The comparative effectiveness of heart disease prevention and treatment strategies.

BACKGROUND Policymakers must be able to calculate the comparative effectiveness of interventions to control heart disease if they are to optimize the population impact of programmatic initiatives. METHODS A model was created to calculate the number of deaths that would be prevented or postponed if perfect care for heart disease prevention and treatment were achieved--that is, the elimination of risk factors and the prescription of all effective medications before and between acute events, and the delivery of all effective therapies to individuals suffering an acute heart disease event. The impact of perfect care was calculated for a hypothetic population aged 30-84 years with risk-factor levels, event rates, current patterns of behavior, levels of treatment, and mortality rates resembling those of the U.S. The analysis was performed in 2007 and 2008. RESULTS In this population, 44% of all deaths were due to heart disease. Perfect care before the first heart disease event would prevent or postpone 33% of all deaths. Perfect care between acute events would prevent or postpone 23% of all deaths. Perfect care during acute events would prevent or postpone 8% of all deaths. CONCLUSIONS This direct comparison of heart disease prevention and treatment strategies indicates that nearly 90% of the impact from perfect care for heart disease would accrue from interventions before and between acute events. The impact of risk-factor interventions before or between events is amplified by the fact that these interventions also reduce the risk of death from other chronic diseases.

[1]  J. Critchley,et al.  Explaining the Increase in Coronary Heart Disease Mortality in Beijing Between 1984 and 1999 , 2004, Circulation.

[2]  W. Rogers,et al.  Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999: the National Registry of Myocardial Infarction 1, 2 and 3. , 2000, Journal of the American College of Cardiology.

[3]  Deepak L. Bhatt,et al.  Utilization of Early Invasive Management Strategies for High-Risk Patients With Non–ST-Segment Elevation Acute Coronary Syndromes: Results From the CRUSADE Quality Improvement Initiative , 2004 .

[4]  D. Annane,et al.  Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis , 2004, BMJ : British Medical Journal.

[5]  R. Tracy,et al.  Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. , 1998, The New England journal of medicine.

[6]  Jessica Grossmeier,et al.  The Relationship Between Health Promotion Program Participation and Medical Costs:: A Dose Response , 2003, Journal of occupational and environmental medicine.

[7]  Jonathan Mant,et al.  Detecting differences in quality of care: the sensitivity of measures of process and outcome in treating acute myocardial infarction , 1995, BMJ.

[8]  Nick Freemantle,et al.  β Blockade after myocardial infarction: systematic review and meta regression analysis , 1999 .

[9]  K. Furie,et al.  Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. , 2007, Circulation.

[10]  A. Mattioli,et al.  Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients , 2002, BMJ : British Medical Journal.

[11]  P. Royle,et al.  Clinical effectiveness and cost-effectiveness of immediate angioplasty for acute myocardial infarction: systematic review and economic evaluation. , 2005, Health technology assessment.

[12]  Device therapy in heart failure , 2007, BMJ : British Medical Journal.

[13]  R. Collins,et al.  Indications for ACE inhibitors in the early treatment of acute myocardial infarction: systematic overview of individual data from 100,000 patients in randomized trials. ACE Inhibitor Myocardial Infarction Collaborative Group. , 1998, Circulation.

[14]  Robert Luben,et al.  Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study , 2008, PLoS medicine.

[15]  T. Gary,et al.  Have Americans increased their fruit and vegetable intake? The trends between 1988 and 2002. , 2007, American journal of preventive medicine.

[16]  R. Goetzel,et al.  Heart healthy and stroke free: successful business strategies to prevent cardiovascular disease. , 2005, American journal of preventive medicine.

[17]  D. Labarthe,et al.  Diet and physical activity of U.S. adults with heart disease following preventive advice. , 2007, Preventive medicine.

[18]  Roberto Marchioli,et al.  Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico. , 1999 .

[19]  R. Collins,et al.  ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither , 1998, BMJ.

[20]  C. Lau,et al.  Prevalence, Awareness, Treatment, and Control of Hypertension Among United States Adults 1999–2004 , 2007, Hypertension.

[21]  Warren Smith,et al.  Home use of automated external defibrillators for sudden cardiac arrest. , 2008, The New England journal of medicine.

[22]  R. Collins,et al.  Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins , 2005, The Lancet.

[23]  Task Force on Community Preventive Services.  Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health-care systems. A report on recommendations of the Task Force on Community Preventive Services. , 2000 .

[24]  S. Wannamethee,et al.  Physical Activity and Mortality in Older Men With Diagnosed Coronary Heart Disease , 2000, Circulation.

[25]  Catherine Sudlow,et al.  Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients , 2002, BMJ : British Medical Journal.

[26]  R. Belardinelli,et al.  Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. , 1999, Circulation.

[27]  D. Labarthe,et al.  Prevalence of heart disease--United States, 2005. , 2007, MMWR. Morbidity and mortality weekly report.

[28]  W. Weaver,et al.  Angiotensin-converting enzyme inhibitors in coronary artery disease and preserved left ventricular systolic function: a systematic review and meta-analysis of randomized controlled trials. , 2006, Journal of the American College of Cardiology.

[29]  K. Bailey,et al.  Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. , 1998, Circulation.

[30]  Sonia S Anand,et al.  Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis. , 1999, JAMA.

[31]  J. McMurray,et al.  Explanation for the Decline in Coronary Heart Disease Mortality Rates in Auckland, New Zealand, Between 1982 and 1993 , 2000, Circulation.

