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Cardiovascular risk stratification by means of the SCORE system in health care workers in Veracruz, Mexico
International Journal of Cardiology 121 (2007) 81 – 83 www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiovascular risk stratification by means of the SCORE system in health care workers in Veracruz, Mexico Felipe González-Velázquez, Gustavo F. Mendez ⁎ Clinical Epidemiology Research Unit, UMAE Hospital de Especialidades No 14, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc esq. Cervantes y Padilla, Col. Formando Hogar, 91897 Veracruz, Mexico Received 17 July 2006; accepted 3 August 2006 Available online 29 November 2006
Abstract Background: To assess cardiovascular disease risk by means of the SCORE system (Systematic Coronary Risk Evaluation) in health care workers (HCW) from Veracruz, Mexico. Methods: A cross-sectional study was undertaken at the Mexican Institute of Social Security from Veracruz. Seventy six HCW without physical limitations (NYHA Functional Class I) were included. All HCW answered a standardised medical history questionnaire and were evaluated by physical examination and lab tests. The cardiovascular risk was assessed through the SCORE system. Results: The median age of participants was 47 years (90% range 42–57 years), female HCW had higher prevalence of obesity and lower prevalence of overweight compared to male HCW (52% vs 23% for obesity and 26% vs 63% for overweight; p = 0.014). The prevalence of hypertension was 22%, type 2 diabetes 8%, hypercholesterolemia 70%, hypertriglyceridemia 47% and mixed hyperlipidemia 26%. Cardiovascular risk assessed by the SCORE system showed that 14% of all patients had a cardiovascular risk higher than 2% and 51% had a risk lower than 1%. Conclusions: In this first study of cardiovascular risk assessment by means of the SCORE system in HCW in Mexico, we found that 14% of them have a cardiac risk higher than 2% and that it is double than expected for their age but it is lower than reported in a European population. Also, we found a higher prevalence of hypercholesterolemia and mixed hyperlipidemia showing poor education and treatment for cardiovascular prevention. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiovascular risk; SCORE system; Health care workers; Hypercholesterolemia; Mexico
1. Introduction Cardiovascular disease (CVD) represents a burden for developed countries accounting for almost 50% of all deaths [1,2]. Based on epidemiological studies from Cardiovascular Risk Factors, the Mexican population have a high risk profile for CVD: prevalence of hypertension 30% [3], type 2 diabetes 11% [4], hypercholesterolemia 43% [5], hypertriglyceridemia 42% [6], and overweight 44%–obesity 30% [5]. As a result of it, CVD represents the second leading cause of general mortality in Mexico [7]. ⁎ Corresponding author. Tel./fax: +52 2299 342031. E-mail addresses: [email protected] (F. González-Velázquez), [email protected] (G.F. Mendez). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.023
A new European risk scoring system for CVD was recently published. The SCORE (Systematic Coronary Risk Evaluation) system is the result of the analysis from a large dataset of prospective European studies and predicts any kind of fatal CVD end-point over a ten year period [8]. The SCORE system considers the major risk factors of CVD (blood pressure, smoking status, type 2 diabetes, cholesterol levels, age and gender) and it is presented in a friendly coloured SCORE Chart [8]. In Mexico, there is neither information about the use of the traditional Framingham cardiovascular risk score [9] nor the SCORE system [8] with the purpose of predicting cardiovascular events. Health care workers (HCW) who are settled in hospitalisation or non-hospitalisation areas have been considered as a population of greater awareness about prevention activities
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F. González-Velázquez, G.F. Mendez / International Journal of Cardiology 121 (2007) 81–83
Table 1 Demographic and clinical characteristics of the study population Characteristics
Total = 76
the Mexican Institute of Social Security (IMSS) in Veracruz, Mexico to establish the compliance and understanding of heart disease prevention in this population.
