Chest-pain patients more cautious when told risk score

Cardiovascular risk calculations are useful for more than just clinical decision-making.

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Patients were significantly more likely to take healthy steps when told their absolute cardiovascular risk, prompting calls for greater communication of the assessment in general practice.

The study, published in the MJA, adds to a growing body of evidence backing risk assessments as a clinically useful educational tool.

Only about 10% of patients referred to the Royal Hobart Hospital’s rapid access chest-pain clinic have active cardiovascular disease, but many more have significant underlying risks for a future event.

Heart Foundation risk reduction manager Natalie Raffoul said many Australians were unaware of their underlying cardiovascular risk factors.

“Out in the community, we know something like 2.5 million Australians are at higher risk of developing heart attack or stroke in the next five years,” the clinical pharmacist told TMR.

“Over half of those people have never had an event,” she said. “[But] that risk develops over time.”

Dr Andrew Black, a cardiologist at the Royal Hobart Hospital, told TMR that patients frequently underestimated their own risk, often believing their risk of heart attack in the next five years was 2%, when it could be as high as 20%.

Dr Black led a study which compared the behavioural changes of a group of patients attending his clinic at the Royal Hobart Hospital who were told their absolute risk rating against a control group who did not.

The study took place between 2014 and 2017, with about 100 patients in each group, all with an absolute five-year cardiovascular risk score of at least 8% as per the Australian National Vascular Disease Prevention Alliance risk calculator.

Patients with a high risk of cardiovascular disease were excluded for safety reasons.

Patients in the intervention group received an initial appointment where they were counselled about their five-year cardiovascular risk score and encouraged to engage with primary care.

They were then followed up 12 months later, and their risk rating was revised.

“Rather than saying, in isolation, ‘you should probably stop smoking’ – which we know has minimal impact – it was a case of saying ‘your absolute risk is 20%, but you could reduce that to 10% by stopping smoking’,” Dr Black told TMR.

At the 12-month follow up, patients who received an intervention had dropped an average of 2.4 absolute risk percentage points, while the control group – who were never given their risk score –gained an average of 0.4 risk percentage points.

The intervention group weren’t any more likely to change their medication schedule, suggesting they were instead more likely to adopt recommended lifestyle changes, said the authors.

“Another important thing we did is show them how they can change their risk score – so if the risk is 15%, and they lowered their blood cholesterol levels or stopped smoking, you can show them what lower risk score they could achieve,” Dr Black said.

Dr Black said a key takeaway for general practitioners was that routine, absolute risk assessments were very useful in a primary care setting, as is sharing that information with patients. Ms Raffoul told TMR this research reiterated the benefits of opportunistic risk assessments.

“[The findings] provides further evidence that if we do inform people of their cardiovascular risk, and educate them about what that risk means, they’re more likely to go off and do something about it,” she said.

MJA 2021, Monday 8 March