Published 28 August 2008, doi:10.1136/bmj.a1371
Cite this as: BMJ 2008;337:a1371

Head to Head

Will screening individuals at high risk of cardiovascular events deliver large benefits? Yes

¹ School of Population Health, University of Auckland, New Zealand

The Department of Health is planning to identify and treat all adults over 40 at high risk of a cardiovascular event. Rod Jackson and colleagues argue that a well targeted programme will save many lives, but Simon Capewell (doi: 10.1136/bmj.a1395) thinks whole population approaches would be more cost effective

Provisional modelling by the Department of Health suggests that up to 9500 heart attacks and strokes and 2000 deaths could be prevented each year by its plan to screen for and manage vascular risk in people aged between 40 and 74.¹ Checks would comprise a brief history, examination, and blood test and could take place in general practices or pharmacies. The programme will be implemented in 2009-10 at an annual cost of about £250m (315m; $465m).¹ This strategy assumes that the high risk approach to preventing cardiovascular disease is effective and cost effective, which we believe to be true.

A large World Health Organization review comparing high risk and population-wide interventions to prevent cardiovascular disease globally showed that treating high risk patients with aspirin, off-patent statins, and blood pressure lowering drugs was not only cost effective but would avert more disability adjusted life years (DALYs) worldwide than population based interventions to reduce salt intake, obesity, and cholesterol concentrations.^{1 2} Furthermore the high risk approach was much more effective and cost effective than approaches targeting high risk factors (such as treatment of hypertension). Rose was right to point out the disadvantages of high risk factor approaches, but he didn’t assess the high predicted cardiovascular risk approaches.³ The key questions to be resolved are how best to define high risk and the optimal mix of high risk personal strategies with other population strategies.^{4 5}

Potential impact

Myriam Hunink’s 1997 disease modelling study suggested that over two thirds of the fall in deaths from coronary heart disease in the US between 1980 and 1990 occurred among the 6% of 35-84 year old Americans with prior coronary disease.⁶ Her hypothesis is even more relevant today with the increasing numbers of people with coronary disease⁷ and the widespread availability of affordable, effective drugs. Between one third and one half of all major coronary disease events in 35-74 year olds now occur in the 5-6% of the population with a previous cardiovascular disease event,^{8 9} and triple therapy with aspirin, statins, and blood pressure lowering drugs can reduce event rates by two thirds or more.^{10 11} If only half these very high risk patients were adherent, this combination of drugs alone would be responsible for a 10% fall in national coronary disease event rates in less than 10 years.

To achieve a similar national reduction in coronary disease events, a primary prevention strategy would need to lower the average coronary risk in the rest of the population by about 20%—a huge challenge, now that much of the low hanging fruit receptive to population-wide strategies has been picked.¹²

Targeting very high risk patients

The most cost effective strategy for preventing cardiovascular events therefore starts by targeting patients who have had a cardiovascular disease event. They are at the highest risk (10 year risk is usually >40%), there are relatively few of them, they are easy to identify, and they are likely to be more motivated than patients without symptoms. However, the NHS intends to provide drug based management for everyone aged between 40 and 74 years with a 20% cardiovascular risk over 10 years.¹ If, for example, the QRISK2 cardiovascular disease risk prediction equation¹³ was used to identify patients meeting the NHS treatment thresholds, then about 10% of Britons aged 35-75 years would be recommended for drug treatment, in addition to the 5-6% with a history of cardiovascular disease.

However, about twice the numbers of asymptomatic patients would need to be treated to prevent half the number of events achieved by treating those with prior cardiovascular disease.

Currently, most patients with established cardiovascular disease are not taking triple therapy. The treatment gap is closing very slowly, but the number of low risk people treated far exceeds the number of high risk people treated.¹⁴ So priority must be given to ensuring general practitioners are able to manage patients with prior cardiovascular disease before widening the net too far to lower risk patients.

New equations to predict risk of cardiovascular disease are better calibrated to UK populations,^{13 15} and their accuracy is improving with the addition of measures of social deprivation and ethnicity, providing an opportunity to target primary prevention more accurately while simultaneously reducing social inequities. However, as risk thresholds for treatment are lowered, large numbers of patients will be eligible for drugs. To cope with the increased workload and cost, simplified primary prevention treatment regimens are required. The recent NICE lipid guidelines are a good start, recommending 40 mg of simvastatin for all asymptomatic high risk patients, without any dose tailoring or systematic follow-up.¹⁶ Similar recommendations are required for blood pressure lowering drugs, and the end game may turn out to be a single daily combination pill.

Getting the right balance

Too often debate about prevention of cardiovascular disease is polarised between opposing evangelists for the high risk and population-wide approaches. An agnostic approach based on effectiveness and cost effectiveness is preferable. Cost effective high risk strategies must be complemented by cost effective population-wide interventions. There is no longer any justification for questioning the role of well targeted treatment with safe, inexpensive, and effective drugs for patients at high risk of cardiovascular disease as a key component of any global cardiovascular disease prevention programme.

Cite this as: BMJ 2008;337:a1371.

---

Competing interests: RJ and AR are investigators on several randomised controlled trials investigating the effectiveness of polypills for managing risk of cardiovascular disease.

