Strategies to prevent cardiovascular disease

Cardiovascular diseases, namely myocardial infarction and stroke, are the first cause of death worldwide. Despite advances in their treatment, mortality and morbidity remain high. Thus, their prevention is of enormous importance and is perhaps the most basic goal of Cardiology today.

The famous English epidemiologist Geffrey Rose (1926-1993) had described two strategies for prevention: the strategy aimed at high-risk individuals and the strategy aimed at the entire population of a society.

Strategy targeting high-risk individuals

This strategy is the usual tactic in everyday medical practice. From the general population, we identify individuals who we estimate have a high future probability of experiencing a vascular event. As the risk is shaped by the coexistence of known and easily measurable risk factors (high cholesterol, smoking, arterial hypertension, diabetes, age) cardiovascular risk calculation models have been created with which we easily classify individuals as low, medium or high risk.

In fact, today, we have at our disposal additional ways to identify high-risk individuals, such as the measurement of Lp(a), the measurement of calcium in the coronary arteries with a special computed tomography without contrast or the detection of early atheromatous lesions in the vessels with ultrasound. For people at moderate or high risk, we give advice on modifying life habits with an emphasis on smoking cessation, weight loss, exercise and we take care, most often with medication, to lower blood pressure and cholesterol. This prevention strategy has the advantage of focusing on the individual concerned who is, after all, motivated to reduce his or her chance of becoming ill in the future. But there is a problem with lower-risk people (who “move under the detection radar”, since they have no reason to see a doctor). These are many in a society, and although they individually have little risk, they ultimately contribute more to a country’s total heart attacks. In other words, as Rose put it in 1985, “the burden of disease in a society comes mainly from the many who have a subtle risk rather than from the few with a very obvious problem.” And that puts a limit on the effectiveness of the prevention strategy we just described.

Strategy targeting the entire population

Precisely because of the above findings, the prevention strategy aimed at the general population is of enormous importance. Here, the philosophy is different. The goal is to change the environmental, social and economic parameters that are responsible for the occurrence of cardiovascular disease, seeking to reduce risk factors in the entire population, without requiring medical examination of individuals and without the use of drugs.

The main goals are to reduce smoking, maintain an ideal body weight, eat healthier, exercise daily for everyone. Some goals will be achieved by legislative measures (bans on smoking everywhere, reducing the amount of salt in packaged food, increasing the price of healthy products), some others by changing the mentality about what is “trendy” (in the school canteen fruits instead of snacks, commuting every day on foot or by bicycle rather than by car). If the entire population lost a little weight, exercised a little more and chose a Mediterranean diet the benefit in reducing vascular events would be enormous.

It has been estimated that a population-wide reduction in blood pressure of just 2-3 mmHg (easily achieved through healthier lifestyles) would reduce the incidence of hypertension by 17%, reduce the risk of coronary heart disease and stroke more than medication was reduced only for those with hypertension.
Of course, this strategy does not provide a visible benefit to the individual (“paradox of prevention”), it is based on a total change of behaviors and requires government funding to be enforced or advertised.

Combined policy

Both complementary approaches are necessary to reduce cardiovascular events. At the individual level, individualized lifestyle instructions, treatment of specific risk factors, medication and interventions based on guidelines and check-up rules are needed.

At the same time, health policy at the population level must aim to create a society without smoking, with a mindset of more exercise, better nutrition without obesity and without exposure to air pollution. By combining the two prevention strategies, the reduction of cardiovascular events is significant.