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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe European Guidelines for the Prevention of Cardiovascular Disease are based on the concept of \u201ctotal risk,\u201d an approach that takes into account the continuous and synergistic nature of the factors that contribute to cardiovascular disease risk. Risk levels were developed using data from the SCORE project [Conroy RM et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2003] and have been translated into a series of tables for ease of use. Using this approach cardiovascular risk can be estimated by taking into account all of the risk factors, rather than examining a single risk factor in isolation.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe European Guidelines for the Prevention of Cardiovascular Disease (\u003Ca href=\u0022http:\/\/www.escardio.org\u0022\u003Ewww.escardio.org\u003C\/a\u003E) are based on the concept of \u201ctotal risk,\u201d an approach that takes into account the continuous and synergistic nature of the factors that contribute to cardiovascular disease (CVD) risk. Risk levels were developed using data from the SCORE project [Conroy RM et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2003] and have been translated into a series of tables for ease of use. \u201cUsing this approach,\u201d said Professor David A. Wood, Imperial College, London, UK, \u201ccardiovascular risk can be estimated by taking into account all of the risk factors, rather than examining a single risk factor in isolation.\u201d\u003C\/p\u003E\u003Cp\u003EProf. Wood suggested that if we are going to measure CVD risk in this way, we should use the same multifactorial approach for prevention. However, the evidence for this approach is extrapolated from a variety of meta-analyses of unifactorial randomized clinical trials that show that:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-4\u0022\u003ESignificant reductions in coronary heart disease (CHD) events and stroke can be achieved by reducing systolic blood pressure (BP) by 10 mm Hg and diastolic BP by 5 mm Hg, regardless of a prior history of vascular disease, CHD, or stroke [Law MR et al. \u003Cem\u003EBMJ\u003C\/em\u003E 2009]\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003ESignificant reductions in major vascular events can be achieved with reductions in LDL cholesterol [CTT Collaborators. \u003Cem\u003ELancet\u003C\/em\u003E 2005]\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003EWith some caveats about total mortality, the probability of nonfatal MI can be reduced with intensive versus standard glucose-lowering treatment [Ray K et al. \u003Cem\u003ELancet\u003C\/em\u003E 2009]\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n      \u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EIn contrast, the evidence for a multifactorial approach is not as strong in studies that use a multiple risk factor reduction strategy in primary prevention [Ebrahim S et al. Cochrane Database of Systemic Reviews 2006]. Prof. Wood noted, however, that the reductions in BP and cholesterol in these multifactorial trials were considerably smaller than in unifactorial trials and suggested that perhaps if they had been greater, much more overall benefit would have been seen. For secondary prevention and rehabilitation, however, the evidence for a multifactorial intervention is much more compelling; yet, there is great variability across Europe in the provision of such services. Average attendance to at least one rehabilitation session among all patients was only 36%, with country-specific rates ranging from 0% (Greece and Spain) to 86% (Lithuania). Patients who received a coronary artery bypass graft were most likely to be offered and attend rehabilitation (68%); ischemia patients were least likely (16%). The risk factors that were most affected by these programs were exercise, followed by smoking. Substantially less of an impact was seen for cholesterol and BP reduction [Taylor R et al. \u003Cem\u003EAm J Med\u003C\/em\u003E 2004].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EIn closing, Prof. Wood said that \u201cthe strategies for the primary and secondary prevention of CVD should be unified. All patients should be provided with a comprehensive program that addresses all aspects of care, including lifestyle, psychosocial factors, risk factor management, and medication adherence.\u201d\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003E\u201cThere are essentially two approaches to combat CVD: one is targeting the high-risk population; the other is to try to treat the population as a whole,\u201d said Professor Diederick E. Grobbee, MD, University Medical Center, Utrecht, The Netherlands.