Risk factors for various diseases prevention strategy. Prevention is a priority in protecting public health

Oganov R.G.

Arutyunov Grigory Pavlovich,Doctor of Medical Sciences, Professor:

On the agenda, it is with great pleasure that we give the floor to the leading cardiologist of our country, Chairman of the All-Russian Scientific Society of Cardiologists, Academician of the Russian Academy of Medical Sciences, Professor Rafael Gegamovich Oganov.

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

Hello, dear colleagues.

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

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

This does not mean that genetic factors do not play a role. Undoubtedly they play a role. But the main one is a way of life. This is well proven by observations of migrants. We know well 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 some time they begin to get sick and die like real Americans.

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

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

The rationale for the need to prevent cardiovascular disease has been expressed. Firstly, the pathology is usually based on atherosclerosis, which occurs covertly for many years and, as a rule, is already very pronounced when symptoms appear.

It is now well known from epidemiological studies that even adolescents who died from some accidents already show 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 reports in the media that a person who appears to be in good 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.

Third, modern treatment methods (drug, endovascular, surgical) do not eliminate the cause of cardiovascular diseases. After all, we are influencing the effect here, not the cause, so the risk of vascular accidents in these patients remains high, even though they may subjectively feel absolutely healthy.

What are the necessary conditions for successful actions to prevent cardiovascular diseases. First, there must be a scientifically based concept of prevention. Then creating the infrastructure to take action to promote health and prevent cardiovascular disease. Staffing of this structure with professional personnel and provision of material, technical and financial resources.

In principle, we have all this, but it does not work at full strength, while we still need a better effect.

Do we have a scientific basis? Yes, I have. 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 precisely 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, and 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 not of 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 when developing prognostic tables or instruments.

One more point I want to draw your attention to. Classic risk factors for cardiovascular diseases lead not only to the development of cardiovascular diseases, but also to a number of other chronic non-communicable diseases. Integrated programs for the prevention of non-communicable diseases are built on this basis.

There are a lot of risk factors. More than 30 - 40 of them have been discovered, so you always have to choose a priority, that is, which risk factors to give priority to. What risk factors do we need to pay attention to first?

The first is factors whose connection with diseases has been proven. Secondly, this connection must be strong. The prevalence of risk factors should be high. Factors that influence several diseases rather than just one. They interest us from a practical point of view. For example, smoking. If we succeed in the fight against smoking, this will lead not only to a reduction in cardiovascular diseases, but also in many other diseases. Such factors are of particular interest to us from a practical point of view.

The most important. When giving priority to a risk factor, one must clearly understand that there are effective methods for preventing and correcting this risk factor.

If we talk about general risk factors for which there are scientifically based and accessible public health methods of identification and correction, 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 reduction in mortality from cardiovascular diseases, but also from a number of other chronic non-communicable diseases.

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

It will be of interest to study the extent to which risk factors can actually predict mortality from ischemic disease or from chronic non-communicable diseases.

In our center, such an analysis was carried out by Professor A. M. Kalinina. She took a long-term prospective 10-year observation 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 was. If you look at the slide “Mortality from coronary heart disease”, then the two “curves” practically merge. This even causes some surprise at how accurate it is.

If you look at the slide “Mortality from chronic non-communicable diseases” (“predicted risk” and “observed risk”), although the “curves” diverge somewhat, 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) unfavorable moments 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 today we cannot personally name who this 50% will be.

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

This is inflammation. The origin of atherosclerosis is given great importance. These are infections. They 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 what clinical studies were carried out and what drugs were used. These clinical studies, unfortunately, either did not give any result (they were zero) 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 mean that. Most likely, we are doing something wrong in terms of our intervention. This was well demonstrated by the situation with female sex hormones and 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 events. The conclusion was that they could be used very carefully.

When analyzed more carefully, it turned out that if this hormone replacement therapy was started immediately or shortly after menopause, the result was positive. If it was prescribed to patients who were 10 to 15 years after menopause, the results were poor.

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

Risk adjustment. There can be three actions here: preventive counseling, non-drug prevention (some kind of physical training program or dietary program) or drug prevention (when we try to normalize some factor like hypertension with the help of medications).

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 call it. We translate it literally. This is an examination 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 individuals with diabetes. Naturally, if we take people who are overweight, obese, or people who have a dietary predisposition to diabetes, then we will identify significantly more of these patients.

This is what these two types of screening are based on. Depending on the task, one or the other is used.

Diagnostic methods, which are improving very quickly, now allow us to identify so-called subclinical markers of increased risk. In particular, damage to atherosclerosis or arterial hypertension.

We can determine intima-media thickness (ultrasound) using 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 on the ankle and on the shoulder (there are special devices, but you can simply do this using a phonendoscope cuff). Plaques in the carotid or peripheral arteries (ultrasound).

This is the carotid-femoral speed of propagation of the pulse wave. The method has been known for a very long time, but now devices have appeared that allow this 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 disease. But they have a better predictive ability, prognostic quality, than the prognostic significance 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 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 lack of commitment is the main problem.

