Carolyn Thomas: Yet another cardiac risk calculator?

carolyn_thomasTo see for myself how reliable the new NHS heart disease risk calculator is, I completed all required fields exactly as I would have answered seven years ago. That was just before I survived what physicians still call “the widowmaker heart attack,” caused by a fully occluded left anterior descending coronary artery. (By the way, note the gender biased semantics here: they don’t call my kind of heart attack the “widowermaker,” do they?)

The new risk calculator results were encouraging. Apparently, I could “expect to live to age 83 without a heart attack or stroke!

Only off by three decades . . .

Critics of the new online tool also worry that it may not only miss people like me entirely, but also mistakenly scare otherwise healthy people to take statins (thus echoing critics of the controversial ACC/AHA calculator in 2013 that basically used the “Do you have a detectable pulse?” qualifying question to warrant a statin prescription).

I had my own myocardial infarction in my 50s. At the time, I was your average healthy, happy middle-aged professional woman who had been a distance runner for 19 years. While recuperating in the coronary intensive care unit afterwards, I asked: “How could this have happened to ME?

What nobody told me then as a freshly diagnosed heart patient was that pregnancy complications many years earlier had increased my subsequent heart disease risk by 2-3 fold. As the Dutch obstetrician Eric Steegers told a Toronto conference audience last fall, reproductive disorders like preeclampsia are “a short term problem for the OB-GYN, but a long term problem for the cardiologist.” (Meeke Hoedjes et al 2012).

Yet out of all the cardiac risk calculators I’ve seen (and there are many), I’ve yet to see even one that asks about pregnancy complications.

If the NHS calculator really wanted to figure this out, it would ask about healthy sleep habits. Or what about the endothelium damaging dangers of living with chronic stress? It didn’t even ask me if or when I exercise, or if I follow a heart smart Mediterranean diet (the most widely studied cardioprotective way to eat).

In short, lifestyle based contributors to heart disease risk are nowhere to be found.

As cardiologist Aseem Malholtra told The Telegraph: “It is a pretty crude evaluation to only use weight as a proxy for lifestyle.

John Deanfield, an NHS cardiologist who helped develop the tool, has called this risk calculator a “wake-up call” that could “nudge” people to make lifestyle changes to improve heart health.

But let’s examine how well we’re doing so far in convincing even those who are already diagnosed with heart disease to make these important changes.

In the PURE study (Teo et al, JAMA, 2013), for example, researchers followed over 7500 heart attack survivors in 17 countries. They found that:
48% of smokers continued to smoke.
• 65% did not exercise.
• over 60% did not improve their diet.
• 14% had adopted not one single lifestyle improvement.

Again, these were people already living with serious, life threatening cardiac conditions.

Finally, a heart disease risk calculator is only as good as its predictive accuracy. And as health journalist Michael O’Riordan of TheHeart.Org astutely asked during the American Heart Association’s scientific meetings in Dallas, while discussing the much ballyhooed US calculator:

How do you have a serious discussion about the patient’s risk if the risk calculator doesn’t accurately calculate risk?

Here’s what I now tell my women’s heart health presentation audiences: why not live your life assuming that you are ALL at very high risk of having a heart attack? There is simply no downside in starting today with a healthier diet, adding more physical activity, not smoking, getting a good night’s sleep, managing your stress, your weight, or your blood pressure. And not because you don’t want to have a heart attack (that’s what psychologists call an “avoidance goal”) but because from now on, you want to feel and look great (an “approach goal”).

You don’t need to wait for yet another cardiac risk calculator to tell you to just start.

Competing interests: I declare that I have read and understood the BMJ Group policy on declarations of interest and I have no relevant interests to declare—except that I do not use a cardiovascular disease risk calculator anymore.

Carolyn Thomas is a heart attack survivor, women’s health activist, and blogger at Heart Sisters.