Basic strategies for the prevention of cardiovascular diseases. Key strategies for disease prevention and health promotion Definition of individual prevention community and population strategies

Oganov R.G.

Arutyunov Grigory Pavlovich,doctor of medical sciences, professor:

On the agenda, we are very pleased to give the floor to the leading cardiologist of our country, Chairman of the All-Russian Scientific Society of Cardiology, Academician of the Russian Academy of Medical Sciences, Professor Oganov Rafael Gegamovich.

Oganov Rafael Gegamovich, President of the All-Russian Scientific Society of Cardiology, Academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences, Professor:

Dear colleagues.

Today we will talk about the main strategies for the prevention of cardiovascular diseases. I must say that, of course, the results of prevention are not as bright and emotional as the results of surgical treatment. The surgeon, having successfully performed the operation, often immediately sees his results. This does not happen in prevention. But without prevention, we still can not do.

One of the achievements of the 20th century was scientific evidence that the epidemic of cardiovascular diseases is mainly due to lifestyle characteristics and associated risk factors. Lifestyle modification and reduction in risk factor levels can slow disease progression both before and after the onset of clinical symptoms.

This does not mean that genetic factors do not play any role. Undoubtedly, they play a role. But the main thing is a way of life. This is well proven by observations of migrants. We are well aware that in Japan the prevalence of atherosclerosis and related diseases is not high. This is due to the lifestyle that the Japanese lead. When the Japanese move to the USA, after a while they start to get sick and die like real Americans.

Such examples can be cited with other diasporas. But I think this example shows quite clearly that genetics, of course, plays a role, but the main thing is still a lifestyle.

Somewhere in the 1960s of the last century, it became obvious that only by improving the methods of diagnostics of treatment, we will not be able to cope with the problem of cardiovascular diseases.

The rationale for the need to prevent cardiovascular diseases was stated. First, the pathology is usually based on atherosclerosis, which proceeds secretly for many years and, as a rule, is already strongly expressed when symptoms appear.

It is now well known from epidemiological studies that even adolescents who died from some kind of accidents are already showing the first manifestations of atherosclerosis.

The second is death, myocardial infarction, stroke. They often develop suddenly when medical care is not available, so many treatment interventions are not applicable. From time to time we hear speeches in the media that a person who looks full of health suddenly dies. As always, doctors are blamed for this. They have absolutely nothing to do with it, because one of the tragic manifestations of myocardial ischemia is sudden death. Doctors in such a situation are often powerless.

Thirdly, modern methods of treatment (medication, endovascular, surgical) do not eliminate the cause of cardiovascular diseases. After all, we are acting here on the effect, and not on the cause, so the risk of vascular accidents in these patients remains high, even though they can subjectively feel completely healthy.

What are the necessary conditions for successful action to prevent cardiovascular disease. First, there must be a science-based concept of prevention. Then the creation of infrastructure for the implementation of actions to promote health and prevent cardiovascular disease. The staffing of this structure with professional personnel and the provision of material, technical and financial resources.

In principle, we have all this, but it does not work at full capacity, while it remains to be desired the best effect.

Do we have a scientific basis? Yes there is. This is the concept of risk factors, which, by the way, was also developed in the last century. It became the scientific basis for the prevention of cardiovascular diseases. All successful projects that have been carried out in the world over the past 30-40 years have used just this concept.

Its essence is quite simple. We do not know the root causes of major cardiovascular diseases. But with the help of epidemiological studies, factors contributing to their development and progression have been identified, which are called "risk factors", which is well known.

Of course, we are primarily interested in modifiable risk factors, that is, those factors that we can influence, change, reduce. They are conditionally divided into three subgroups. These are behavioral and social, biological and environmental.

This is not to say that unmodified factors are of no interest to us. If we take two well-known unmodified factors: age and gender, then, fortunately or unfortunately, we cannot change them yet. But we use them well in the development of prognostic tables or instruments.

There is one more point to which I would like to draw your attention. Classic risk factors for cardiovascular disease lead not only to the development of cardiovascular disease, but also to a number of other chronic non-communicable diseases. On this basis, integrated programs for the prevention of non-communicable diseases are built.

There are many risk factors. There are more than 30 - 40 of them, so you always have to choose a priority, that is, which risk factors to prioritize. What risk factors should we pay attention to first of all?

The first is the factors, the relationship of which with diseases has been proven. Second, this connection must be strong. The prevalence of risk factors should be high. Factors affecting several diseases, not just one. They interest us from a practical point of view. For example, smoking. If we achieve success in the fight against smoking, this will lead not only to a decrease in cardiovascular diseases, but also to many other diseases. Such factors are of particular interest to us from a practical point of view.

The most important. Giving priority to some risk factor, it is necessary to clearly understand that there are effective methods for the prevention and correction of this risk factor.

If we talk about common risk factors for which there are evidence-based and affordable methods for detecting and correcting health care, then they are well known to everyone. These are smoking, alcohol abuse, dyslipidemia, arterial hypertension, psycho-social factors, obesity and physical inactivity.

This does not mean that other factors do not play a role. But these are common risk factors. Their correction will lead not only to a decrease in mortality from cardiovascular diseases, but also from a number of other chronic non-communicable diseases.

We are approaching (not only on us, but in the world in general) an epidemic of two risk factors that were known before, but now they are practically an epidemic. This is overweight, obesity. Impaired carbohydrate tolerance, diabetes mellitus. Metabolic syndrome, since these two factors - obesity and diabetes - are components of the metabolic syndrome.

It is of interest to explore the extent to which risk factors can actually predict mortality from ischemic disease or from chronic noncommunicable diseases.

In our center, such an analysis was carried out by Professor Kalinina A.M. She took a long-term prospective 10-year follow-up and calculated the risk based on the initial level of risk factors. She called it "predicted risk." Then I checked what actually happened, that is, what the observed risk is. If you look at the slide “Mortality from coronary heart disease”, then there the two “curves” practically merge. It even causes a certain surprise how accurate it is.

If you look at the slide Mortality from chronic non-communicable diseases (predicted risk and observed risk), although the curves are somewhat divergent, they run very parallel.

Today we have become very good at predicting risk in certain groups of people. But one of these (I would not call it a disadvantage) moments unfavorable for us is the so-called anonymity of prevention. We can say that out of a hundred people with this level of risk factors, 50% will die in 10 years. But who these 50% will be, we personally cannot name today.

Risk factors that did not live up to expectations. What do I mean by risk factors that do not live up to expectations. This is oxidative stress. They talk about it endlessly, especially when they talk about dietary supplements. This is hyperhomocysteinemia. In the United States and Canada, they even began to add B vitamins and folic acid to foods in order to reduce hyperhomocysteinemia among their population.

This is inflammation. The origin of atherosclerosis is given great importance. These are infections. Even tried to treat with broad-spectrum antibiotics. Acute coronary syndrome, myocardial infarction. This is a deficiency of female sex hormones. In parentheses it is indicated which clinical studies were, which drugs. These clinical studies, unfortunately, either did not give any result (were null) or even turned out to be negative.

Does this mean that these factors do not play a role in the development and progression of diseases. Of course it doesn't. Most likely, we are doing something wrong in terms of our intervention. This was well shown by the situation with female sex hormones, with hormone replacement therapy. There have been several meta-analyses that have shown that hormone replacement therapy after menopause leads to an increased risk of vascular accidents. This concluded that they can be used very carefully.

When more carefully analyzed, it turned out that if this hormone replacement therapy was started immediately or in a short time after the onset of menopause, then the result was positive. If it was given to patients 10 to 15 years after menopause, these results were poor.

Actions of structures providing preventive care. What needs to be done to provide preventive care. Just three very simple things. This is the identification of risk factors (screening). Risk assessment using tables or using some kind of computer programs.

