Intended for healthcare professionals

Analysis And Comment Preventive medicine

Revisiting Rose: strategies for reducing coronary heart disease

BMJ 2006; 332 doi: (Published 16 March 2006) Cite this as: BMJ 2006;332:659
  1. Douglas G Manuel, scientist (,
  2. Jenny Lim, research coordinator1,
  3. Peter Tanuseputro, research coordinator1,
  4. Geoffrey M Anderson, professor2,
  5. David A Alter, scientist1,
  6. Andreas Laupacis, chief executive officer1,
  7. Cameron A Mustard, president and senior scientist3
  1. 1 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5
  2. 2 Department of Public Health Sciences, University of Toronto, Toronto
  3. 3 Institute for Work and Health, Toronto
  1. Correspondence to: D G Manuel
  • Accepted 1 December 2005

The way we assess risk of coronary heart disease has become more accurate in recent years. How does this affect the efficacy of primary and secondary prevention strategies?

Twenty years ago Geoffrey Rose used the examples of blood pressure and cholesterol to show that shifting the distribution curve of a single risk factor by a small amount in an entire population has a greater effect on death rates than does treating only people with high levels of that risk factor.1 2 Rose did not entirely discount screening and treatment, but he cautioned that it should target people at high risk of developing an adverse health outcome rather than people with a single raised risk factor such as cholesterol concentration. In the case of coronary heart disease, medical practice has evolved to include assessment of the baseline risk of disease when recommending drug treatment. Rose's argument that a population based strategy reduces more deaths from coronary heart disease than drug treatment should be re-evaluated now that the medical treatment has incorporated the high baseline risk strategy.

Medical strategies for coronary heart disease

At the time of Rose's work, the typical medical strategy was to treat people with cholesterol lowering drugs if their total cholesterol concentration was above a defined threshold (Rose used 6.2 mmol/l). Today, we use a baseline risk strategy that recommends treatment for people with an increased risk of a coronary event or death. Risk is assessed by algorithms that include age, sex, smoking status, blood pressure, cholesterol concentration, and other behavioural or disease risk factors.3 4 This means that cholesterol lowering drugs (typically statins) are recommended for almost everyone with pre-existing coronary heart disease because they have a high risk of an adverse event, regardless of their total cholesterol or other lipid concentrations, and statins have been shown to reduce coronary events …

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