Perceptions of cardiovascular risk among patients with hypertension or diabetes

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Abstract

We aimed to examine risk perceptions among patients at moderate to high cardiovascular risk. A questionnaire about perceived absolute risk of myocardial infarction and stroke was sent to 2424 patients with hypertension or diabetes. Response rate was 86.3% and 1557 patients without atherosclerotic disease were included. Actual cardiovascular risk was calculated by using Framingham risk functions. A total of 363 (23.3%) of the 1557 patients did not provide any risk estimates and these were particularly older patients, patients with a lower educational level, and patients reporting no alcohol consumption. The remaining 1194 patients tended to overestimate their risk. In 42.3% (497/1174) and 46.8% (541/1155) of the cases, patients overestimated their actual 10-year risk for myocardial infarction and stroke, respectively, by more than 20%. Older age, smoking, familial history of cardiovascular disease (CVD), and actual absolute risk predicted higher levels of perceived absolute risk. Male sex, higher scores for an internal health locus of control, lower scores for a physician locus of control, and self-rated excellent or (very) good health were positively related to higher accuracy. In conclusion, patients showed inadequate perceptions of their absolute risk of cardiovascular events and physicians should thus provide greater information about absolute risk when offering preventive therapy.

Introduction

The benefits of treatment with aspirin, statins, or antihypertensive drugs depend on a patient’s risk of cardiovascular disease (CVD). The absolute risk reduction by such treatment increases with pretreatment absolute risk [1], [2], [3]. As a consequence, current recommendations for the use of aspirin, statins, and antihypertensive drugs are based on specific thresholds of absolute risk [4], [5].

The purpose of the present study was to examine risk perceptions among patients with hypertension or diabetes but no known atherosclerotic disease. We explored the ability to estimate absolute cardiovascular risk and we also examined the levels and accuracy of perceived absolute risk. Of particular interest were patient’s perceptions of their 10-year risk of myocardial infarction and stroke.

Decisions with regard to whether to take medications or not should be jointly made between patients and physicians [6]. Shared decision making respects the autonomy of the patient and may improve patient satisfaction [7], [8], well-being [9], and even health outcomes [9]. Shared decision making is considered particularly appropriate for problems involving medical uncertainty [10]. Whether an individual patient will actually benefit from preventive therapy of CVD is often uncertain and shared decision making is, therefore, an important issue in preventive cardiology. The patient and the physician should discuss the level of the patient’s absolute cardiovascular risk, the actual harm of cardiovascular events, and the absolute risk reduction which can be achieved by treatment. The decision to take medications should be jointly made and physicians may handle the process of shared decision making better when given insight into patient’s perceptions of absolute risk.

Insights into risk perceptions are particularly relevant with regard to patients with hypertension or diabetes but no known atherosclerotic disease. The absolute risk of patients with atherosclerotic disease is very high and their benefits of preventive drug treatment will therefore generally surpass any arguments against such treatment. Patients with hypertension or diabetes but no known atherosclerotic disease are at moderate to high cardiovascular risk and thus require jointly made decisions with regard to the initiation, continuation, and adjustment of treatment with aspirin, statins, or antihypertensive drugs. Middle-aged people selected from the general population have been found to be overly optimistic when estimating their relative risk of having a cardiovascular event (i.e. their risk compared to other people of the same age and sex) [11], [12]. Another study showed that healthy people between the ages of 65 and 79 overestimate the absolute risk of stroke for hypothetical patients with hypertension [13]. In the latter study, the people estimated the risk with help of a visual aid and trained research assistants. Just how accurately patients with hypertension or diabetes but no known atherosclerotic disease estimate their absolute risk of a cardiovascular event without the help of a health professional is currently not known.

Physicians may be better able to tailor the provision of risk information to patients when better informed about the factors which determine the risk perceptions of patients. In previous studies in the general population, self-reported risk factors and actual absolute risk have been found to be related to the level of perceived relative risk, while age, self-rated health, and educational level have been found to be related to the accuracy of perceived relative risk [11], [12]. It is very possible that these factors are also related to the level and accuracy of perceived absolute risk among patients with hypertension or diabetes. A patient’s cardiovascular risk is associated with internal and external factors (for example, age, gender, lifestyle, medical treatment, and chance) and we therefore have assumed that health locus of control (i.e. the extent to which patients attribute health and disease to internal and external factors) may be related to risk perceptions as well. Furthermore, lifestyle (smoking, body mass index) has been found to be related to perceived risk [11], [12], and we also therefore have assumed that alcohol consumption may be related to risk perceptions.

Section snippets

Study design and patients

The survey was carried out in 1999 after a randomised controlled trial was conducted in 124 general practices in The Netherlands. The 21-month trial examined the effects of a multifaceted intervention on the structure and process of cardiovascular and diabetes care [14]. The practices were randomly allocated to receive intensive support (feedback reports and outreach visits from facilitators) or no special attention. The intervention did not address cardiovascular risk perception. At baseline,

Study population

A total of 2093 patients returned their questionnaires, which represents a response rate of 86.3%. A total of 1557 patients remained after inclusion of only those patients 80 years or younger and not reporting a history of atherosclerotic disease. Patient characteristics including actual risk are displayed in Table 1. A total of 1130 patients were labelled by the practice teams as having hypertension and 1102 (97.0%) of these patients reported a history of high blood pressure; 450 patients were

Discussion

Patients with hypertension or diabetes but no known atherosclerotic disease appeared to have inadequate perceptions of their absolute risk of cardiovascular events. One-fourth of the patients did not provide any risk estimates and these were particularly older patients, patients with a lower educational level, and patients reporting no alcohol consumption. Almost 50% of the remaining patients overestimated their absolute risk by more than 20%. The level of perceived risk of myocardial

Acknowledgements

This study was supported by a research grant from The Netherlands Heart Foundation. We would like to thank all the patients, general practitioners, and practice assistants who participated in the study.

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