Risk correction. There can be three actions here: preventive counseling, non-drug prevention (some kind of exercise program or dietary program), or drug prevention (when we try to normalize some factor like hypertension with medication).

The higher the risk, the more we move towards drug prevention.

There are two types of screening. Selective and opportunistic. Opportunistic screening is a very political name. In English literature they are called. We translate it verbatim. This is a survey of everyone who goes to the doctor. Or we conduct some kind of preventive examination, we examine everyone in a row - this is called opportunistic screening.

There is selective screening. We take some target group in which we expect a greater spread of the disease or some risk factor. For example, we want to identify people with diabetes. Naturally, if we take people who are overweight, obese, or have a dietary predisposition to diabetes, then we will find significantly more of these patients.

These two types of screening are based on this. One or the other is used depending on the task.

Diagnostic methods, which are improving very rapidly, today allow us to isolate the so-called subclinical markers of increased risk. In particular, the defeat of atherosclerosis or arterial hypertension.

We can determine the thickness of the intima-media (ultrasound) by non-invasive methods. Calcification of the coronary arteries (computed tomography). Left ventricular hypertrophy (ultrasound, ECG). Index: ankle - shoulder, that is, the ratio of systolic pressure at the ankle and at the shoulder (there are special devices, or you can simply do this with the help of a phonendoscope cuff). Plaques in the carotid or peripheral arteries (ultrasound).

This is the carotid-femoral velocity of the pulse wave. A method that has been known for a very long time, but now devices have appeared that allow it to be determined very accurately and easily. Glomerular filtration rate. Microalbuminuria, proteinuria. I think this list could be continued, but the essence is clear enough. These markers are the gap between risk factors and the disease. But they have better predictive power, predictive quality, than the predictive value of such scales as the Framingham scale or the SCORE scale.

In addition, the use of these subclinical markers makes it possible to isolate and reclassify patients. Those patients who agree and were at risk or at intermediate risk on the scale can move to another group. Ultimately, imaging of atherosclerosis may improve patient adherence to preventive measures. It's not that easy, because non-commitment is the main problem.

Strategy for the prevention of cardiovascular disease. We are now approaching the reason why I am giving this lecture today. It all depends on what task we set. The long-term goal is a population strategy. It is the impact on those lifestyle and environmental factors that increase the risk of cardiovascular disease in the general population. Simply put, this is what we call a "healthy lifestyle."

This strategy lies largely outside the health sector. However, it is one of the main strategies that has a number of advantages. This positive effect will reach a large part of the population, including those at high risk or suffering from noncommunicable diseases.

Implementation cost is very low. There is no need to strengthen the health system extensively, as this strategy is largely outside the health system. By now, it has been well established that well-planned prevention programs can have a significant impact on lifestyle and the prevalence of risk factors. Lifestyle changes and reduction in risk factor levels do lead to a reduction in cardiovascular and other chronic non-communicable diseases.

A systematic analysis was conducted that explored the possibility of reducing mortality through lifestyle and dietary changes in patients with coronary and coronary heart disease and in the general population.

(Slide show).

On the left, the column is the decrease in mortality in patients. On the right is the decrease in mortality in the population. Stopping smoking gives 35 - 50%. Increasing physical activity by 25 - 30% reduces mortality. Reasonable use of alcohol also reduces mortality. Nutritional changes. With the help of a lifestyle, you can achieve results that are no worse than with the help of medications.

I talk all the time about the population strategy and I emphasize that this strategy mainly lies outside the healthcare system, nevertheless, the role of physicians is quite high. Physicians should be initiators, if I may say, catalysts, analyzers, informants of the processes that contribute to the prevention of cardiovascular diseases.

Physicians should initiate these processes. They should stir up society and our political decision makers, analyze and inform both the population and the authorities about what is happening. It is not entirely correct when they say that this strategy lies outside of healthcare, there is nothing for doctors to do there.

Physicians play a very large role in this strategy. Although its implementation is indeed largely outside of healthcare.

The medium-term goal is a so-called high-risk strategy. Its essence is to identify and reduce the levels of risk factors in people with a high or increased risk of developing diseases. Here it is necessary to be very clear that there is a latent period between the impact on the factors and the result. If everyone quits smoking tomorrow, this does not mean that in 2-3 months mortality from coronary heart disease or lung cancer will decrease. It will take some time for the risk to disappear.

The contribution of risk factors is well studied. The contribution of the seven leading risk factors to the lost years of healthy life for Russia. Known risk factors: hypertension, alcohol, smoking, hypercholesterolemia, overweight, nutrition and physical inactivity.

The contribution of seven leading risk factors to premature death of the Russian population. Again, the same risk factors, but there was some rearrangement. Arterial hypertension again in the first place. Hypercholesterolemia, smoking and so on.

The SCORE table I mentioned earlier, which determines the risk of death. But it must be borne in mind that in people who do not yet have manifestations of cardiovascular diseases, this is sometimes forgotten. If there are clinical manifestations, then these are already high-risk individuals. You don't need to use any table. These are individuals at high and very high risk.

If not, then you can use this table. Of course, it's pretty simplistic. However, for such mass screening, it is now widely used. There are few indicators. These are: by age, cholesterol, smoking and blood pressure. Based on these factors, the risk can be predicted as a percentage. Accordingly, monitor the effectiveness of ongoing activities.

A feature for Russia is that against the background of high levels of traditional risk factors (smoking, alcohol abuse, hypertension, and others), psycho-social factors have a significant impact (especially after the collapse of the Soviet Union) on the health of the population.

Of the psycho-social factors for which their influence on the development of disease progression has been proven, the following can be mentioned:

depression and anxiety;

Work-related stress: low ability to perform work with high demands, unemployment;

Low social status;

Low social support or its absence;

Type A behavior;

General distress and chronic negative emotions.

These are the psycho-social factors that are well studied and that influence the development and progression of diseases.

If we talk about psychopharmacotherapy, then there are three groups. These are herbal remedies. These are tranquilizers, which mainly affect anxiety states. Antidepressants that affect both depression and anxiety.

Among over-the-counter drugs, Afobazol is the most popular - it is the original domestic anxiolytic of the non-benzodiazepine series. It reduces anxiety, sleep disorders and various autonomic disorders. What is very important - it is not addictive, does not cause a sedative effect.

Despite the fact that this is an over-the-counter drug, of course, I advise you to consult a doctor before buying it at a pharmacy, as far as it is really suitable in this situation.

There was a fairly large study that showed that indeed its anxiolytic effect, that is, the effect on anxiety, was in 85% of patients. This is an effective drug that can be used after consulting a doctor (I emphasize).

Third strategy. This is a short-term task, a strategy that gives a quick effect. This is secondary prevention - early detection and prevention of disease progression.

A systematic analysis that shows what can be achieved with the integrated treatment of patients with coronary heart disease or other vascular diseases. Acetylsalicylic acid - up to 30%. Beta blockers - up to 35%. ACE inhibitors - 25%, statins - 42%. Cessation of smoking is quite effective - 35%, no worse than all drugs and money is not particularly necessary to spend.

Goals of treatment of patients with coronary artery disease. Why I settled on IBS. This is one of the main forms of cardiovascular disease. Drugs that are used to improve prognosis, to prevent complications. These are antiaggregants Aspirin, Clopidogrel. Now there are new antiplatelet agents. But while these two drugs occupy a leading position. Lipid-lowering therapy, here statins beat all other drugs. Although, this is probably not entirely correct. These are beta-blockers (especially after myocardial infarction). ACE inhibitors. Perindopril, Ramipril have the largest evidence base.

There has been renewed interest in omega-3 polyunsaturated fatty acids following the emergence of certain clinical studies. The most popular with us are Omacor and Vitrum cardio omega-3. Not only do these drugs lower triglycerols, which we used to know, but they also appear to have an antiarrhythmic effect. Due to this, it is possible to achieve good results in secondary prevention.

