Copyright © 2004 by the European Society of Cardiology.
Clinical research
Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease
a Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London NW3 2PF, UK
b Department of Community Health Sciences, St. George's Hospital Medical School, London SW17 0RE, UK
c Department of Social Medicine, University of Bristol, Canygne Hall, Whiteladies Road, Bristol BS8 2PR, UK
Received July 30, 2003;
accepted November 21, 2003
* Corresponding author. Tel.: +44-20-7830-2239; fax: +44-20-7794-1224
E-mail address: j.emberson{at}pcps.ucl.ac.uk
See page 457 for the editorial comment on this article1
Aims To estimate the potential effectiveness of different "high-risk" and "population" approaches to the primary prevention of cardiovascular disease (CVD) in middle-aged British men, after correction for regression dilution bias.
Methods and results We used a combination of cohort and randomised controlled trial evidence to estimate the effectiveness of high-risk strategies, based on the identification of high-risk factors or high absolute risk, and strategies based on population-wide reductions in cholesterol and blood pressure. High-risk strategies were potentially effective but would need to be used widely to have a substantial effect on CVD in the population. Aggressive pharmacological treatment (using statins, ß-blockers, ACE-inhibitors and aspirin) in individuals with a 10-year Framingham event risk of 
30% (6% of population) would have reduced major CVD by at most 11%. This figure increased to 34% at a 20% treatment threshold (26% of population). In contrast, modest downwards shifts in the population distributions of serum total cholesterol and systolic blood pressure led to marked expected reductions in major CVD. Taking regression dilution bias into account, 10% reductions in long-term mean blood cholesterol and blood pressure could have reduced major CVD by 45%.
Conclusions If high-risk strategies are to have a major impact on CVD in the population, they need to be more widely used than previously envisaged. Population-wide reduction of major risk factors is needed if CVD is to be substantially reduced.
Key Words: Cardiovascular disease • Primary prevention • Regression dilution bias • Logistic regression
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