Principles for National and Regional Guidelines on Cardiovascular Disease Prevention
2004; Lippincott Williams & Wilkins; Volume: 109; Issue: 25 Linguagem: Inglês
10.1161/01.cir.0000133427.35111.67
ISSN1524-4539
AutoresSidney C. Smith, Rod Jackson, Thomas A. Pearson, Valentı́n Fuster, Salim Yusuf, Ole Færgeman, David A. Wood, M. H. Alderman, John Horgan, Philip Home, Marilyn Hunn, Scott M. Grundy,
Tópico(s)Cardiac Health and Mental Health
ResumoHomeCirculationVol. 109, No. 25Principles for National and Regional Guidelines on Cardiovascular Disease Prevention Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBPrinciples for National and Regional Guidelines on Cardiovascular Disease PreventionA Scientific Statement From the World Heart and Stroke Forum* Sidney C. SmithJr, MD, Rod Jackson, MBChB, PhD, Thomas A. Pearson, MD, MPH, PhD, Valentin Fuster, MD, PhD, Salim Yusuf, MBBS, DPhil, Ole Faergeman, MD, DMSc, David A. Wood, MSc, Michael Alderman, MD, John Horgan, MD, Philip Home, MA, DPhil, DM, Marilyn Hunn, BS and Scott M. Grundy, MD, PhD Sidney C. SmithJrSidney C. SmithJr From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Rod JacksonRod Jackson From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Thomas A. PearsonThomas A. Pearson From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Valentin FusterValentin Fuster From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Salim YusufSalim Yusuf From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Ole FaergemanOle Faergeman From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , David A. WoodDavid A. Wood From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Michael AldermanMichael Alderman From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , John HorganJohn Horgan From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Philip HomePhilip Home From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). , Marilyn HunnMarilyn Hunn From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). and Scott M. GrundyScott M. Grundy From the Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland (R.J.); Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY (T.A.P.); Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry Kravis Center for Cardiovascular Health, Mount Sinai Medical Center, New York, NY (V.F.); Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (S.Y.); University Hospital, Aarhus Amtssygehus, Denmark (O.F.); National Heart and Lung Institute, Faculty of Medicine, Imperial College London, UK (D.A.W.); Albert Einstein College of Medicine, Bronx, NY (M.A.); Cardiac Department, Beaumont Hospital, Dublin, Ireland (J.H.); Department of Medicine, University of Newcastle upon Tyne, UK (P.H.); World Heart and Stroke Forum, World Heart Federation, Geneva, Switzerland (M.H.); and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas, Tex (S.M.G.). Originally published29 Jun 2004https://doi.org/10.1161/01.CIR.0000133427.35111.67Circulation. 2004;109:3112–3121In the global effort to reduce suffering and death from CVD, the World Heart and Stroke Forum (WHSF) Guidelines Task Force of the World Heart Federation (WHF) recommends that every country develop a policy on CVD prevention. National policy should grow out of systematic and ongoing dialogue among governmental, public health, and professional clinical groups. National policy should set priorities for public health and clinical interventions appropriate to the country. It should also be the foundation for the development of national guidelines on CVD prevention, which are the focus of the present document.Cardiovascular disease (CVD) is a leading cause of global mortality, accounting for almost 17 million deaths annually. Nearly 80% of this global mortality and disease burden occurs in developing countries. In 2001, CVD was the leading cause of mortality in 5 of the 6 World Health Organization (WHO) worldwide regions. Of concern in developing countries is the projected increase in both proportional and absolute CVD mortality. This can be related to an increase in life expectancy due to public health advances, which reduce perinatal infections and nutritional deficiencies in infancy, childhood, and adolescence, and in some countries to improved economic conditions. This increasing longevity provides longer periods of exposure to CVD risk factors and thus a greater probability of clinically manifest CVD. The concomitant decline of infections and nutritional disorders (competing causes of death) also increases the proportional burden due to CVD. Adverse lifestyle changes accompanying industrialization, urbanization, and increased discretionary income increase the degree of exposure to CVD risk factors. Altered diet with increased fat and total caloric consumption and increased tobacco use are prevalent lifestyle trends. Demographic changes coupled with adverse lifestyle changes will accelerate the number of deaths due to CVD worldwide, many of which will be premature in the developing countries. Although continuation of this adverse trend is not inevitable, the CVD disease patterns now present in the economically developed countries are, in fact, becoming established in developing countries, as noted in the World Health Report 20021 (Data Supplement Figure I).Whereas the causes of CVD are common to all parts of the world, the approaches to its prevention at a societal or individual level will differ between countries for cultural, social, medical, and economic reasons. Although national guidelines will embrace the principles of CVD prevention recommended in this report, they may differ in terms of the organization of preventive cardiology, risk factor treatment thresholds and goals, and the use of medical therapies. The recommendations in this report focus on clinical management