The debate on the best way forward for primary prevention continues, and today cebmblog published:

Heneghan C. Considerable uncertainty remains in the evidence for primary prevention of cardiovascular disease [editorial]. The Cochrane Library 2011 19 Jan.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide, and therefore strategies that aim to improve prevention in people without existing disease (primary prevention) are important for managing the overall burden of disease. This edition of The Cochrane Library adds to the evidence-base in this area with publication of two Cochrane Reviews on such preventive strategies: multiple risk factor interventions for primary prevention of coronary heart disease, and statins for the primary prevention of CVD. read more

One of my major issues with primary prevention is:
'Given the current limitations of the evidence-base, the alternative approach for policy is to focus on population-wide prevention. Widely publicised by Geoffrey Rose,legislating for smoke-free public spaces, re-designing public spaces to improve exercise or reducing daily dietary salt intake prove generally effective and can be cost-saving interventions.'

If you haven't already read a copy of Rose's book, you should,
get yourself a copy now. It should be compulsary reading for commissioners, docs and anyone involved in health prevention.

Coronary heart disease (CHD), which usually presents as a heart attack (or myocardial infarction, MI) is the most common cause of death and disability both in the UK and globally. The way in which CHD is treated and prevented therefore has huge implications for patients, health professionals and policymakers. Once a person has a heart attack, prevention of further heart attacks, stroke or death, or secondary prevention, is crucial. There is strong evidence for benefit of several drugs and treatments after heart attacks to this end, including aspirin, statins, ACE inhibitors and beta-blockers. Such treatments have undoubtedly saved lives, but studies in the US and the UK, have shown that between 30-60% of MI patients receive appropriate treatment. There are strong arguments for giving more people the right drugs with benefits in terms of mortality and cost-effectiveness. Current NICE guidelines therefore recommend these treatments for all patients following a heart attack.

This week, the British Heart Foundation reported that only 38% of such patients were receiving adequate rehabilitation care. “Cardiac rehab includes advice from dieticians, physiotherapists and psychologists about how to live with the consequences and improve the survival chances following heart attacks, coronary artery bypass operations and angioplasties.” The components of cardiac rehab have benefits individually and together. For example, a review of 46 trials including 9000 patients showed that exercise-based rehabilitation reduces all deaths by 20%, and cardiac deaths by 26%. Some patients are too ill to benefit from cardiac rehabilitation, and others choose not to partake or continue with the rehabilitation programme.

Provision of drug treatment and primary angioplasty programmes has improved more than cardiac rehabilitation, which has remained the poor relation. This is partly because we tend to favour treatment rather than prevention, and pills rather than behaviour changes. To a greater extent than other treatments, cardiac rehabilitation needs the commitment of the patient. However, this does not mean that we cannot be innovative in designing ways of increasing access to this vital aspect of care for patients after MI.

Cardiovascular disease (CVD) causes more mortality and morbidity than any other disease in both rich countries and poor countries [1]. The risk factors have been well-known for 50 years, but the optimal prevention strategy is still elusive. Primary prevention treats individuals before they have a heart attack, whereas secondary prevention focuses on individuals who have had a heart attack. Several classes of drugs treat cardiovascular risk factors, demonstrating benefits in both primary and secondary prevention [2]. Many of these drugs are off-patent, and therefore cheap. Six years ago, Wald and Law hypothesised that a “Polypill”, containing three anti-hypertensives, folic acid, simvastatin and aspirin, could reduce the rates of CVD by over 80%, if all adults over the age of 55 years took it [3]. This week the Lancet published the first ever trial of such a Polypill [4, 5].