Theme articleFamily-centered approaches to understanding and preventing coronary heart disease
Introduction
Recognition of the familial nature of coronary heart disease (CHD) is actually over a century old. The first mention in the English literature of its familial nature in connection with xanthomas was made by Fogge in 1873, and in 1897 Sir William Osler pointed out that angina could recur in families.1 Reports of early heart disease in pedigrees increased after the turn of the 20th century. As a consequence of developments in the field of epidemiology and cardiology, by the mid-1900s, investigators2 began to undertake more systematic population and hospital-based studies. Among the early studies were landmark papers by Thomas and Cohen3 in 1955 and Slack and Evans4 in 1966 that demonstrated the first statistically significant evidence of increased frequency of CHD for individuals with a family history of the disease.
There has been considerable progress in this field of research over the last 25 years. Some would even argue that we are quite close to having established sufficient clinical validity and utility to motivate new national standards and practices for applying family histories as a regular part of preventive medicine and public health programs. In this article, we review the importance of family history for identifying individuals and families at increased risk for CHD, discuss findings from family-centered interventions, and provide a rationale for why family history, as mundane as it might sound in this genomic era, should be considered an important measure of a person’s genomic and total environmental risk of future CHD.
Section snippets
The last 25 years of research
Literally hundreds of articles have been published on the importance of family history to prediction of CHD. The sheer mass of articles reflects the long-standing interest of investigators in using family history to explain the variation seen in cardiac events and cardiac risk assessment that is not accounted for by other traditional risk factors. Family history has been considered as both an independent risk factor for CHD5, 6, 7, 8, 9, 10 and a surrogate for coronary risk factors, such as
Defining family history
The definition of family history varies from study to study in terms of the relatives assessed (first-, second-, and third-degree relatives) and CHD endpoints investigated. The majority of studies base family history on the participant’s reports of parents’ CHD status. In general, there has been a recent trend toward including all first-degree relatives (parents, siblings, offspring) because of the importance of sibling health status in the family history. For example, a recent case–control
Family history explains a significant fraction of prevalent CHD
Case–control studies have firmly established that individuals who have had MIs or other CHD events are significantly more likely to have first-degree relatives with CHD than corresponding control groups.10, 19, 20, 21, 23 Although these studies provide evidence of the importance of a family history, they do not provide insight into the prevalence of a positive family history and its relationship to the population burden of disease.
By far the most impressive study of the usefulness of CHD family
Family history predicts future CHD
The late 1970s and early 1980s saw the emergence of the first large studies of the potential clinical utility of family history. The Western Collaborative Group prospective study involving 3524 male participants showed that subjects with any parental history of CHD had rates of MI and angina that were 2.0 times greater than those participants without a family history.25 The Rancho Bernardo California Study involving 4014 participants aged 40 to 79 years, followed prospectively for approximately
How valid is family history information?
A general problem cited by many authors is the possibility of proband recall or reporting bias when being asked for family histories. Hunt et al.28 provide one of the more detailed studies of the validity of a simple family history assessment tool as part of the Health Family Tree Study. Comparing individuals’ accounts of their relatives’ CHD to information given by the relatives themselves, the Health Family Tree questionnaires were found to have 79% sensitivity, 91% specificity, 67%
Families have many configurations
One of the most important questions involved in deciding on how to best use family history in clinical and public health practices is: How can we deal with the diverse nature of family structures? From an integrated gene–environment perspective, assessing family history should take into account biological relationships (i.e., genetically related members of a family) as well as social relationships (e.g., step-parents or adoptive parents). Cultural, social, and physical environments are often
Family history as a guide to primary prevention
By the time a parent suffers an MI in his or her fifties, his children are likely to have reached young adulthood and already started plaque development in their arteries. Early preventive measures cannot wait if they are to have a meaningful effect.35 A prognostic instrument that is easy to use, has good accuracy and predictive power, and incorporates familial knowledge is needed (e.g., the FRS could be used to estimate a 10-year CHD risk for a patient). Public health stresses prevention and
Family-centered intervention strategies
Since the mid-1970s, it has been known that spouses have significantly positive correlations for the main risk factors for CHD: smoking, body mass index (BMI), systolic and diastolic blood pressure, and lipid levels.47, 48 Moreover, it has been known for many years that social environments supportive of healthy behaviors are associated with reduced risk of CHD and are a major factor in changing negative behaviors.49 One of the earliest examples of the power of family-centered interventions has
Family history as a genomic and ecologic measure of risk
Although it is well known that family history of CHD is an indicator of future risk—even after taking into consideration traditional risk factors such age, cholesterol, smoking, and BMI—we have yet to really understand why family history persists as an important and independent risk factor.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 27, 31 Given our increased understanding of the nature of the human genome and the impact of a wide range of social and physical environments on health, family history
Ethical and legal issues
Until recently, the collection of family history information on research subjects was seen as a routine part of CHD research. According to the standard definition, family members are third parties within these studies and, moreover, some would argue that consent is not required, since the information is obtained from someone else, and the risk from holding and using the information is minimal.58 Others would argue that an investigator’s interaction with a family member (under federal Common
Future research needs
Although there has been a tremendous amount of research on the clinical utility of family history as an indicator of a person’s future risk of disease, gaps in our knowledge still need to be filled in order to move family history more centrally into public health and clinical practice. When should people be asked about their family history? How should one take and record a family history? How often should family history information be updated? What are the best ways to quantify family history
Acknowledgements
Support for this project was provided by Centers for Disease Control and Prevention grant S1957-21/21, National Heart, Lung, and Blood Institute grant HL68737, and National Institutes of Health grant HL46292.
