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Third, resources can be allocated to acute and chronic higher cost treatments and secondary prevention interventions for those with clinically manifest disease. Typically, resources are allocated simultaneously to all three strategies; however, this three-pronged approach has been implemented mostly in EstME with abundant financial resources for health care. In the following sections are outlined the major challenges and possible solutions for each region.
First, socioeconomic and racial disparities in CVD rates continue to linger. In the United States, for example, whereas rates of CVD mortality have fallen across the population, there are still wide disparities across racial and ethnic boundaries. Thus, a major goal will be to accelerate the widespread application of preventive and therapeutic technologies to all racial, ethnic, and socioeconomic groups.
Second, the rate of declining CVD mortality appears to be stagnating. Over the past 5 years in United States, age-adjusted. These may be the result of troubling trends in a number of coronary risk factors--whereas older men and women continue to stop smoking, young adults and teenagers, particularly young women, are smoking at increasing rates; the rates of those appropriately treated for hypertension has decreased slightly in the past 5 years; obesity and diabetes rates are accelerating at rapid rates.
Perhaps most troubling are observations of increasing rates of obesity and physical activity in children. Taken together, these trends may explain the flattening of mortality curves and may also explain why mortality rates have fallen faster than CVD incidence rates.
In the absence of efforts to reverse these trends in risk factors, we may once again see increasing rates of CVD. More public health dollars need to be directed at antismoking efforts that target high-risk groups such as teenage girls and at broader application of guidelines for detecting and managing hypertension and hyperlipidemia. Effective strategies to increase activity and reverse trends in obesity and diabetes must be developed and implemented. Third, the prevalence of CVD will continue to increase with the increasing mean age of a population even if that population's age-adjusted mortality rates continue to decline.
In addition, incremental advances in therapeutic health technology and secondary prevention have led to increasing numbers of people surviving with CVD, which consumes increasing amounts of resources.
With the institution of many life-saving strategies among those who present with acute manifestations of atherosclerotic disease, more and more individuals are surviving acute events such as myocardial infarction. For example, approximately one third of those who presented to hospitals with acute myocardial infarction in the s died.
Today, mortality is less than half that, despite the fact that sicker and older patients are presenting to the hospital. Furthermore, CHD is being diagnosed in increasing numbers of individuals before cardiovascular events. Thousands of pacemakers and defibrillators are implanted each year. As more and more individuals survive longer with CVD, so does the prevalence of congestive heart failure.
Between and in the United States, hospitalizations for congestive heart failure increased from 1. More efficient and cost-effective strategies for treating CVD will have to be developed. This region is largely in the third phase of the epidemiological transition. However, the resources available are considerably less than those available in the EstME.
This mandates making careful choices in terms of allocating health care dollars to each of the strategies outlined earlier. In the EmgME, the two overarching goals are to manage the increasing number of people with CVD and to hasten the transition from the third to the fourth phase of the epidemiological transition.
This will likely enhance overall productivity in the region because during the third phase of the epidemiological transition CVD, and particularly CHD, often afflicts those at the age of highest productivity. In terms of challenges facing the former socialist countries, the region can be divided into two categories: those countries with stable or declining rates and those countries with increasing CVD rates.
For countries with stable or declining rates, the three-pronged approach used in the EstME should serve as a model. For those countries experiencing rapid rises in CVD rates, an important first step will be toward more centralized efforts at compiling data on rates of disease and risk factors and then determining the major contributors to the rise.
All countries in this economic sector need more careful tracking and assessment of risk factors in terms of population attributable risk. Better tracking of CVD rates risk factors will allow for more careful allocation of scarce preventive resources. Governments should initiate major public health initiatives aimed at life-style factors, including lowering rates of smoking and drinking, modifying diet, and increasing physical activity. Major public health priorities should include smoking cessation and the detection and control of hypertension, both of which are highly cost effective.
