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Primary and Secondary

Prevention of

Cardiovascular Disease

Approaches to Primary and

Secondary Prevention of CVD

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Primary prevention involves prevention ofonset of disease in persons withoutsymptoms.

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Primordial prevention involves theprevention of risk factors causative o thedisease, thereby reducing the likelihood ofdevelopment of the disease.

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Secondary prevention refers to theprevention of death or recurrence of diseasein those who are already symptomatic

Population vs. High-Risk Approach

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Risk factors, such as cholesterol or blood pressure, havea wide bell-shaped distribution, often with a “tail” ofhigh values.

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The “high-risk approach” involves identification andintensive treatment of those at the high end of the“tail”, often at greatest risk of CVD, reducing levels to“normal”.

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But most cases of CVD do not occur among the highestlevels of a given risk factor, and in fact, occur amongthose in the “average” risk group.

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Significant reduction in the population burden of CVDcan occur only from a “population approach” shiftingthe entire population distribution to lower levels.

Expected Shifts in Cholesterol Distribution

from High-Risk, Population, and

Combined Approaches

Communitywide CVD Prevention

Programs

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Stanford 3-Community Study (1972-75) showed massmedia vs. no intervention in high-risk residents toresult in 23% reduction in CHD risk score

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North Karelia (1972-) showed public educationcampaign to reduce smoking, fat consumption, bloodpressure, and cholesterol

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Stanford 5-City Project (1980-86) showed reductionsin smoking, cholesterol, BP, and CHD risk

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Minnesota Heart Health Program (1980-88) showedsome increases in physical activity and in womenreductions in smoking

Materials Developed for US

Community Intervention Trials

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Mass media, brochures and direct mail

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Events and contests

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Screenings

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Group and direct education

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School programs and worksiteinterventions

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Physician and medical setting programs

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Grocery store and restaurant projects

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Church interventions

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Policies

Individual Risk Assessment

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Careful assessment of medical history,physical examination, laboratoryexaminations

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Tobacco, diet, and physical activity history

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Blood pressure, height/weight, waist/hip orwaist circumference, lipid profile

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Determination of global risk score (forassessing 10-year CHD risk probability)

Framingham Risk Algorithms

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Provides 10-year estimated risk of CHD (some focusonly on hard endpoints, others include angina pectoris),Stroke, CHF, or Intermittent Claudication

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Applicable to specific ages and persons w/o CHD

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Different versions published:^ –

Wilson 1998 includes LDL-C but ages limited to

30-

NCEP III 2001 version has wider age range but doesnot include diabetes

D’Agastino 2001 version includes diabetes)

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Applicable to other ethnic groups as shown fromvalidation studies in other population-based studies

Considerations for Secondary

Prevention (cont.)

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Framingham altorithms can be used for predictionof recurrent CHD events over next 2 years

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SBP, total cholesterol, and diabetes remainimportant predictors of reinfarction or CHD deathover 10-years post-MI (Wong et al. 1989)

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Females often at poorer early prognosis, but can beshown to be at survival advantage post-MI afteradjusting for risk factor differences: females areolder, have more diabetes, hypercholesterolemia, andelevated BP levels post-MI (Wong et al.1989).

Secondary Prevention Strategies

of Proven Benefit

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AHA Secondary Prevention Statementoutlines recommended assessment,management, and risk factor goal levels.

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Proven strategies include:^ –

cholesterol-lowering (4S, CARE, LIPID, HIT)

blood pressure reduction (HDFP, HOT)

antiplatelet rx (Antiplatelet Trialists Collab)

smoking (CASS)

dietary therapy and exercise (Lifestyle HeartTrial, Hdidelberg)

AHA Get With The Guidelines

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Major AHA program to implement thesecondary prevention guidelines forpatients hospitalized with CHD

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Focuses on evidence-based guidelines

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National rollout began in New Englandand California

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Future expansion planned for stroke,CHF, and diabetes to address QAreporting requirements