Strategy for the prevention of cardiovascular diseases. We are already 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 targeting those lifestyle and environmental factors that increase the risk of developing cardiovascular disease in the general population. To put it simply, this is what we call a “healthy lifestyle.”

This strategy lies largely outside the health sector. However, this 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 non-communicable diseases.

The cost of implementation is very low. There is no need to extensively strengthen the health system, since this strategy is largely outside the health system. It is now well proven that well-planned prevention programs can have a significant impact on lifestyle and the prevalence of risk factors. Changing lifestyles and reducing risk factor levels does lead to a reduction in cardiovascular and other chronic non-communicable diseases.

A systematic analysis was conducted that examined 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).

The column on the left is a decrease in mortality in patients. On the right is a decrease in mortality in the population. Quitting smoking gives 35 - 50%. Increasing physical activity by 25 - 30% reduces mortality. Reasonable alcohol consumption also reduces mortality. Changes in diet. With the help of lifestyle, you can achieve results no worse than with the help of medications.

I always talk about the population strategy and emphasize that this strategy mainly lies outside the health care system, however, the role of doctors is quite high. Doctors should be initiators, so to speak, catalysts, analyzers, informants of processes that contribute to the prevention of cardiovascular diseases.

Doctors must initiate these processes. They must excite society and our political decision makers, analyze and inform both the population and the government about what is happening. It is not entirely correct when they say that this strategy lies outside the scope of healthcare; doctors have nothing to do there.

Doctors play a very important role in this strategy. Although its implementation really lies mainly 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 we must be very clear that there is a hidden period between the influence on factors and the result. If everyone stops smoking tomorrow, this does not mean that in 2-3 months the mortality rate from coronary heart disease or lung cancer will decrease. It will take some time for the risk to disappear.

The contribution of risk factors has been well studied. Contribution of seven leading risk factors to lost years of healthy life for Russia. Risk factors known to us: hypertension, alcohol, smoking, hypercholesterolemia, excess weight, diet and physical inactivity.

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

The SCORE table, which I already mentioned, which determines the risk of death. But we must take into account 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. No need to use any table. These are high and very high risk individuals.

If not, then you can use this table. Of course, it is quite simplified. However, it is now widely used for such mass screening. There are few indicators there. 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 special feature for Russia is that, against the backdrop 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.

Among 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 or no social support;

Type A behavior;

General distress and chronic negative emotions.

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

If we talk about psychopharmacotherapy, then three groups can be distinguished. These are herbal remedies. These are tranquilizers that mainly affect anxiety. Antidepressants that affect both depression and anxiety.

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

Despite the fact that this is an over-the-counter drug, of course, I advise you to consult with your doctor before buying it at the pharmacy to see how suitable it is in this situation.

There was a fairly large study that showed that it actually had an anxiolytic effect, that is, an effect on anxiety, 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 quick results. This is secondary prevention - early detection and prevention of disease progression.

A systematic analysis that shows what can be achieved through comprehensive treatment for patients with coronary heart disease or other vascular diseases. Acetylsalicylic acid - up to 30%. Beta blockers - up to 35%. ACE inhibitors - 25%, statins - 42%. Quitting smoking is quite effective - 35%, no worse than all medications and you don’t have to spend much money.

Goals of treatment for patients with coronary artery disease. Why did I choose IBS? This is one of the main forms of cardiovascular disease. Drugs that are used to improve prognosis and prevent complications. These are antiplatelet agents Aspirin, Clopidogrel. New antiplatelet agents are now appearing. But for now, these two drugs occupy a leading position. Lipid-lowering therapy, here statins have killed all other drugs. Although this is probably not entirely correct. These are beta blockers (especially after myocardial infarction). ACE inhibitors. Perindopril and 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. These drugs not only lower triglycerol levels, which we previously knew, but also appear to have an antiarrhythmic effect. Due to this, it is possible to achieve good results in secondary prevention.

Ivabradine (Coraxan) is a drug that affects heart rhythm. Naturally, myocardial revascularization.

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

Nitrates;

Beta blockers;

Calcium antagonists;

Metabolic drugs;

Ivabradine (Coraxan).

I would like to say a few words about metabolic drugs. 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 debate. There is a lot of discussion about them, how effective they are.

Our two most popular drugs are Preductal and Mildronate. Why are these discussions going on? Firstly, these drugs are usually used in combination with other antianginal drugs. It is often difficult to isolate how much of this effect is due to metabolic drugs. Then their effect is still not as strong as that of other antianginal drugs. Much research is 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 large study on mildronates was recently completed. International research. Large number of patients. Its objective 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 exercise tolerance in patients with stable angina on the background of standard therapy for 12 months.

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

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

(Slide show).