References

1. Department of Health. Putting prevention first. 2008. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083822.
2. Murray CJ, Lauer JA, Hutubessy RC, Niessen L, Tomijima N, Rodgers A, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 2003;361:717-25.[CrossRef][Web of Science][Medline]
3. Rose G. The strategy of preventive medicine. Oxford: Oxford University Press, 1992.
4. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008;(2):CD000165.
5. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044-53.[CrossRef][Web of Science][Medline]
6. Hunink MG, Goldman L, Tosteson AN, Mittleman MA, Goldman PA, Williams LW, et al. The recent decline in mortality from coronary heart disease, 1980-1990. The effect of secular trends in risk factors and treatment. JAMA 1997;277:535-42.[Abstract/Free Full Text]
7. Davies AR, Smeeth L, Grundy EM. Contribution of changes in incidence and mortality to trends in the prevalence of coronary heart disease in the UK: 1996 to 2005. Eur Heart J 2007;28:2142-7.[Abstract/Free Full Text]
8. Kerr AJ, Broad J, Wells S, Riddell T, Jackson RT. Should the first priority in cardiovascular risk management be those with prior cardiovascular disease? Heart 2008 Apr 1 [Epublication ahead of print].
9. Manuel DG, Lim J, Tanuseputro P, Anderson GM, Alter DA, Laupacis A, et al. Revisiting Rose: strategies for reducing coronary heart disease. BMJ 2006;332:659-62.[Free Full Text]
10. Yusuf S. Two decades of progress in preventing vascular disease. Lancet 2002;360:2-3.[CrossRef][Web of Science][Medline]
11. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003;326:1419.[Abstract/Free Full Text]
12. Jackson R, Lynch J, Harper S. Preventing coronary heart disease. BMJ 2006;332:617-8.[Free Full Text]
13. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Brindle P. Performance of the QRISK cardiovascular risk prediction algorithm in an independent UK sample of patients from general practice: a validation study. Heart 2008;94:34-9.[Abstract/Free Full Text]
14. Rafter N, Connor J, Hall J, Jackson R, Martin I, Parag V, et al. Cardiovascular medications in primary care: treatment gaps and targeting by absolute risk. N Z Med J 2005;118:U1676.[Medline]
15. Woodward M, Brindle P, Tunstall-Pedoe H. Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart 2007;93:172-6.[Abstract/Free Full Text]
16. Cooper A, O’Flynn N. Risk assessment and lipid modification for primary and secondary prevention of cardiovascular disease: summary of NICE guidance. BMJ 2008;336:1246-8.[Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Articles

Erectile dysfunction predicts cardiovascular risk in men

Geoffrey I Hackett
BMJ 2008 337: a2166. [Extract] [Full Text]

A plea for broader perspectives on health

Fiona Godlee
BMJ 2008 337: a1923. [Extract] [Full Text]

Will screening individuals at high risk of cardiovascular events deliver large benefits? No

Simon Capewell
BMJ 2008 337: a1395. [Extract] [Full Text]

Risk assessment and lipid modification for primary and secondary prevention of cardiovascular disease: summary of NICE guidance

Angela Cooper, Norma O’Flynn on behalf of the Guideline Development Group
BMJ 2008 336: 1246-1248. [Extract] [Full Text] [PDF]

Preventing coronary heart disease

Rod Jackson, John Lynch, and Sam Harper
BMJ 2006 332: 617-618. [Extract] [Full Text] [PDF]

Revisiting Rose: strategies for reducing coronary heart disease

Douglas G Manuel, Jenny Lim, Peter Tanuseputro, Geoffrey M Anderson, David A Alter, Andreas Laupacis, and Cameron A Mustard
BMJ 2006 332: 659-662. [Full Text] [PDF]

A strategy to reduce cardiovascular disease by more than 80%

N J Wald and M R Law
BMJ 2003 326: 1419. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• Jontell, M., Glick, M. (2009). Oral Health Care Professionals' Identification of Cardiovascular Disease Risk Among Patients in Private Dental Offices in Sweden. Journal of the American Dental Association 140: 1385-1391 [Abstract] [Full text]  
• de Koning, H. J. (2009). Testing at home--the screening of the future?. Eur J Public Health 0: ckn120v1-ckn120 [Full text]  
• Rosengren, A., Perk, J., Dallongeville, J. (2009). CHAPTER 12 Prevention of Cardiovascular Disease. ESC Textbook of Cardiovascular Medicine 2: med-9780199566990-chapter-med-9780199566990-chapter [Abstract] [Full text]  
• Hackett, G. I (2008). Erectile dysfunction predicts cardiovascular risk in men. BMJ 337: a2166-a2166 [Full text]  

Rapid Responses:

Read all Rapid Responses

Erectile dysfunction as a screening tool for cardiovascular disease

Anne L. Appleton
bmj.com, 12 Oct 2008 [Full text]

Erectile Dysfunction is the best predictor of Cardiovascular risk in men - why do we ignore it?

Geoffrey I Hackett
bmj.com, 13 Oct 2008 [Full text]

Optimal targeting of statins for primary prevention: global cardiovascular risk or LDL-cholesterol and CRP?

Aroon D Hingorani, et al.
bmj.com, 12 Nov 2008 [Full text]

Online poll

Find out more on doc2doc >>