Guidelines on preventing cardiovascular disease in clinical practice

Absolute risk rules—but raises the question of population screening

Papers pp 671, 676, 677General practice pp 680, 686, 690Education and debate pp 702, 705, 709

Ten years ago clinical recommendations on preventing cardiovascular disease focused primarily on managing individual risk factors, particularly raised blood pressure and cholesterol concentrations. Typically, separate guidelines were developed for each risk factor and treatment was recommended when that factor was above a specified level1 The recommendations were informed mainly by evidence from cohort studies showing increased relative risks of cardiovascular disease in people with raised levels of the risk factor2 and by evidence from randomised controlled trials showing relative benefits from lowering the factor.3 4

Over the past decade we have witnessed a remarkable change from these recommendations based on relative risk to ones based on absolute risk—that is, incidence. If Geoffrey Rose, arguably the most influential cardiovascular disease epidemiologist ever, was living today, he would support this revolution, which echoes his 1991 advice that “All policy decisions should be based on absolute measures of risk; relative risk is strictly for researchers only.”5 This week's BMJ brings together a range of papers relevant to this paradigm shift in cardiovascular risk management.

One of the most recent examples of guidelines based on absolute risk is the Joint British Recommendations on the Prevention of Coronary Heart Disease in Clinical Practice, published late last year6 and summarised in this issue (p 705).7 Taking the lead from the European societies of cardiology, atherosclerosis, and hypertension, which jointly published coronary heart disease prevention guidelines in 1998, 8 the British Cardiac Society, British Hyperlipidaemia Association, and British Hypertension Society joined forces to develop the current British recommendations. These new clinical guidelines recommend that priority for treatment should be given to patients at high absolute risk …