The results were as follows. Orange bars - due to risk factors. Green - due to treatment. I was more struck by the relatively high contribution of treatment to the reduction in mortality. 46%, 47%, 38%, 35%. We often hear that treatment does not have a very good effect on health. But these tests show that prevention is ahead. You can’t do without it, but the treatment is also quite effective. There is no need to oppose them, but to use them together.

Another clearer analysis is in England and Wales. Again we see a 58% reduction in mortality from coronary disease due to reduction in risk factor levels, and 42% due to the treatment of patients with coronary heart disease. These two types of intervention need to be combined, rather than pitted against each other.

Regardless of advances in medical high technologies, the main reduction in mortality and disability from non-communicable diseases will be achieved 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 opinions of individual, even prominent, scientists and public figures. This, unfortunately, often happens with us.

In clinical medicine there is a "prophylactic dose". In preventive medicine there is also such a “preventive dose”. For prevention to be effective, the “preventive dose” must be optimal, which means: the right action, aimed 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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Disease Prevention (Diseases Prevention) is a system of medical and non-medical measures aimed at preventing, reducing the risk of developing health conditions and diseases, preventing or slowing their progression, and reducing their adverse consequences.

Providing primary health care, specialized medical care within the framework of the guaranteed volume of medical care to the population, including preventive, diagnostic and therapeutic services.

• 1. Improving the work of the institution for providing primary health care to the population, improving the material and technical base.
• 2. Improving the quality of medical care, increasing the qualification level of doctors and nurses.
• 3. Increasing the health index of children and women of fertile age, high-quality implementation and 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 adults and infant mortality; prevention of child and maternal mortality.
• 6. Reducing the level of initial disability.
• 7. Promotion of a healthy lifestyle as the implementation of one of the strategic ones.

Medical prevention is a system of preventive measures implemented through the healthcare 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, as a rule, is not limited to medical interventions - these are local prevention programs or mass campaigns aimed at promoting health and preventing disease.

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

Primary prevention includes:

• 1. Measures to reduce the influence of harmful factors on the human body (improving the quality of atmospheric air, drinking water, the structure and quality of nutrition, working conditions, living and recreation, the level of psychosocial stress and others affecting the quality of life), carrying out environmental and sanitary-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 and the possibilities for 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) encouraging the population to have a physically active lifestyle, physical education, tourism and sports, increasing the availability of these types of health improvement.

3. Measures to prevent the development of somatic and mental diseases and injuries, including those caused by work, accidents, disability and mortality from unnatural causes, road traffic injuries, etc.

Identification during preventive medical examinations of factors harmful to health, including those of a behavioral nature, in order to take measures to eliminate them in order to reduce the level of action of risk factors. Article 46. Medical examinations and medical examinations provide for: .

• 1) A medical examination is a set 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 carried out for the purpose of early (timely) identification of pathological conditions, diseases and risk factors for their development, non-medical use of narcotic drugs and psychotropic substances, as well as for the purpose of forming health status groups and developing recommendations for patients;
• 2. A preliminary medical examination carried out upon entry to work or study, in order to determine the compliance of the employee’s health status with the work assigned to him, and the student’s compliance with training requirements;
• 3. Periodic medical examination, carried out at established intervals, for the purpose of dynamic monitoring of the health status of workers, students, timely detection of 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 status workers, students, in order to form risk groups for the development of occupational diseases, identify medical contraindications to certain types of work, and 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 interfere with the performance of work duties, including alcohol, narcotic or other toxic intoxication and 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 provided for by the legislation of the Russian Federation, in-depth medical examinations may be carried out in relation to certain categories of citizens, which are periodic medical examinations with an expanded list of medical specialists and examination methods participating in them.
• 4) Carrying out immunoprophylaxis of various population groups.
• 5) Improvement of health of individuals and groups of the population under the influence of unfavorable health factors using medical and non-medical measures
• 6) Medical examination of the population in order to identify the risks of developing chronic somatic diseases and the improvement of the health of individuals and populations under the influence of adverse factors using medical and non-medical measures.

Article 46. Medical examinations, clinical examination.

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

Secondary prevention (sеsondaryprevention) is a set of medical, social, sanitary-hygienic, psychological and other measures aimed at early detection and prevention of exacerbations, complications and chronicity of diseases, limitations in life activity, causing disadaptation of patients in society, decreased ability to work, including disability and premature mortality.

Secondary prevention includes:

• 1. Targeted sanitary and hygienic education, including individual and group counseling, training patients and their families in knowledge and skills related to a specific disease or group of diseases.
• 2. Conducting dispensary medical examinations in order to assess the dynamics of health status, the development of diseases in order to determine and carry out appropriate health-improving and therapeutic measures.
• 3. Conducting courses of preventive treatment and targeted health improvement, including therapeutic nutrition, physical therapy, medical massage and other therapeutic and preventive methods of recovery, sanatorium and resort treatment.
• 4. Carrying out medical and psychological adaptation to changes in the health situation, developing the correct perception and attitude towards 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, preserving residual working capacity and the ability to adapt in the social environment, creating conditions for optimal support of the life of sick and disabled people (for example: production of medical nutrition, sales architectural and planning solutions and creation of appropriate conditions for persons with disabilities, etc.).