n [%] Age (yrs) [median, 90% range] Women Current or ex-smoker Body mass index (kg /m2) [mean, SD] Overweight Obese Systolic blood pressure (mm Hg) [mean, SD] Diastolic blood pressure (mm Hg) [mean, SD]
47 [42–57] 46 [60] 36 [47] 29 [5] 31 [41] 31 [41] 123 [17] 76 [9]
Medical history Hypertension Type 2 diabetes Hypercholesterolemia Hypertriglyceridemia Mixed hyperlipidemia
22 [28%] 8 [11%] 53 [70%] 36 [47%] 20 [26%]
Current medication Loop diuretics ACE/ARB inhibitors Beta-blockers Statins
3 [4%] 15 [20%] 3 [4%] 6 [8%]
Biochemical parameters Creatinine (mg/dl) [mean, SD] Glucose (mg/dl) [mean, SD] Cholesterol (mg/dl) [mean, SD] HDL-cholesterol (mg/dl) [mean, SD] LDL-cholesterol (mg/dl) [mean, SD] Triglycerides (mg/dl) [mean, SD]
0.9 [0.1] 96 [27] 199 [47] 45 [14] 124 [43] 163 [101]
2. Materials and methods A cross-sectional study was undertaken at the Specialties Hospital No 14 from the IMSS in Veracruz, Mexico. All IMSS HCW from this hospital were invited to attend the Clinical Epidemiology Research Unit (CERU) for a complete (clinical and laboratory) cardiovascular risk assessment. We included all patients who were working at the moment of the screening and without physical limitations (NYHA Functional Class I). Cholesterol levels were measured in a fasting state by means of Cholestech LDX® System [13]. Diabetes mellitus, hypertension, hypercholesterolemia and hypertriglyceridemia were defined following current international guidelines [9,14,15]. The cardiac risk was evaluated through the SCORE system. Risk was defined in terms of the absolute probability of developing a fatal cardiovascular event within 10 years. The chart comprises a table of the following parameters: sex, smoking status, systolic blood pressure, total cholesterol (or ratio of total cholesterol to high density lipoprotein), and age (40, 50, 55, 60, and 65 years). Risk is estimated by rounding a person's age to the nearest one shown on the chart, their cholesterol level to the nearest whole unit, and their blood pressure to the nearest multiple of 20 mm Hg [8]. Written informed consent was obtained from each patient prior to inclusion in the study. 3. Results
as a result of the working environment and the prevention activities provided by the employers [10,11]. However, it has been reported that such population has higher prevalence of smoking and a neglected component for receiving education about risk factors [11,12]. On this basis, we undertake a CVD risk assessment by means of the SCORE system in health care personnel from
Between December 2004 and March 2005, 96 HCW attended the cardiovascular risk assessment at the CERU. Twenty patients were excluded of the final analysis because of age younger than 40 years old. Demographic and clinical characteristics of the 76 HCW are shown in Table 1. The median age of participants was 47 years (90% range 42–
Fig. 1. SCORE cardiovascular risk assessment in health workers.
F. González-Velázquez, G.F. Mendez / International Journal of Cardiology 121 (2007) 81–83
57 years). We found that 82% of the HCW are overweight or obese. Female HCW had higher prevalence of Obesity and lower prevalence of overweight compared to male HCW (52% vs 23% for obesity and 26% vs 63% for overweight; p = 0.014). Prevalence of CVR risk factors was similar to national average, with higher prevalence of hypercholesterolemia and obesity. With regard to the cholesterol profile we found that HCW have cholesterol levels that are borderline desirable (199 ± 47 mg/dl) with LDL-cholesterol above optimal (124 ± 43 mg /dl) following current American guidelines [9]. Fig. 1 shows the ten year Risk of Fatal Cardiovascular Disease of the HCW population. We observed that 14% of these patients had a cardiovascular risk higher than 2% and that it is double than expected for a younger HCW population and 51% of the population had a risk lower than 1%. 4. Discussion In this first study of cardiovascular risk stratification in HCW in Mexico by means of the SCORE system we found that 14% of this population have double the ideal risk expected for its age. This is very important if we considered that such population should have a greater awareness about cardiovascular prevention, as a result of the working environment and the prevention activities provided by the IMSS. Even though, if we considered previous studies comparing risk stratification strategies for cardiovascular risk by the SCORE system just 11.8% of our population had an intermediate risk (2–4%) compared to 48% of the Finish population [16]. Also, high risk fatal cardiovascular disease was found in 2.6% of the HCW that is lower compared to the Spanish population which have a prevalence of high risk of 7% [17]. However, in our study, we found similar prevalence of CVR factors to the National average: hypertension 28%, type 2 diabetes 11%, hypertriglyceridemia 47% and overweight 41% with a higher prevalence of hypercholesterolemia 70% and obesity 41%. Considering that these prevalence were obtained in a younger population the possibilities of an increased risk of fatal cardiovascular disease in the following 10 years would increase dramatically if no adequate strategies of cardiovascular prevention are applied to them. On this basis, we conclude that HCW are at intermediate risk of cardiovascular disease as a result of a higher prevalence of single risk factors (hypercholesterolemia, hypertension and diabetes) and a risk assessment in 14% of the population higher than expected for their age. References [1] Lopez AD. Assessing the burden of mortality from cardiovascular diseases. Wld hlth statist quart, vol. 46; 1993. p. 91–6.
