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FROM THE HEART DOC

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DNA, THE NEXT BIG THING
While there are many people discussing DNA tests, so far none has performed well enough to warrant using them except in research studies. Even if results were better, at current prices, they are unlikely to be cost eective. For South Asians in particular, Salim Yusuf of MacMaster University has shown that various gene tests add very little attributable risk to the other known factors.

Prone to Heart Disease?

WITH heart disease there are a lot of tests, (see 7 Tests that Could Make the Difference) and it can be confusing for patients to understand what is useful and what isnt. This is complicated by the fact that doctors themselves have difculty understanding the relative merits of different tests, because the underlying statistical principles are not intuitive for our Palaeolithic minds. Add to this complexity the variations in local practice and medical culture, which are often determined by accidents of circumstance or cold business calculations, it is no wonder that so much confusion abounds. The key driver for this: everyone knows that heart disease can lurk silently for years and that heart attacks can come out of the blue and be fatal. This is a powerful driver of the search for solutions. And a powerful driver of the cardiac business.

Risk assessment for your heart neednt be complicated and expensive

MY TOP TIP

Assess your risk on your own: do you smoke, have diabetes, hypertension, high cholesterol or a family history of premature coronary disease? If yes, you are at risk.

Risk factors are simple to check

Statistics are important in trying to understand the issue. The results of a test really depend on the under-

DR VIKAS SAINI is a clinical cardiologist and researcher at Harvard Medical School and Harvard School
of Public Health. He is president of the Lown Cardiovascular Research Foundation in Boston. Write to him at vikas.s@preventionindia.com.

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SHUTTERSTOCK/INDIAPICTURE

A statistical trap

PHOTOGRAPH BY: BENN GROVER, EDITOR PROCOR

Ever since the Framingham Heart Study was conducted 50 years ago here in Boston, the concept of risk factors has taken rm root. The original Framingham risk factors are: a family history of premature coronary disease, diabetes, hypertension, smoking and high cholesterol. Add to these a lack of exercise, psycho-social stress and lack of leafy vegetables and one can capture a surprisingly large amount of risk. However, it is well known that residual risk exists which has driven the search for newer tests. While there are many which are being promoted, precious few have been shown to add signicantly to the FHS risk score, which is relatively easy to calculate.

lying likelihood that the disease may be present. This means that if heart disease is unlikely to begin with, a test which seems to indicate risk simply indicates a little more risk than before, which still may not be very much. In fact, since no test is perfect, if it is applied to a healthy population, more tests will be falsely positive for the disease than will be true indicators of the condition. This leads to many, many people getting more and more tests to chase the original false results. This applies to practically all tests, and is such a basic law of medicine that tries to evade it usually lead to unhappy outcomes. For example, statins for people with proven coronary disease reduce mortality, but statins for every healthy person who happens to have a high cholesterol have not been shown to reduce total mortality. Statins for everybody with high cholesterol is therefore highly contested and not yet accepted as standard practice (see The Truth about Statins).

When simple measures indicate intermediate risk, getting additional studies can add information. For example, a fasting glucose or a hemoglobin A1C may indicate enough additional risk to justify taking the statin. Similarly with the coronary calcium score in cases where the risk is intermediate, that may help tip the scales in favour of statin use, more exercise and meditation. But getting calcium scores without consideration of other factors will subject many more people to a conveyor belt into hospitals and OTs. Mindless chasing of abnormal test results and then procedures like stents and bypasses is how much overtreatment occurs. India needs to be careful how it adopts American medicine. The US has the worst performing health care system of the developed world: it spends the most without any signicant improvement in life expectancy. The aggressive selling of illusory solutions is one reason for this sad fact.
PREVENTION SEPTEMBER 2011

Beware overtreatment

SEPTEMBER 2011

PREVENTION

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