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

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

• 1. Educating patients and their families in knowledge and skills related to a specific disease or group of diseases.
• 2. Carrying out clinical examination of patients with chronic diseases and people with disabilities, including clinical medical examinations in order to assess the dynamics of health status and the course of diseases, carrying out permanent monitoring of them and carrying out adequate treatment and rehabilitation measures.
• 3. Carrying out medical and psychological adaptation to changes in the health situation, developing the correct perception and attitude towards 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 ability to work and the ability to adapt to the social environment; creating conditions for optimal support of the life of sick and disabled people (for example, production of medical nutrition, implementation of architectural and planning solutions, 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 unfavorable 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 lifestyle and environmental factors associated with diseases, as well as their social and economic determinants. The main areas of activity are monitoring of chronic diseases and their risk factors, policy, legislation and regulation, intersectoral cooperation and partnership, public education, involvement of the media, formation of a healthy lifestyle. The implementation of this strategy is primarily the task of the government and legislative bodies at the federal, regional and municipal levels. The role of doctors comes down mainly to initiating these actions and analyzing the processes taking place.

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

One of the leading directions in creating a healthy lifestyle is the fight against smoking. Smokers are sick more often and for a longer period of time, among them the level of temporary and permanent disability is significantly higher, and they use inpatient and outpatient treatment more intensively. It is necessary to pay great attention to such problems as alcohol and drug use. Therefore, measures to promote mental and sexual health are important components of creating a healthy lifestyle. A pressing 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 proper balanced nutrition. The basic principles of rational nutrition must be observed:

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

balanced diet according to the main components (proteins, fats, carbohydrates, microelements, vitamins);

mode and conditions of food intake.

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

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 widespread - primary medical care to the population.

The success of a population strategy aimed at reducing smoking, excess alcohol consumption and road traffic accidents can be achieved through 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, living in extreme conditions, etc.)

The high-risk strategy involves primary health care providers identifying individuals at high risk of disease, assessing the degree of risk and adjusting this risk through recommendations for improving lifestyle or the use of medications and non-drug treatments.

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

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

For quotation: Amberson D., Whincup P., Morris R., Walker M., Ebraim S. The role of population and high-risk strategies in the primary prevention of cardiovascular diseases // Breast Cancer. 2008. No. 20. S. 1320

Introduction

Introduction

There are two main strategies for the primary prevention of cardiovascular diseases (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 influencing risk factors throughout the entire population. populations. For physicians dealing with specific patient cases in their practice, a high-risk strategy is more natural. But more often, CVDs occur not in a small cohort of maximum risk, but among a much larger group of people with a not so high risk, and here a population-based strategy becomes relevant. Since both approaches were formulated, their potential relevance has evolved. Thus, a high-risk strategy allows, on the one hand, to assess the absolute risk of CVD (and not a single 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 likelihood of CVD in a cohort of high-risk patients. However, it is now obvious that the effectiveness of the population strategy was previously underestimated. This is because regression dilution bias (underestimation of the significance of risk factors that occurs when baseline values ​​are used in the analysis) was not taken into account, resulting in even small reductions in key CVD risk factors (such as blood cholesterol and 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 is more often chosen than a population-based strategy for the purposes of primary prevention of CVD. For example, in the UK, there is a strong emphasis on identifying individuals with a predicted 10-year CVD risk of 30% or more (based on the CVD risk formula used in the Framingham Study). In contrast, very little attention has been paid to reducing blood cholesterol and blood pressure levels in the population as a whole. However, few investigators have yet attempted to evaluate the potential value of different high-risk and population-based strategies, considering both the benefits of CVD preventive treatment and the underestimation of the population-based strategy associated with regression bias due to dilution. Below we analyze and compare the potential effectiveness of a high-risk strategy (aimed both at controlling individual risk factors, in particular, blood cholesterol levels and blood pressure, and at identifying individuals with a high total risk of CVD) and a population strategy (the goal of which is to control blood pressure and blood cholesterol levels) in a representative sample of middle-aged British people. Because the emphasis is on primary prevention, patients with documented CVD who were almost certainly receiving pharmacotherapy and were particularly at risk for subsequent CVD events were excluded from the study.

To examine the impact of population-based and high-risk strategies on the incidence of a first major cardiovascular event (fatal or non-fatal myocardial infarction (MI) or stroke) in middle-aged men without previous CVD and its symptoms, we collected data from a prospective observational study CVD (British Regional Heart Study) and meta-analysed results of randomized clinical trials regarding relative CVD risk reduction.