Ivabradine (Coraksan) is a drug that affects the rhythm of the heart. Naturally, myocardial revascularization.

The second group is drugs that improve the quality of life, reduce angina attacks, myocardial ischemia. Antianginal/antiischemic drugs:

Nitrates;

beta blockers;

calcium antagonists;

metabolic drugs;

Ivabradin (Coraksan).

I would like to say a few words about metabolic preparations. They are very popular in our country. Doctors love them very much. Apparently, one of the reasons for such love is that they have very few or no side effects. At the same time, these are drugs that are always in a state of discussion. There is a lot of discussion about them, how effective they are.

We have the most popular two drugs - Preductal and Mildronate. Why are these discussions going on. First, these drugs are usually used in combination with other antianginal drugs. It is often difficult to isolate how this effect is related to metabolic drugs. Then their effect is still not as strong as from other antianginal drugs. Large studies are needed to identify and prove it.

Third. There are no clear surrogate points. For hypertension - blood pressure level or hypercholesterolemia - cholesterol level. There are no such points here, so this discussion is constantly going on.

A major study on mildronates has recently been completed. International research. A large number of patients. His task was to evaluate the effect of mildronate at a dose of 1000 mg (that is, two capsules) on the symptoms of coronary heart disease, using indicators of exercise tolerance in patients with stable angina on standard therapy for 12 months.

The results of this study showed that the total load time increased. Mildronate, placebo - very minor changes. The time to the onset of ST segment depression, which generally indicates that the drug does indeed have anti-ischemic effects and can be used in combination therapy.

There are quite a few countries that have achieved a 50% or more reduction in mortality from coronary heart disease over the past 20-30 years. They analyzed how it happened. By changing the levels of risk factors or by treatment.

(Slide show).

The results were as follows. Orange bars - due to risk factors. Green - due to treatment. I was more struck by the rather high contribution of treatment to reducing mortality. 46%, 47%, 38%, 35%. We often hear that treatment does not have a very good effect on health. But these analyzes show that prevention is ahead. You can’t do without it, but the treatment is also quite effective. They should not be opposed, but should be used together.

Another clearer analysis is in England and Wales. Again, we see a 58% reduction in coronary deaths by reducing levels of risk factors, and 42% by treating patients with coronary heart disease. We need to combine these two types of intervention, and not pit them against each other.

Regardless of advances in medical high technology, the bulk of the reduction in mortality and disability from noncommunicable diseases will come through prevention.

Recommendations for the prevention of cardiovascular diseases and health promotion, as well as their implementation, should be based on the principles of evidence-based medicine, and not on the opinion of individual, even prominent, scientists and public figures. This, unfortunately, is often the case with us.

In clinical medicine, there is a "prophylactic dose". In preventive medicine, there is also such a “prophylactic dose”. For prophylaxis to be effective, the "prophylactic dose" must be optimal, which means: the right action, directed at the right number of people, for the right period of time, at the right intensity.

The slogan of the World Health Organization, which is very relevant to us. The reasons are known, what to do next is clear, now it's your turn to act. Unfortunately, we talk a lot and act much less.

I thank you for your attention.

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Sergey Boytsov, Chief Freelance Specialist of the Russian Ministry of Health for Medical Prevention, Director of the State Research Center for Preventive Medicine, told AiF.ru about the importance of clinical examination, which is often criticized, and why it is not carried out conscientiously everywhere.

— Sergey Anatolyevich, everyone knows what prevention is, but how effective is it?

— Prevention is an effective way to prevent the development of a disease or its exacerbation.

Preventive measures at the primary care level have long been proven to be effective. Thanks to active preventive measures carried out at the medical site, a significant reduction in the incidence and mortality from coronary heart disease can be achieved within 10 years. This is confirmed by the experience of our doctors: in the 80s. in the polyclinics of the Cheryomushkinsky district of Moscow, dispensary observation of patients with cardiovascular diseases was organized, as a result, mortality in these areas decreased by almost 1.5 times, compared with general practice. Even after the end of the study, the effect persisted for 10 years.
- Were there any unique techniques? What were they?

- In general, three strategies are distinguished in the implementation of preventive measures: population-based, high-risk strategy and secondary prevention strategy.

The population strategy involves the formation of a healthy lifestyle by informing the population about risk factors. The implementation of this strategy goes beyond the activities of the health system - the media, education, and culture play an important role here.

It is important to create comfortable conditions for people who decide to change their lifestyle: for example, a person who has quit smoking should be able to get into a smoke-free environment. To this end, the Ministry of Health of Russia initiated the development of regional and municipal programs aimed at improving the system for the prevention of non-communicable diseases and the formation of a healthy lifestyle for the population of the constituent entities of the Russian Federation, including the construction of sports facilities, the availability of healthy products.

What is a high risk strategy? What is it?

— It consists in the timely identification of people with an increased level of risk factors for the development of non-communicable diseases: diseases of the circulatory system, diabetes mellitus, oncology, bronchopulmonary diseases. This strategy is implemented through the health system. The most effective tool is clinical examination in primary care.

By the way, the modern method of medical examination is significantly different from that which was practiced in our country earlier. Then doctors tried to find all diseases without targets, but we are looking first of all for those diseases from which people most often die. For example, the diseases I have listed are the cause of death for 75% of the population. Now the screening method is the basis of medical examinations: on the recommendation of the World Health Organization, screening programs contain tests for the early detection of risk factors for chronic non-communicable diseases, which are the main causes of death in the population.
The third strategy is secondary prevention. It is implemented in outpatient and inpatient settings. For example, each district therapist should take into account each hypertensive patient based on the results of the medical examination.

- It should, but does it really take? Where does so much information about postscripts in the regions come from?

- Yes, now a number of media criticize the medical examination, and indeed, in some cases it is not carried out in good faith. This leads to a scatter of indicators - mortality statistics and statistics on the detection of malignant neoplasms sometimes differ significantly. Even within the same district, you can see a different level of quality of medical examinations. However, most doctors support the idea of ​​preventive examinations - this is a really effective way to prevent diseases.
How can this situation be changed?

— It is important to monitor the quality of medical care in primary care. For example, to assess the situation, the Ministry of Health for the first time in history launched a project on the public rating of Russian polyclinics, where each medical institution can be assessed according to a number of objective indicators.

On the ground, it is necessary that doctors have a better command of the procedure for conducting medical examinations. In addition, it is necessary to strengthen special structures - departments and offices of medical prevention. For their work, it is enough to connect two doctors or a paramedic and a doctor. These organizations should take responsibility for completing all necessary documentation. The duties of the local therapist should only include summarizing the first stage - this is the diagnosis and determination of the health group. This takes 10-12 minutes. Such departments and offices are already operating in the regions, helping, among other things, to get help to get rid of addictions such as smoking, get advice on healthy eating.
— How to motivate the population for timely vaccination?

- Here, population work should be carried out with the involvement of the media and social advertising. Now vaccination is actively developing - modern medicine is developing vaccinations even for the treatment of diseases such as atherosclerosis or arterial hypertension.

Primary care physicians, of course, should be the main conductors of the idea of ​​vaccination. It is important to understand that vaccination is not just a way to avoid illness. For example, the flu vaccine reduces the risk of developing cardiovascular disease. Vaccination against pneumococcal disease significantly reduces mortality in older people.
- Everything that you have listed, doctors can and do. And what can a person himself do in order to prevent?

- It is well known that the main causes of the development of diseases are smoking, alcohol abuse, poor nutrition, low physical activity, and as a result, overweight or obesity, and then arterial hypertension and atherosclerosis, followed by the development of myocardial infarction or stroke. Therefore, smoking cessation, blood pressure control, rational nutrition, an adequate level of physical activity, limiting alcohol consumption, normalizing body weight are the most important conditions for maintaining health.

