Transport for primary PCI in AMI: one-way or roundtrip journey?

We welcome the contribution from Drs Assman, Cullen, Hense and Schulte. The issues which they raise are among the many which were debated at the SCORE project workshops, and, indeed, we gratefully acknowledge the participation of Drs Cullen and Schulte in these workshops. Their views are given added significance as three of the four authors have themselves authored guidelines for prevention of coronary heart disease. Their first comment concerns the disadvantages of calculating total cardio-vascular risk rather than risk of coronary heart disease alone. We would like to reiterate our concern that by concentrating on coronary heart disease alone, the true health consequences of the person's risk factors will be misrepresented. Prevention must address the problems of the patient, not just the concerns of the cardiologist. However, as we note in the paper, the SCORE formula can be used to calculate coronary heart disease and other cardio-vascular disease separately, and so make it is possible to calculate the relative contribution of each risk to the total burden. We incorporated this feature, however, to aid economic analysis rather than to encourage the adoption of a narrow, disease specific focus to prevention. We do, of course, acknowledge that such a focus still has its proponents among physicians. We are also familiar with the drawbacks of using fatal events alone to estimate risk, and discuss this in our paper. 1 Space precludes rehearsing the arguments again, but we should note that whatever the drawbacks of using fatal events only, this approach opens up the possibility of evidence-based clinical management of cardiovascular risk factors for countries without morbidity data-which includes a significant proportion of Europe. Even countries in which there are population-based cohort studies may face the dilemma of basing risk prediction on ageing data which uses different definitions of nonfatal events to those in current clinical practice. The SCORECARD initiative will be adapting the SCORE risk estimation method for use in forty countries, based on national mortality data. While there are many factors which are statistically associated with coronary heart disease, their usefulness in identifying important numbers of persons at significant risk who would otherwise have been undetected remains poorly documented. Clearly, identifying strategies for optimal identification of persons at risk is a current research priority, but we would argue that an important component of this is to identify the least number of tests and the appropriate sections of the patient population to …