CVD prevention strategies

Reviewed Several high-risk prevention strategies: (1) identification of individual risk factors and control of them: (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 threshold value of the 10-year risk according to the Framingham study (according to the recommendations in the UK it is ≥30%, and in Europe - ≥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. An ancillary analysis assessed the potential effectiveness of a prophylaxis regimen that used a combination of ASA, a β-blocker or diuretic, an ACE inhibitor, and a statin based on age. And although more and more scientists are inclined to believe that calculations using the Framingham study formulas overestimate the real risk indicators among Europeans, these original formulas were used in this study so that the results were understandable from the standpoint of modern guidelines (correction of inflated indicators will lead to a decrease in the group size high risk, which 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 research results, it was concluded that lowering blood cholesterol levels during statin therapy reduces the risk of myocardial infarction by 31% and stroke by 24%. Reducing 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 Framingham risk score, 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 that the ratio between the incidence of first myocardial infarction and stroke in middle age is 4:1 (in the first 10 years of our study), then by calculating the weighted average between the reduction values ​​of two different relative risk indicators (i.e. 4/ 5 reduction in the relative risk of MI plus 1/5 reduction in the relative risk of stroke) can be calculated by how much the relative risk indicators for combined CVD outcomes are reduced. The effectiveness of treatment is enhanced, and ultimately the combined relative risk reduction with 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 CVDs in the case of a high-risk strategy is comparable to that in the case of three different population-based approaches: (a) a decrease in the average cholesterol level in the population as a whole; (b) a decrease in average blood pressure in the population as a whole; (c) a combined decrease in mean cholesterol levels and mean blood pressure in the population as a whole.

British regional
heart examination

British Regional Heart Study ( BRHS) was a prospective study of CVD conducted at GP level in 24 British cities from 1978 to 1980. The study included patients aged 40-59 years. Indicators of overall mortality and structural morbidity for CVD were monitored; Less than 1% of participants dropped out of the trial. The initial findings of the physical examination and biochemical tests are presented in detail previously. In two cities (with high and low CVD mortality rates), patients were re-examined after 16 and 20 years of follow-up, with blood pressure measured and blood lipid levels assessed. This allowed us to assess the impact of within-person bias (regression bias due to dilution) on the results of this study.

Baseline assessment of CVD history

During the initial examination, subjects were asked for a history of MI, stroke, or angina, or severe chest pain lasting at least 30 minutes that would prompt medical attention. 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. Persons with a history of myocardial infarction, angina or stroke, severe chest pain, overt or hidden symptoms of angina based on the results of answers to the Rose questionnaire were excluded from the study.

Analysis of CVD cases

To collect information on time and cause of death, a standard tagging procedure was used from the Southport (England and Wales) and Edinburgh (Scotland) NHS registries. Fatal coronary events were defined as death due to coronary heart disease (primary 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 non-fatal heart attacks and strokes were obtained from information provided by the treating physicians and supplemented by the results of systematic examinations every 2 years until the end of the trial. Non-fatal heart attack was diagnosed based on WHO criteria. Non-fatal strokes included all cerebrovascular events accompanied by the development of neurological deficits that persisted for more than 24 hours. For the present work, the group of major CVDs included deaths due to coronary heart disease or stroke, as well as MI and nonfatal strokes.

Statistical methods
processing the results

The correlation of baseline risk exposure and 10-year risk of major CVDs was examined using logistic regression; During the analysis, adjustments were made for age, blood cholesterol level, blood pressure, smoking status (current, past, never), body mass index, level of physical activity (absence, occasional, slight, moderate), presence/absence of sugar diabetes and place of residence (Southern Counties, Midlands and Wales, Northern Counties, Scotland). The associative influence of blood cholesterol levels (total cholesterol and cholesterol/HDL ratio), as well as systolic blood pressure (BP) syst.) and diastolic (BP diast.) BP for predicting the risk of major CVDs was assessed in a fully adjusted model using the likelihood ratio χ 2 (HDL content was not taken into account, since it was measured only in 18 out of 24 cities). The assumption was made that cholesterol levels and blood pressure were measured with error, and over time these indicators underwent intrapersonal variations. The effects of these biases were analyzed over 4 years (using 16- and 20-year follow-up data) to describe the true correlations in the first 10 years of observation compared with the empirical “baseline” correlations (to calculate the usual expected level of exposure and the true values ​​of the regression coefficients calibrated it).

Taking into account the greatest information value of blood cholesterol levels and blood pressure for predicting CVD risk (and after adjusting the regression coefficients for its bias due to dilution), the potential information value of each of the high-risk prevention strategies was predicted using logistic regression (the results of measurements of blood cholesterol levels and blood pressure values ​​were recalibrated). If a sample was predicted based on data obtained from the same individuals, there could be errors (and sometimes quite significant ones) in the calculations of risk differences. Therefore, the risk was predicted using the so-called. the “jackknife” method, which eliminated these errors. The mean of the predicted risk scores was the expected absolute 10-year CVD risk in the population before the introduction of the prevention strategy (which exactly corresponds to the empirical CVD risk). In cases where the empirical level of risk exposure was high enough to make a positive decision about starting preventive treatment (i.e. in a high-risk group), the predicted risk indicators were recalculated taking into account the effects of therapy. The average of the predicted risk after implementation of the prevention strategy was then calculated, which allowed us to obtain the expected reduction in the risk of major CVDs due to the implementation of the high-risk prevention strategy. With regard to population-based strategies, the expected reduction in the incidence of major CVDs over 10 years was analyzed by comparing the predicted CVD risk indicators in the studied sample with similar indicators of subjects in the same sample after an absolute decrease in blood cholesterol and blood pressure. When these strategies were applied, the reduction in the incidence of major CVDs corresponded to the predicted reduction that would occur if blood cholesterol and blood pressure remained low in this sample throughout their lives.

