WSO and WHF joint position statement on population-wide prevention strategies

In 2008, Rod Jackson and colleagues¹ proposed that prevention strategies for high-risk cardiovascular disease, based on screening individuals at high risk of cardiovascular disease, would deliver large benefits for the population. Simon Capewell² cautioned that these strategies could mislead health professionals and politicians into thinking they can tick the box reading mission accomplished and, with screening completed, cardiovascular disease prevention would be resolved. Both sides of this debate were based on assumptions and therefore did not reach consensus, but the high-risk approach to the prevention of cardiovascular disease has since been widely recommended and implemented.

There is reliable evidence from the Inter99 randomised controlled trial,³ which included 59 616 people aged 30–60 years followed up for 10 years, and a Cochrane meta-analysis⁴ of 15 randomised controlled trials, totalling 251 891 adults, that screening individuals in the general population for the risk of cardiovascular disease and risk factors (even with lifestyle counselling, as in the Inter99 trial³) has no significant effect on the incidence and mortality of ischaemic heart disease and stroke. At a population level, the age-standardised incidence and mortality of cardiovascular disease (including stroke) were decreasing before the implementation of high-risk prevention strategies, but have shown less decline since 2010 than the decline during the past 25 years.⁵

In some countries, such as the UK, the Netherlands, the USA, and New Zealand (specifically the Māori and Pacific people), the incidence and mortality of cardiovascular disease is increasing, particularly in middle-aged individuals. Furthermore, there is a paucity of robust economic evidence that screening for the risk of cardiovascular disease is cost-effective,⁶ there is some evidence that screening might exacerbate socioeconomic inequalities,⁷ and there are potential hazards in labelling people as being at low risk of disease, giving them false reassurance that they are protected from cardiovascular disease and compromising any motivation to control risk factors. Therefore, when communicating the absolute risk of cardiovascular disease to patients, the World Stroke Organization (WSO) has suggested that categorising people by low, moderate (mild), and high risk of disease (including heat charts) should be abandoned.⁸

Because many of the underlying causes of stroke and cardiovascular disease are well established, identifiable, and controllable, according to Geoffrey Rose,⁹ there is not a major role for the high-risk strategy in the primary prevention of stroke and cardiovascular disease. Rather this strategy has a complementary role to the more powerful population-wide strategy. Unfortunately, today the priority is given to the high cardiovascular risk strategy, and this reality needs to be changed.10, 11 There is an urgent need to improve the primary prevention of stroke and cardiovascular disease, with priority given to population-wide primary prevention strategies⁴ that would also strengthen global health systems and aid economic recovery in the wake of pandemics such as COVID-19. Further references in support of this position statement are listed in the appendix.

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