Strategies for primary coronary heart disease prevention

With increasing knowledge of coronary heart disease (CHD) epidemiology, it has become apparent that preventive treatment of high-risk individuals--the high-risk strategy--will reduce individual risk but is insufficient by itself to reduce the burden of CHD in the population as a whole because more than half of the future victims of CHD have risk factor levels below the high range, leaving these persons unprotected. Since the relationship between risk factors and clinical CHD risk is continuous in most instances, without a sharp dividing line between high and low risk, the aim of optimal preventive action must be to shift the entire risk factor distribution curves to the left, in order to reduce the number of persons in the upper end of the distribution on the right. The strategy designed to effect this shift is the community strategy which requires that the whole population adopts preventive measures, i.e. makes changes in lifestyles, especially as regards diet, smoking habits, daily exercise and patterns of stress which favour unhealthy habits or may be harmful in themselves. The two strategies are not alternatives but complementary and, for optimal effectiveness, must be carried out simultaneously in the community. It can be shown that the combined strategy is more effective than either strategy alone. Each of the strategies has on comparison its own particular strengths, adding up to create a community climate favourable for prevention. The practicing physician is primarily concerned with the high-risk strategy but also plays an essential role in providing active support for the community strategy through giving preventive advice on health-promoting living habits to all of his patients and their families.