Are there diseases for which prevention is useless?

— Unfortunately, there is. These diseases are genetically determined, and risk factors affecting their development have not yet been identified. As an example, I will give diffuse diseases of the connective tissue.

Cancer is also one of the hottest topics in modern medicine. Is there a way to protect yourself from cancer? What prevention methods are effective? And at what age is it worth thinking about this question?

— The most effective way of protection is the prevention of the onset of the disease and its early diagnosis. Now, early active detection at stages 1-2 of cancer within the framework of medical examinations can reach 70% of all cases, while in normal practice it is slightly more than 50%. Only with cancers of the reproductive sphere in women, this made it possible to save 15 thousand lives. It is important to undergo a regular examination, mammography and cytological examination of a cervical smear are mandatory for women, timely diagnosis of the state of the prostate gland for men, and fecal occult blood testing for all.
- What mistakes do people most often make when trying to protect themselves from diseases?

- Errors are mainly observed in methods of reducing body weight and hardening.

I am against mass winter swimming, because I believe that swimming in ice water often leads to complications than to recovery. The increase in hardening should be gradual, these procedures may consist of taking a cold shower.

As for diets, it is important not to provoke anorexia. The method of controlling body weight should become the norm. Whatever ways to lose weight are invented, it all comes down to reducing the number of calories and, accordingly, the amount of food. There should not be a clear division in the diet - you can not eat only proteins or only carbohydrates. Any mono-diets are extremely unbalanced and lead to health problems.

- How can you comment on the passion of the population for dietary supplements?

- Biologically active additives enrich the diet, supplying the body with essential trace elements. However, their manufacturers do not always follow the correct concentration of substances. As a result, taking some dietary supplements can cause significant harm to health. To reduce risks, this issue must be resolved at the level of legislation. We have regulation of the pharmaceutical market - from my point of view, a similar procedure should be extended to the market of dietary supplements.
— What can you say about the increase in mortality, widely discussed in the media?

- I would like to clarify that it is wrong to evaluate demographic processes for six months or a year. Statistics can be related to previous demographic processes that took place several decades ago.

We have a growing number of older people, and this affects the performance. Another factor that could affect the figures is mortality, "pushed back" by medical interventions. These are patients with severe forms of oncological diseases, whose life has been extended.

It is important to remember that medicine determines only a small part of mortality. The contribution of social factors is much more significant.

— What is being done now to reduce these negative processes to a minimum?

It is important to understand that science does not stand still. The life expectancy and quality of life of the elderly are increasing, the geriatric direction is developing. Methods of treatment and preservation of health are being improved.

With regard to prevention, the number of people covered by preventive examinations is generally growing. Now more than half of the country's population - more than 92.4 million people - has already taken part in a large-scale medical examination program. In 2014, 40.3 million people underwent medical examinations and preventive measures, including 25.5 million adults and 14.8 million children. More and more people receive high-tech medical care - last year more than in 2013, by 42%.

And it is especially important that since 2013 medical examination has become a part of the compulsory medical insurance program, which means that preventive examinations are completely free for every citizen. But, except for ourselves, still no one can save our health. Therefore, it is especially important to avoid risk factors, which will allow you to live a long and healthy life.

Recognition of cases of dangerous and harmful use of surfactants

Providing multidisciplinary specialized assistance

Implement targeted lifestyle interventions

· Work with parents of this group (lectures and practical classes teaching the skills of socially supportive and developmental behavior in the family and in relationships with children).

Brief interventions include a variety of interventions aimed at people who are starting to use hazardous amounts of alcohol or drugs but are not yet addicted to alcohol or drugs.

Target - prevention of drug-related problems in patients.

The content of these brief interventions varies, but most often they are instructive and motivational, and are designed to address specific behavioral problems associated with substance use and provide feedback through screening, education, practical advice, rather than intensive psychological analysis and long-term treatments. .

Short-term interventions can reduce the use of psychoactive substances by up to 30%.

Intervention "A Simple Advice"

Within 5-10 minutes, according to a clearly structured scheme, in a firm but friendly tone, indicate to the patient the danger of further alcohol / drug use. It is recommended to focus on the types and forms of such damage and specific problems (negative causes) associated with the real somatic, mental, social, psychological, family status of the patient

At the same time, positive reasons should be singled out - in the form of positive effects from a decrease in the volume and frequency of alcoholism and drug withdrawal.

Intervention "Motivational interview"

The patient is motivated in the direction of the necessary positive changes through the consistent implementation of individual strategies (5-15 minutes).

1. Introductory conversation: the patient's lifestyle, stress and alcohol / drug use (answer to the question about the role of PAS in everyday life, adaptation to it).

2. Introductory conversation: the patient's health and alcohol consumption (answer to the question about the effect of alcohol on the manifestation of health problems).

3. Typical questions: occasion of use, day, week, (confidential discussion of real consumption patterns and the role of alcohol/drugs in patients' lives).

4. "Good and not so" in the use of alcohol/drugs (generalization without setting problems and goals for behavior change).

5. Providing the patient with special information (in general terms).

6. The present and future of the patient (identifying - only in the presence of a personal concern of the patient - a discrepancy between the real circumstances of his life and plans for the future; leading to the realization of the need to change his behavior).

7. "Investigation of the patient's concerns"

8. Assistance in decision-making (only if the patient is ready to start positive changes; with an emphasis on personal choice in their favor and indicating the readiness of the medical worker to further cooperate in case of failures).

General objective-subjective principles of work

Confidence

Primary level of trust– based on information about the usefulness of medicine and treatment received in childhood and adolescence from family members, and confirmed by personal experience.

Secondary level of trust– determined by contact with a specific subject of preventive work:

a. meeting with a medical worker - trust is determined by their appearance, manner of bearing, expressing their thoughts, culture of speech, ethics of behavior, etc.

b. the quality of the medical and preventive environment (the state of the material base).

At this stage, the level of trust is due to the constructive completeness of the communicative process, the presence of the patient and the health worker in a common, unified language context.

Tertiary level of trust– determined by specific arguments - withdrawal symptoms disappear, the severity of attraction decreases, the general condition stabilizes

partnership

The use of medical and psycho-social techniques is possible only if there is a genuine partnership with the patient. With mutual disposition and respect, the patient becomes a co-therapist and thereby helps himself and the healing process.

For citation: Amberson D., Winkup P., Morris R., Walker M., Ebraim S. The role of population strategy and high-risk strategy in primary prevention of cardiovascular disease // BC. 2008. No. 20. S. 1320

Introduction

Introduction

There are two main strategies for the primary prevention of cardiovascular disease (CVD) - the so-called "high-risk strategy", according to which preventive measures are carried out among people at high risk of the disease, and the "population strategy", which involves the impact on risk factors throughout populations. For physicians who deal in their practice with cases of diseases in specific patients, a high-risk strategy is more natural. But more often CVD does not occur in a small cohort of maximum risk, but among a much larger group of individuals with not so high risk, and here the population strategy becomes relevant. Since both approaches were formulated, their potential relevance has changed. Thus, a high-risk strategy allows, on the one hand, to assess the absolute risk of CVD (and not the only risk factor, as is traditionally accepted) and, on the other hand, to select several treatment regimens, each of which will provide a noticeable and (apparently) ) independent reduction in the probability of CVD in a cohort of patients at high risk. However, it is now clear that the effectiveness of the population strategy was underestimated in the past. This is because the regression bias due to dilution (underestimation of the importance of risk factors that occurs when baseline values ​​are used in the analysis) was not taken into account, and as a result, even a slight decrease in the level of key CVD risk factors (such as blood cholesterol and the value blood pressure) in the entire population can lead to an unexpectedly sharp decrease in the incidence of CVD.

