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EDITORIALS: Peter Brindle and Tom Fahey Primary prevention of coronary heart disease BMJ 2002; 325: 56-57 [Full text]

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CAD Primary Prevention: it is necessary a new Weltanschauung.

Sergio Stagnaro   (12 July 2002)

Informed choices are indeed a long way off

Diane Reeves   (16 July 2002)

CAD Primary Prevention: it is necessary a new Weltanschauung. 12 July 2002
Sergio Stagnaro, Specialist in Blood, Gastrointestinal and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio N° 23/8 Send response to journal: Re: CAD Primary Prevention: it is necessary a new Weltanschauung.	Sirs, I agree completely with recommending that general practitioners and primary healthcare teams should identify all people at significant risk of cardiovascular disease, but who have not yet developed symptoms, and offer them appropriate advice and treatment to reduce their risk. However, how can general practitioners, who know and use only the old, traditional physical semeiotics, do it? Aiming to prevent CAD on very large scale, we need to can use a new physical tool easy to apply and reliable in recognizing individuals at "real" risk for such a disorder, who must undergo suddenly to correct diet, ethymologically speaking, including physical excercise, in order to mantain body weight (BMI) in normal ranges. In other words, it is necessary for us a new Weltanschauung. (See the site, HONCode ID., N° 233736, http://digilander.libero.it/semeioticabiofisica, “Biophysical Semeiotic Constitutions”). Notoriously, a major cause of decline in quality of life of patients already involved by cardiovascular disease, e.g. Cardiac Heart Failure (CHF), is reduced exercise tolerance. Exercise intolerance in patients with CHF is a result of several factors, including poor left ventricular function and abnormal peripheral factors such as blood flow, skeletal muscle changes, and ventilatory dysfunction (1). A large number of well- known randomized trials report the benefits of exercise training in both health, but at CAD risk, and cardiovascular “patient”. To the best of my knowledge, however, neither the exact effects in healthy subject at “real risk” for CAD, nor the real action mechanisms in patient involved by CAD are now-a-days completely known. As a matter of fact, as I illustrated in previous papers, physical training, such as walking,120 paces/min.for 1 h., brings about three important effects also in “healthy” individual, involved by diabetic and/or hypertensive and/or arteriosclerotic (especially coronary) constitution: first of all, it ameliorates endothelial cells functions (2, 3, 4), improving “gradient shear stress”, and, in turn, causing physiological distribution of endothelial membrane “adhesion points”, which play notoriously a primary role in normal endothelial cell functioning. Moreover, the above-illustrated exercise training stimulates ubidecarenone synthesis, activating CoQ10 mithocondrial cycle, in both endothelial and scheletric muscle cells (5). Finally, physical exercise, I suggested to my patients, both at CAD risk and already diseased, ameliorated significantly Insulin Resistance biophysical-semeiotic syndrome, as far as to normalize it (4). Sergio Stagnaro MD, Active Member NYAS. References. 1) American Heart Association. Heart and Stroke Statistical Update (2000). Dallas, Tex: American Heart Association; 2000. p. 15. 2) Stagnaro S., Diagnosi percusso-ascoltatoria delle alterazioni emoreologiche precoci nelle arteriopatie periferiche clinicamente silenti. I Congr. Naz. Soc. It. di Emoreologia. Atti, pag. 51. 30 Giugno-2 Luglio, 1982, Siena. 3) Stagnaro-Neri M., Stagnaro S., Auscultatory Percussion Evaluation of Arterio-venous Anastomoses Dysfunction in early Arteriosclerosis. Acta Med. Medit. 5, 14, 1989. 4) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning and Myocardial Oxygenation evaluated clinically with the aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta Med. Medit. 13, 109, 1997. 5) Stagnaro-Neri M., Stagnaro S., Acidi grassi Omega-3, scavengers dei radicali liberi e attivatori del ciclo Q e della sintesi del Co Q10. Gazz. Med. It. – Arch. Sc. Med. 151, 341,1992 (Infotrieve). 6) Stagnaro S.-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzione diabetica. Il ruolo della Carnitina nella prevenzione del diabete mellito. Il Cuore. 6, 617 (Pub-Med indexed for Medline)
Informed choices are indeed a long way off 16 July 2002
Diane Reeves, Hon. clinical senior lecturer University of Birmingham, B15 2TT, UK Send response to journal: Re: Informed choices are indeed a long way off	Brindle and Fahey are correct in their assertion that 'involving patients in making genuinely informed choices about coronary heart disease screening seems a long way off'. However, it is not simply a lack of evidence of benefit which prevents patients from making informed choices. Earlier in their editorial they state that 'once an estimate has been made of a patient's risk...a dialogue needs to be started...to enable an informed decision to be made'. If clinicians genuinely want to promote informed choice for patients then the discussion of risks, benefits and possible outcomes needs to happen before any risk assessment takes place, not afterwards. Patients agreeing to an initial screening tests (such as blood pressure or lipid profile) are often seen as inherently agreeing to further investigation or treatment if the tests show high risk (1).Because of the power differentials inherent in the nature of the doctor patient relationship it is often difficult for patients to refuse further intervention once initial tests have been taken. Much of the adverse effects of screening such as false reassurance and unnecessary anxiety occur at the initial stage of risk factor assessment. The GMC is quite clear in it's directions to clinicians that information on uncertainties and risks of screening should be discussed with patients prior to screening (2). Health care professionals therefore need to have the discussion about the risks and benefits of cardiovascular risk factor screening with people before any risk factor assessment occurs. The implications of this for clinical practice are huge, given the common practice in primary care of assessing risk factors such as blood pressure opportunistically and with little prior discussion, and the large amount of time any adequate discussion of relevant evidence would take. 1. Foster P (1998) "Informed consent in practice" in Sheldon S, Thomson M (eds) (1998) Feminist perspectives on health care law, London, Cavendish. 2. GMC (1999) Seeking patients' consent: the ethical considerations, London, GMC.