BMJ: Will screening those at high risk for cardiovascular events be cost effective?
As the British government closed its consultation on the effectiveness of vascular checks for high-risk individuals aged 40 to 74, experts debated the value of the strategy in the Aug. 28 issue of British Medical Journal.

The U.K. Department of Health suggested that up to 9,500 heart attacks and strokes and 2,000 deaths could be prevented each year by vascular screening and managing high-risk individuals aged 40 to 74.

The screening program will be cost effective, and result in significant health improvements, if appropriately targeted, according to Rod Jackson, PhD, professor of epidemiology, and colleagues from the University of Auckland in New Zealand. The greatest benefits will come from treating the relatively few patients at very high risk who have had a cardiovascular event, who are easy to identify and who are more likely to be motivated than patients without symptoms, according to the authors.

The World Health Organization suggests that in the short term, targeting very high-risk patients with aspirin, off-patent statins and blood-pressure lowering drugs would prevent more events than population-based interventions to reduce salt intake, obesity and cholesterol levels, and would be very cost effective.

The authors pointed out that between one-third and one-half of all major coronary disease events in 35- to74-year-olds, who have had a previous cardiovascular event, occur in 5 to 6 percent of the population. They argue that if half of the high-risk patients were given triple therapy with aspirin, statins and blood pressure lowering drugs, there would be a 10 percent fall in the coronary disease event rate in less than 10 years in the U.K.

Currently, most patients with cardiovascular disease are not receiving triple therapy, Jackson and colleagues noted. They warned that lower risk thresholds will result in large numbers of patients becoming eligible for treatment which will have a substantial impact on workload and costs.

According to the authors, general practitioners should be encouraged and rewarded for managing patients with existing cardiovascular disease first.

However, Simon Capewell, PhD, from the University of Liverpool in England, argued that public health approaches targeting the whole population are both cheaper and more effective than tablets. He pointed to a large body of evidence that shows that even with generous resources screening programs have substantial drop-outs, which also favor affluent and educated individuals, thereby increasing inequalities.

According to Capewell, the inherent message of such a screening program is that “the doctor can fix it.” But contrary to expectations, he said, even with continuing treatment, more than half the cardiovascular risk remains. He added that drug treatment does not eliminate underlying disease, and if treatment is stopped, the risk rapidly returns.

The NHS strategy, which is expected to be rolled out in the 2009-2010, will also mean that more than 80 percent of English men aged 65 to 74 will be categorized as high-risk, committing the majority of middle-aged adults to life-long drug treatment and a lower quality of life at huge cost to the NHS, according to Capewell.

He also argued that the high-risk screening strategy diverts attention from “cheap policy interventions,” which reduce risk factors for cardiovascular disease across entire populations, such as banning trans fats, or halving the salt hidden in food or banning smoking in public places.

Even small reductions in population cholesterol, smoking or blood pressure would translate into substantial reductions in cardiovascular events and death, Capewell concluded.