Currently, in many European countries, a high-risk strategy rather than a population-based strategy is more often chosen for primary prevention of CVD. For example, in the UK, emphasis is placed on identifying individuals with a 10-year predicted CVD risk of 30% or more (according to the Framingham Study CV risk formula). On the contrary, very little attention is paid to reducing the level of cholesterol in the blood and blood pressure in the population as a whole. However, few investigators have so far attempted to assess the potential value of different high-risk and population-based strategies, given both the benefits of preventive treatment of CVD and the underestimation of the population-based strategy associated with regression bias due to dilution. The following analyzes and compares the potential effectiveness of a high-risk strategy (aimed both at controlling individual risk factors, in particular blood cholesterol and blood pressure, and at identifying individuals with a high overall risk of CVD) and a population-based strategy (aimed at controlling blood pressure and cholesterol levels) in a representative sample of middle-aged Britons. Because the emphasis is on primary prevention, patients with verified CVD were excluded from the study, who almost certainly received pharmacotherapy, and their risk of subsequent cardiovascular events was especially high.

To examine the impact of a population-based strategy and a high-risk strategy on the incidence of the first major CV event (myocardial infarction (MI) or stroke with or without fatal outcome) in middle-aged men without pre-existing CVD and their symptoms, we took data from a prospective observational study. for CVD (British Regional Heart Study) and meta-analyzed results of randomized clinical trials regarding the reduction of the relative risk of CVD.

CVD Prevention Strategies

Considered several high-risk prevention strategies: (1) identification and control of individual risk factors: (a) determination of the threshold level of cholesterol in the blood and treatment with statins; (b) determination of the threshold level of blood pressure and treatment with β-blockers or diuretics; (2) determination of the Framingham Study 10-year risk threshold (recommended in the UK for ≥30% and in Europe for ≥20%) and treatment with (a) statins, (b) β-blockers or diuretics, (c) acetylsalicylic acid (ASA) in combination with a β-blocker or diuretic, an ACE inhibitor and a statin. A sub-analysis assessed the potential efficacy of a prophylaxis regimen that included combination treatment with ASA, a β-blocker or diuretic, an ACE inhibitor, and a statin depending on age. While there is a growing consensus that the Framingham formulas overestimate the real risk among Europeans, this study used these original formulas to make the results understandable from the point of view of modern guidelines (correcting the overestimated figures will reduce the size of the group high-risk, and this, in turn, will reduce the expected effectiveness of the high-risk strategy). Based on data from the most important clinical trials and a meta-analysis of study results, it was concluded that lowering blood cholesterol levels during statin therapy reduces the risk of MI by 31% and stroke by 24%. A decrease in blood pressure while taking first-line antihypertensive drugs (diuretics or β-blockers) reduces the risk of MI by 18%, and stroke by 38%. Among individuals with a high score on the Framingham risk scale, treatment with ASA reduces the risk of MI and stroke by 26% and 22%, respectively, and treatment with ACE inhibitors by 20% and 32%, respectively. Assuming a 4:1 ratio between the incidence of first episodes of MI and stroke in middle age (in the first 10 years of our study), then by calculating the weighted average between the reductions in two different measures of relative risk (i.e., 4/ 5 reduction in the relative risk of MI plus 1/5 reduction in the relative risk of stroke), it is possible to calculate by how much the relative risk of combined CVD outcomes is reduced. The effectiveness of treatment is enhanced, and ultimately the combined relative risk reduction against the background of taking ASA, statins, ACE inhibitors and β-blockers / diuretics is 68% (1-0.75 [ASA] × 0.70 [ statins] × 0.78 [ACE inhibitors] × 0.78 [β-blockers/diuretics]) . The reduction in the incidence of major CVD in the case of using a high-risk strategy is comparable to that in the case of using three different population-based approaches: (a) reducing the average level of cholesterol in the population as a whole; (b) a decrease in mean BP in the population as a whole; (c) a combined decrease in mean cholesterol and mean BP in the general population.

British Regional
heart examination

British Regional Heart Study ( BRHS) is a prospective study of CVD conducted at the level of general practitioners in 24 British cities from 1978 to 1980. The study included patients aged 40-59 years. There were indicators of total mortality and structural morbidity in CVD; less than 1% of participants dropped out of the trials. Baseline data from the physical examination and biochemical analyzes are presented in detail earlier. In two cities (with high and low rates of CVD mortality), patients were re-evaluated at 16 and 20 years of follow-up, with BP measured and blood lipid levels assessed. This made it possible to evaluate the influence of intrapersonal deviations (regression bias factor due to dilution) on the results of this study.

Baseline Assessment of CVD History

During the initial examination, the subjects were asked about the presence of a history of MI, stroke or angina pectoris, as well as severe chest pain lasting at least 30 minutes, which would warrant a visit to a doctor. In addition, patients completed the WHO questionnaire (Rose questionnaire) on angina pectoris, which made it possible to identify overt or hidden symptoms of angina pectoris. Individuals with a history of myocardial infarction, angina pectoris or stroke, severe chest pain, overt or covert symptoms of angina pectoris based on the results of the Rose questionnaire were excluded from the study.

Analysis of CVD cases

To collect information on the time and cause of death, the standard “tagging” procedure provided by the NHS Southport (England and Wales) and Edinburgh (Scotland) registries was used. Fatal coronary events were defined as death due to ischemic heart disease (the main cause), including cases of sudden death presumably due to heart problems (ICD-9 410-414), and fatal strokes were defined as death due to diseases with codes 430-438 according to ICD-9. Data on the incidence of heart attacks and non-fatal strokes were obtained from information provided by the attending physicians, and supplemented by the results of systematic examinations every 2 years until the end of the trial. The diagnosis of non-fatal heart attack was based on criteria approved by WHO. Non-fatal strokes included all cerebrovascular events accompanied by the development of a neurological deficit that persisted for more than 24 hours. For the present study, deaths due to coronary heart disease or stroke, as well as MI and non-fatal strokes, were included in the major CVD group.

Statistical methods
results processing

The correlation between baseline risk exposure and 10-year major CVD risk was examined using logistic regression; during the analysis, adjustments were made for age, blood cholesterol, blood pressure, smoking status (current, past, never), body mass index, physical activity level (absent, episodic, slight, moderate), presence/absence of sugar diabetes and place of residence (southern counties, midlands and Wales, northern counties, Scotland). The associative effect of blood cholesterol levels (total cholesterol and cholesterol / HDL ratio), as well as the value of systolic (BP syst.) and diastolic (BP diast.) BP for predicting the risk of major CVD was assessed in a fully adjusted model with a likelihood ratio χ 2 (HDL content was not taken into account, since it was measured only in 18 out of 24 cities). It was assumed that cholesterol levels and blood pressure values ​​were measured with an error, and over time, these indicators underwent intrapersonal deviations. The effects of these deviations were analyzed over 4 years (using observational data at 16 and 20 years) in order to describe the true correlations in the first 10 years of observation in comparison with the empirical "baseline" correlations (to calculate the usual expected level of exposure and the true values ​​of the regression coefficients calibrated).