The targeting of higher-risk individuals for higher-cost preventive strategies such as pharmacological cholesterol lowering will initially need to be confined to areas such as urban centers, where the burden is high and the necessary laboratory-based health care infrastructure is available. Throughout this economic sector, improvements in health care delivery systems will be needed to manage the already high rates of CVD prevalent in these countries.
Careful attention must be paid to the transfer of lower-cost health technology, keeping in mind the considerably lower annual health care expenditures in the EmgME countries compared with those in the EstME.
Interventions such as the more widespread and appropriate use of aspirin and beta blockers during acute myocardial infarction is an example of an extremely cost-effective life-saving therapy that should be implemented universally before extensive resources are directed at higher-cost interventions such as angioplasty.
Manpower issues must also be addressed, given the general shortage of health care professionals in the EmgME. The problems facing the DevE may be the most challenging. These countries have rapidly increasing burdens of CVD early in their economic transitions. They often do not have the per capita resources needed to create the three-pronged type of public health and health care infrastructure currently available in the EstME.
In addition, there are a number of competing national priorities, including the stimulation of economic growth, social and political change, and the devastation wrought by communicable diseases.
Rising CVD rates will eventually exert a drag on economic growth. Early in the epidemiological transition, CVD deaths occur among younger individuals than they do later in the transition. Thus, the economic impact on both the family and national productivity is greater in developing economies than in established market economies. The loss of the head of a household from CVD or any other disease has a devastating impact on the health and well-being of the entire family.
In Bangladesh, for example, when there is an adult death, a child who depends on that adult has a fold higher probability of death. Much more work is needed to refine estimates that would permit more thoughtful allocation of health care resources. As mentioned earlier, the epidemiological transition has been accelerated at least in part by an efficient translation of risk factors and risk behaviors from the EstME to the DevE early in the economic transition. The rapid spread of cigarette smoking is a prime example of this.
A major challenge for developing countries is to attempt to change the natural history of the epidemiological transition. That such. Although imbedded cultural practice such as diet likely played a large role, the Japanese experience illustrates that the nature of the transition is variable. As is true for the EmgME, a critical first step in developing a comprehensive plan for many of the DevE is better assessment of cause-specific mortality and morbidity as well as the prevalence of the major preventable risk factors for CVD.
This will enable better allocation of resources based on country-wide burdens of disease. Beginning first in the urban centers and then moving out to rural areas, government agencies will need to make careful assessments of, and create longitudinal surveillance of, major CVD risk factors for which low-cost strategies are available.
High priorities include smoking and hypertension, for which the population attributable risks are likely to be high and the cost efficacy favorable. The strategy for the detection and management of high cholesterol must be carefully tailored for each region due to higher costs. Public health approaches aimed at educating the general population about diet and exercise may be useful, but precise estimates of cost efficacy are not available on these even for EstME countries.
Drug therapy for cholesterol lowering is likely less cost effective than short-term smoking cessation programs or managing hypertension with low-cost medications. Once these initial assessments have been made, guidelines for their management from a public health standpoint must be developed based on the population attributable risk and the available resources.
These guidelines must be implemented with low-cost campaigns. Such prevention-directed efforts could blunt the rise in disease rates already apparent in many developed countries. Given the extreme limitations in per capita health care resources in many DevE, the allocation of resources to higher-cost strategies for treating CVD may divert resources from the potentially more effective population-wide efforts.
In the World Health Report, Director General Gro Harlem Brundtland states that we are "halfway through a two century transition" in which CVD will dominate as the major cause of death and disease. From a worldwide perspective the rate of change in the global burden of CVD is accelerating, reflecting the change in the developing economies, which represent over 80 percent of the world's population, as they move rapidly through the second and third phases of the epidemiological transition.
The consequences of this epidemic will be substantial on many levels--individual mortality and morbidity, family suffering, and staggering economic costs, both the direct costs of diagnosis and treatment and the indirect costs of lost productivity. Each region of the world faces major challenges presented by the epidemic of CVD.
