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Innovation in clinical specialities: cardiovascular disease
number of deaths postponed or prevented but did not alter the
relative contribution of each risk factor (Table 5, columns 5 and 6).
Thus, regardless of whether best, minimum or maximum
estimates were considered, the most substantial contributions
came from the changes in cholesterol, blood pressure and
smoking (Table 5).
Discussion
Success in achieving the HP2010 targets could almost halve
predicted CHD deaths in 2010, or indeed in 2015. Our findings are
reassuringly consistent with earlier studies in the England, 23
Scotland 22 and the USA 12 . In the United Kingdom, a modest
reduction in mean population cholesterol level from 225 mg/dl to
200 mg/dl could reduce CHD deaths by approximately half. 14,15,24 In
contrast, a rather optimistic 25% reduction in the prevalence of
obesity would probably prevent just 2% of CHD deaths. 15,24 A
corresponding 25% reduction in the prevalence of inactivity might
prevent 1% of CHD deaths. 15,29
Although CHD death rates have been falling in the USA for four
decades, they are now plateauing in young men and women. 2
Recent declines in total cholesterol have been modest, blood
pressure is now rising among women and obesity and diabetes are
20 000
0
-20 000
-40 000
-60 000
-80 000
-100 000
-120 000
-140 000
-160 000
-180 000
-5000
-45 000
-85 000
-125 000
-28 300
-33 540
C holes terol
-103 080
25-34
355-300
1525 2235
-1525
2190
-48 635
Systo lic B P
-82 520
35-44
-4190
-12 175
Smoking
-10 020 -6810
-12 010
-26 270
-33 670
-60 135
IF Current trends continue to 2010
IF Healthy People 2010 targets
IF USA Low Risk stratum
-20815
45-54
-45 770
-1450
IF Current trends continue to 2010
IF Healthy People 2010 targets
IF USA Low Risk stratum
-43 615
55-64
-88 500
8105
BMI
P hysical A ctivity
-17 430
-20 535
-8775
-52 300
65-74
-106 295
15885
rising steeply. Furthermore, population aging will increase the
numbers of CHD deaths in that country and elsewhere. 30 There is
no room for complacency. Continuation of recent risk factor trends
should result in approximately 20 000 fewer coronary deaths in
2010 than in 2000. This reflects some 50 000 fewer deaths
expected from improvements in total cholesterol, smoking, physical
activity and male blood pressure, but more than half of the gain is
negated by approximately 30 000 additional deaths attributable to
increases in rates of obesity and diabetes, plus systolic blood
pressure increases among women. Increasing treatments could
not compensate for these worsening risk factors. In 2000, barely
40% of eligible patients received appropriate therapies. 10 Even
raising this proportion to an optimistic 50% would only postpone
approximately 60 000 additional deaths in 2010. 31
Successfully achieving the specific risk factor reductions
proposed in the HP2010 targets could prevent or postpone
approximately 190 000 CHD deaths. This would potentially halve
the mortality burden seen in 2000. The HP2010 objectives for
cholesterol and physical activity remain potentially attainable.
However, attaining the targets for obesity, diabetes and female
blood pressure appear more challenging because of the need to
actually reverse recent adverse trends. 3 Successfully reducing
population risk factor levels to those already seen in
the healthiest (lowrisk) stratum could result in
approximately 370 000 fewer CHD deaths among
people aged 25–84 years. This figure would represent
a 96% decrease compared to the 2000 baseline of
388 000 1,3 and is somewhat larger than the 85%
reduction predicted by other studies. 24,25 Although
probably an overestimate, the results for this third
scenario show an aspirational ideal to highlight
potential future gains. However, the “low-risk stratum”
in the population of the USA remains frustratingly
small, even when defined only by smoking, blood
-71 860
pressure and cholesterol: 6% in the 1970s 32 and,
even now, only 7.5% among whites and 4% among
African Americans. 33
-43 900
-11 840
-61 790
Diabetes
Figure 1: Estimated reductions in coronary heart disease mortality in the United
. States 2. Estimated of America reductions in 2010 under in coronary three different heart disease scenarios mortality in the United State
75-84
-119 705
Figure 2: Estimated reductions in coronary heart disease mortality in the United
States of America in 2010 by age group under three different scenarios
Achieving risk factor reductions
Although fashionable, screening and treating high-risk
individuals would necessitate medicating 15% to
25% of all adults. 34,35 Furthermore, the key goal is not
intervention but sustained risk factor reductions. 35 The
whole population approach described by Rose 13
appears both more effective and cost-effective. 13–15
Similar conclusions have been reported previously in
Dutch, Finnish and American cohorts. 12,35
Lowering cholesterol should therefore remain a
priority in the USA, as it offers a potentially powerful
1% mortality reduction for every 1 mg/dl decrease in
total cholesterol. 6 Large cholesterol declines have
already been achieved by comprehensive national
policies elsewhere (-20% in Finland 18 and -15% in
Mauritius 36 ). In contrast, in the USA between 1988
and 2004 total cholesterol fell barely 3% in adults
(from 206 to 201 mg/dl). 37 Furthermore, these levels
remain well above the optimal, prompting recent
national dietary policies to further reduce total
cholesterol levels. 2,3,38
Hospital and Healthcare Innovation Book 2009/2010 73