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EDITORIALS: Rod Jackson, John Lynch, and Sam Harper Preventing coronary heart disease BMJ 2006; 332: 617-618 [Full text]

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Populations vs people

Joan McClusky   (22 March 2006)

Editorial appears unbalanced, superficial, simplistic and misleading

Simon Capewell, Julia Critchley, Belgin Unal, Zhao Dong, Tiina Laatikainen, Erkki Vartiainen   (6 April 2006)

Populations vs people 22 March 2006
Joan McClusky, Medical writer New York, NY Send response to journal: Re: Populations vs people	Everyone knows the importance of seeing patients as people, not cases. But the idea seems to have made a less successful transfer in terms of risk reduction. Lowering some factor by a small percentage in everyone--regardless of level of risk--requires seeing everyone as a disease waiting to happen. It requires people with no reason for concern to make unnecessary adjustments to their lives in yet another area. And it requires physicians to provide more warnings about potential problems, even as the time available for the truly sick becomes more limited. Competing interests: None declared
Editorial appears unbalanced, superficial, simplistic and misleading 6 April 2006
Simon Capewell, Chair of Clinical Epidemiology University of Liverpool, L69 3GB, Julia Critchley, Belgin Unal, Zhao Dong, Tiina Laatikainen, Erkki Vartiainen Send response to journal: Re: Editorial appears unbalanced, superficial, simplistic and misleading	We read with interest the editorial “Preventing coronary heart disease” (BMJ 2006;332:617-618). However, we were slightly disappointed. BMJ Editorials are expected to be balanced, objective, authoritative and correct. This one looked more like one side of a debate. As an editorial, it runs a “High Risk” of misleading some BMJ readers. The problems start with the header “Does Rose's population prevention axiom still apply in the 21st century? “ This implies that Rose’s axiom was sound until December 1999, but flawed thereafter. Coronary heart disease (CHD)aetiology, pathology and therapy did not change in January 2000. Cholesterol, smoking and blood pressure remain the three major risk factors for CHD [1,2]; they thus remain the key targets for prevention activities. The crucial issues are the effectiveness and cost- effectiveness of the two contrasting risk-reduction strategies [3,4]. Perhaps the editorial’s main problem is its readiness to uncritically accept the results from Manuel and colleagues [5]. We and others have identified a number of potentially serious limitations with that analysis; these are detailed in the BMJ responses webpages. The editorial describes our own 2005 results [6] as “inexplicable”. The findings may be unpalatable; however, the issues highlighted in the editorial are actually addressed in our various papers [3,6]. Furthermore, the editorial’s decision to use Hunink’s analysis as the “Gold standard” appears brave. [7] While valuable, Prof Goldman and colleagues would not claim that the 1990s version of their CHD Policy Model was exact or definitive. [7,8,9] The editorial appears contradictory. Having strongly advocated the High Risk Approach, paragraph ten then unequivocally states “Population based prevention is the only sustainable strategy for reducing the burden of coronary heart disease”, and citing Rose [10]. We certainly support that statement, and must emphasise that planners in middle income and developing countries have no other realistic option. The editorial’s subsequent assumption, that population approaches cannot impact on CHD morbidity and mortality in the “short to medium term” is also wrong. It ignores the clear meta-analysis evidence of benefits within a very short time of smoking cessation [11] or cholesterol reduction [12]. Furthermore, the recent, dramatic reversal in Poland’s CHD mortality rates, generally attributed to a rapid change in the dietary Polyunsaturate/Saturate fat ratio, then requires an alternative, more convincing explanation [13]. Perhaps most seriously, the editorial ignores key papers in the population versus high risk literature, not least Kottke 1988, Kristiansen 1991, Goldman 2001, Emberson 2004 and Unal 2005 [1,3,4,9,14] Debate is good; however, labelling a partisan article as an objective Editorial is less good. BMJ readers deserve better. Yours Sincerely Simon Capewell, Julia Critchley, Belgin Unal, Zhao Dong, Tiina Laatikainen, & Erkki Vartiainen REFERENCES 1. Emberson J, Whincup P, Morris R, Walker M, Ebrahim S. Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Eur.Heart J. 2004;25:484-91. 2. Yusuf S, Hawken S, Ounpuu S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364:937 -952. 3. B U Aslan, J A Critchley & S Capewell. Small changes in UK cardiovascular risk factors could halve coronary heart disease mortality. J Clin Epid, 2005, 58 (7) 733-40. 4. Kristiansen IS. Eggen AE. Thelle DS. Cost effectiveness of incremental programmes for lowering serum cholesterol concentration: is individual intervention worth while?. BMJ. 1991; 302(6785):1119-22. 5. 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. 6. Unal B, Critchley J A, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1980-2000: comparing contributions from primary prevention and secondary prevention. BMJ 2005;331: 614-7. 7. Hunink M, Goldman L, Tosteson A, Mittleman M, Goldman P, Williams L, et al. The recent decline in mortality from CHD, 1980-1990. JAMA 1997;277: 535-42 8. Weinstein MC, O'Brien B, Hornberger J, Jackson J, Johannesson M, McCabe C. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices-Modeling Studies. Value Health 2003;6:9-17. 9. Goldman L, Phillips KA, Coxson P, Goldman PA, Williams L, Hunink MG et al. The effect of risk factor reductions between 1981 and 1990 on coronary heart disease incidence, prevalence, mortality and cost. J.Am.Coll.Cardiol. 2001;38:1012-7. 10. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14: 32-8. 11. Critchley, J. A. and Capewell, S. A Systematic Review of the Mortality Risk reduction When Patients With Coronary Heart Disease Stop Smoking. JAMA 2003-290; 86-97. 12. Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994; 308(6925):367-372. 13. W A Zatonski, W Willett. Changes in dietary fat and declining coronary heart disease in Poland: population based study BMJ; 2005; 331: 187 - 188. 14. Kottke TE, Gatewood LC, Wu SC, Park HA. Preventing heart disease: is treating the high risk sufficient? J Clin Epidemiol. 1988;41(11):1083-93. Competing interests: None declared