Results

Of the 7,735 men identified during baseline screening, 1,186 (15.3%) had baseline evidence of CVD, and an additional 210 were initially taking antihypertensive or lipid-lowering medications. For 5997 patients (of the remaining patients), a complete set of risk factor data was available. Baseline characteristics of these subjects are presented in Table 1. Of the 165 subjects without baseline CVD symptoms who were not taking any antihypertensive or lipid-lowering drugs at the 16- or 20-year follow-up, repeated measurements of cholesterol and blood pressure were available for 4 years (between 16 and 20 years). The dilution regression bias coefficient for total cholesterol was 0.79; for the logarithm of the cholesterol/HDL ratio - 0.88; for blood pressure syst.- 0.75; for blood pressure diast. - 0,65.

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

Strategy effectiveness
high risk prevention

Table 2 presents the estimated effectiveness of each high-risk prophylaxis regimen based on specific treatment thresholds, and Figure 1 shows the relationship between these thresholds, treatment effectiveness, and the proportion of people in the population treated according to the selected scheme. As the threshold is lowered (i.e. the proportion of individuals treated increases), the expected reduction in the incidence of CVD in the population becomes more pronounced. For a single treatment, the effectiveness of detection based on overall disease risk (as calculated by the Framingham risk equation) is higher than that of detection based on a single risk factor, and this difference becomes more pronounced as the threshold decreases. From a prevention standpoint, combination therapy brings much greater benefits compared to prescribing only antihypertensive or lipid-lowering drugs. However, even when taking multiple medications, the reduction in the incidence of the first episode of major CVD, expected with the implementation of a prevention strategy at a threshold value of ≥30% (calculated using the Framingham study 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 on Coronary Prevention), then the reduction in the incidence of the first episode of major CVD will be 34%, and if reduced to ≥15% - 49% . Thus, at these thresholds, one quarter and one half of the population without CVD symptoms, respectively, would need to receive combination preventive treatment.

Selection of therapy based only on age

Of the 450 patients who experienced a first episode of CVD during 10 years of follow-up, 296 (65.8%) were over 55 years of age at the time of the event. If, from the age of 55, subjects begin to take 4 drugs for prophylactic purposes, it will be possible to prevent 201 first episodes of CVD (296x 0.68). Therefore, approximately 45% of all first episodes of major CVD over 10 years (201/450) could be prevented by implementing this particular high-risk prevention strategy (assuming 100% prescribing rates and maximum adherence as in clinical trials). If preventive therapy is carried out from the age of 50, the proportion of such persons will increase to 60% (399x 0.68/450).

Population efficiency
prevention strategies

Figure 2 and Table 2 show the predicted effectiveness of each population approach. A decrease in total serum cholesterol and systolic blood pressure by 5% (by 0.3 mmol/l and 7 mm Hg, respectively) over a long period of time causes a decrease in the incidence of the first episode of major CVD over 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 due to dilution has no effect on the expected performance of high-risk strategies, whereas its impact on the performance of population-based approaches is significant. The adjusted figures presented in Table 2 and Figure 2 were 20-30% higher than the unadjusted ones.

Discussion

When analyzing the potential effectiveness of different strategies for primary prevention of high-risk CVD and population-based strategies, it is necessary to take into account the inaccuracies arising in the measurement of blood cholesterol and blood pressure, as well as within-person bias (regression bias due to dilution). Our findings suggest that significant changes in CVD incidence occur only with widespread adoption of high-risk primary prevention strategies involving combination therapy (less than 3% of the expected risk per year according to UK guidelines and less than 2% of the expected risk per year in the UK). 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) on a population-wide basis could lead to a significant reduction in the incidence of major CVDs.