There is no single global solution to the rising burden of CVD given the vast differences in social, cultural, and economic circumstances. To hasten the transition from the third to the fourth phase of the epidemiological transition, the EmgME must find ways to efficiently care for increasing numbers of individuals with CVD as well as to deploy lower cost prevention strategies.
The most complex challenges are those facing the DevE. They must dedicate often minuscule resources to better assessment of rates of death, disease, and CVD risk factors. The allocation of resources to lower cost preventive strategies will likely be more cost effective than dedicating resources to high-cost management of CVD.
The EstME must continue to bear the burden of research and development into every aspect of prevention and treatment. Through further expansion of the knowledge base, particularly regarding the economic consequences of various treatment and prevention strategies, it is possible that the efficient transfer of low-cost preventive and therapeutic strategies may alter the natural course of the epidemiological transition in every part of the world and thus reduce the excess global burden of preventable CVD.
Omran AR: The epidemiologic transition: A theory of the epidemiology of population change. Milbank Mem Fund Q , New York: Oxford University Press, , pp Pearson TA: Global perspectives on cardiovascular disease. Evidence Based Cardiovasc Med , Can 7. Med Assoc J , National Center for Health Statistics: U. Department of Health and Human Services publication No. Centers for Disease Control and Prevention: Control of infectious diseases.
Food Supply, A Summary. Department of Agriculture, CDC Rockville, MD, U. Department of Health and Adults, 18 Years of Age and Older, Government Printing Office, , pp Centers for Disease Control and Prevention: Decline in deaths from heart disease and stroke--United States, Goldman L, Cook EF: The decline in ischemic heart disease mortality rates: An analysis of the comparative effects of medical interventions and changes in lifestyle.
Ann Intern Med , Hunink MG, Goldman L, Tosteson AN, et al: The recent decline in mortality from coronary heart disease, The effect of secular trends in risk factors and treatment. N Engl J Med , Health Aff Millwood , PHS Lopez AD: Assessing the burden of mortality from cardiovascular diseases. World Health Stat Q , Jpn Circ J , Reddy KS: Cardiovascular diseases in India. Bertrand E: Cardiovascular disease in developing countries.
Ecological analysis of the association between mortality and major risk factors of cardiovascular disease. Int J Epidemiol , Geneva, Switzerland, World Health Organization, Cigarette smoking among adults--United States, Pandey MR, Neupane RP, Gautam A: Epidemiological study of tobacco smoking behaviour among adults in a rural community of the hill region of Nepal with special reference to attitude and beliefs. Retrospective proportional mortality study of one million deaths.
BMJ , Seven Countries Study Research Group. NIH publication No. Bethesda, MD, National Institutes of Ethn Health , Wu X, Huang Z, Stamler J, et al: Changes in average blood pressure and incidence of high blood pressure to in four population cohorts in the People's Republic of China. The J Hypertens , Implications for coronary heart disease.
Council on Arteriosclerosis of the International Society and Federation of Circulation , Current state of and recent trends in serum lipid levels in the general Japanese population. J Atheroscler Thromb , J Am Coll Nutr , Atherosclerosis , Cent Afr J Med , Twenty-five-year follow-up of the seven countries study. Okayama A, Ueshima H, Marmot MG, et al: Different trends in serum cholesterol levels among rural and urban populations aged in Japan from to J Clin Epidemiol , J R Soc Med , Department of Health and Human Services, Diabetes Care , Diabetes Metab Rev , World Health Organization.
Monitoring trends and determinants in cardiovascular diseases. Ann Med , Hodge AM, Dowse GK, Gareeboo H, et al: Incidence, increasing prevalence, and predictors of change in obesity and fat distribution over 5 years in the rapidly developing population of Mauritius. S Afr Med J , Obesity: Preventing and Managing the Global Epidemic. Geneva, World Health Organization, Am Heart J , Changes in mortality from heart failure--United States, Chapter 2 - Economics and Cardiovascular Disease.