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThe high-risk strategy, which starts with risk stratification and then proceeds to targeted treatment, is the most familiar. It clearly benefits those at risk and is based on reductions in individual risk that outweigh the side effects of treatment. It is an affordable approach. High-risk strategies are not a solution to the epidemic of CVD in our society, however, since they fail on a number of levels:\u003C\/p\u003E\u003Col class=\u0022list-ord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-11\u0022\u003EInadequate detection and diagnosis\u003C\/p\u003E\n            \u003Cul class=\u0022list-unord \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                  \u003Cp id=\u0022p-12\u0022\u003Ethe majority of at-risk individuals reside in underdeveloped countries that do not have medical resources\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n            \u003Cp id=\u0022p-13\u0022\u003EInadequate prediction of risk\u003C\/p\u003E\n            \u003Cul class=\u0022list-unord \u0022 id=\u0022list-4\u0022\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n                  \u003Cp id=\u0022p-14\u0022\u003Emost events occur at modest elevations of risk\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                  \u003Cp id=\u0022p-15\u0022\u003Ea single risk factor is not very powerful to discriminate high from low risk\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n                  \u003Cp id=\u0022p-16\u0022\u003Emodest elevations in multiple risk factors may share common etiology (eg, the metabolic syndrome)\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n                  \u003Cp id=\u0022p-17\u0022\u003Erisk scores are still far from perfect\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n                  \u003Cp id=\u0022p-18\u0022\u003Eimportant population groups will easily be missed (eg, the young)\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n            \u003Cp id=\u0022p-19\u0022\u003EInsufficient treatment\u003C\/p\u003E\n            \u003Cul class=\u0022list-unord \u0022 id=\u0022list-5\u0022\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\n                  \u003Cp id=\u0022p-20\u0022\u003Ein the highest risk group, there is marked undertreatment, and in the lowest risk group, there is marked overtreatment\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-14\u0022\u003E\n            \u003Cp id=\u0022p-21\u0022\u003ELack of compliance\/motivation of physician and\/or patient\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-15\u0022\u003E\n            \u003Cp id=\u0022p-22\u0022\u003EExpensive for nonestablished market economies\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-16\u0022\u003E\n            \u003Cp id=\u0022p-23\u0022\u003ETargets only a small fraction (\u223c25%) of the population at risk\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ol\u003E\u003Cp id=\u0022p-24\u0022\u003EThe alternative approach\u2014a population strategy\u2014considers risk in populations rather than risk in individuals (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/4\/9\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Population Strategy.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-392437986\u0022 data-figure-caption=\u0022Population Strategy.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/4\/9\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/4\/9\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/4\/9\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11412\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-25\u0022 class=\u0022first-child\u0022\u003EPopulation Strategy.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduce with permission by D. Grobbee.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-26\u0022\u003EThere are some clear benefits for the population strategy. It tackles the underlying causes of CVD, and the effects are magnified over the entire population\u2014it can change the norm. \u201cThere are also problems,\u201d said Prof. Grobbee. Low-risk individuals are not likely to benefit very much (the so-called prevention paradox), which leads to poor motivation (public and physician). In addition, little is known about the cost-benefit ratio or what the risks might be.\u003C\/p\u003E\u003Cp\u003EPopulation strategies fail for several reasons:\n\u003C\/p\u003E\u003Col class=\u0022list-ord \u0022 id=\u0022list-6\u0022\u003E\u003Cli id=\u0022list-item-17\u0022\u003E\n               \u003Cp id=\u0022p-28\u0022\u003EResponsibility for individuals unclear\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-18\u0022\u003E\n               \u003Cp id=\u0022p-29\u0022\u003EMessage not sexy, not fashionable\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-19\u0022\u003E\n               \u003Cp id=\u0022p-30\u0022\u003ERequires societal attitudes\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-20\u0022\u003E\n               \u003Cp id=\u0022p-31\u0022\u003EPolitics\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-21\u0022\u003E\n               \u003Cp id=\u0022p-32\u0022\u003EEconomics (can be expensive)\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-22\u0022\u003E\n               \u003Cp id=\u0022p-33\u0022\u003EIncomplete understanding of lifestyle factors and ways to influence them\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ol\u003E\u003Cp\u003E\n      \u003C\/p\u003E\u003Cp id=\u0022p-34\u0022\u003EIn conclusion, Prof. Grobbee said that prevention, using multiple strategies, needs to be moved higher on the global agenda.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2009 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/9\/4\/9.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmike\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmike\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}