Considering that blood cholesterol levels and BP were the most informative for predicting CV risk (and after adjusting the regression coefficients for its bias by dilution), the potential informativeness of each of the high-risk prevention strategies was predicted using logistic regression (measurements of blood cholesterol and BP values ​​were recalibrated). If the forecast for the sample was made on the basis of data obtained from the same individuals, errors (and sometimes quite significant ones) could occur in the calculation of the difference in risk indicators. Therefore, the risk was predicted using the so-called. the jackknife method to eliminate these errors. The mean predicted risk score was the expected absolute 10-year CV risk in the population prior to the implementation of the prevention strategy (which is exactly the same as the empirical CV risk score). In cases where the empirical level of risk exposure turned out to be high enough to make a positive decision to start preventive treatment (i.e., in the high-risk group), the predicted risk indicators were recalculated taking into account the effects of therapy. The average predicted risk after the implementation of the prevention strategy was then calculated, which made it possible to obtain the expected reduction in the risk of major CVD due to the implementation of the high-risk prevention strategy. With regard to population strategies, the expected reduction in the incidence of major CVD over 10 years was analyzed by comparing the predicted CV risk rates in the study sample with those of subjects in the same sample after an absolute reduction in blood cholesterol and BP. In the case of these strategies, the reduction in the incidence of major CVD was consistent with the predicted decrease that would occur if blood cholesterol and blood pressure in the subjects of this sample remained low throughout their lives.

results

Of the 7735 men selected during the baseline screening, 1186 (15.3%) had baseline signs of CVD, and another 210 men were initially taking antihypertensive or lipid-lowering drugs. For 5997 patients (of the remaining patients), a complete set of data on risk factors was available. Baseline characteristics of these subjects are presented in Table 1. In 165 individuals without baseline CVD symptoms who were not taking any antihypertensive or lipid-lowering drugs at the time of the survey after 16 or 20 years, there were results of repeated measurements of cholesterol and blood pressure for 4 years (between 16 and 20 years). The dilution bias of the regression for total cholesterol was 0.79; for the logarithm of the cholesterol/HDL ratio, 0.88; for AD syst.- 0.75; for AD diast. - 0,65.

In the first 10 years of follow-up, 450 men (7.5%) developed an episode of underlying CVD. The “relative informativeness” of the influence of various levels of cholesterol and blood pressure on the predicted risk of CVD was assessed in a fully adjusted logistic regression model with a likelihood ratio χ 2. Compared to total cholesterol in blood serum, the HDL/cholesterol ratio turned out to be less informative by 55%, and compared to garden syst. and BP diast.- by 67%. Therefore, for predicting the risk of CVD, two criteria were recognized as the most informative - the content of total cholesterol and blood pressure. syst..

Strategy effectiveness
high risk prevention

Table 2 provides data on the estimated effectiveness of each high-risk prevention regimen according to specific thresholds at which treatment is initiated, while Figure 1 shows the relationship between these thresholds, the effectiveness of therapy and the proportion of people in the population treated according to the chosen scheme. When the threshold is lowered (i.e., the proportion of people treated increases), the expected reduction in the incidence of CVD in the population becomes more pronounced. On a single treatment basis, detection based on the risk of the disease as a whole (calculated as a score from the Framingham Risk Equation) is higher than detection based on a single risk factor, and as the threshold decreases, this difference becomes more pronounced. From the point of view of prevention, combination therapy brings much more advantages compared with the appointment of only antihypertensive or lipid-lowering drugs. However, even when taking multiple drugs, the reduction in the incidence of the first episode of major CVD expected against the background of the implementation of a prevention strategy at a cut-off value of ≥30% (calculated using the Framingham risk equation and recommended in the UK) does not exceed 11%. If the 10-year risk threshold is reduced to ≥20% (according to the recommendations of the Joint European Committee for Coronary Prevention), then the decrease in the incidence of the first episode of major CVD will be 34%, and if it is reduced to ≥15% - 49% . Thus, at these thresholds, one-quarter and one-half of the asymptomatic population, respectively, would be required to receive combination prophylaxis.

Selection of therapy based on age alone

Of the 450 patients who had their first episode of CVD during 10 years of follow-up, 296 (65.8%) were over 55 years of age at the time of the onset of the event. If, from the age of 55, subjects start taking 4 drugs for prophylactic purposes, then 201 first episodes of CVD can be prevented (296x 0.68). Therefore, approximately 45% of all first episodes of major CVD within 10 years (201/450) can be prevented by implementing this particular high-risk prevention strategy (at 100% prescribing frequency and maximum adherence to drug regimens, as in clinical trials). If preventive therapy is carried out from the age of 50, then the proportion of such persons will increase to 60% (399x 0.68/450).

The effectiveness of population
prevention strategies

Figure 2 and Table 2 show the predicted performance of each of the population based approaches. A decrease in total cholesterol in blood serum and systolic blood pressure by 5% (by 0.3 mmol / l and 7 mm Hg, respectively) for a long time causes a decrease in the incidence of the first episode of major CVD within 10 years by 26%, and a decrease in the values ​​of these indicators by 10% - by 45%.

Impact of regression bias
due to dilution

Regression bias by dilution has no effect on the expected performance of high-risk strategies, while its effect on the performance of population-based approaches is significant. The adjusted figures presented in Table 2 and Figure 2 turned out to be 20-30% higher than the unadjusted ones.

Discussion

When analyzing the potential effectiveness of various strategies for the primary prevention of high-risk CVD and population-based strategies, it is necessary to take into account the inaccuracies that arise in the measurement of blood cholesterol and BP, as well as intrapersonal bias (regression bias due to dilution). The data obtained in this study suggest that a measurable change in the incidence of CVD occurs only against the backdrop of widespread implementation of high-risk primary prevention strategies that involve combination therapy (at less than 3% of the expected risk per year according to the UK recommendations and less than 2% of the expected risk per year according to the recommendations adopted in Europe). Potentially, a relatively small reduction in two key risk factors (blood cholesterol and blood pressure) across the entire population could lead to a significant reduction in the incidence of major CVD.

Assumptions

The validity of the assumptions regarding high-risk strategies is determined by the hypothetical effectiveness of the treatment and the appropriateness of the use of these strategies. The effectiveness of statins, ASA and first-line antihypertensive drugs can be judged on the basis of a meta-analysis of the results of randomized controlled trials, and ACE inhibitors - a specific large-scale controlled trial of drugs in this class. The study used these calculations rather than cohort analyzes because cohort analyzes assess the impact of differences in risk scores that result from long-term changes in risk exposure, while clinical trials provide an opportunity to determine how much such epidemiological correlations are reversible against the background of therapy. In addition, during clinical trials, non-compliance with the treatment plan is also taken into account in the calculation, since these results are obtained in accordance with the so-called. “the principle of prescribed treatment” (although in everyday medical practice the real effectiveness of drugs can be overestimated, since often subjects who do not comply with the drug regimen were excluded during the preparatory phase of the study, and patients are monitored more closely). As a rule, the effectiveness of ongoing therapy is studied in a group of high-risk individuals (including patients with a history of CVD), and therefore extrapolating these data to subjects without previous CVD also leads to an overestimation of the effectiveness of a high-risk strategy. This is true, in particular, for ACE inhibitors, information about the effectiveness of which is based mainly on the results of studies conducted in patients with a verified diagnosis of CVD. When prescribing statins and ASA, this assumption looks more reasonable, because Relative risk indicators decrease quite stably in a wide range of patient groups. Further, assuming that the treatment has a multifactorial effect, it is possible to overestimate the combined effects of taking all four drugs (for example, ACE inhibitors may be less effective in combination with ASA). Using different combinations of drugs (including several drugs at low doses), one can expect a greater reduction in the risk of CVD than the data presented in this article, but even if this is true, this assumption is unlikely to seriously affect results of our study (e.g., if the combination pill reduces the true relative risk of 85%, then treating patients with ≥30% risk using the Framingham Study formula will reduce the incidence of major CVD by 14% compared to the value of 11% given in table 2).

