Estimating the population impact of screening strategies for identifying and treating people at high risk of cardiovascular disease: modelling study

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Abstract

Objective To estimate the potential population impact of different screening strategies for identifying and treating people at high risk of cardiovascular disease, including strategies using routine data for cardiovascular risk stratification, in light of the UK government’s recommended national strategy to screen all adults aged 40-74 for cardiovascular risk.

Design Modelling study using data from a prospective cohort, EPIC-Norfolk (European Prospective Investigation of Cancer-Norfolk).

Setting An English county.

Participants 16 970 men and women aged 40-74 and free from cardiovascular disease and diabetes at baseline.

Main outcome measures The main outcomes were the population attributable fraction, the number needed to screen to prevent one new case of cardiovascular disease, the number needed to treat to prevent one new case of cardiovascular disease, and the number of new cardiovascular events that could be prevented. Relative risk reductions for estimated treatment effects were derived from meta-analyses of clinical trials or guidelines from the National Institute for Health and Clinical Excellence.

Results 1362 cardiovascular events occurred over 183 586 person years of follow-up. Compared with the recommended government strategy, a stepwise screening approach using a simple risk score incorporating routine data could prevent a similar number (lower to upper estimates) of new cardiovascular events annually in the United Kingdom (26 789, 20 778 to 36 239) and 25 134 (19 450 to 34 134), respectively) but requiring only 60% of the population to be invited to attend a vascular risk assessment. A similar number of cardiovascular events (25 016, 19 563 to 33 372) could also be prevented by inviting everyone aged 50-74 for a vascular assessment. Using a participant completed Finnish diabetes risk score questionnaire or anthropometric cut-off points for risk prestratification was less effective.

Conclusions Compared with the UK government’s recommended national strategy to screen all adults aged 40-74 for cardiovascular risk, an approach using routine data for cardiovascular risk stratification before inviting people at high risk for a vascular risk assessment may be similarly effective at preventing new cases of cardiovascular disease, with potential cost savings.

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Most cited references 40

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General cardiovascular risk profile for use in primary care: the Framingham Heart Study.

Ralph B. D’Agostino, Ramachandran S. Vasan, Michael J. Pencina … (2008)

Separate multivariable risk algorithms are commonly used to assess risk of specific atherosclerotic cardiovascular disease (CVD) events, ie, coronary heart disease, cerebrovascular disease, peripheral vascular disease, and heart failure. The present report presents a single multivariable risk function that predicts risk of developing all CVD and of its constituents. We used Cox proportional-hazards regression to evaluate the risk of developing a first CVD event in 8491 Framingham study participants (mean age, 49 years; 4522 women) who attended a routine examination between 30 and 74 years of age and were free of CVD. Sex-specific multivariable risk functions ("general CVD" algorithms) were derived that incorporated age, total and high-density lipoprotein cholesterol, systolic blood pressure, treatment for hypertension, smoking, and diabetes status. We assessed the performance of the general CVD algorithms for predicting individual CVD events (coronary heart disease, stroke, peripheral artery disease, or heart failure). Over 12 years of follow-up, 1174 participants (456 women) developed a first CVD event. All traditional risk factors evaluated predicted CVD risk (multivariable-adjusted P<0.0001). The general CVD algorithm demonstrated good discrimination (C statistic, 0.763 [men] and 0.793 [women]) and calibration. Simple adjustments to the general CVD risk algorithms allowed estimation of the risks of each CVD component. Two simple risk scores are presented, 1 based on all traditional risk factors and the other based on non-laboratory-based predictors. A sex-specific multivariable risk factor algorithm can be conveniently used to assess general CVD risk and risk of individual CVD events (coronary, cerebrovascular, and peripheral arterial disease and heart failure). The estimated absolute CVD event rates can be used to quantify risk and to guide preventive care.

