Academic journal article Bulletin of the World Health Organization

Potential Impact of Single-Risk-Factor versus Total Risk Management for the Prevention of Cardiovascular Events in Seychelles/Impact Potentiel De la Prise En Charge Du Risque Principal Par Rapport a la Prise En Charge Du Risque Total Dans la Prevention Des Evenements Cardiovasculaires Aux Seychelles/Posible Impacto De la Gestion del Riesgo Individual En Comparacion Con El Riesgo

Academic journal article Bulletin of the World Health Organization

Potential Impact of Single-Risk-Factor versus Total Risk Management for the Prevention of Cardiovascular Events in Seychelles/Impact Potentiel De la Prise En Charge Du Risque Principal Par Rapport a la Prise En Charge Du Risque Total Dans la Prevention Des Evenements Cardiovasculaires Aux Seychelles/Posible Impacto De la Gestion del Riesgo Individual En Comparacion Con El Riesgo

Article excerpt

Introduction

Every year approximately 17 million people die from cardiovascular (CV) disease. Of the deaths attributable to CV disease, which comprise roughly 29% of all deaths, about 80% occur in low- and middle-income countries, often in people less than 60 years of age. (1) However, morbidity and mortality from CV disease could be greatly reduced through interventions that target its risk factors. Thanks to population-wide policies and individual risk management, (2) in the past 30 years CV disease has decreased by more than 50% in many developed countries. (3)

At the individual level, prevention centres mainly on identifying and treating individuals with increased CV risk to prevent heart attacks and stroke. Traditionally, treatment has targeted individuals with one or more risk factors, such as high arterial blood pressure or high serum cholesterol. (4) Reducing blood pressure and serum cholesterol can, indeed, effectively prevent or delay CV events. (5) However, single-risk-factor approaches are only partially effective because individuals with both mildly elevated blood pressure and mildly elevated serum cholesterol, or those with high levels of one but not the other, may be at low total risk of CV disease.

Total CV risk factor management has been advocated for several years as an alternative approach. (6,7) It posits that the higher an individual's total CV risk before treatment is initiated, the greater the cost-effectiveness of treatment. (5,6) Under this approach, individuals are managed in accordance with their baseline CV risk. This strategy is in principle more effective and less costly than the single-risk-factor approach because treatment is limited to individuals with a high total CV risk. (5,7,8)

The total risk approach relies on prediction scores. These have been developed and validated primarily in high-income countries (9,10) and subsequently adapted to other populations after re-calibration. (11,12) The World Health Organization (WHO) and the International Society of Hypertension (ISH) recently developed a set of CV risk prediction charts for use in all regions of the world. (7,13)

While treatment relying on separate medications to control individual risk factors such as high serum cholesterol and high blood pressure remains a valid option, individuals with high CV risk could perhaps be managed in a more cost-effective way with a fixed-dose combination drug (polypill) targeting multiple risk factors simultaneously. (14,15) A polypill has several potential advantages: (i) avoidingcomplex treatment algorithms; (ii) avoiding multiple dose titration steps; (iii) improving treatment adherence; and (iv) reducing costs. (15) Yusuf has suggested that a combination of four drugs (aspirin, a [beta]-blocker, a statin and an angiotensin-converting enzyme inhibitor) could reduce the incidence of CV events by 75% in patients with vascular disease. (16) Wald & Law have shown that administering a polypill containing three antihypertensives, a statin, aspirin and folic acid to all individuals who either have CV disease or are older than 55 years would safely reduce ischaemic heart disease and stroke by more than 80%. (17) While this promising approach has generated considerable debate, (15) a first trial has now been successfully completed in India (18) and at least seven other trials are being conducted in both developing and developed countries. (15)

The present study has two objectives: (i) to assess the distribution of CV risk in Seychelles based on the actual distribution of CV risk factors in the population and on data derived from WHO/ISH risk prediction charts, and (ii) to compare two distinct risk management strategies--single-risk-factor management and total risk management--in terms of the number of people one would need to treat and the number of CV events that would be averted with each over a span of 10 years.

Methods

Seychelles is a small and rapidly developing middle-income island state located east of Kenya in Africa. …

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