Re-evaluating the Rose approach: comparative benefits of the population and high-risk preventive strategies.
BACKGROUND
Options for the prevention of cardiovascular disease, the greatest global cause of death, include population preventive measures (the Rose approach), or specifically seeking out and managing high-risk cases. However, the likely benefit of a population approach has been recently questioned.


OBJECTIVE
To compare the estimated effects of population strategies at varying levels of population-wide risk factor reduction and high-risk strategies at varying rates of screening uptake on cardiovascular disease mortality.


METHODS
Data (of 109 954 participants) were pooled from six European general population cohort studies [the high-risk cohorts from the SCORE (Systematic COronary Risk Evaluation) dataset]. The effects of various population and high-risk strategies for the reduction of risk factors were estimated by calculating the change in 10-year risk of cardiovascular disease mortality (SCORE risk) before and after the particular intervention. Risk factors studied were: total cholesterol, blood pressure and smoking.


RESULTS
At population level, if a 10-year reduction of blood cholesterol level of 10%, a BP reduction of 10% and a 10% reduction in the prevalence of smoking is considered possible, then 9125 lives per million of the population would be saved over 10 years. In contrast, an approach that treats all high-risk individuals with a polypill containing statin, three half-dose antihypertensives and aspirin, with a 20-80% uptake, would save 1861-7452 lives per million. However, the high-risk estimates are very optimistic, as their achievement would require complete compliance.


CONCLUSIONS
High-risk and population strategies are complementary. These estimates of the benefits of each may be useful to health planners, when combined with their local knowledge. Recently, benefits of population strategies have been underestimated.
Department of Cardiology, Adelaide Meath Hospital, Tallaght, Dublin, Ireland.
Marie-Therese
MT
Cooney
Alexandra
A
Dudina
Peter
P
Whincup
Simon
S
Capewell
Alessandro
A
Menotti
Pekka
P
Jousilahti
Inger
I
Njølstad
Raphel
R
Oganov
Troels
T
Thomsen
Aage
A
Tverdal
Hans
H
Wedel
Lars
L
Wilhelmsen
Ian
I
Graham
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use*; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D002784:Cholesterol / Q000097:blood; D015331:Cohort Studies; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D010349:Patient Compliance; D011159:Population Surveillance; D011314:Preventive Health Services; D018570:Risk Assessment; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012907:Smoking / Q000009:adverse effects; D016540:Smoking Cessation; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D000959:Antihypertensive Agents; D015415:Biomarkers; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002784:Cholesterol; D001241:Aspirin