The feasibility and outcome of a community-based primary prevention program for cardiovascular disease in the 21st century.

OBJECTIVE: There is no evidence that systematic screening and risk factor modification in an unselected, asymptomatic population will reduce cardiovascular disease (CVD) mortality. This study aimed to evaluate the effectiveness of a primary care CVD prevention program on mortality during a 13-year follow-up. DESIGN: A risk factor survey was sent, followed by a nurse-led lifestyle counselling to respondents with at least one CVD risk factor, and a general practitioner's (GP) appointment for high-risk persons. Screening and interventions were performed during 2005-2006. SETTING: A public health care centre in the town of Harjavalta, Finland. SUBJECTS: All home-dwelling 45-70-year old inhabitants without manifested CVD or diabetes. MAIN OUTCOME MEASURES: All-cause and CVD mortality. RESULTS: Altogether 74% (2121/2856) inhabitants responded to the invitation. The intervention was received by 1465 individuals (52% of the invited population): 398 risk persons had an appointment with a nurse, followed by an appointment with a GP for 1067 high-risk persons. During the follow-up, 370 persons died. Mortality among the non-respondents was twofold compared to the participants'. In subjects who received the intervention, the age- and gender-adjusted hazard ratio for all-cause mortality was 0.44 (95% CI: 0.36 to 0.54) compared to the subjects who did not receive the intervention. CONCLUSIONS: Reducing mortality is possible in a primary care setting by raising health awareness in the community with screening, by targeted lifestyle counselling and evidence-based preventive medication for persons at high risk for CVD. Subjects not willing to participate in health surveys have the worst prognosis.Key PointsPreviously, there is no evidence that systematic screening and risk factor modification in an unselected, asymptomatic population will reduce cardiovascular disease (CVD) mortality.With a stepwise screening program it is possible to scale the magnitude of CVD prevention in the community.Reducing mortality in a community is possible by screening, targeted lifestyle counselling, and by evidence-based preventive medication for high-risk persons.Subjects not willing to participate in health surveys have the worst prognosis.

Glycemic status and effect on mortality: Multifactorial prevention programme for cardiovascular disease in Finnish primary care.

AIMS: To compare 13-year mortality rates in normoglycemic, prediabetic and diabetic subjects attending a community-based screening and intervention programme. METHODS: Population survey identified 2569 cardiovascular disease (CVD) white risk subjects aged 45-70 years and without manifested CVD or diabetes. Oral glucose tolerance test was performed, and multifactorial intervention was provided. Effect of glycemic status on mortality was estimated in models adjusted for age, gender, education years, smoking, body mass index, mean arterial pressure, total cholesterol, and physical activity. RESULTS: Of the subjects, 2055 (77 %) were normoglycemic, 380 (14 %) had prediabetes and 224 (9 %) diabetes. Compared to the normoglycemic group, the fully adjusted hazard ratios (HR) for all-cause mortality were 1.34 (95 % CI: 0.98-1.83) in the prediabetes group and 2.31 (95 % CI: 1.62-3.31) in the diabetes group. Standardized mortality rates were 0.63 (95 % CI: 0.54-0.73), 0.91 (95 % CI: 0.69-1.18), and 1.55 (95 % CI: 1.19-2.02) in the normoglycemic, prediabetes, and diabetes groups, respectively. The most common cause of death was cancer (42 % of all deaths), followed by CVD (28 %). CONCLUSIONS/INTERPRETATION: Screen-detected diabetes carries a substantial risk of death even after primary care intervention. The pattern of excess mortality has shifted towards cancer deaths.

Multifactorial prevention program for cardiovascular disease in primary care: hypertension status and effect on mortality.

The aim of this study was to investigate if mortality during a 13-year follow-up varied between normotensive subjects, screen-detected hypertensive subjects, and subjects with antihypertensive medication at baseline. A population-based screening and intervention program identified 2659 apparently healthy, middle-aged cardiovascular-risk persons in southwestern Finland. Screen-detected hypertension was verified by home blood pressure measurements. Lifestyle counseling was provided for all participants and preventive medications were started or intensified if needed. All-cause and cardiovascular mortality were obtained from the official statistics. Screen-detected hypertension was diagnosed in 17% of the participants, 51% were normotensive and 32% had antihypertensive medication at baseline. The screen-detected hypertensives had higher mean blood pressure and cholesterol levels than the two other groups. Altogether 289 subjects died during the follow-up, 83 (29%) from cardiovascular disease. Those with screen-detected hypertension had decreased cardiovascular mortality risk compared to the medicated hypertensives [sHR 0.40 (95% CI: 0.19 to 0.88, p = 0.023)], and comparable with that of the normotensives [sHR 0.53 (95% CI: 0.24 to 1.15)]. Newly diagnosed diabetes at baseline was a powerful predictor of cardiovascular mortality [sHR 2.71 (95% CI: 1.57 to 4.69)]. Early detection of hypertension and timely multifactorial intervention seem to be important in preventing hypertension-related mortality.