References (60)
- et al.
History of premature coronary heart diseasean independent risk factor of myocardial infarction
J Clin Epidemiol
(1996) - et al.
Parental history is an independent risk factor for coronary artery diseasethe Framingham Study
Am Heart J
(1990) - et al.
Family history as an independent risk factor for incident coronary artery disease in a high-risk cohort in Utah
Am J Cardiol
(1988) - et al.
Family history as an independent risk factor for coronary artery disease
J Am Coll Cardiol
(1984) - et al.
A prospective study of parental history of myocardial infarction and coronary artery disease in men
Am J Cardiol
(1991) - et al.
Coronary risk associated with age and sex of parental heart disease in the Framingham Study
Am J Cardiol
(1989) - et al.
Usefulness of cardiovascular family history data for population-based preventive medicine and medical research (the Health Family Tree Study and the NHLBI Family Heart Study)
Am J Cardiol
(2001) - et al.
Family history as a risk factor for early onset myocardial infarction in young women
Atherosclerosis
(2001) - et al.
A comparison of positive family history definitions for defining risk of future disease
J Chron Dis
(1986) Epidemiology and prevention of coronary heart disease in families
Am J Med
(2000)
AHA/ACC scientific statementassessment of cardiovascular risk by use of multiple-risk factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology
J Am Coll Cardiol
The Tromso Surveythe family intervention study—the effect of intervention on some coronary risk factors and dietary habits, a 6-year follow-up
Prev Med
Correlates of family history of coronary artery disease in children
J Clin Epidemiol
Cardiovascular diseases: genetics, epidemiology, and prevention
Coronary artery disease in men eighteen to thirty-nine years of age
Am Heart J
The familial occurrence of hypertension and coronary artery disease, with observations concerning obesity and diabetes
Ann Intern Med
The increased risk of death from ischaemic heart disease in first-degree relatives of 121 men and 96 women with ischaemic heart disease
J Med Genet
Family history as an independent risk factor of coronary artery disease
Eur Heart J
Family history of coronary heart diseaseis it an independent risk factor?
Am J Epidemiol
Family history of myocardial infarction as an independent risk factor for coronary heart disease
Br Heart J
Maternal and paternal history of myocardial infarction and risk of cardiovascular disease in men and women
Circulation
Family history of heart attach as an independent predictor of death due to cardiovascular disease
Circulation
A prospective study of parental history of myocardial infarction and coronary heart disease in women
Am J Epidemiol
NHLBI Family Heart Studyobjectives and design
Am J Epidemiol
Family history of heart attacka modifiable risk factor?
Circulation
Family risk score of coronary heart disease (CHD) as a predictor of CHDthe Atherosclerosis Risk in Communities (ARIC) study and the NHLBI Family Heart Study
Genet Epidemiol
Family history as a risk factor of coronary heart disease in patients under 60 years of age
Eur Heart J
Role of family history in patients with myocardial infarctionan Italian case-control study
Circulation
Myocardial infarction in women under 50 years of age
JAMA
Relation of family history and reversible risk factors to coronary heart disease prevalence in an Afrikaner community
Arterioscler Thromb
Cited by (64)
3.20 - Dissecting Human Microbiome for Personalized Therapy
2022, Comprehensive Gut MicrobiotaThe Role of Family Health History in Predicting Midlife Chronic Disease Outcomes
2021, American Journal of Preventive MedicineCitation Excerpt :The intergenerational transmission of health represents a variable contribution from heritable factors and mutual health behaviors, values, and beliefs. The risks for conditions such as heart disease, diabetes, cancer, and depression run in families11,13–16; however, the relative value ones’ FHH contributes to the prediction of disease occurrence remains a source of debate. For example, parental history of cardiovascular disease (CVD) is an established risk factor for heart disease in adult offspring,17–19 and cardiovascular risks track across parent and offspring generations.20,21
Screening for Atherosclerotic Cardiovascular Disease in Asymptomatic Individuals
2018, Chronic Coronary Artery Disease: A Companion to Braunwald's Heart DiseaseAssociation between family history of diabetes and cardiovascular disease and lifestyle risk factors in the United States population: The 2009–2012 National Health and Nutrition Examination Survey
2017, Preventive MedicineCitation Excerpt :Both diabetes and cardiovascular disease have known genetic susceptibility among progeny. However, evidence suggests that lifestyle behaviors play a major role in influencing the risk of disease, particularly among susceptible individuals (Lauer, 1999; Williams et al., 2001; Harrison et al., 2003; Colditz et al., 1991; Kardia et al., 2003; Hunt et al., 2003). Therefore, the significance of family history as a way of identifying individuals who should receive more intensive lifestyle modification counseling by health care providers should be a priority.
Screening for Atherosclerotic Cardiovascular Disease in Asymptomatic Individuals
2017, Chronic Coronary Artery Disease: A Companion to Braunwald's Heart Disease