The United States leads the world in spending on health care, whether measured as a percentage of gross domestic product or as dollars per capita. The decisions made by physicians control the bulk of these expenditures, and society has increasingly called for greater stewardship of the tremendous resources that doctors command.
In this chapter some of the key economic principles that underlie clinical and health policy decision-making are discussed and important economic studies evaluating management of cardiovascular disorders are reviewed. Readers interested in more in-depth presentations of health economics can consult several excellent overviews. A key principle of economics is that all resources have alternative uses, so devoting resources to any particular activity makes them unavailable for different, and perhaps better, uses.
Society's application of resources to medical care diminishes the resources available for alternative programs, such as public safety, assistance to the elderly or the poor, or environmental protection. This same principle applies to the resources earmarked to health care: the resources devoted to coronary bypass surgery within a health care system might be used to meet alternative health needs, such as treatment of heart failure, prenatal care programs, or provision of vaccinations.
Thus, the goal of health economics is to define the most efficient use of the resources available to provide health care to a population of patients. An economic principle of special relevance to medicine is the so-called law of diminishing returns, indicated schematically in Figure Because resources are initially applied to a particular end, the returns are large, but with each additional increment of resources applied, the returns become smaller and smaller to the point that there is no further gain, and perhaps even a loss, with application of even more resources.
This type of response is familiar to clinicians caring for patients. In the case of acute myocardial infarction AMI , for example, access to defibrillation and hospital monitoring provides great benefits and the addition of thrombolytic therapy further improves patient outcomes. The provision of yet more care may improve outcomes a bit further, but eventually at some point outcomes cannot be improved further this point has been called the "flat of the curve" [4].
Beyond this point, providing yet more resources can actually harm patients e. A key economic insight is that society is best served by medical care that operates not on the flat of the curve but at a point on the shoulder of the curve see Fig. A major goal of economic analysis of cardiovascular care is to find the optimal level of resources for a given clinical problem.
Economic analyses most often employ the societal perspective: how will society as a whole benefit from the new clinical program and what will society have to pay for it.
In contrast, clinicians are focused on individual patients. Their traditional role is to be the patient's advocate, to do what is possible for the patient before them, regardless of the value provided to society. Thus, economic analysis is really meant as a policy tool, for informing spending decisions about populations, not as a tool for assisting with bedside decision-making.
As exemplified in Figure , a key economic measure of value is the cost of adding an additional unit of medical benefit, or the slope of the curve. Thus, cost-effectiveness analysis assesses the marginal or incremental costs required to produce one extra unit of outcome. The ratio is defined as:. The cost of a program includes all relevant costs, including the intervention itself e.
The effectiveness of a medical intervention should be measured in outcomes of direct relevance to the patient, such as life-years of survival or quality of life. Economic analysis commonly measures effectiveness in "quality-adjusted life years" QALYs to assess both of these dimensions of improved clinical outcome on a common outcome scale. Laboratory-based outcome measures e. Another final economic principle of relevance to medical care is that the production of goods and services is often more efficient in larger quantities due to "economies of scale.
Figure General relationship between application of health care resources horizontal axis and health outcomes vertical axis. At point A, outcomes are improving rapidly with increased resources and treatment is cost effective.
At point B, outcomes are still improving with increased resources, but at a rate that is less cost effective. At point C, increased resources are no longer improving outcome i. In medical care, there is also evidence that higher patient volumes are associated with greater technical proficiency and better clinical outcomes. Nevertheless, there is strong empirical evidence of the value of maintaining a minimum level of clinical volume in procedures such as coronary angioplasty and coronary bypass surgery, and in the care of critically ill patients such as those with AMI.
Provision of medical care requires resources: the time and energy of physicians, nurses, and other health care professionals; specialized facilities such as intensive care units, angiography suites, and operating rooms; and costly drugs and supplies.