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[2] Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease. Lancet 1997;349:1269–76. [3] Velasquez-Monroy O, Rosas-Peralta M, Lara-Esqueda A, et al. Prevalencia e interrelación de enfermedades crónicas no transmisibles y factores de riesgo cardiovascular en México: Resultados finales de la Encuesta Nacional de Salud (ENSA) 2000. Arch Cardiol Mex 2003;73:62–77. [4] Velasquez-Monroy O, Rosas-Peralta M, Lara-Esqueda A, et al. Hipertensión arterial en México: Resultados de la Encuesta Nacional de Salud (ENSA) 2000. Arch Cardiol Mex 2002;72:71–84. [5] Lara A, Rosas M, Pastelin G, Aguilar C, Attie F, Velasquez-Monroy O. Hipercolesterolemia e hipertension arterial en México. Consolidación urbana actual con obesidad, diabetes y tabaquismo. Arch Cardiol Mex 2004;74:231–45. [6] Aguilar-Salinas CA, Olaiz G, Valles V, et al. High prevalence of low HDL cholesterol concentrations and mixed hyperlipidemia in a Mexican nationwide survey. J Lipid Res 2001;42:1298–307. [7] Secretaria de Salud, México. Principales causas de mortalidad general 2000. http://www.ssa.gob.mx/apps/htdocs/estadisticas/estadisticas/ mortalidad/mortalidad.htm 2002. [8] De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts). Atherosclerosis 2004;173:381–91. [9] National Cholesterol Education Program expert panel. Third report of the National Cholesterol Education Program (NCEP) expert panel on Detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): final report. National Institute of Health. III. 2002. National Heart and Lung Institute. NIH Publication 02-5215 September 2002. [10] Fanghanel-Salmon G, Padilla-Retana J, Sanchez-Reyes L, Torres-Acosta EM, Cortinas-Lopez L, Espinosa-Campos J. Prevalence of coronary artery disease risk factors in workers at the general hospital of Mexico of the ministry of health. Endocr Pract 1997;3:313–9. [11] McEwan SR, Dewhurst NG, Daly F, Forbes CD, Belch JJ. Results of a survey of cardiovascular risk factor prevalence amongst health care workers. The Executive Committee of SHARP (Scottish Heart and Arterial Risk Prevention). Scott Med J 2000;45:84–5. [12] Vasquez-Martínez JL, Gomez-Dantes H, Gomez-Garcia F, Lara-Rodriguez MA, Navarrete-espinosa J, Perez-Perez G. Obesity and overweight in IMSS female workers in Mexico City. Salud Publica Mex 2005;47: 268–75. [13] Santee J. Accuracy and precision of the Cholestech LDX System in monitoring blood lipid levels. Am J Health Syst Pharm 2002;59: 1774–9. [14] The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2002;25:S5–S20. [15] Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003;42:1206–52. [16] Getz L, Sigurdsson JA, Hetlevik I, Kirkengen AL, Romundstad S, Holmen J. Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study. BMJ 2005;331:551. [17] Fornasini M, Brotons C, Sellares J, Martinez M, Galan ML, Saenz I. Consequences of using different methods to assess cardiovascular risk in primary care. Fam Pract 2006;23:28–33.
