Norway’s new principles for primary prevention of cardiovascular disease: age differentiated risk thresholds

BMJ 2011; 343 doi: (Published 13 July 2011) Cite this as: BMJ 2011;343:d3626
  1. Ole Frithjof Norheim, professor1,
  2. Bjørn Gjelsvik, senior researcher2,
  3. Tor Ole Klemsdal, chief consultant3,
  4. Steinar Madsen, medical director4,
  5. Eivind Meland, professor1,
  6. Stein Narvesen, patient representative5,
  7. Anne Negård, senior adviser6,
  8. Inger Njølstad, professor7,
  9. Serena Tonstad, professor3,
  10. Frøydis Ulvin, patient representative5,
  11. Torbjørn Wisløff, senior adviser8
  1. 1Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
  2. 2Department of Primary Care and Public Health, University of Oslo, Oslo, Norway
  3. 3Department of Preventive Medicine, Oslo University Hospital, Ullevål, Oslo
  4. 4Norwegian Medicines Agency, Oslo
  5. 5Norwegian Heart and Lung Patient Organization, Oslo
  6. 6Norwegian Directorate of Health, Oslo
  7. 7Department of Community Medicine, University of Tromsø, Norway
  8. 8Norwegian Knowledge Centre for the Health Services, Oslo
  1. Correspondence to: O F Norheim ole.norheim{at}
  • Accepted 3 May 2011

Norway decided not to follow European guidelines on preventing cardiovascular disease and instead developed its own with age based thresholds. Ole Norheim and colleagues explain the rationale behind them

European Society for Cardiology guidelines on preventing cardiovascular disease in clinical practice classify most elderly people at high risk of cardiovascular disease and lead to widespread prescription of drugs for prevention.1 General practitioners in the Nordic countries have repeatedly expressed concern at this advice for reasons including increased workload for physicians, time and prescription costs, the risk of medicalisation of healthy people, and the risk of undermining patients’ informed choice.2 3 4 5 6 On the other hand, cardiologists and other specialists point to the overwhelming evidence supporting use of statins and other drugs for prevention in terms of lower morbidity and mortality.7

During the past decade, various guidelines for cardiovascular prevention were presented in Norway, with diverging recommendations on the thresholds for starting drug treatment. General practice specialist organisations and hospital specialists held contradictory views, both in Norway and within Europe.2 The Norwegian health directorate found this situation unsatisfactory and invited key stakeholders to develop new national guidelines for general practitioners and other specialists prescribing primary prevention. The guidelines, published and implemented in 2009, adopt a new approach using differentiated risk thresholds according to age.8 This article describes the process and reasons underlying the choices made.

Development process

The Norwegian primary prevention guidelines group was established in 2004 and agreed on key principles for the development of new recommendations. We agreed that the process should be evidence based and combined with a systematic and transparent approach. To clarify disagreement, all stakeholders were asked to explain their arguments and acknowledge medical evidence, evidence on cost effectiveness, and health policy and ethical concerns. Recommendations on treatment thresholds are arguably …

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