The effectiveness of population-based prevention strategies depends primarily on the severity of changes across the entire population, which can actually be achieved in practice. Reducing the average level of total cholesterol and blood pressure in the range from 5 to 15% on the scale of the entire population (Table 2) is very small; by a similar amount, the values ​​of these indicators may decrease if a certain diet is followed. In terms of total cholesterol, a Mauritius study found that after switching to soy (rather than palm) oil and implementing health promotion programs, total cholesterol levels in the general population increased over 5 years. decreased by 15%. Meta-analysis of the results of studies conducted in the so-called. Metabolic Chamber, indicates that if 60% of the consumed saturated fats are replaced with other fats, and the amount of cholesterol received from food is reduced by 60%, then the same decrease in the values ​​​​of indicators can be achieved. Salt restriction has been associated with a population-wide reduction in blood pressure of about 10%, although this approach has been less effective in clinical practice. And although when compared with the difference in cholesterol and blood pressure levels in different populations, it turns out that the values ​​of these indicators in the population as a whole decrease slightly, our assessment of the potential effectiveness of population strategies is quite safe. Long-term trends in blood pressure levels are also subject to pronounced fluctuations over fairly short periods of time; Thus, in the period from 1948 to 1968, the average value of systolic blood pressure in Glasgow students decreased by 9 mm Hg. , and regardless of antihypertensive therapy, the same data were obtained from the results of medical examinations in England. Finally, the implementation of prevention regimens aimed at reducing cholesterol and blood pressure levels in the population has an additional positive effect on other cardiovascular risk factors, such as body mass index and physical activity level.

In the present study, it was mainly about the content of cholesterol, the level of blood pressure and the corresponding methods of pharmacological correction of these indicators, and questions regarding the effect of smoking on the risk of CVD were not raised. If this aspect is also taken into account, then the effectiveness of both high-risk strategies and population-based strategies becomes even more obvious (for example, the reduction in the number of deaths due to CVD over the past two decades by about one-third is associated with smoking cessation). But even when smoking is taken into account, the ratio of potential effectiveness of both prevention strategies remains unchanged.

Impact of regression bias
due to dilution

The analysis adjusted for regression bias due to dilution (underestimation of the correlation between levels of common risk factors and disease risk due to intrapersonal bias). In the case of the implementation of the high-risk strategy, this phenomenon did not affect the effectiveness of the approach (since the data on the effectiveness of treatment were taken from the results of clinical trials), but when implementing the population-based strategy, this effect was noticeable. This difference is explained by the fact that the true shift in the distribution of exposure values ​​relative to fluctuations in its level is higher compared to the situation when intrapersonal deviations are not taken into account. Therefore, when analyzing the effectiveness of population strategies, it is critical to correct for regression bias due to dilution. Otherwise, it is likely that the effectiveness of the approach will be largely underestimated.

Practical
application of results

The results obtained indicate that impact on any one risk factor has a limited effect on the incidence of CVD in the population. When multiple factors are taken into account, the risk score predicted by the Framingham Study formula generally provides a more accurate estimate on which treatment is selected than calculations made using a single risk factor such as total cholesterol or blood pressure (although these differences are only in the case when the therapy is carried out in a sufficient sample size (Table 2). These facts do not contradict previously published data regarding the effect of antihypertensive and lipid-lowering treatment on the risk of CVD. But even if drugs are given in combination to reduce the risk of CVD, the impact of a high-risk primary pharmacological prevention strategy will still be limited until these strategies are implemented much more actively than they are now (according, for example, to the recommendations adopted in the UK ). More than a third of middle-aged men without clinical symptoms of CVD should be treated with all 4 drugs to achieve benefits comparable to those achieved by a 10% reduction in cholesterol and BP in the population. The same is said in the revised report of the Third Joint Committee on CVD Prevention, according to which the key attention should be paid to patients with a 10-year risk of developing CVD with a fatal outcome of at least 5% (according to the results of the SCORE project); with this value of this criterion, 36% of participants in the BHRS study initially fall into the high-risk group. However, treatment in such a large group of clinically healthy individuals is very costly, and as a result, the cost-effectiveness of pharmacotherapy, as part of a high-risk prevention strategy, is reduced, as the absolute risk threshold decreases. At the same time, population strategies are highly effective in economic terms, and in addition (more importantly), they are focused not only on eliminating the influence of risk factors, but on identifying the determinants of their distribution. Population-based approaches to a greater extent allow to stop the progression of atherosclerosis, while high-risk strategies provide prolongation of treatment in middle-aged patients who need pharmacotherapy.

The data presented indicate a tangible hypothetical benefit of population-based high-risk prevention strategies. Compared to international standards, mean levels of total cholesterol and blood pressure in the UK remain high and have declined very little over the past decade. The current national health policy on CVD prevention in the UK takes only minimal account of the need to lower total cholesterol and blood pressure levels in the population as a whole and does not give decisive importance to government actions as a key tool for influencing these changes (which could be expressed, for example, in the adoption of a law to limit the content of salt and fat in groceries). It appears that prioritizing population-based approaches to lower cholesterol and BP will preserve the notable advances that have been made in CVD prevention over the past two decades, especially given the dramatic increase in obesity and diabetes. as well as a sedentary lifestyle.

Abstract prepared by E.B. Tretyak
based on the article
J. Emberson, P. Whincup, R. Morris,
M. Walker, S. Ebrahim
"Evaluating the impact of the population
and high-risk strategies
for the primary prevention
of cardiovascular disease"
European Heart Journal 2004, 25: p. 484-491

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Prevention of diseases (Diseases Prevention) - a system of measures of a medical and non-medical nature, aimed at preventing, reducing the risk of developing deviations in the state of health and diseases, preventing or slowing down their progression, and reducing their adverse effects.

Provision of primary health care, specialized medical care within the guaranteed volume of medical care to the population, including preventive, diagnostic and treatment services.

• 1. Improving the work of the institution for the provision of primary health care to the population, improving the material and technical base.
• 2. Improving the quality of medical care, raising the qualification level of doctors and nurses.
• 3. Increasing the index of health of children, women of childbearing age, quality conduct, implementation of the plan for preventive medical examinations.
• 4. Carrying out work to stabilize and reduce socially significant diseases.

medical examination health adult population

• 5. Reducing premature mortality of the adult population, infant mortality; prevention of child and maternal mortality.
• 6. Reducing the level of primary exit to disability.
• 7. Promoting a healthy lifestyle as one of the strategic ones.

Medical prevention - a system of preventive measures implemented through the health care system.

Medical prevention in relation to the population is defined as:

individual - preventive measures carried out with individual individuals;

group - preventive measures carried out with groups of people; having similar symptoms and risk factors (target groups);

population (mass) - preventive measures covering large groups of the population (population) or the entire population as a whole. The population level of prevention is generally not limited to medical interventions, but is local prevention programs or grassroots campaigns aimed at promoting health and preventing disease.

Primary prevention (Primaryprevention) - a set of medical and non-medical measures aimed at preventing the development of deviations in the state of health and diseases common to the entire population, certain regional, social, age, professional and other groups and individuals.

Primary prevention includes:

• 1. Measures to reduce the impact of harmful factors on the human body (improving the quality of atmospheric air, drinking water, the structure and quality of nutrition, working conditions, life and rest, the level of psychosocial stress and others affecting the quality of life), environmental and sanitary and hygienic control .
• 2. Measures to promote a healthy lifestyle, including:

a) creation of an information and propaganda system to increase the level of knowledge of all categories of the population about the negative impact of risk factors on health, the possibilities of its reduction;

b) health education - hygiene education;

c) measures to reduce the prevalence of smoking and consumption of tobacco products, reduce alcohol consumption, prevent the use of drugs and narcotic drugs;

d) encouragement of the population to a physically active lifestyle, physical culture, tourism and sports, increasing the availability of these types of health improvement.

3. Measures to prevent the development of somatic and mental illnesses and injuries, including professionally caused, accidents, disability and death from unnatural causes, road traffic injuries, etc.

Identification during preventive medical examinations of factors harmful to health, including behavioral ones, in order to take measures to eliminate them, in order to reduce the level of action, risk factors. Article 46. Medical examinations, clinical examination provides for: .