Assumptions

The validity of assumptions regarding high-risk strategies is determined by the hypothetical effectiveness of 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 of this class. The study used these calculations more often than those made in a cohort analysis because a cohort analysis allows us to estimate the impact of differences in risk scores that arise from long-term changes in risk exposure, whereas clinical trials can reveal the extent to which Such epidemiological correlations are reversible with therapy. In addition, during clinical trials, non-compliance with the treatment plan is also taken into account when making calculations, 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 may 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). Typically, the effectiveness of therapy is studied in a group of high-risk individuals (including patients with a history of CVD), and therefore extrapolation of these data to subjects without previous CVD also leads to an overestimation of the effectiveness of the high-risk strategy. This is true, in particular, for ACE inhibitors, information about the effectiveness of which is based primarily on the results of studies conducted in patients with a verified diagnosis of CVD. When prescribing statins and ASA, this assumption seems more justified, because relative risk indicators decrease quite steadily in a wide range of patient groups. Further, if we assume that treatment has a multifactorial effect, then there is a possibility of overestimating the combined effects of taking all four drugs (for example, ACE inhibitors may be less effective in combination with ASA). By using different combinations of drugs (including multiple drugs at low dosages), one might expect a greater reduction in CVD risk than the data reported in this article, but even if this were true, it is unlikely that this assumption would have a significant impact on results from our study (e.g., if the true relative risk reduction was 85% with the combination pill, then treating patients with ≥30% risk using the Framingham study formula would reduce the incidence of major CVD by 14% compared with the 11% reported in table 2).

The effectiveness of population-based prevention strategies depends primarily on the severity of changes on the scale of the entire population, which can actually be achieved in practice. Reductions in mean total cholesterol and blood pressure ranging from 5 to 15% throughout the population (Table 2) are very small; the values ​​of these indicators can decrease by a similar amount if you follow a certain diet. In terms of total cholesterol levels, a study on the island of Mauritius found that after switching to soybean (rather than palm) oil consumption and introducing programs aimed at promoting a healthy lifestyle, the level of total cholesterol in the population as a whole 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 consumed saturated fats are replaced with other fats, and the amount of dietary cholesterol is reduced by 60%, then the same reduction in indicator values ​​can be achieved. Restricting salt intake is associated with a population-wide reduction in blood pressure of approximately 10%, although this approach appears to be less effective in clinical practice. And although when compared with the difference in cholesterol content 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-based 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 systolic blood pressure among Glasgow students decreased by 9 mm Hg. , and regardless of antihypertensive therapy, the same data were obtained from clinical examination results in England. Finally, the implementation of prevention regimens aimed at reducing cholesterol and blood pressure in the population has an additional positive effect on other cardiovascular risk factors, such as body mass index and level of physical activity.

In the present study, we were talking primarily about cholesterol levels, blood pressure levels and appropriate methods of pharmacological correction of these indicators, and questions regarding the effect of smoking on the risk of CVD were not addressed. If we take this aspect into account, the effectiveness of both high-risk 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 is attributed to smoking cessation by approximately one third). But even taking into account smoking, the ratio of the potential effectiveness of both prevention strategies remains unchanged.

Impact of Regression Bias
due to dilution

Analyzes adjusted for regression dilution bias (underestimation of the correlation between levels of conventional risk factors and disease risk due to within-person variation). In the case of a high-risk strategy, this phenomenon did not affect the effectiveness of the approach (since data on the effectiveness of treatment were taken from the results of clinical trials), but when implementing a population-based strategy, such an 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 turns out to be 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 adjust 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 predicted by the Framingham Study formula generally provides a more accurate estimate on which to base treatment decisions than calculations made using a single risk factor, such as total cholesterol or blood pressure (although these differences are detected only when therapy is carried out in a sufficiently large sample; Table 2). The above 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 used in combination to reduce the risk of CVD, the impact of high-risk primary pharmacological prevention strategies will still be limited until these strategies are implemented much more actively than they are now (according to, for example, guidelines adopted in the UK ). To obtain benefits comparable to those achieved by reducing cholesterol and blood pressure by 10% in the entire population, more than a third of middle-aged men without clinical symptoms of CVD would need to be treated with all 4 drugs. The same thing is discussed in the revised report of the Third Joint Committee on Prevention of CVD, according to the provisions of which key attention should be paid to patients with a 10-year risk of developing CVD with a fatal outcome of at least 5% (based on the results of the SCORE project); At this value of this criterion, 36% of participants in the BHRS study initially fall into the high-risk group. However, providing treatment to 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 focus not just on eliminating the influence of risk factors, but on identifying the determinants of their distribution. Population-based approaches are better able to halt the progression of atherosclerosis, while high-risk strategies provide prolongation of treatment in middle-aged patients requiring pharmacotherapy.

The data presented indicate a tangible hypothetical benefit of population-based high-risk prevention strategies. Compared to international standards, average total cholesterol and blood pressure levels among UK residents remain high and have fallen only slightly over the past decade. Current national health policy for CVD prevention in the UK takes only minimal consideration of the need to reduce total cholesterol and blood pressure levels throughout the population and does not emphasize government action as a key tool for influencing these changes (which could be expressed, for example, in the adoption of a law limiting the content of salt and fat in grocery products). It appears that if we prioritize population-based approaches to lowering cholesterol and blood pressure, we will be able to maintain the remarkable gains that have been made in CVD prevention over the past two decades, especially given the sharply increased incidence of obesity and diabetes. as well as a sedentary lifestyle.

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

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The chief freelance specialist of the Russian Ministry of Health for medical prevention, director of the State Research Center for Preventive Medicine, Sergei Boytsov, told AiF.ru about how important clinical examination is, which is often criticized, and why it is not carried out in good faith everywhere.