Letter to the Editor
Cardiovascular risk stratification by means of the SCORE system in health care workers in Veracruz, Mexico Felipe González-Velázquez, Gustavo F. Mendez ⁎ Clinical Epidemiology Research Unit, UMAE Hospital de Especialidades No 14, Instituto Mexicano del Seguro Social, Av. Cuauhtemoc esq. Cervantes y Padilla, Col. Formando Hogar, 91897 Veracruz, Mexico Received 17 July 2006; accepted 3 August 2006 Available online 29 November 2006
Abstract Background: To assess cardiovascular disease risk by means of the SCORE system (Systematic Coronary Risk Evaluation) in health care workers (HCW) from Veracruz, Mexico. Methods: A cross-sectional study was undertaken at the Mexican Institute of Social Security from Veracruz. Seventy six HCW without physical limitations (NYHA Functional Class I) were included. All HCW answered a standardised medical history questionnaire and were evaluated by physical examination and lab tests. The cardiovascular risk was assessed through the SCORE system. Results: The median age of participants was 47 years (90% range 42–57 years), female HCW had higher prevalence of obesity and lower prevalence of overweight compared to male HCW (52% vs 23% for obesity and 26% vs 63% for overweight; p = 0.014). The prevalence of hypertension was 22%, type 2 diabetes 8%, hypercholesterolemia 70%, hypertriglyceridemia 47% and mixed hyperlipidemia 26%. Cardiovascular risk assessed by the SCORE system showed that 14% of all patients had a cardiovascular risk higher than 2% and 51% had a risk lower than 1%. Conclusions: In this first study of cardiovascular risk assessment by means of the SCORE system in HCW in Mexico, we found that 14% of them have a cardiac risk higher than 2% and that it is double than expected for their age but it is lower than reported in a European population. Also, we found a higher prevalence of hypercholesterolemia and mixed hyperlipidemia showing poor education and treatment for cardiovascular prevention. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiovascular risk; SCORE system; Health care workers; Hypercholesterolemia; Mexico
1. Introduction Cardiovascular disease (CVD) represents a burden for developed countries accounting for almost 50% of all deaths [1,2]. Based on epidemiological studies from Cardiovascular Risk Factors, the Mexican population have a high risk profile for CVD: prevalence of hypertension 30% [3], type 2 diabetes 11% [4], hypercholesterolemia 43% [5], hypertriglyceridemia 42% [6], and overweight 44%–obesity 30% [5]. As a result of it, CVD represents the second leading cause of general mortality in Mexico [7]. ⁎ Corresponding author. Tel./fax: +52 2299 342031. E-mail addresses: [email protected] (F. González-Velázquez), [email protected] (G.F. Mendez). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.023
A new European risk scoring system for CVD was recently published. The SCORE (Systematic Coronary Risk Evaluation) system is the result of the analysis from a large dataset of prospective European studies and predicts any kind of fatal CVD end-point over a ten year period [8]. The SCORE system considers the major risk factors of CVD (blood pressure, smoking status, type 2 diabetes, cholesterol levels, age and gender) and it is presented in a friendly coloured SCORE Chart [8]. In Mexico, there is neither information about the use of the traditional Framingham cardiovascular risk score [9] nor the SCORE system [8] with the purpose of predicting cardiovascular events. Health care workers (HCW) who are settled in hospitalisation or non-hospitalisation areas have been considered as a population of greater awareness about prevention activities
82
F. González-Velázquez, G.F. Mendez / International Journal of Cardiology 121 (2007) 81–83
Table 1 Demographic and clinical characteristics of the study population Characteristics
Total = 76
the Mexican Institute of Social Security (IMSS) in Veracruz, Mexico to establish the compliance and understanding of heart disease prevention in this population.