of patients with established CVD and those at high risk; however, it is essential that each country include a societal approach to CVD prevention. As stated in the WHO publication Integrated Management of Cardiovascular Risk,2 "Epidemiological theory indicates that, compared with intensive individual treatment of high-risk patients, small improvements in the overall distribution of risk in a population will yield larger gains in disease reduction, when the underlying conditions that confer risk are widespread in the population." Each country should seek to implement national clinical guidelines directed toward high-risk individuals and give equal importance to developing low-risk population strategies.Nomenclature and Profile of the Various Cardiovascular Risk FactorsA great advance in the prevention of CVD has resulted from the identification of measurable factors that predict the development of CVD. These factors are termed risk factors. Several risk factors are direct causes of CVD; these are termed major risk factors and include tobacco smoking, high blood pressure, high serum LDL cholesterol, and elevated glucose. A low level of HDL cholesterol is also considered a major risk factor because it independently predicts the incidence of CVD. A final major risk factor is advancing age; chronological age is considered a risk factor because it also independently predicts CVD. Age per se does not cause CVD but may reflect the accumulation of atherosclerosis, the severity of which predicts the likelihood of suffering a major CVD event. Persons who have multiple major risk factors generally are more likely to experience a CVD event than those with a single risk factor. Many prospective epidemiological studies provide estimates of the relative contributions of each major risk factor to CVD risk. Prediction equations have been developed from these estimates and can be used to estimate risk for individuals. Risk estimate based on risk equations is termed total CVD risk.In clinical practice, it is convenient to categorize total risk estimates into high, intermediate, and lower risk. Patients with established CVD are said to be at high risk because they are highly likely to experience new CVD events in the next 10 years. However, some asymptomatic patients with multiple risk factors, particularly those with type 2 diabetes, may carry as high a risk for future CVD events as patients with established CVD. These persons with multiple risk factors likewise are said to be at high risk. Multiple risk factors also typically are required to elevate persons to the intermediate-risk category, whereas most persons with only a single risk factor are at lower short-term risk. Nonetheless, even single risk factors, if severe and sustained, can lead to premature CVD and should not be ignored in clinical practice.Other risk factors, in addition to the aforementioned major risk factors, may further contribute to total risk. They are underlying risk factors and emerging risk factors. The underlying risk factors are overweight/obesity, physical inactivity, atherogenic diet, socioeconomic and psychosocial stress, family history of premature CVD, and various genetic and racial factors. To some extent, the underlying risk factors affect risk by acting through the major risk factors, and they also appear to influence risk in ways unrelated to the major risk factors. Although these underlying risk factors likely add an independent component to total risk, their contribution has been difficult to distinguish in prospective studies from their effects on major risk factors; for this reason, they generally are not included in clinical predictive equations. Nonetheless, the underlying risk factors apparently affect population baseline risk. Thus, the available predictive equations may not be applicable equally to all populations. The major risk factors are similar in relative predictive power in different populations, but absolute estimates of risk are variable. Differences in the underlying risk factors probably account for much of this variability in absolute risk.Emerging risk factors are factors that are correlated with CVD risk in prospective or case-control studies, but the strength of their correlation and/or their prevalence in the population is less than that for the major risk factors. For this reason, the emerging risk factors generally are not included in risk-prediction equations. Among the emerging risk factors are various lipid factors [triglycerides, apolipoproteins, lipoprotein(a), and lipoprotein subfractions] and nonlipid factors (insulin resistance, prothrombotic markers, and proinflammatory markers). Similarly, subclinical atherosclerosis may also be useful in predicting the risk of CVD events. Because the emerging risk factors are not incorporated into risk predictions, their use in clinical practice must be individualized and based on clinical judgment. Most importantly, they should not be given more priority in risk assessment than that given to the major risk factors.Concept of Total CVD RiskIn general, the benefits of interventions on particular risk factors are related more to the magnitude of the preintervention total CVD risk than to relative risk associated with a single, specific risk factor. Therefore, determination of total CVD risk is critical to recommendations on the effective and efficient management and control of CVD risk at both population and individual levels. Total CVD risk is a measure of the number of events in a defined population per unit of time (eg, CVD events per 1000 in 55- to 64-year-old men per year). In effect, a total risk compares a person's or population's risk with a zero risk. The combined effects of all risk factors determine total CVD risk, and often, modest increases in