Use of these resources has a cost, even if medical care is provided to the patient "for free. As a practical matter, cost is measured by the prices paid in a competitive market. The overall cost of a medical program can then be measured as Sigmai Pi Qi , where Pi is the price for resource "i", Qi is the quantity of resource "i" that is used, and the summation is over all "i" resources used in care of the patient. Modern hospital cost accounting systems facilitate such "microcosting" of medical care services.
When microcosting is not feasible, an alternative measure of the cost of hospital services has been found by multiplying the charge for the service by a correction factor, the ratio of costs to charges,[12] found on the hospital's annual financial reports filed with the Health Care Financing Administration.
In medical economic studies, the cost of an intervention includes all relevant costs, regardless of who pays for them. The cost of an angioplasty might be borne in part by the insurance company, in part by the patient e.
An expensive new therapy in the angioplasty laboratory may reduce total costs in the year after the procedure, and therefore be quite economically attractive.
Nevertheless, hospitals may resist using the new therapy because the costs they pay are increased and they do not share the downstream savings. Even programs that save total medical costs can create economic winners and losers, whose incentives and disincentives can distort optimal resource allocation from a societal perspective.
Thus, whereas economic analysis can adopt a number of valid perspectives or points of view, the societal one is preferred because it is the broadest. Medical costs and benefits are typically spread over long time intervals, which leads to two related issues regarding measurement. Inflation changes the units of cost measurement, such that a dollar in does not have the same value as a dollar in To compare costs of alternative strategies within a given study, or those from different studies, it is therefore necessary to adjust all costs to a single standard value, such as dollars.
A separate issue is that even if there were no cost inflation, it is still preferable to be paid today than to be paid in 5 years, and, conversely, it is preferable to repay a debt sometime in the future than to repay it immediately.
To adjust for these time preferences, medical economic studies typically discount future costs and medical benefits by 3 percent per year.
Economic analysis can be applied to treatment of acute illness e. In the remainder of this chapter, the principles of economic analysis are illustrated by discussing cardiovascular management strategies drawn from each of these areas. Detailed review of the economics of all cardiovascular therapies is beyond the scope of this chapter and can be found elsewhere.
Application of economic analysis to medical care can be illustrated by the use of thrombolytic therapy for AMI. As discussed in Chapter 35 , AMI most commonly results from the thrombotic occlusion of a major coronary artery at the site of a disrupted atherosclerotic plaque. After plaque rupture, there is a brief initial period of high risk in which appropriate therapy reduces mortality, and after a few weeks the patient's risk and quality of life settle at their chronic, steady state values.
Clinical investigations have clearly established that timely reperfusion of the occluded coronary artery improves mortality of the patient with an AMI[15] and that this survival benefit is maintained over long-term follow-up. The value of streptokinase administration for AMI compared with the alternative of no reperfusion therapy can be analyzed using cost-effectiveness analysis.
We further assume that hospital survival is improved from 88 to 92 percent by streptokinase treatment and that the life expectancy of MI survivors is 15 years, regardless of whether they were treated with streptokinase.
Based on these assumptions, the incremental cost-effectiveness of streptokinase for the treatment of AMI can be calculated as:.
To judge whether streptokinase therapy for AMI represents a good value for the money spent i. Because the cost of dialysis is covered by the federal Medicare program, it represents a good benchmark of how much society is willing to spend to add a life year.
Programs with cost-effectiveness ratios much worse than renal dialysis i. Based on these benchmarks, streptokinase therapy for AMI is a very economically attractive intervention. Treatment of acute coronary syndromes AMI [see Chap. Coronary reperfusion by pharmacological or mechanical methods has been extensively investigated, as have antithrombotic and anticoagulation regimens.
