Targeted cardiovascular prevention and secondary prevention
THE CONTEXT
Cardiovascular prevention includes public health measures, treatment directed at high-risk individuals and interventions for people who have already had cardiovascular disease.
Population measures and targeted assessment
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Legislation restricting smoking in public places has been associated with reduced rates of myocardial infarction.
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A targeted strategy identifies and treats high-risk individuals whose combined risk factors can be quantified using composite scoring systems.
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Absolute risk of atheromatous cardiovascular disease should be assessed before treatment to judge whether potential benefits outweigh expense, inconvenience and possible side effects.
Absolute risk and treatment benefit
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The example of a 65-year-old man with blood pressure of 150/90 mmHg, smoking, diabetes and a total:high-density lipoprotein cholesterol ratio of 8 gives a 10-year myocardial infarction or stroke risk of 56%.
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A 55-year-old woman with the same blood pressure, no smoking or diabetes, and a total:high-density lipoprotein cholesterol ratio of 6 has a corresponding risk of 5.7%.
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The passage states that cholesterol lowering reduces risk by 30% in both individuals and blood pressure lowering produces a further 20% reduction.
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The combined interventions are stated to reduce risk from 56% to 25% in the man, with 4 patients treated to prevent one event, and from 5.7% to 2.5% in the woman, with 40 treated to prevent one event.
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Treatment thresholds vary between countries. The passage gives a 10-year cardiovascular risk threshold of 7.5%–10% for starting cholesterol- and blood pressure-lowering therapies in the UK and North America.
Secondary prevention
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Secondary prevention targets individuals who have already had cardiovascular disease.
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Patients recovering from a myocardial infarction are often particularly receptive to dietary modification and smoking cessation advice.
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Additional interventions are indicated for patients with angina pectoris or an acute coronary syndrome, although their details are not provided in this passage.