n [%] Age (yrs) [median, 90% range] Women Current or ex-smoker Body mass index (kg /m2) [mean, SD] Overweight Obese Systolic blood pressure (mm Hg) [mean, SD] Diastolic blood pressure (mm Hg) [mean, SD]
47 [42–57] 46 [60] 36 [47] 29 [5] 31 [41] 31 [41] 123 [17] 76 [9]
Medical history Hypertension Type 2 diabetes Hypercholesterolemia Hypertriglyceridemia Mixed hyperlipidemia
22 [28%] 8 [11%] 53 [70%] 36 [47%] 20 [26%]
Current medication Loop diuretics ACE/ARB inhibitors Beta-blockers Statins
3 [4%] 15 [20%] 3 [4%] 6 [8%]
Biochemical parameters Creatinine (mg/dl) [mean, SD] Glucose (mg/dl) [mean, SD] Cholesterol (mg/dl) [mean, SD] HDL-cholesterol (mg/dl) [mean, SD] LDL-cholesterol (mg/dl) [mean, SD] Triglycerides (mg/dl) [mean, SD]
0.9 [0.1] 96 [27] 199 [47] 45 [14] 124 [43] 163 [101]
2. Materials and methods A cross-sectional study was undertaken at the Specialties Hospital No 14 from the IMSS in Veracruz, Mexico. All IMSS HCW from this hospital were invited to attend the Clinical Epidemiology Research Unit (CERU) for a complete (clinical and laboratory) cardiovascular risk assessment. We included all patients who were working at the moment of the screening and without physical limitations (NYHA Functional Class I). Cholesterol levels were measured in a fasting state by means of Cholestech LDX® System [13]. Diabetes mellitus, hypertension, hypercholesterolemia and hypertriglyceridemia were defined following current international guidelines [9,14,15]. The cardiac risk was evaluated through the SCORE system. Risk was defined in terms of the absolute probability of developing a fatal cardiovascular event within 10 years. The chart comprises a table of the following parameters: sex, smoking status, systolic blood pressure, total cholesterol (or ratio of total cholesterol to high density lipoprotein), and age (40, 50, 55, 60, and 65 years). Risk is estimated by rounding a person's age to the nearest one shown on the chart, their cholesterol level to the nearest whole unit, and their blood pressure to the nearest multiple of 20 mm Hg [8]. Written informed consent was obtained from each patient prior to inclusion in the study. 3. Results
as a result of the working environment and the prevention activities provided by the employers [10,11]. However, it has been reported that such population has higher prevalence of smoking and a neglected component for receiving education about risk factors [11,12]. On this basis, we undertake a CVD risk assessment by means of the SCORE system in health care personnel from
Between December 2004 and March 2005, 96 HCW attended the cardiovascular risk assessment at the CERU. Twenty patients were excluded of the final analysis because of age younger than 40 years old. Demographic and clinical characteristics of the 76 HCW are shown in Table 1. The median age of participants was 47 years (90% range 42–
Fig. 1. SCORE cardiovascular risk assessment in health workers.
F. González-Velázquez, G.F. Mendez / International Journal of Cardiology 121 (2007) 81–83
57 years). We found that 82% of the HCW are overweight or obese. Female HCW had higher prevalence of Obesity and lower prevalence of overweight compared to male HCW (52% vs 23% for obesity and 26% vs 63% for overweight; p = 0.014). Prevalence of CVR risk factors was similar to national average, with higher prevalence of hypercholesterolemia and obesity. With regard to the cholesterol profile we found that HCW have cholesterol levels that are borderline desirable (199 ± 47 mg/dl) with LDL-cholesterol above optimal (124 ± 43 mg /dl) following current American guidelines [9]. Fig. 1 shows the ten year Risk of Fatal Cardiovascular Disease of the HCW population. We observed that 14% of these patients had a cardiovascular risk higher than 2% and that it is double than expected for a younger HCW population and 51% of the population had a risk lower than 1%. 4. Discussion In this first study of cardiovascular risk stratification in HCW in Mexico by means of the SCORE system we found that 14% of this population have double the ideal risk expected for its age. This is very important if we considered that such population should have a greater awareness about cardiovascular prevention, as a result of the working environment and the prevention activities provided by the IMSS. Even though, if we considered previous studies comparing risk stratification strategies for cardiovascular risk by the SCORE system just 11.8% of our population had an intermediate risk (2–4%) compared to 48% of the Finish population [16]. Also, high risk fatal cardiovascular disease was found in 2.6% of the HCW that is lower compared to the Spanish population which have a prevalence of high risk of 7% [17]. However, in our study, we found similar prevalence of CVR factors to the National average: hypertension 28%, type 2 diabetes 11%, hypertriglyceridemia 47% and overweight 41% with a higher prevalence of hypercholesterolemia 70% and obesity 41%. Considering that these prevalence were obtained in a younger population the possibilities of an increased risk of fatal cardiovascular disease in the following 10 years would increase dramatically if no adequate strategies of cardiovascular prevention are applied to them. On this basis, we conclude that HCW are at intermediate risk of cardiovascular disease as a result of a higher prevalence of single risk factors (hypercholesterolemia, hypertension and diabetes) and a risk assessment in 14% of the population higher than expected for their age. References [1] Lopez AD. Assessing the burden of mortality from cardiovascular diseases. Wld hlth statist quart, vol. 46; 1993. p. 91–6.
