Doctors often gloss over a key question for assessing a person's risk for coronary heart disease, according to a new study: What is the patient's family history of cardiovascular illness?
Detailed family information could help doctors better predict who is at risk and more accurately target patients for preventive care that may help avert the disease altogether, according to a recent study, published in the Annals of Internal Medicine. Routinely tracking family history sharply boosted the number of people in the study considered at high risk for heart disease.
A widely used scorecard for measuring heart risk, the Framingham Risk Score, fails to take family history directly into account. And while many doctors currently collect some information about the health of their patients' families, the data often lack the detail to be clinically useful for assessing risk and prescribing care.
"Family history remains one of the most important predictors of an event for an individual," says Donna Arnett, a genetic epidemiologist at the University of Alabama at Birmingham and president-elect of the American Heart Association. Still, "most of the family history that we're collecting is just the presence or the absence of heart disease, not the age of onset or the type of disease," says Dr. Arnett, who wasn't involved in the latest research.
Guidelines for heart-risk screening, issued by the heart association in late 2010, encouraged doctors to take family histories into account. Doctors sometimes make judgment calls to treat people as high risk because of family history, even if it isn't part of the patient's risk score.
Family history has been linked to higher risk for a number of illnesses, including cancer and diabetes. Unlike some other diseases, however, clear genetic markers for coronary heart disease, which accounts for 1 in 6 U.S. deaths, remain elusive. Family histories can be used as a proxy for detailed genetic work that may someday be used to help predict heart-disease risk, researchers say.
Another risk-measurement tool, known as the Reynolds Risk Score, developed by Harvard University researchers in the 1990s, does consider if a patient's parent had a heart attack and at what age. However, many medical practices don't yet use the tool, which became available in 2007.
Using the Reynolds system, the researchers tracked 25,000 initially healthy patients over a decade. They found that a 50-year-old male patient who, among other things, smoked, and had high blood pressure and cholesterol, but no family history of heart disease, had a 12%, or moderate, chance of having a heart attack in the 10-year period. But a similar patient with a parent who had a heart attack before age 60 had a 20% risk, putting that patient at high risk for heart disease. Heart risk wasn't significantly affected in patients with a parent who had a heart attack at the age of 60 or older.
Still, many medical practices continue to rely on the older Framingham Risk Score, which became available in the 1990s. Researchers believed that other factors, including blood pressure and cholesterol levels, provided all the information needed to determine a patient's risk for heart disease.
Primary-care doctors say there are obstacles to gathering family histories from patients, including competing priorities for time in the examination room. And patients often don't know many details about their family members. In the Annals of Internal Medicine study, patients were mailed questionnaires and instructed to gather the material before seeing their doctor.
"It's a little bit of detective work," says Charles Cutler, a primary-care doctor in Norristown, Pa. Patients should make a point of knowing the health histories of their parents, siblings and grandparents, he says. To identify clues about specific diseases, however, Dr. Cutler says he sometimes asks patients questions like: "What do you remember about Grandpop's hospitalization? Were his legs swollen?"
Dominic Francis, a 37-year-old high school teacher and wrestling coach in Delaware, says his family history has forced him to be an advocate for his own health. Mr. Francis says he watches his diet and exercises regularly. Although he currently does not suffer with heart disease or heart related problems, he has discussed his paternal family history of heart disease with his doctor.
"I went to the cardiologist and said, 'I may look healthy and my numbers are all good. But my dad and his brother both had a heart attack when they were 40. For my uncle it was a fatal attack. I need to know whether I have any other risk factors that I should be aware of,' Francis says.
