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| Risk assessment and progression of thrombotic cardiovascular disease |
Human beings need to anticipate dangers in order to survive. Predicting danger and preventing it is an important part of human evolution. People pay special attention to disasters such as volcanoes, floods and earthquakes, and the biggest fatal risk each of us faces is cardiovascular disease. Among the 240 causes of death, stroke and ischemic heart disease ranked first; and ischemic heart disease (such as coronary heart disease) has jumped from the seventh place of early death to the second place. In general, the greatest risk of human death comes from cardiovascular disease.
Doctors are the performers of health-related risk management. In the face of every patient, they are consciously and unconsciously doing risk assessment-dangerous treatment decisions. The guidelines for drug or interventional recommendations are based on risk stratification, the main decision for who to take the drug, for whom to perform the surgery, and for the comprehensive intervention of risk factors. Different treatment options depending on the patient's risk, which requires not only the doctor's judgment, but also the support of scientific evidence. Why do you want to do a risk assessment? In fact, the purpose of risk assessment is to provide clinicians with a basis for treatment decisions. The speaker emphasized that this is mainly for patients without a history of stroke or coronary heart disease, because patients with history are high-risk patients.
Technical basis for cardiovascular disease assessment
What are the key factors and key links in the occurrence of cardiovascular disease? What is the law of action? We need to establish a mathematical model of risk prediction with high accuracy, develop evaluation tools suitable for practical applications, and incorporate risk assessment as a necessary factor into conventional practice.
The Framingham Heart Study is a milestone in the cohort study. In 1948, the study examined more than 4,000 patients and followed up for 10 years. In 1961, the first paper was published, which found that high cholesterol, high blood pressure and smokers had higher mortality. The first concept of cardiovascular risk factors was laid, which laid the foundation for prevention of coronary heart disease. The main cardiovascular disease development process can be divided into upstream (smoking drinking, lack of exercise, poor diet, lack of sleep, sustained stress and chronic infection), midstream (hypertension, diabetes, dyslipidemia and obesity) and downstream (coronary heart disease, Three stages of stroke and peripheral vascular disease are caused by death and disability.
Because many patients have risk factors such as hypertension and dyslipidemia, we begin to emphasize the overall risk of patients. Doctors need to be aware that the goal of treatment is to reduce risk rather than simply dealing with risk factors. Minimize risk by minimizing disease incidence. The European Guide first proposed a visual risk assessment scale, but the definition of high risk for different scales is artificial and an important decision for risk stratification research. For example, the United States has classified the risk of >7.5% for 10 years as a high-risk group. Subsequent evaluation methods for calculating the number of risk factors are based on scientific evidence, which is a simplification of mathematical formulas.
Key factors for cardiovascular disease risk assessment in clinical practice
According to the survey data, 60% of European doctors do not use the risk factor counting method because many clinicians do not understand why they should be used. If the assessment method recommended by the guide is not very intuitive or cumbersome, the doctor does not like to use it. The definition of high-risk groups should be simple and easy to remember, because the most important thing for the clinic is to find out who is at high risk. In addition, risk assessments are relevant to treatment decisions. Another problem is that the guide should include risk assessment in the standardized diagnosis and evaluation system. At present, national guides have a wide range of recommendations for risk assessment. These differences are mainly reflected in three aspects: 1 risk factors included; 2 risk stratification standards; The definition of high risk.
High-risk or low-risk is a probabilistic problem, and the scoring method recommended by the dogmatic guidelines should not be used in the risk assessment process.
Progress in clinical CVD risk assessment
At present, there are many problems in the assessment of cardiovascular disease risk. For example, the risk assessment of people under the age of 60 cannot effectively distinguish high and low risks; the residual risk of known risk factors; the criteria for high risk definition lack rationality and cost benefit evaluation; the risk prediction is not accurate enough. .
In 1999, Professor Donald M Lloyd-Jones first reported the lifetime risk of cardiovascular disease in the general population based on the Framingham study. Lifetime risk is the absolute cumulative risk of an observed event occurring within an average life expectancy of an observed individual. Given that individuals' cardiovascular risk varies greatly with age, this year's guidelines for blood lipids recommend not only assessing the 10-year risk of people under the age of 55, but also assessing their lifetime risk. Another problem is residual risk. People with no known risk factors (blood pressure, total cholesterol, smoking, and diabetes) may also have cardiovascular disease, so we are still looking for additional risk factors.
The exploration of new risk factors is to explain the residual risk of cardiovascular disease beyond the traditional factors. The main target population is the cardiovascular population, and the new risk factors should have the following characteristics:
1. Simple and reliable measurement indicators, whether it is laboratory examination, imaging or clinical examination, should have reference values of the population;
2, in the risk of cardiovascular disease (no coronary heart disease and other risk) can independently predict the risk of cardiovascular disease;
3. A considerable part of the middle-risk population can be divided into high-risk groups;
4. Re-hazard stratification will bring about changes in treatment strategies, and such changes can reduce the risk of cardiovascular disease in people who are re-stratified;
5. If two or more risk factors have the same predictive value, the indicators are convenient, accessible, low cost, and safe.
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