The Widening Role of Family Medicine in Cardiovascular Risk Control Improvement

Mini Review

J Fam Med. 2015;2(2): 1023.

The Widening Role of Family Medicine in Cardiovascular Risk Control Improvement

Mirjana Rumboldt* and Dragomir Petric

Department of Family Medicine, Split University School of Medicine, Croatia

*Corresponding author: Mirjana Rumboldt, Split University School of Medicine, Department of Family Medicine, Croatia

Received: March 25, 2015; Accepted: March 27, 2015; Published: March 30, 2015


Although theoretically very effective and apparently quite straightforward, cardiovascular prevention in practice leaves much to be desired. Several reasons, including psychological, ethical, conceptual, and operative issues are involved resulting in the current situation, where lifestyle changes are mostly ignored, overdiagnosis and overtreatment are expanding, so that drug therapy is often prescribed with no good reason, and performed in an episodic or on/ off pattern. In this essay analyzed are the reasons for these aberrations and suggested are some intuitive solutions and opportunities, best fitted to family medicine.

Keywords: Cardiovascular disease; Prevention; Family medicine


The expanding knowledge about etiology, prevention, and management of cardiovascular diseases has pawed the way to radical reduction in the prevalence of these disorders [1]. Indeed, several years ago the global community was seemingly approaching the eradication of atherosclerosis, the leading cause of cardiovascular morbidity and mortality. Unfortunately, the reality did not meet the expectations: the decrease in coronary heart disease in developed countries is nowadays stagnant at best [2], and probably increasing [3], while escalating in developing and transitional countries [4]. This glum picture is often attributed to unavailability or delay in application of modern invasive procedures and new medications, particularly in the case of heart attack or stroke. Although this segment of management should not be neglected (e.g. quick and reliable diagnosis, prompt treatment initiation in family practice, faster transportation, better organization and distribution of adequately staffed and well equipped interventional units), the bulk of the problem lies at the other end of the clinical spectrum – in unsatisfactory prevention. Indeed, according to the EURASPIRE III results the prevalence of obesity among coronary patients in Europe has increased in the last decade from 25% to 38%, and that of diabetes from 17.4% to 28%, while smoking and hypertension are keeping the same level, about 20 and 60%, respectively [5].

Which are the obstacles on the path of effective CHD prophylaxis, particularly primary prevention, i.e. adequate protection of apparently healthy, relatively young people against adverse cardiovascular events? In the following paragraphs analyzed are some of the most prominent issues from the family physician’s standpoint, partly skewed due to our view from Croatia, a transitional, post communist country.

Low perception of deferred risk

Most patients will request urgent medical attention for acute, painful, but minor chest conditions, such as intercostal neuralgia or a similar musculoskeletal disorder. On the other hand, chronic conditions, such as arterial hypertension or dyslipidemia, are much less alarming, often do not hurt at all, and their management, especially primary prevention consisting of adequate nutrition, avoidance of weight gain, exercise and/or smoking cessation is mostly ignored or performed from time to time at best. The reasons for this divide are probably psychological [6]: notwithstanding often good theoretical knowledge of the problem, practical execution leaves much to be desired because human perception of deferred risk is considerably inferior to the appreciation of imminent danger. For this reason people unwillingly apply seatbelts, and put them on more for the fear of being fined than for the statistically tiny, but individually immense risk in the case of a car crash. More than twenty years ago we have shown in a field investigation that declaratively appropriate and cost-effective measures in the management of arterial hypertension are seldom operatively implemented in daily practice [6]. Within the medical profession, as among patients and population at large there is a vast gap between words and deeds.

Ethical issues

From the middle of the past century the human rights movement is rapidly expanding, which is good and quite understandable after incredible crimes against human dignity have been committed, not only during World War II but previously and subsequently alike [7]. Patient autonomy should be respected whenever possible, and the traditional, paternalistic doctor-patient relationship replaced by a kind of negotiating, mutually agreeable partnership, with informed consent as one of its cornerstones. It seems however that modern society is moving towards the other extreme: while striving for human rights, the dues are almost neglected. Although these components of moral judgment should stay in balance – more rights beget more obligations – the ethics of rights is overruling the ethics of responsibilities [7]. It is increasingly overlooked that individual rights are limited by the rights of the neighbors and the community at large, so that current moral judgment is focusing more closely on individual than on collective interest. Personal responsibility for careless and hazardous life-style is left out in the cold, but in the case of misfortune instead of silent suffering the health problem is suddenly and vociferously socialized, requesting costly treatment at the expense of solidarity. These inconsistencies in ethics should be corrected if adequate and coherent attitudes towards health care in the community are contemplated.

Cardinal role of risk factors

A number of large investigations, from the Framingham cohort to the recent INTERHEART case-control study [4,8], have clearly demonstrated that CHD is uncommon without concurrent or antecedent exposure to one or more major risk factors. With the clustering of these factors the probability of CHD complications increases exponentially [4,9] (Figure 1). Unfortunately, these plain and simple notions, explaining over 90% of the global coronary risk [9], often go unknown or ignored. A straightforward evaluation of cumulative individual risk, emanating from these studies, is widely disseminated (charts, calculators etc.) and easily accessible to family practitioners, sometimes even overestimating the risk [10]. Although it is scientifically sound to investigate additional, novel risk factors, improvement in population levels of several “conventional” risk factors remains the main goal of scientific elucidation and practical enforcement [4].