— Sergey Anatolyevich, everyone knows what prevention is, but how effectively does it work?

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

Preventive measures at the primary care level have long proven their effectiveness. Thanks to active preventive measures carried out at the doctor's office, within 10 years it is possible to achieve a significant reduction in morbidity and mortality from coronary heart disease. This is confirmed by the experience of our doctors: in the 80s. In the clinics 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 these some unique techniques? What were they?

— In general, there are three strategies 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 care 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 quits smoking should be able to get into a smoke-free environment. To this end, the Russian Ministry of Health initiated the development of regional and municipal programs aimed at improving the system for preventing non-communicable diseases and creating a healthy lifestyle for the population of the constituent entities of the Russian Federation, including the construction of sports facilities and 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 medical examination in primary care.

By the way, the modern method of medical examination differs significantly from the one that was previously practiced in our country. Back then, doctors tried to find all diseases without targets, but we are looking primarily 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. Nowadays, clinical examination is based on the screening method: according to the recommendations 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 local physician must register each hypertensive patient based on the results of the clinical examination.

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

— Yes, now a number of media outlets are criticizing the medical examination, and indeed, in some cases it is not carried out conscientiously enough. This leads to a dispersion of indicators - mortality statistics and statistics on the detection of malignant neoplasms sometimes differ significantly. Even within the same district, you can see different levels of quality of medical examinations. However, most doctors support the idea of ​​preventive examinations - this is a truly 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 for a public rating of Russian clinics, where it is possible to evaluate each medical institution according to a number of objective indicators.

At the local level, it is necessary for doctors to have a better understanding of the procedure for conducting medical examinations. In addition, it is necessary to strengthen special structures - departments and medical prevention rooms. For their work, it is enough to connect two doctors or a paramedic and a doctor. These organizations must take responsibility for completing all necessary documentation. The responsibilities of the local therapist should only include summing up the first stage - making a diagnosis and determining 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 in getting rid of addictions such as smoking, and get advice on healthy eating.
— How to motivate the population to get vaccinated in a timely manner?

— Population work should be carried out here 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.

The main promoters of the idea of ​​vaccination, of course, should be primary care doctors. It is important to understand that vaccination is not just a way to avoid disease. For example, the flu vaccine reduces the risk of developing cardiovascular disease. Vaccination against pneumococcal infection significantly reduces mortality in older people.
— Everything you listed can and is done by doctors. What can a person do for prevention purposes?

— 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 with the subsequent development of myocardial infarction or stroke. Therefore, quitting smoking, controlling blood pressure, a balanced diet, a sufficient level of physical activity, limiting alcohol consumption, and 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 connective tissue diseases.

— Oncological diseases are also one of the most pressing topics in modern medicine. Is there a way to protect yourself from cancer? What prevention methods are effective? And at what age should you think about this question?

— The most effective way to protect yourself is to prevent the occurrence of the disease and diagnose it in the early stages. Now early active detection of cancer at stages 1-2 during clinical examination can reach 70% of all cases, whereas in normal practice it is slightly more than 50%. In cases of reproductive cancers in women alone, this saved 15 thousand lives. It is important to undergo regular examinations; for women, mammography and cytological examination of a cervical smear are required; for men, timely diagnosis of the condition of the prostate gland; and for everyone, a stool test for occult blood.
— What mistakes do people most often make when trying to protect themselves from diseases?

— Errors are mainly observed in methods of weight loss and hardening.

I am an opponent of mass “winter swimming”, because I believe that swimming in icy water more often leads to complications than to health improvement. The build-up of hardening should be gradual; these procedures may involve taking a cold shower.

As for diets, it is important not to provoke anorexia. The method of controlling body weight should become the norm of life. No matter what methods of losing weight you come up with, it all comes down to reducing the number of calories and, accordingly, the amount of food. There should be no clear division in the diet - you cannot eat only proteins or only carbohydrates. Any mono-diets are extremely unbalanced and lead to health problems.

— How can you comment on the population’s passion for dietary supplements?

— Dietary supplements enrich the diet, supplying the body with essential microelements. However, their manufacturers do not always maintain 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 legislative level. 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, which is widely discussed in the media?

— I would like to clarify that assessing demographic processes over six months or a year is incorrect. Statistics may be related to previous demographic processes that took place several decades ago.

Our number of elderly people is growing, and this affects the indicators. Another factor that could affect the indicators is mortality, “postponed” by medical interventions. These are patients with severe forms of cancer whose lives have been extended.

It is important to remember that medicine accounts for only a small portion 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. Life expectancy and quality of life of older people are increasing, and geriatric care is developing. Methods of treatment and health preservation are being improved.

As for prevention, the number of people covered by preventive examinations is generally growing. Nowadays, more than half of the country’s population—more than 92.4 million people—has already taken part in the 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 are receiving high-tech medical care - last year more than in 2013, by 42%.

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