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

Abstract

Objective: There is no evidence that systematic screening and risk factor modification in an unselected, asymptomatic population will reduce cardiovascular disease (CVD) mortality. This study aimed to evaluate the effectiveness of a primary care CVD prevention program on mortality during a 13-year follow-up.

Design: A risk factor survey was sent, followed by a nurse-led lifestyle counselling to respondents with at least one CVD risk factor, and a general practitioner's (GP) appointment for high-risk persons. Screening and interventions were performed during 2005-2006.

Setting: A public health care centre in the town of Harjavalta, Finland.

Subjects: All home-dwelling 45-70-year old inhabitants without manifested CVD or diabetes.

Main outcome measures: All-cause and CVD mortality.

Results: Altogether 74% (2121/2856) inhabitants responded to the invitation. The intervention was received by 1465 individuals (52% of the invited population): 398 risk persons had an appointment with a nurse, followed by an appointment with a GP for 1067 high-risk persons. During the follow-up, 370 persons died. Mortality among the non-respondents was twofold compared to the participants'. In subjects who received the intervention, the age- and gender-adjusted hazard ratio for all-cause mortality was 0.44 (95% CI: 0.36 to 0.54) compared to the subjects who did not receive the intervention.

Conclusions: Reducing mortality is possible in a primary care setting by raising health awareness in the community with screening, by targeted lifestyle counselling and evidence-based preventive medication for persons at high risk for CVD. Subjects not willing to participate in health surveys have the worst prognosis.Key PointsPreviously, there is no evidence that systematic screening and risk factor modification in an unselected, asymptomatic population will reduce cardiovascular disease (CVD) mortality.With a stepwise screening program it is possible to scale the magnitude of CVD prevention in the community.Reducing mortality in a community is possible by screening, targeted lifestyle counselling, and by evidence-based preventive medication for high-risk persons.Subjects not willing to participate in health surveys have the worst prognosis.

Keywords: Cardiovascular disease; general practice; mortality; primary prevention; screening.

Figure 1.

The design of the Harmonica Project and the groups studied.

Figure 2.

Cumulative all-cause mortality curves adjusted for age and gender.

Figure 3.

Hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality in the study groups with Group C as the reference. Adjustments were made for age and gender. Whiskers show 95% confidence intervals.

Figure 4.

Standardized mortality ratio (SMR) for all-cause and cardiovascular disease (CVD) deaths in the study groups during the follow-up period. Whiskers show 95% confidence intervals.