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Role of screening in primary prevention


The Symposium on the role of screening in primary prevention gathered quite a large audience. This is no surprise, because this is a hot issue and an integral bridge to population based interventions and investments introduced by the governmental bodies in low- and high-risk European countries. In England, the NHS has introduced screening of the general population.
In the U.S., facts and expectations regarding the intensity of breast cancer screening have evoked some controversies and vivid discussions. Prof. T. Joergensen reported that cancer screening done by professionals with primarily surgical treatment of new cases and short time span really works. Some initial trials showed a 30% reduction in mortality. However, in CVD, risk factor screening projects -even when done by professionals- encounter problems because of the lifestyle changes and medical treatment that are required for final success.
Prof. Joergensen stated that health screening and lifestyle counseling does not reduce cardiovacular disease or total mortality in the general population. Most probably this is because we do not reach those who are in greatest need, i.e. lower social classes, and because people do not maintain a lifestyle different from society. Thus, we should concentrate on structural changes in society which have been shown to work (Jørgensen T, Eur J Prev Cardiol 2012, Mozaffarian D, Circulation 2012). Even though the global effects of screening in primary prevention are not very rewarding, the symposium participants could learn much on the progress and the latest evidence on screening and early intervention.
Dr. MT. Cooney (London, GB) delivered a comprehensive review of population screening strategies in CVD prevention.
Dr. U. Nixdorff (Duesseldorf, DE) presented in a very elegant way the ESC and EACPR guidelines on implementation of imaging methods in screening for cardiovascular risk beyond SCORE. He presented 2012 recommendations on early detection of CVD by magnetic resonance imaging in asymptomatic subjects, as well as coronary calcium score, carotid ultrasound, and ankle–brachial index.
Last but not least, the lecture delivered by Dr. M. O'Flaherty (Liverpool, GB) on cost effectiveness of cardiovascular screening and intervention was highly appreciated. CVD experts need strong arguments when talking to and convincing health politicians and decision-makers to invest money in screening and interventions in primary prevention. Health economics is about taking decisions on often competing alternatives. Essentially, CVD is a "screenable" disease. However we don't have much empirical evidence of programme effectiveness based on RCT evidence, like we do for prostate or lung cancer screening programmes.
Good quality primary prevention guidelines, agreeing on several points like use of multiple risk-factor based risk estimation, rescreening period and intervention recommendations. However, substantial disagreement exists in terms of target populations and outcomes used for risk estimation, which makes comparisons difficult. In fact, cost effectiveness was not always used to shape guidelines. This analysis is needed for each setting, as the “one size fits all” solution is too simplistic. In high-risk CVD countries, health checks would be more cost effective compared to countries with lower disease burden. However, the decision is not just "to screen or not to screen". The decision is a bit different, since population level interventions offer huge gains in terms of health and usually cost-saving, therefore their value for money is higher.





Role of screening in primary prevention

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.