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Presents several letters to the editor responding the articles and editorials appearing in the "British Medical Journal.' Topics of letters including racism in healthcare, spirituality and clinical care, a national service framework for diabetes, cardiovascular risk tables in assessing patients with diabetes, getting medical consent and the use of deception by researchers, heart failure clinics, and congestion charging.

SummaryBackground: The revolution in coronary care in the mid-1980s to mid-1990s corresponded with monitoring of coronary heart disease (CHD) in 31 populations of the WHO MONICA Project. We studied the impact of this revolution on coronary endpoints.Methods: Case fatality, coronary-event rates, and CHD mortality were monitored in men and women aged 35-64 years in two separate 3-4-year periods. In each period, we recorded percentage use of eight treatments: coronary-artery reperfusion before, thrombolytics during, and Beta-blockers, antiplatelet drugs, and angiotensin-converting-enzyme (ACE) inhibitors before and during non-fatal myocardial infarction. Values were averaged to produce treatment scores. We correlated changes across populations, and regressed changes in coronary endpoints on changes in treatment scores.Findings: Treatment changes correlated positively with each other but inversely with change in coronary endpoints. By regression, for the common average treatment change of 20, case fatality fell by 19% (95% CI 12-26) in men and 16% (5-27) in women; coronary-event rates fell by 25% (16-35) and 23% (7-39); and CHD mortality rates fell by 42% (31-53) and 34% (17-50). The regression model explained an estimated 61% and 41% of variance for men and women in trends for case fatality, 52% and 30% for coronary-event rates, and 72% and 56% for CHD mortality.Interpretation: Changes in coronary care and secondary prevention were strongly linked with declining coronary endpoints. Scores and benefits followed a geographical east-to-west gradient. The apparent effects of the treatment might be exaggerated by other changes in economically successful populations, so their specificity needs further assessment. [ABSTRACT FROM AUTHOR]

The article presents information on the use of Framingham Risk Score and others to estimate the cardiovascular risk of an individual the in Great Britain. According to the author, application of a Framingham score with large social gradients in disease will result in relative under-treatment of socially deprived, and over-treatment of the socially privileged. It is suggested that to be efficient and effective, focus should be on those at highest risk by medical interventions.