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Primary Care

Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention

BMJ 2005; 331 doi: (Published 15 September 2005) Cite this as: BMJ 2005;331:614
  1. Belgin Unal (belgin.unal{at} (belgina{at}, associate professor1,
  2. Julia Alison Critchley, lecturer in research synthesis2,
  3. Simon Capewell, professor of clinical epidemiology3
  1. 1 Department of Public Health, Dokuz Eylul University School of Medicine, 35340 Izmir, Turkey
  2. 2 International Health Group, Liverpool School of Tropical Medicine, Liverpool L3 5QA
  3. 3 Division of Public Health, University of Liverpool, Liverpool L69 3GB
  1. Correspondence to: B Unal
  • Accepted 26 July 2005


Objective To investigate whether population based primary prevention (risk factor reduction in apparently healthy people) might be more powerful than current government initiatives favouring risk factor reduction in patients with coronary heart disease (CHD) (secondary prevention).

Design, setting, and participants The IMPACT model was used to synthesise data for England and Wales describing CHD patient numbers, uptake of specific treatments, trends in major cardiovascular risk factors, and the mortality benefits of these specific risk factor changes in healthy people and in CHD patients.

Results Between 1981 and 2000, CHD mortality rates fell by 54%, resulting in 68 230 fewer deaths in 2000. Overall smoking prevalence declined by 35% between 1981 and 2000, resulting in approximately 29 715 (minimum estimate 20 035, maximum estimate 44 675) fewer deaths attributable to smoking cessation: approximately 5035 in known CHD patients and approximately 24 680 in healthy people. Population total cholesterol concentrations fell by 4.2%, resulting in approximately 5770 fewer deaths attributable to dietary changes (1205 in CHD patients and 4565 in healthy people) plus 2135 fewer deaths attributable to statin treatment (1990 in CHD patients, 145 in people without CHD). Mean population blood pressure fell by 7.7%, resulting in approximately 5870 fewer deaths attributable to secular falls in blood pressure (520 in CHD patients and 5345 in healthy people) plus approximately 1890 fewer deaths attributable to antihypertensive treatments in people without CHD. Approximately 45 370 fewer deaths were thus attributable to reductions in the three major risk factors in the population: some 36 625 (81%) in people without recognised CHD and 8745 (19%) in CHD patients.

Conclusions Compared with secondary prevention, primary prevention achieved a fourfold larger reduction in deaths. Future CHD policies should prioritise population-wide tobacco control and healthier diets.


  • Contributors BU developed the protocol; collected and critically reviewed the data; built the IMPACT model for England and Wales; analysed and interpreted the results; drafted and wrote the paper; finalised, approved, and submitted the paper; and is the guarantor. JAC contributed to the conception and design of the study and the building of the IMPACT model for England and Wales, critically reviewed the data and interpreted the results, revised the paper, and approved the final version. SC built the original IMPACT model and supervised its adaptation for England and Wales, contributed to the conception and design of the study, acquired and critically reviewed the data, analysed and interpreted the results, revised and contributed to the paper, and approved the final version.

  • Funding BU was funded by the NHS Executive North West Research and Development Directorate as a research training fellow. Competing interest: None declared.

  • Ethical approval Not needed.

  • Accepted 26 July 2005
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