[32]  M. Piepoli,et al.  Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH) , 2004, BMJ : British Medical Journal.

[33]  A Laupacis,et al.  What is the quality of life for survivors of cardiac arrest? A prospective study. , 1999, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[34]  D. Faust.  The limits of scientific reasoning , 1984 .

[35]  Roger D. White,et al.  Preventing sudden death with n-3 (omega-3) fatty acids and defibrillators. , 2006, American journal of preventive medicine.

[36]  Julia A. Critchley,et al.  Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980–2000 , 2004 .

[37]  Salim Yusuf,et al.  Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients , 2000, The Lancet.

[38]  B. Pitt,et al.  The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. , 1999, The New England journal of medicine.

[39]  J Lau,et al.  Effects of omega-3 fatty acids on cardiovascular disease. , 2004, Evidence report/technology assessment.

[40]  GISSI-Prevenzione Investigators,et al.  Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial , 1999, The Lancet.

[41]  B. Pitt,et al.  The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure , 2000 .

[42]  M. Piepoli,et al.  Exercise training in patients with chronic heart failure , 2004, BMJ : British Medical Journal.

[43]  Jun Ma,et al.  National Trends in Statin Use by Coronary Heart Disease Risk Category , 2005, PLoS medicine.

[44]  J. Critchley,et al.  Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. , 2003, JAMA.

[45]  H. Krumholz,et al.  Statins and Mortality Among Elderly Patients Hospitalized With Heart Failure , 2006, Circulation.

[46]  M. Josephson,et al.  Prevention of Fatal Arrhythmias in High-Risk Subjects by Fish Oil n-3 Fatty Acid Intake , 2005, Circulation.

[47]  Douglas W Mahoney,et al.  Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. , 2003, JAMA.

[48]  P. Jousilahti,et al.  Systolic blood pressure, isolated systolic hypertension and risk of coronary heart disease, strokes, cardiovascular disease and all‐cause mortality in the middle‐aged population , 1998, Journal of hypertension.

[49]  A. Owen,et al.  Combined resynchronisation and implantable defibrillator therapy in left ventricular dysfunction: Bayesian network meta-analysis of randomised controlled trials , 2007, BMJ : British Medical Journal.

[50]  E. Topol,et al.  Long-Term Results After the Glycoprotein IIb/IIIa Inhibitor Abciximab in Unstable Angina: One-Year Survival in the GUSTO IV-ACS (Global Use of Strategies To Open Occluded Coronary Arteries IV—Acute Coronary Syndrome) Trial , 2003, Circulation.

[51]  A. Mokdad,et al.  Aspirin use among U.S. adults: Behavioral Risk Factor Surveillance System. , 2006, American journal of preventive medicine.

[52]  H A Feldman,et al.  Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial. , 2000, JAMA.

[53]  Duolao Wang,et al.  Systematic review of the impact of beta blockers on mortality and hospital admissions in heart failure , 2001, European journal of heart failure.

[54]  S. Yusuf,et al.  Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. , 2001, The New England journal of medicine.

[55]  J. Strong,et al.  Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. , 2000, Arteriosclerosis, thrombosis, and vascular biology.

[56]  S. Yusuf,et al.  Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. , 2000 .

[57]  Louise B. Russell,et al.  Is Prevention Better Than Cure , 1987 .

[58]  F. D. H. Hall.  St. Luke's Hostel , 1895 .

[59]  Simon Capewell,et al.  Explaining the Decline in Coronary Heart Disease Mortality in England and Wales Between 1981 and 2000 , 2004, Circulation.

[60]  D. Anderson,et al.  The Impact of a Worksite Health Promotion Program on Short-Term Disability Usage , 2001, Journal of occupational and environmental medicine.

[61]  G. Fraser,et al.  Ten years of life: Is it a matter of choice? , 2001, Archives of internal medicine.

[62]  Elizabeth R DeLong,et al.  ORIGINAL CONTRIBUTION Association Between Hospital Process Performance and Outcomes Among Patients With Acute Coronary Syndromes , 2022 .

[63]  S. Yusuf,et al.  The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial programme; rationale, design and baseline characteristics including a meta-analysis of the effects of thienopyridines in vascular disease. , 2000, European heart journal.

[64]  E. Antman,et al.  Invasive therapy along with glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival in non-ST-segment elevation acute coronary syndromes: a meta-analysis and review of the literature. , 2004, The American journal of cardiology.

[65]  Effect of combinations of drugs on all cause mortality in patients with ischaemic heart disease: nested case-control analysis , 2005, BMJ : British Medical Journal.

[66]  Richard Doll,et al.  Mortality in relation to smoking: 22 years' observations on female British doctors. , 1980, British medical journal.

[67]  J. McMurray,et al.  Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994 , 1999, Heart.

[68]  J P Ornato,et al.  Public-access Defibrillation and Survival after Out-of-hospital Cardiac Arrest Recommended Citation Public-access Defibrillation and Survival after Out-of-hospital Cardiac Arrest , 2022 .

[69]  K. Eagle,et al.  Impact of Combination Evidence-Based Medical Therapy on Mortality in Patients With Acute Coronary Syndromes , 2004, Circulation.

[70]  C. Gross,et al.  Adoption of Spironolactone Therapy for Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction in the United States, 1998–2001 , 2005, Circulation.

[71]  S. Ebrahim,et al.  Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. , 2004, The American journal of medicine.