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—We believe the totality of evidence strongly supports a judgment of proof beyond a reasonable doubt that obesity, smoking, and hypertension (along with elevated blood cholesterol) are the leading avoidable causes of premature mortality from cardiovascular diseases in the United States and most developed countries. Thus, for pulmonary embolism, ethical considerations would preclude the conduct of randomized trials of these factors to provide the most direct evidence. Therefore, while we agree with Dr Landzberg that the totality of evidence is less complete for pulmonary embolism, we nonetheless strongly recommend modification of these risk factors.
Goldhaber SZ, Hennekens CH. Modifiable Risk Factors for Pulmonary Embolism-Reply. JAMA. 1997;277(24):1933. doi:10.1001/jama.1997.03540480033029