The European Journal of Public Health Advance Access published online on June 8, 2009
The European Journal of Public Health, doi:10.1093/eurpub/ckp067
National cardiovascular prevention should be based on absolute disease risks, not levels of risk factors
John Powles1, Amir Shroufi2, Colin Mathers3, Witold Zatonski4, Carlo La Vecchia5 and Majid Ezzati6
1 Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK
2 NHS Mid Essex, Swift House, Chelmsford, Essex, CM2 5PF, UK
3 Department of Health Statistics and Informatics, World Health Organization, 20, Avenue Appia 1211 Geneva 27, Switzerland
4 Cancer Epidemiology and Prevention Division, M Slodowska-Curie Memorial Cancer Centre, ul W.K. Roentgena 5, 02-781 Warsaw, Poland
5 Istituto di Ricerche Farmacologiche "Mario Negri," and University of Milan School of Medicine, Via La Masa, 19 20156 Milan, Italy
6 Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, USA
Correspondence: Amir Shroufi, NHS Mid Essex, Swift House, Chelmsford, Essex, CM2 5PF, UK, tel: +44 0 1245 398732, fax: +44 0 1245 398711, e-mail: amir.shroufi{at}doctors.org.uk
Received January 8, 2009 , accepted April 21, 2009
Background: It has been shown that the prevention of multicausal diseases such as heart attack (at an individual level) should be guided by absolute risks rather than by the level of risk factors. Here, we show that an analogous argument should form the basis of population-level prevention. Methods: Estimates of age- and sex-specific means and standard deviations for systolic blood pressures and blood cholesterol concentrations and for deaths assigned to all vascular causes in 2002 were obtained from the World Health Organization for 25 current member states of the European Union, for the ages 30–69 years. Predicted effects of 5 mmHg reductions in mean systolic blood pressures and 0.5 mmol l–1 reductions in mean total blood cholesterol concentrations on deaths and years of life lost (YLL) per 100 000 person-years from vascular diseases were modelled using proportional risk coefficients from meta-analyses of cohort studies and randomized controlled trials. Results: Potential absolute benefits were strongly positively associated with current levels of absolute mortality risk: in the case of systolic blood pressure, predicted vascular deaths averted in the highest risk populations (Romania, Bulgaria) were over five times higher than in the lowest risk populations (Spain, France). Potential benefits were only weakly related to existing levels of the risk factor of interest. Conclusions: High-risk populations should give the highest priority to achieving favourable shifts in all modifiable risk factors. Irrespective of the level of any particular risk factor, the rewards will be greatest in these populations.
Keywords: absolute benefit, absolute risk, cardiovascular, prevention, risk.