Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomised trial cohort of patients
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.38603.656076.63 (Published 13 October 2005) Cite this as: BMJ 2005;331:869All rapid responses
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Dear Editor,
Clayton and his team have formed a risk score for predicting death,
myocardial infarction and stroke in patients with stable angina. [1]
The score seems be useful in identification of the groups of patients for
divers treatment orientations.
We are studying a group of patients with cardiovascular disease and
we used, for grading of cumulating atherosclerosis risk factors, the
Pocock’s score (published in B.M.J.) for predicting the risk of death by
cardiovascular disease based on data from randomized controlled trials [2]
After reading of Clayton’s and all paper, we tried to compare
Clayton’s score with older Pocock’s score. On a little number of patients
who fulfilled all conditions for the both scores calculations, we stated a
very good correlation between Pocock’s and Clayton’s scores: r=0.617,
p<_0.0001 pearson="pearson" correlation="correlation" number="number" of="of" cases="cases" _-="_-" _66.="_66." this="this" high="high" significant="significant" coefficient="coefficient" shows="shows" that="that" both="both" scores="scores" have="have" very="very" close="close" values="values" in="in" predicting="predicting" death="death" stroke="stroke" or="or" myocardial="myocardial" infarction.="infarction." p="p"/> Practically, we think that all these works on the role of
atherosclerosis risk factors in prognosis appreciation of cardiovascular
disease have importance and must be continued.
On the other hand, we sustain that, in analysis of atherosclerosis
risk factors, is necessary to retain for analysis the “new”
atherosclerosis risk factors such as: low level non specific inflammation
(with markers C reactive protein, fibrinogen, 6-interleukine, etc.) and
dental state appreciation. These “new” risk factors may intervene in
atherogenesis and may have weight in any prognostic score.[3.4.5]
In Clayton’s score, the authors mention that they have retained white
blood cells number
only, not C reactive protein or others.
We think any risk score in predicting death, coronary obstruction or
stroke must use the “new” atherosclerosis risk factors, too.
References:
1.Clayton TC, Lubsen J, Pocock SJ et al: Risk score for predicting
death, myocardial infarction, and stroke in patients with stable angina,
based on a large randomized trial cohort of patients. BMJ 2005;331:869-
872.
2. Pocock SJ, McCormack V, Gueyffier F et al: A score for predicting
risk of death from cardiovascular disease in adults with raised blood
pressure, based on individual patient data from randomized controlled
trials. BMJ 2001;323:75-81.
3. Hansson GK: Mechanisms of Disease: Inflammation, Atherosclerosis,
and Coronary Artery Disease. N Engl J Med 2005; 352:1685-1695.
4. Janket SJ, Qvarnstroem M, Meurman JK, et all: Asymptotic Dental
Score and Prevalent Coronary Heart Disease. Circulation 2004;109:1095-
1109.
5. Desvariuex M, Demmer RT, Rundek T, et all: Relationship Between
Periodontal Disease, Tooth Loss, and Carotid Artery Plaque. The Oral
Infections and Vascular Disease Epidemiology Study (INVEST). Stroke
2003;34:2120-2125.
Competing interests:
None declared
Competing interests: No competing interests
Observational studies showing the influence of psychosocial factors
on outcomes of people with coronary heart disease (CHD) have been
appearing in the scientific literature for decades (1). The magnitude of
the increased risk afforded by depression following acute myocardial
infarction (MI), for example, was shown to be comparable to that of left
ventricular dysfunction and prior MI (2). There is also strong evidence
for a number of underlying behavioural and pathophysiological mechanisms
linking psychosocial factors to both the onset and prognosis of CHD (3,4).
The work of Clayton, et al., on behalf of the ACTION Investigators,
in developing a risk prediction algorithm in patients with stable angina,
is yet another example of epidemiologists and researchers continuing to
focus solely on clinical and biomedical variables to calculate risk
scores, thereby overlooking the obvious and substantial contribution to
risk afforded by well-established psychosocial risk factors (5).
Inexplicably, psychosocial variables, particularly depression,
continue to be routinely excluded from studies by cardiovascular
epidemiologists and researchers. This is despite the availability of a
number of simple, robust, well-established screening instruments. Until
the clinical significance of psychosocial factors is recognised and
incorporated into risk factor equations and analysis, current models for
CHD risk prediction will continue to significantly underestimate true risk
in at least 30% of patients with CHD who have depression or depressive
symptoms. It is no longer acceptable to ignore psychosocial risk factors
when assessing CHD risk.
1. Ruberman W, Weinblatt E, Goldberg JD, Chaudhary BS. Psychosocial
influences on mortality after myocardial infarction. NEJM 1984;311:552-
559.
2. Frasure-Smith N, Lesperance F, Talajic M. Depression following
myocardial infarction: impact on 6 month survival. JAMA 1993;270:1819-
1825.
3. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The
epidemiology, pathophysiology, and management of psychosocial risk factors
in cardiac practice: the emerging field of behavioral cardiology. J Am
Coll Cardiol. 2005;45:637-51.
4. Carney RM, Freedland KE, Miller GE, Jaffe AS. Depression as a risk
factor for cardiac mortality and morbidity: a review of potential
mechanisms. J Psychosom Res. 2002;53:897-902.
5. Bunker SJ, Colquhoun DM, Esler MD, Hickie IB, Hunt D, et al.
“"Stress" and coronary heart disease: psychosocial risk factors. National
Heart Foundation of Australia position statement update. Med J Aust
2003;178:272-276.
Competing interests:
None declared
Competing interests: No competing interests
Re: Authors reply: Epidemiologists and researchers continue to overlook the obvious & A comparison of Clayton & Pocock scores
Author’s reply:
We agree with Dr. Bunker that psychosocial factors may contribute to
long-term risk. The main reason we could not include them in our risk
score is that we used data from one large multi-national clinical trial
and the database of that trial does not contain any information relevant
to psychosocial factors. It is not customary to collect such information
in large scale trials involving many different countries. In addition,
although psychosocial factors may indicate increased risk in stable angina
patients this does not mean such factors would necessarily be selected in
a multivariate model after inclusion of variables that are themselves
associated to psychosocial factors, such as smoking, severity of angina
and history of myocardial infarction. Finally, the risk score is intended
to incorporate readily available standard risk factors and to incorporate
psychosocial factors requires a simple, reliable method to measure them,
and that is not easily done in practice.
Dr. Gutio’s observation that our risk score and the earlier Pocock
score are correlated shouldn’t be a surprise as the scores partly overlap
as regards included variables. Hence, a person having a high value of one
score is also liable to have a high value of the other. What matters is
how the score value translates to absolute risk. This question isn’t
addressed by the correlation analysis that was performed.
Lastly, readers might like to know that our website
www.anginarisk.org is now up and running, and should help to make our risk
score more user-friendly.
Tim Clayton, Jacobus Lubsen & Stuart Pocock
Competing interests:
None declared
Competing interests: No competing interests