multiple risk factors have a greater impact on CVD risk than a significant increase in 1 risk factor.For example, a 46-year-old woman with high blood pressure (170/100 mm Hg), but who is a nonsmoker, is nondiabetic, and has a total cholesterol level of 5.5 mmol/L and HDL cholesterol level of 1.5 mmol/L, has an absolute CVD risk of 20/100 in the next 5 years. Moreover, although blood pressure–lowering drugs would reduce the relative CVD risk by at least one quarter in both patients, the woman's risk would fall from 4% to 3% (ie, a 1% absolute risk reduction in the next 5 years), whereas the man's risk would fall from 20% to 15% (ie, a 5% absolute risk reduction in the next 5 years). Appropriately, most practitioners would treat the first patient in concordance with national guidelines; unfortunately, many clinicians might not start a blood pressure–lowering drug in the second patient.Total CVD Risk and Policy Development: Efficacy and Cost IssuesSeveral risk factors that are only moderate often incur a greater total risk in the short term than does a single, severe risk factor. Risk assessment in both individuals and populations must take this fact into account. The greatest efficacy of treatment occurs in patients who are at highest risk. Thus, persons who are at higher total risk will attain greater reductions in absolute risk with any given lowering of risk factors. Giving priority in risk-reduction therapies to patients at higher total risk will produce a substantial reduction in total CVD events. Furthermore, more high-risk individuals will benefit; in other words, the number needed to treat over a given period of time to achieve prevention of 1 CVD event will be fewer in higher-risk persons than in lower-risk persons.One important issue to consider in CVD prevention is cost of medical management. In traditional medical practice, priority in spending has gone to treatment of persons who already manifest disease. However, there is increasingly a demand on the part of society to prevent the chronic diseases that rob individuals of health in their later years. Among the latter, heart disease, stroke, and chronic renal failure are high on the list. Moreover, advances in medical practice now make it possible to prevent or to delay the onset of these diseases. Consequently, prevention is assuming increasing importance. On the other hand, adding prevention to conventional medical practice increases the cost and cuts into the overall healthcare budget of individuals and nations. Consequently, the health policy of each nation must determine what portion of the total healthcare budget can go into prevention and what portion must go into treatment of existing disease. Medical economists have attempted to compare benefits of prevention and treatment through estimations of "cost-effectiveness." Estimates of benefits have been made for both and have been expressed in terms of quality life extension. These estimates suggest that the greatest cost-effectiveness for prevention occurs for individuals at high short-term risk, whether they have established CVD or not. Most of the more economically privileged nations can readily afford to institute preventive measures in high-risk individuals. However, considerable controversy exists about where to draw the line for primary prevention in lower-risk persons with the use of public funds. In societies with higher socioeconomic levels, primary prevention in the clinical setting can be employed in intermediate-risk persons. In less economically privileged societies, even high-risk prevention may strain available resources. Regardless of healthcare policy for clinical intervention, in all societies, public health measures can be instituted for primary prevention, and these are highly cost-effective. These include programs to discourage cigarette smoking, to promote appropriate nutrition, and to encourage physical activity. The cardiology and medical communities can play a major role in public health efforts for primary prevention of CVD.Total CVD Risk for Specific IndividualsThe principle of assessing the total or global risk associated with multiple risk factors was first introduced in New Zealand in 1993, in relation to the management of blood pressure.3 The following year, the European Society of Cardiology, European Atherosclerosis Society, and European Society of Hypertension proposed total multifactorial risk as the primary determinant of drug treatment for both blood pressure and blood lipids in preventing the development of coronary heart disease (CHD).4 The US National Cholesterol Education Program (Adult Treatment Panel II),5 published in the same year, also recommended, for the first time, assessing and managing lipids in the context of other cardiovascular risk factors. The principle of global risk was also supported by conclusions of the 27th Bethesda Conference6 (Matching the Intensity of Risk Factor Management with the Hazard of Coronary Disease Events), followed by the Sixth report of the Joint National Committee on High Blood Pressure,7 the AHA Prevention V Conference,8 the International Task Force on Coronary Heart Disease,9 the WHO/International Society of Hypertension Guidelines for Management of Hypertension,10 the National Cholesterol Education Program (Adult Treatment Panel III),11 and, most recently, the Third Joint European Societies' Task Force on CVD Prevention in Clinical Practice12 and the Seventh report of the Joint National Committee on High Blood Pressure.13 All of these guidelines since 1993 have embraced, to different extents, the principle of multifactorial or global risk assessment as a basis for deciding whom to treat with drugs, although patients with hypertension and end-organ
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