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[2] Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease. Lancet 1997;349:1269–76. [3] Velasquez-Monroy O, Rosas-Peralta M, Lara-Esqueda A, et al. Prevalencia e interrelación de enfermedades crónicas no transmisibles y factores de riesgo cardiovascular en México: Resultados finales de la Encuesta Nacional de Salud (ENSA) 2000. Arch Cardiol Mex 2003;73:62–77. [4] Velasquez-Monroy O, Rosas-Peralta M, Lara-Esqueda A, et al. Hipertensión arterial en México: Resultados de la Encuesta Nacional de Salud (ENSA) 2000. Arch Cardiol Mex 2002;72:71–84. [5] Lara A, Rosas M, Pastelin G, Aguilar C, Attie F, Velasquez-Monroy O. Hipercolesterolemia e hipertension arterial en México. Consolidación urbana actual con obesidad, diabetes y tabaquismo. Arch Cardiol Mex 2004;74:231–45. [6] Aguilar-Salinas CA, Olaiz G, Valles V, et al. High prevalence of low HDL cholesterol concentrations and mixed hyperlipidemia in a Mexican nationwide survey. J Lipid Res 2001;42:1298–307. [7] Secretaria de Salud, México. Principales causas de mortalidad general 2000. http://www.ssa.gob.mx/apps/htdocs/estadisticas/estadisticas/ mortalidad/mortalidad.htm 2002. [8] De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts). Atherosclerosis 2004;173:381–91. [9] National Cholesterol Education Program expert panel. Third report of the National Cholesterol Education Program (NCEP) expert panel on Detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): final report. National Institute of Health. III. 2002. National Heart and Lung Institute. NIH Publication 02-5215 September 2002. [10] Fanghanel-Salmon G, Padilla-Retana J, Sanchez-Reyes L, Torres-Acosta EM, Cortinas-Lopez L, Espinosa-Campos J. Prevalence of coronary artery disease risk factors in workers at the general hospital of Mexico of the ministry of health. Endocr Pract 1997;3:313–9. [11] McEwan SR, Dewhurst NG, Daly F, Forbes CD, Belch JJ. Results of a survey of cardiovascular risk factor prevalence amongst health care workers. The Executive Committee of SHARP (Scottish Heart and Arterial Risk Prevention). Scott Med J 2000;45:84–5. [12] Vasquez-Martínez JL, Gomez-Dantes H, Gomez-Garcia F, Lara-Rodriguez MA, Navarrete-espinosa J, Perez-Perez G. Obesity and overweight in IMSS female workers in Mexico City. Salud Publica Mex 2005;47: 268–75. [13] Santee J. Accuracy and precision of the Cholestech LDX System in monitoring blood lipid levels. Am J Health Syst Pharm 2002;59: 1774–9. [14] The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2002;25:S5–S20. [15] Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003;42:1206–52. [16] Getz L, Sigurdsson JA, Hetlevik I, Kirkengen AL, Romundstad S, Holmen J. Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study. BMJ 2005;331:551. [17] Fornasini M, Brotons C, Sellares J, Martinez M, Galan ML, Saenz I. Consequences of using different methods to assess cardiovascular risk in primary care. Fam Pract 2006;23:28–33.