• 1) Medical examination is a complex of medical interventions aimed at identifying pathological conditions, diseases and risk factors for their development.
• 2) Types of medical examinations are:
• 1. Preventive medical examination conducted for the purpose of early (timely) detection of pathological conditions, diseases and risk factors for their development, non-medical use of narcotic drugs and psychotropic substances, as well as for the formation of health status groups and recommendations for patients;
• 2. Preliminary medical examination, carried out upon admission to work or study, in order to determine the compliance of the employee's state of health with the work assigned to him, the student's compliance with the requirements for training;
• 3. Periodic medical examination, carried out at regular intervals, for the purpose of dynamic monitoring of the health status of workers, students, timely detection of the initial forms of occupational diseases, early signs of the impact of harmful and (or) hazardous production factors of the working environment, labor, educational process on health employees, students, in order to form risk groups for the development of occupational diseases, to identify medical contraindications for the implementation of certain types of work, to continue their studies;
• 4. Pre-shift, pre-trip medical examinations carried out before the start of the working day (shift, flight) in order to identify signs of exposure to harmful (or) hazardous production factors, conditions and diseases that impede the performance of work duties, including alcohol, drug or other toxic intoxication and the residual effects of such intoxication;
• 5. Post-shift, post-trip medical examinations carried out at the end of the working day (shift, flight) in order to identify signs of the impact of harmful and (or) dangerous production factors of the working environment and the labor process on the health of workers, acute occupational disease or poisoning, signs of alcohol, narcotic or other toxic intoxication.
• 3) In cases stipulated by the legislation of the Russian Federation, in-depth medical examinations may be carried out with respect to certain categories of citizens, which are periodic medical examinations with an extended list of specialist doctors and examination methods involved in them.
• 4) Carrying out immunoprophylaxis of various groups of the population.
• 5) Rehabilitation of individuals and groups of the population under the influence of factors unfavorable to health using medical and non-medical measures
• 6) Medical examination of the population in order to identify the risks of developing chronic somatic diseases and improve the health of persons and contingents of the population under the influence of adverse factors using medical and non-medical measures.

Article 46

7) Carrying out medical examination of the population to identify the risks of developing chronic somatic diseases and improving the health of individuals and contingents of the population under the influence of factors unfavorable to health using medical and non-medical measures.

Secondary prevention (secondary prevention) - a set of medical, social, sanitary-hygienic, psychological and other measures aimed at early detection and prevention of exacerbations, complications and chronicity of diseases, disability, causing maladjustment of patients in society, reduced working capacity, including disability and premature mortality.

Secondary prevention includes:

• 1. Targeted health and hygiene education, including individual and group counseling, teaching patients and their families the knowledge and skills associated with a particular disease or group of diseases.
• 2. Conducting dispensary medical examinations in order to assess the dynamics of the state of health, the development of diseases in order to determine and carry out appropriate health and therapeutic measures.
• 3. Conducting courses of preventive treatment and targeted rehabilitation, including therapeutic nutrition, physiotherapy exercises, medical massage and other therapeutic and preventive methods of rehabilitation, sanatorium treatment.
• 4. Carrying out medical and psychological adaptation to changes in the situation in the state of health, the formation of the correct perception and attitude to the changed capabilities and needs of the body.
• 5. Carrying out measures of a state, economic, medical and social nature aimed at reducing the level of influence of modifiable risk factors, maintaining residual working capacity and the ability to adapt in the social environment, creating conditions for optimal support of the life of patients and disabled people (for example: the production of clinical nutrition, the sale architectural and planning solutions and the creation of appropriate conditions for persons with disabilities, etc.).

Tertiary prevention - rehabilitation (synonymous with restoring health) (Rehabilitation) - a set of medical, psychological, pedagogical, social measures aimed at eliminating or compensating for life restrictions, lost functions in order to restore social and professional status as fully as possible, prevent relapses and chronic disease .

Tertiary prevention refers to actions aimed at preventing the deterioration of the course or the development of complications. . Tertiary prevention includes:

• 1. Teaching patients and their families knowledge and skills related to a specific disease or group of diseases.
• 2. Carrying out clinical examination of patients with chronic diseases and the disabled, including dispensary medical examinations in order to assess the dynamics of the state of health and the course of diseases, the implementation of permanent monitoring of them and the implementation of adequate therapeutic and rehabilitation measures.
• 3. Conducting medical and psychological adaptation to changes in the situation in the state of health, the formation of the correct perception and attitude to the changed capabilities and needs of the body.
• 4. Carrying out measures of a state, economic, medical and social nature aimed at reducing the level of influence of modifiable risk factors; preservation of residual working capacity and the possibility of adaptation in the social environment; creation of conditions for the optimal support of the life of the sick and disabled (for example, the production of clinical nutrition, the implementation of architectural and planning solutions, the creation of appropriate conditions for persons with disabilities, etc.).

Prevention activities can be implemented using three strategies - population strategy, high risk strategy and individual prevention strategies.

1. Population strategy - identifying adverse lifestyle and environmental factors that increase the risk of developing diseases among the entire population of a country or region and taking measures to reduce their impact.

The population strategy is to change the lifestyle and environmental factors associated with diseases, as well as their social and economic determinants. The main areas of activity are monitoring of NCDs and their risk factors, policy, legislation and regulation, intersectoral cooperation and partnership, public education, involvement of the media, and the formation of a healthy lifestyle. The implementation of this strategy is primarily the task of the government and legislative bodies of the federal, regional and municipal levels. The role of physicians is reduced mainly to the initiation of these actions and the analysis of ongoing processes.

The formation of a healthy lifestyle, which involves a well-organized promotion of medical and hygienic knowledge in combination with some organizational measures, is a highly effective measure that reduces the incidence rate and associated labor losses, and helps to increase the body's resistance to various adverse effects.

One of the leading directions in the formation of a healthy lifestyle is the fight against smoking. Smokers get sick more often and for a longer time, among them the level of temporary and permanent disability is significantly higher, they use inpatient and outpatient treatment more intensively. It is necessary to pay great attention to such problems as the use of alcohol and drugs. Therefore, measures for the formation of mental and sexual health are important components of the formation of a healthy lifestyle. An urgent problem in our society is the problem of chronic fatigue, people should undergo regular medical examination and treatment of chronic fatigue.

An indispensable condition for a healthy lifestyle is a proper balanced diet. The basic principles of rational nutrition must be observed:

energy balance of the diet (correspondence of energy consumption to energy consumption);

balanced diet for the main components (proteins, fats, carbohydrates, trace elements, vitamins);

mode and conditions of eating.

It is also advisable to implement health education programs to improve the structure and quality of nutrition, proper eating behavior and weight management.

Preserving and strengthening the health of the population by promoting a healthy lifestyle is the highest priority in the development of national prevention strategies and requires the development and implementation, first of all, of organizational, information, educational technologies, including at the level of the most massive - primary medical care to the population.

The success of a population-based strategy to reduce smoking, excessive drinking and road traffic accidents can be achieved with the improvement and strict implementation of relevant laws and regulations.

2. High-risk strategy - identifying and reducing the levels of risk factors in various population groups of people with high risks of developing the disease (working in various difficult and unfavorable working conditions, staying in extreme conditions, etc.)

A high-risk strategy involves primary health care identifying high-risk individuals, assessing the degree of risk, and managing that risk through lifestyle recommendations or the use of drugs and non-drugs.

3. Individual strategy - identification of specific, most often complex and combined risks of the development and progression of diseases for each patient and implementation of individual preventive and rehabilitation measures.

An individual strategy is applied at the level of medical and preventive and health-improving institutions and is aimed at preventing diseases in each case, taking into account individual risks.