Principles of prevention of cardiovascular disease

H. Greten*

Department of Internal Medicine, University Hospital Eppendorf Hamburg, Martinistr. 52, 20246 Hamburg, Germany

* Tel.: +49-4042-8033901; fax: +49-4042-8039723
E-mail address: ias{at}uke.uni-hamburg.de

Dear Sir

The International Atherosclerosis Society (IAS) recently released harmonized guidelines for prevention of atherosclerotic disease through clinical management.1 These guidelines integrate and harmonize existing guidelines for this purpose. Thanks to a large number of clinical trials, it is now possible to provide strong evidence-based guidelines for risk factor modification to prevent both recurrent atherosclerotic events (secondary prevention) and new onset events (primary prevention). Most guidelines in the cardiovascular field are in agreement that intensive risk-factor intervention is both efficacious and cost effective for secondary prevention. Moreover, recent guidelines have extended the concept of secondary prevention to include high-risk patients having several types of cardiovascular disease (CVD) including established coronary heart disease (CHD), peripheral arterial disease, and stroke. In addition, many patients with diabetes have been shown to be at high risk, as are some persons with multiple risk factors. Both of these latter groups are candidates for intensive risk reduction as well. In the United States, a category of moderately high risk has further been identified as including patients with multiple risk factors who are not yet at high risk but who nonetheless will benefit from clinical risk intervention.

Although most guidelines are in agreement that patients with established CVD are strong candidates for aggressive risk-reduction therapy, a major challenge in the field of CVD prevention is the identification of patients without CVD who are at high enough risk to justify clinical intervention, especially with drug therapy. Risk assessment for this purpose generally has employed multiple-risk-factor algorithms. Two risk-assessment tools widely used are the Framingham algorithm and the PROCAM algorithm. These two approaches give similar although not identical results. Both algorithms assess 10-year risk for "hard CHD" (myocardial infarction+CHD death). A new algorithm, called SCORE, was recently published.2 This algorithm is designed to be used specifically in Europe, and it divides the European population into high-risk and low-risk regions. The same risk factors are used for both regions, but their relations to CVD are weighted differently. A critical feature of the SCORE algorithm is that it is based on prediction of total fatal CVD outcomes and not on total CVD events. The consequences for clinical management of this change in outcome for the risk algorithm must be examined. A critical question is whether the major purpose of primary prevention is to reduce the burden of atherosclerotic disease in society or to reduce CVD mortality. Use of the SCORE algorithm likely will shift the balance in public health policy more to secondary prevention and away from primary prevention. It employs the weaker association between risk factors and CVD mortality than between risk factors and CVD morbidity (CVD burden). Many persons at higher risk for new-onset CVD will not be identified. A particular deficit of the SCORE algorithm is its failure to identify older people at higher risk who have been shown to benefit from risk-reducing therapies.

The IAS views this shift in emphasis implied by SCORE risk assessment as being ill-advised. The need for intensive intervention for secondary prevention is well established. The future of CVD prevention lies in reducing CVD burden by preventing new-onset CVD. We view the major need in this area to be for improved algorithms to assess risk for total CVD events. Such would allow for application of more efficacious and cost-effective preventive therapies to deserving individuals without CVD. In the meantime, Framingham and PROCAM algorithms provide the best risk-assessment tools for primary prevention. Indeed, both algorithms are currently being adjusted to improve risk assessment in specific populations.

References

  1. International Atherosclerosis Society. Harmonized clinical guidelines on prevention of atherosclerotic vascular disease, 2003. Available from www.athero.org.
  2. Conroy RM, Pyörälä K, Fitzgerald AP et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur. Heart J. 2003;24:987–1003.[Abstract/Free Full Text]




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