Peking university health science center College of Public Health, Wang Peiyu, Liu Aiping
Cardiovascular diseases, including coronary heart disease and stroke, have become the main diseases that endanger human health and bring heavy economic and mental burdens to individuals, families and society.
Risk factors of cardiovascular diseases are common in the population, such as hypertension, hyperlipidemia, hyperglycemia, obesity, smoking and so on. Health risk assessment is an effective method to identify high-risk groups; Risk assessment itself is also an incentive mechanism for health management; Intervention on risk factors can effectively reduce health risks, thus delaying the occurrence of diseases.
I. Health management and health risk assessment
Health management is a process of overall management of health risk factors of individuals or groups. Its purpose is to mobilize the enthusiasm of individuals, collectives and society, make effective use of limited resources and achieve the maximum health effect [1]. Health risk assessment is a key technical part in the process of health management, which can only be achieved through health management. It is the first step of chronic disease prevention, also known as risk prediction model. Based on a large number of personal health information collected, it analyzes and establishes the quantitative relationship between lifestyle, environment, heredity and other risk factors and health status, predicts the possibility of an individual suffering from a certain disease or dying from a certain disease in a certain period of time, and accordingly provides targeted control and intervention according to the needs of the crowd, thus helping the government, enterprises, insurance companies and individuals to achieve the maximum health effect at the lowest cost.
The most commonly used method of health risk assessment is multi-factor model method, which is based on multi-factor mathematical analysis, that is, the relationship model between disease risk and risk factors is obtained by using statistical probability theory, which can contain multiple risk factors at the same time, and the commonly used methods are multiple regression (logistic regression and Cox regression).
Two. Progress in cardiovascular disease risk assessment
The progress of cardiovascular disease prevention practice is largely due to the study of various risk factors (such as hypertension, hypercholesterolemia, diabetes, obesity, etc.). ), its onset is the result of the comprehensive action of many risk factors. How to comprehensively evaluate the absolute risk of cardiovascular diseases in the future according to the levels of various risk factors, so as to carry out different intensity interventions for patients with different risk levels, is a hot spot in the field of cardiovascular prevention and treatment at present. The cardiovascular disease risk prediction model takes morbidity or mortality as the dependent variable and risk factors as the independent variable, and establishes regression equations through logistic regression and Cox regression to predict the possibility (that is, absolute risk) of cardiovascular disease morbidity or mortality in a certain time in the future (5 years or 10 years). Because the result of the equation reflects the comprehensive risk of individual main risk factors, it is also called total risk. Absolute risk is to adjust Cox survival function according to the average risk factor level and average incidence rate of the population. For example, the formula for calculating the incidence risk probability (P) in 10 year is:
Among them, β 1 to βp are the partial regression coefficients of different risk factors, x 1…xp is the level of each risk factor, and M 1…Mp is the average level of each risk factor in this population. S0 (t) is the average survival function at time t (such as 10 year), that is, the survival function at the average level of risk factors.
From 65438 to 0993, New Zealand became the first country to introduce "comprehensive risk" in hypertension management [2]. In the same year, the National Cholesterol Education Program (NCEP) proposed to combine the management of blood lipids with the management of other cardiovascular risk factors [3]. Later, the European Heart Association, the European Atherosclerosis Association and the European Hypertension Association put forward the comprehensive risk of multiple risk factors as the main standard of antihypertensive and lipid-lowering treatment in the Guidelines for the Prevention and Treatment of Coronary Heart Disease [4], and many international cardiovascular disease associations adopted the concept of comprehensive risk in the guidelines for disease prevention and treatment, and applied it in practice [5-8].
The typical representative of cardiovascular disease risk prediction model is the coronary heart disease risk prediction model established by Framingham Heart Research [9], which is used to predict the probability of coronary heart disease risk of individuals with different risk levels in a certain period (such as 10 years). Based on the risk assessment model established by Framingham Heart Research, western countries have formulated comprehensive risk assessment guidelines suitable for their own countries [10]. Because the Framingham heart research object is white Americans, some studies show that its prediction results are not applicable to all people (people from different regions or races) [1 1- 12]. Therefore, many countries and regions have established their own forecasting models with their own research queues [13- 15].
