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Extensive family history improves cardiovascular disease risk assessment

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Systematic collection of extensive family history can improve the risk assessment of cardiovascular disease in primary care, according to a report in the February 21st Annals of Internal Medicine.

These findings contrast with a National Institutes of Health State-of-the-Science conference that found the evidence base supporting systematic collection of extensive family history to be significantly lacking.

Dr. Nadeem Qureshi from University of Nottingham, Nottingham, UK and colleagues in the Added Value of Family History in CVD Risk Assessment (ADDFAM) study group compared the value of family history of premature coronary heart disease systematically collected and incorporated into cardiovascular risk assessment in primary care with risk assessment based on usual practice.

“To our knowledge,” the researchers say, “ours is the first controlled trial to evaluate the clinical utility of systematically collecting family history as part of a multifactorial cardiovascular risk assessment in primary care.”

Incorporation of standard family history from electronic health records increased the percentage of participants with high risk of coronary heart disease by 5.1 percentage points in the intervention group, compared with a 0.5 percentage point increase in the control group.

When family history information from the intervention questionnaire was added, the number of participants at high risk in the intervention group increased by 40.8% (from 49 to 69 participants).

About 5% of participants in each group had a family history of premature coronary heart disease in their electronic health records; this increased to 29.2% in the intervention group when information from the family history questionnaire was added.

Despite the differences in identified risk level, there were no significant differences between the groups in most of the 6-month clinical outcome variables. Participants in the intervention group were more likely than those in the control group to stop smoking, and aspirin use increased to a greater extent in the intervention group than in the control group.

“Compared with universal screening of untreated persons,” the authors note, “recent modeling suggests that using a targeted strategy to identify about 60% of the population at highest risk could prevent almost all cardiovascular disease. Our study shows that using systematic family history information increases the proportion of persons who can be identified as having the highest cardiovascular risk in the general primary care population.”

“Although we did not compare targeted screening with universal screening, our findings highlight the promising role that greater use of systematic family history collection could play in a targeted strategy in primary care,” they conclude. “This potentially low-cost approach also seems feasible in practice and is acceptable to patients.”

“This study did not assess eventual clinical outcomes, a formidable task, but strongly suggests that a well-conducted evaluation would have a good chance of demonstrating clinical benefit if fully implemented and followed for a sufficient time,” writes Dr. Alfred O. Berg from University of Washington, Seattle, Washington in a related editorial.

Dr. Berg adds that the pathway to implementation would be rocky: “At minimum, one would need validated instruments for family history and cardiac risk; a practical way to collect, enter, and analyze the information; and systems in place to act on the information that are both acceptable to the patient and feasible for the practice.”

But he says, “This study tips the balance in that it makes the whole effort more promising—one has good reason to expect a positive payoff in quality care.”

“It is time to take systematic family history collection more seriously,” Dr. Berg concludes.


Effect of Adding Systematic Family History Enquiry to Cardiovascular Disease Risk Assessment in Primary Care

Family History Gets a Boost

Annals of Internal Medicine 2012;156:253-262,315-316.