovascular disease, say Romulus Heart Doctors.

Findings from the U.K.-based study reflect similar use of family history among doctors in the U.S., several U.S.-based physicians say.

Family history has been linked to higher risk for a number of illnesses, including cancer and diabetes. Unlike some other diseases, however, clear genetic markers for coronary heart disease, which accounts for 1 in 6 U.S. deaths, remain elusive. Family histories can be used as a proxy for detailed genetic work that may someday be used to help predict heart-disease risk, researchers say.

Another risk-measurement tool, known as the Reynolds Risk Score, developed by Harvard University researchers in the 1990s, does consider if a patient's parent had a heart attack and at what age. However, many medical practices don't yet use the tool, which became available in 2007.

Using the Reynolds system, the researchers tracked 25,000 initially healthy patients over a decade. They found that a 50-year-old male patient who, among other things, smoked, and had high blood pressure and cholesterol, but no family history of heart disease, had a 12%, or moderate, chance of having a heart attack in the 10-year period. But a similar patient with a parent who had a heart attack before age 60 had a 20% risk, putting that patient at high risk for heart disease. Heart risk wasn't significantly affected in patients with a parent who had a heart attack at the age of 60 or older.

Still, many medical practices continue to rely on the older Framingham Risk Score, which became available in the 1990s. Researchers believed that other factors, including blood pressure and cholesterol levels, provided all the information needed to determine a patient's risk for heart disease.

Doctors use the scoring systems to single out patients who could benefit from counseling about lifestyle changes, such as losing weight and quitting smoking, or from preventive interventions such as low-dose aspirin and cholesterol drugs, says Yul Ejnes, the chairman of the American College of Physicians board of regents. The college publishes the Annals of Internal Medicine.

Primary-care doctors say there are obstacles to gathering family histories from patients, including competing priorities for time in the examination room. And patients often don't know many details about their family members. In the Annals of Internal Medicine study, patients were mailed questionnaires and instructed to gather the material before seeing their doctor.

Patients should make a point of knowing the health histories of their parents, siblings and grandparents, he says. To identify clues about specific diseases, however Riverview Heart Doctors say that they sometimes asks patients questions like: "What do you remember about Grandpop's hospitalization? Were his legs swollen?"

A 33-year-old a senior marketing director at a Boston technology firm, says her family history has made her an advocate for her own health. She says she watches her diet and exercises regularly. And although she currently isn't on any heart medication, she regularly pushes her doctor to check thoroughly for signs of developing heart disease.

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