The Prevention Of Cardiovascular Disease: Have We Really Made Progress?

Thomas A. Pearson


Health Affairs. 2007;26(1):49-60. 

In This Article

Primordial Prevention Of Cardiovascular Disease

AHA Guide for Improving Cardiovascular Health at the Community Level

These guidelines are directed at the social and physical environment, rather than the medical care system or even public health agencies.[35] Indeed, the targets for these guidelines are policymakers, community leaders, employers, teachers, and social service agencies. The origins of the targeted behavior are within society; therefore, the solutions for removing these risks are likely to be social and economic. The clear distinction between primordial and primary prevention relates to primordial prevention activities lying outside the doctor-patient relationship and the medical model. The social/ecologic model moreover carries economic and social benefits outside the health arena, as well as extending cost reduction to diseases other than CVD. The International Heart Health Network has issued a series of declarations that provide a policy framework for such societally oriented approaches.[36] The AHA community guide organizes these efforts along three dimensions: (1) behavior targeted for change; (2) community settings in which intervention might be implemented; and (3) interventions themselves, usually organized along the lines of essential public health services. Some behavior needs to be targeted, including diet, sedentary lifestyle, tobacco use, behavior dealing with seeking screening and treatment for blood pressure and cholesterol, as well as the early recognition of symptoms of heart attack and stroke. The evidence base has tested interventions in specific community settings (such as schools, health care settings, worksites, and religious organizations). The essential public health services specifically deal with interventions at the community level, including assessment of burden of disease (surveillance), public health education involving mass media, the organization and mobilization of communities, the assurance of essential health services, and environmental change through legislation and policy change. The resulting three-dimensional matrix identifies discrete opportunities for intervention by behavior, community setting, and public health strategy.

Policy Issues in Primordial Prevention.

Is a community approach needed in the presence of clinical programs for primary and secondary prevention? Risk-factor trends over the past fifteen years provide a strong rationale for a population approach, even in the setting of large expenditures for primary and specialty cardiovascular care. The National Conference on CVD Prevention documented difficulty in reducing national rates of tobacco use below 25 percent; no change in physical activity, with 40 percent of U.S. adults being sedentary; and dietary increases in carbohydrates and calories.[37] These are population health issues as well as clinical ones.

Policies to encourage healthy lifestyles. The AHA community guide contains fifty-nine recommendations to attain nineteen goals for policy change. For example, policy recommendations for changes in one risk behavior (physical activity) with the use of one essential public health service (environmental change) include five recommendations for improving access to physical-activity opportunities in schools, worksites, and whole communities. One area with major success from policy formulation has been the reduced initiation of tobacco use by adolescents and young adults. Policies related to taxation, elimination of tobacco advertising to young people, and restriction of tobacco sales to minors are examples of policies that have successfully targeted risk behavior.

Adequate reimbursement for clinical preventive and rehabilitative services. Advocacy positions must emphasize the empirical evidence supportive of primary and secondary prevention services, including behavior modification programs, nutritional counseling, tobacco-use cessation, physical activity regimens, and cardiac rehabilitation. The current reimbursement for diabetic counseling services but not for other CVD risk factors appears inconsistent with the overall goals of the program namely, the reduction in disease progression leading to disability, poor quality of life, and additional health care spending. Such reimbursement needs to be extended universally for control of all established CVD risk factors.

Further reductions in cvd mortality will likely need to involve the entire range of opportunities to prevent CVD. Secondary prevention programs have driven case-fatality rates to extremely low levels, which suggests that there are relatively limited opportunities to make inroads on mortality through this approach alone. However, persistent treatment gaps should be removed. Primary prevention will require expansion of risk-factor assessments and global-risk scoring, with prioritization of cost-effective interventions in moderate-and high-risk people. The best opportunity to reduce CVD may be at the community and societal levels, where improvements in diet, exercise, and tobacco use have recently been elusive and where an obesity epidemic threatens to overwhelm progress made on the clinical treatment of individual risk factors. A balanced, integrated approach by policymakers should create a comprehensive program across the risk spectrum, rather than focusing on one risk factor, one segment of risk, or one type of intervention.


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