PubMed · 14697487
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William Clifford Roberts. 2004-01-01. Miscellany.. https://doi.org/10.1016/j.amjcard.2003.09.001
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This paper examines a brief preventive intervention as a model for embedding public health action in primary care. BACKGROUND: Low fruit and vegetable intake is a major risk factor for cancer, coronary heart disease and stroke. The recommended intake of five portions per day would reduce death rates from these causes by 20%. However, average daily consumption in the UK is under three portions, and it is significantly lower in men, young people and lower socio-economic groups. In order to tackle risk factors such as poor diet, the white paper Choosing Health promises action and funding to mainstream prevention and transform the NHS from a sickness service to a genuine health service. THE INTERVENTION: To promote increased fruit and vegetable consumption, primary care professionals working in a deprived area issue prescriptions which offer the patient discounts on fruit and vegetable purchases. Hand over of each prescription to the patient is linked explicitly to key five a day messages. This brief intervention takes 1-2 min to deploy. IMMEDIATE OUTCOMES: Evaluation is ongoing. However, early feedback suggests that the intervention of prescription plus key messages has a significant impact on patients in highlighting the connection between food and health. Clinicians express satisfaction at having a preventive intervention that can be deployed with confidence and consistency in routine primary care consultations. DISCUSSION: This brief intervention is presented as a potential model for embedding prevention in the day-to-day work of health professionals. Primary care is a natural setting for the promotion of health, but despite success in implementing some public health programmes, it has a patchy record in primary prevention. The reasons for this are examined, the impact of new contractual and commissioning levers is explored, and a general framework for mainstreaming public health action in primary care is proposed.
BACKGROUND: We previously demonstrated that reduced vagal activity and/or increased sympathetic activity identify post-myocardial infarction patients at high risk for cardiac mortality. Simple and inexpensive autonomic markers are necessary to perform autonomic screening in large populations. We tested our hypothesis that abnormally elevated heart rate (HR) responses at the onset of an exercise stress test, which imply rapid vagal withdrawal immediately preceding sympathetic activation, might predict adverse cardiac events in patients with documented coronary artery disease. METHODS AND RESULTS: The HR increase during the first minute (DeltaHR1 minute) of a symptom-limited exercise stress test was quantified in 458 patients with documented coronary artery disease. During a 6-year (interquartile range 3.7 to 9.0 years) follow-up, 71 patients experienced adverse cardiac events (21 cardiac deaths, 56 nonfatal myocardial infarctions). In univariate analysis, DeltaHR1 minute > or =12 bpm (above the median value of its distribution) predicted both adverse outcome and cardiac death with a hazard ratio of 5.0 (95% CI 2.7 to 9.1; P<0.0001) and of 15.6 (95% CI 2.0 to 118.7; P<0.001), respectively. After adjustment for potential confounders, DeltaHR1 minute remained predictive for both combined end points and for cardiac death. CONCLUSIONS: A marked HR increase at the onset of a standard exercise stress test is a novel and easily available parameter that could be clinically useful as an independent predictor of adverse cardiac events, including death, among patients with documented coronary artery disease.
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