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Validity and repeatability of a simple index derived from the short physical activity questionnaire used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

Nicholas J. Wareham, Rupert W. Jakes, Kirsten L Rennie … (2003)

To assess the validity and repeatability of a simple index designed to rank participants according to their energy expenditure estimated by self-report, by comparison with objectively measured energy expenditure assessed by heart-rate monitoring with individual calibration. Energy expenditure was assessed over one year by four separate episodes of 4-day heart-rate monitoring, a method previously validated against whole-body calorimetry and doubly labelled water. Cardio-respiratory fitness was assessed by four repeated measures of sub-maximum oxygen uptake. At the end of the 12-month period, participants completed a physical activity questionnaire that assessed past-year activity. A simple four-level physical activity index was derived by combining occupational physical activity together with time participating in cycling and other physical exercise (such as keep fit, aerobics, swimming and jogging). One hundred and seventy-three randomly selected men and women aged 40 to 65 years. The repeatability of the physical activity index was high (weighted kappa=0.6, ). There were positive associations between the physical activity index from the questionnaire and the objective measures of the ratio of daytime energy expenditure to resting metabolic rate and cardio-respiratory fitness As an indirect test of validity, there was a positive association between the physical activity index and the ratio of energy intake, assessed by 7-day food diaries, to predicted basal metabolic rate. The summary index of physical activity derived from the questions used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study suggest it is useful for ranking participants in terms of their physical activity in large epidemiological studies. The index is simple and easy to comprehend, which may make it suitable for situations that require a concise, global index of activity.

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The effect of fruit and vegetable intake on risk for coronary heart disease.

Kaumudi Joshipura, Frank Hu, JoAnn Manson … (2001)

Many constituents of fruits and vegetables may reduce the risk for coronary heart disease, but data on the relationship between fruit and vegetable consumption and risk for coronary heart disease are sparse. To evaluate the association of fruit and vegetable consumption with risk for coronary heart disease. Prospective cohort study. The Nurses' Health Study and the Health Professionals' Follow-Up Study. 84 251 women 34 to 59 years of age who were followed for 14 years and 42 148 men 40 to 75 years who were followed for 8 years. All were free of diagnosed cardiovascular disease, cancer, and diabetes at baseline. The main outcome measure was incidence of nonfatal myocardial infarction or fatal coronary heart disease (1127 cases in women and 1063 cases in men). Diet was assessed by using food-frequency questionnaires. After adjustment for standard cardiovascular risk factors, persons in the highest quintile of fruit and vegetable intake had a relative risk for coronary heart disease of 0.80 (95% CI, 0.69 to 0.93) compared with those in the lowest quintile of intake. Each 1-serving/d increase in intake of fruits or vegetables was associated with a 4% lower risk for coronary heart disease (relative risk, 0.96 [CI, 0.94 to 0.99]; P = 0.01, test for trend). Green leafy vegetables (relative risk with 1-serving/d increase, 0.77 [CI, 0.64 to 0.93]), and vitamin C-rich fruits and vegetables (relative risk with 1-serving/d increase, 0.94 [CI, 0.88 to 0.99]) contributed most to the apparent protective effect of total fruit and vegetable intake. Consumption of fruits and vegetables, particularly green leafy vegetables and vitamin C-rich fruits and vegetables, appears to have a protective effect against coronary heart disease.

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Author and article information

Contributors

: Role: PhD student

: Role: research fellow

: Role: professor of clinical gerontology

: Role: director

: Role: programme leader

Journal

Journal ID (nlm-ta): BMJ

Journal ID (publisher-id): bmj

Title: BMJ : British Medical Journal

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1468-5833

Publication date Collection: 2010

Publication date (Print): 2010

Publication date (Electronic): 23 April 2010

Volume: 340

Electronic Location Identifier: c1693

Affiliations

[1 ]MRC Epidemiology Unit, Institute of Metabolic Science, Box 285, Addenbrooke’s Hospital, Cambridge CB2 0QQ

[2 ]Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge CB2 2SR

Author notes

Correspondence to: S J Griffin simon.griffin@ 123456mrc-epid.cam.ac.uk

Article

Publisher ID: chap713974

DOI: 10.1136/bmj.c1693

PMC ID: 2859321

PubMed ID: 20418545

SO-VID: 9405cddb-dd50-4f5f-baec-0dbab188685d

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

Estimating the population impact of screening strategies for identifying and treating people at high risk of cardiovascular disease: modelling study

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Most cited references 40

General cardiovascular risk profile for use in primary care: the Framingham Heart Study.

Validity and repeatability of a simple index derived from the short physical activity questionnaire used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

The effect of fruit and vegetable intake on risk for coronary heart disease.

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