Three. Current Situation of Cardiovascular Disease Risk Assessment in China
In China, because the disease spectrum and epidemic characteristics of cardiovascular risk factors are obviously different from those in western developed countries [16- 17], a risk prediction model suitable for China population was developed in 2003. The main research contents include:
1. Based on "China 1 1 provincial cohort study population" established by Beijing Cardiopulmonary Vascular Research Institute 1992, Cox proportional hazard model was used for multivariate analysis of risk factors and morbidity risk [18], with coronary heart disease and ischemic stroke as predictive indicators. Taking age, blood pressure, TC, HDL-C, smoking and blood sugar as the main parameters, a prediction model of coronary heart disease and ischemic stroke in both sexes was established, and the absolute risk of coronary heart disease and ischemic stroke in 10 was calculated by using this model. The results show that the absolute risk of ischemic cardiovascular disease increases with the increase of the number of risk factors, and there are synergistic effects among different risk factors. The absolute risk distribution of ischemic cardiovascular disease among people aged 35-64 in China is as follows: risk probability
2. National Tenth Five-Year Plan "Study on Comprehensive Risk Assessment and Intervention Scheme of Coronary Heart Disease and Stroke" [20-2 1]. Considering that China is a country with a relatively low incidence of coronary heart disease and a relatively high incidence of stroke, if the comprehensive risk of cardiovascular diseases of individuals or groups is measured by the risk of coronary heart disease, it will obviously underestimate its risk to a great extent and cannot attract people's due attention. It is also found that the main risk factors of coronary heart disease and ischemic stroke are basically the same, and the contribution order of each risk factor to the onset is also the same. In order to better reflect the risk of cardiovascular disease in China population, according to the follow-up data of the Sino-US cooperative epidemiological study cohort, the joint end point of coronary heart disease and ischemic stroke is called ischemic cardiovascular event (that is, if an individual has both coronary heart disease and ischemic stroke, it is only recorded as 1 ischemic cardiovascular event).
Cox proportional hazard model was adopted in this study, with ischemic cardiovascular events as dependent variables and six major risk factors such as age, systolic blood pressure (SBP), body mass index (BMI), serum total cholesterol (TC), diabetes mellitus (GLU) and smoking as independent variables to fit the optimal gender-specific prediction model. In addition, the risk factors of continuous variables are transformed into grouped variables to fit a simple tool for comprehensive risk assessment of cardiovascular diseases in China. The tool determines the scores of different risk factors according to the regression coefficients of each risk factor at different levels in the simple prediction model, and the sum of all risk factors' scores corresponds to the absolute risk of ischemic cardiovascular events in 10 year. For example, a 50-year-old male, with blood pressure 150/90mmHg, body mass index of 25 kg/m2 and total serum cholesterol of 5.46mmol/L, smokes and has no diabetes. The assessment steps are as follows: Step 1: Age 50 =3, SBP 150mmHg=2, body mass index 25kg/m2= 1, TC5.46mmol/L= 1, smoking =2, and no diabetes =0. Step 2: The total score is 3+2+ 1+ 1+2+0=9 points. Step 3: The absolute risk of 10 ICVD corresponding to 9 points in the table is 9.6%.
At the same time, the study calculates the area under ROC curve by using independent population regression test, which proves that the model has strong forecasting ability and can well reflect the comprehensive risk of cardiovascular diseases in China.
In 2005, Qingdao People's Hospital used this assessment tool to assess the risk of cardiovascular disease in 2287 middle-aged cadres, and discussed the clinical application value of this assessment method. This evaluation method can accurately detect the incidence distribution of the population, which is conducive to the simple screening of high-risk groups. In the low-risk population, according to the average risk and minimum risk of different age groups, the absolute risk of individuals is calculated to evaluate their relative risk [23].
In addition, the Institute of Cardiovascular Epidemiology of Fuwai Hospital of Peking Union Medical College Hospital took 4,400 male capital steel workers as the research object, followed up for an average of 65,438 03.5 years, and established risk prediction models of coronary heart disease, ischemic stroke and hemorrhagic stroke by using Cox proportional hazard model [22].
With the change of chronic disease prevention and control strategy to comprehensive risk high-risk population strategy in China, the research field of disease occurrence risk prediction model will be further expanded.
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