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• Management includes primary prevention
  M Justin S Zaman
  Published on: 7 January 2008

• Published on: 7 January 2008

  Management includes primary prevention

  • M Justin S Zaman, Specialist Registrar in Cardiology

  Dear Editor,

  Though the mandate of Karthikeyan et al’s article is the management of manifest coronary disease, primary prevention at the population level should not be ignored. India is rapidly urbanising, and urban India shows marked increases in both coronary heart disease prevalence and risk factors when compared with rural settings. (1)Though coronary risk factors tend to be concentrated in those of higher s...

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  Dear Editor,

  Though the mandate of Karthikeyan et al’s article is the management of manifest coronary disease, primary prevention at the population level should not be ignored. India is rapidly urbanising, and urban India shows marked increases in both coronary heart disease prevalence and risk factors when compared with rural settings. (1)Though coronary risk factors tend to be concentrated in those of higher social classes, (2) the poor in India are also increasingly affected whilst continuing to suffer from diseases of the age of pestilence and famine. Prevalence of cardiovascular risk factors such as smoking, high blood pressure and overweight are also higher than might have been expected in rural settings. (3) More than 70% of India still lives outside cities, and these data provide an early indication of the burden of heart disease that will occur in rural India in the coming years.

  Geoffrey Rose presented two approaches to prevention of disease—one based on the individual and the other on populations. In the individual strategy, high-risk individuals are sought and offered individual protection. In contrast, the ‘population strategy’ seeks to control the determinants of incidence in the population as a whole. (4) Rose argued that though the ‘high-risk’ strategy was the traditional medical approach to prevention and though this approach allowed the doctor to identify appropriate interventions for their patient in clinic, it was palliative and temporary in that it did not seek to alter the underlying causes of the disease but to identify individuals who were particularly susceptible to those causes.

  The population approach to primary prevention seeks to achieve leftward shift in the normal distribution of cardiovascular risk. The decline in coronary heart disease deaths in the developed world has been mostly attributed to primary prevention. (5)

  The Seven Countries Study initially led to the concept that cardiovascular disease prevention should be implemented at the population level. Though both individual and population approaches to disease prevention are needed, implementation and evaluation of the population approach is difficult whereas proof of efficacy is easier in the high-risk approach. (6)

  The policies for the primary prevention of cardiovascular diseases in most developed countries thus emphasise high-risk rather than population strategies. (7) However, to create an environment in which individual behavioural initiatives can succeed, major shifts in population behaviour through public health policy are necessary. The wider environment impacts on the health of an individual in addition to individual behavioural and biological influences. In developing countries such as India, any increase expenditure on 'healthcare' should not be used to imitate the western model of high-risk and secondary prevention but focus more on primary prevention at the population level. Without this approach, inequities in care - especially in urban poor and rural communities - are bound to worsen.

  References

  1. Ganesan Karthikeyan, Denis Xavier, Doriaraj Prabhakaran, and Prem Pais
  Perspectives on the management of coronary artery disease in India
  Heart 2007; 93: 1334-1338

  2. Gupta R, Gupta VP
  Meta-analysis of coronary heart disease prevalence in India
  Indian Heart J, vol. 48, no. 3, pp. 241-245.

  3. Singh RB, Beegom R, Mehta AS, Niaz MA, De AK, Mitra RK, Haque M, Verma SP, Dube GK, Siddiqui HM
  Social class, coronary risk factors and undernutrition, a double burden of diseases, in women during transition, in five Indian cities
  International Journal of Cardiology, vol. 69, no. 2, pp. 139-147.

  4. Chow C, Cardona M, Raju PK, Iyengar S, Sukumar A, Raju R, Colman S, Madhav P, Raju R, Srinath RK, Celermajer D, Neal B
  Cardiovascular disease and risk factors among 345 adults in rural India-the Andhra Pradesh Rural Health Initiative
  Int.J.Cardiol

  5. ROSE GEOF.
  Sick Individuals and Sick Populations
  International Journal of Epidemiology, vol. 14, no. 1, pp. 32-38

  6. Unal B, Critchley JA, Capewell S
  Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention
  BMJ, vol. 331, no. 7517, p. 614

  7. Emberson J, Whincup P, Morris R, Walker M, Ebrahim S
  Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease
  European Heart Journal, vol. 25, no. 6, pp. 484-491

  8. Department of Health
  National Service Framework for coronary heart disease: modern standards and service models

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  Conflict of Interest:
  None declared.

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