Dr Burch is correct in asserting that changes in the levels of causative factors should be reflected in subsequent mortality rates in both the clinical trial and the ecological situation. His genetic explanation of the well-established CHD risk factor relationships, however, presents a difficulty in interpreting the results of studies such as those of migrant populations and the effects of riskfactor reduction (eg, cigarette smoking) seen in other observational studies. The most likely candidates suggested by Dr Burch for "genuine precipitating agent(s)" have little data to support such a role in contrast to the extensive literature on conventional risk factors.Contrary to the impression left by Dr Seltzer's one-sided literature review, there was and is overwhelming evidence implicating the three major CHD risk factors. The several possible reasons for the lack of clear-cut support from the MRFIT for the role of these factors in reducing CHD mortality were
Cutler JA. The Multiple Risk Factor Intervention Trial-Reply. JAMA. 1983;249(11):1437. doi:10.1001/jama.1983.03330350017015
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