Although there are vast differences among these therapies clinically, they share common features from the perspective of economic evaluation. The cost-effectiveness of t-PA was therefore investigated, first by the use of decision analysis[18] and subsequently using empirical data in conjunction with the randomized Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-1 GUSTO-1 trial.
The cost of therapy was assessed by assigning standardized costs to each resource consumed e. This evaluation showed that, apart from the cost of the thrombolytic agents themselves, hospital and follow-up costs were quite similar in t-PA- and streptokinase-treated patients. The day survival rate of t-PA-treated patients was improved by 1 percent in GUSTO-1; and based on long-term post-MI follow-up data collected by the Duke University data base, the life expectancy of survivors was projected to be The use of streptokinase and t-PA for AMI provides a striking example of the economic principle of diminishing returns.
Simple and inexpensive therapies usually provide most of the potential improvement in outcomes for a given clinical condition, with smaller and smaller marginal improvements coming at greater and greater cost.
This example also illustrates the comparative nature of economic evaluations--the value of a treatment can only be assessed in light of the therapeutic alternatives.
This example also demonstrates that the difference in clinical benefit between two or more active therapies will generally be a fraction of the difference in clinical benefit between the least expensive effective therapy and placebo. Primary angioplasty for AMI has been compared with thrombolytic therapy in several clinical trials, some of which also included an economic evaluation.
When rates of subsequent angiography are high, the primary angioplasty strategy has only a modest impact on net incremental costs, since many patients treated initially with thrombolysis subsequently undergo angioplasty or coronary artery bypass grafting CABG later in the same admission. When rates of subsequent angiography are low, however, primary angioplasty increases costs by adding revascularization procedures that would not otherwise have been done.
A formal cost-effectiveness analysis of primary angioplasty relative to thrombolysis showed it to be cost-effective when performed in hospitals with existing cardiac angiography laboratories and minimal delay to therapy.
Anticoagulant and antiplatelet regimens in the treatment of unstable angina and AMI have been investigated intensively in clinical trials. Because the newer agents of these classes tend to be more expensive than the standard alternatives heparin, aspirin , economic evaluation is important. Economic evaluations are difficult to perform in these settings, however, because some or all of the benefit of these therapies come from reducing nonfatal MI, not hospital mortality.
The economic analysis must therefore assess the long-term value of preventing a nonfatal MI, not just the value of improving short-term survival. In , CABG was performed on , patients in the United States and , coronary angioplasty procedures were also performed.
CABG is an effective treatment for angina in symptomatic patients and extends life expectancy in patients with extensive coronary disease see Chap.
An overview of randomized clinical trials of surgery versus medical therapy[28] suggests that patients with left main disease may live more than 0. These data suggest that CABG is more economically attractive in patients with more extensive coronary disease who are at higher risk of death, because the absolute improvement in survival is greatest in these patients whereas the cost of the surgery is roughly the same.
More recent analyses[30] confirm that the cost-effectiveness of CABG is most favorable in patients with higher clinical risk more extensive coronary disease, reduced left ventricular function , and greater degrees of angina. The clinical results of these studies were quite consistent in showing significantly less angina and a nonsignificant reduction in mortality in surgery patients.
These studies all showed that this initial cost advantage of PTCA was almost completely lost over the subsequent 2 years of follow-up as a result of the frequent need for repeat coronary revascularization procedures among angioplasty-treated patients. At 3 to 5 years of follow-up, the total medical costs averaged 4 to 6 percent lower in PTCA patients than in surgery patients.
Coronary stents have now become a standard part of percutaneous revascularization. Stents reduce the need for emergency bypass surgery after initial PTCA and significantly reduce the likelihood of restenosis and frequency of repeat revascularization over the subsequent 4 to 6 months.
Formal cost-effectiveness models based on recent randomized trial results have not been reported; an older decision model suggested that stenting would be cost effective if restenosis were reduced by 25 percent or more. Some randomized trials have reported that the ICD see Chaps. These studies illustrate several general points about the economic evaluation of procedures and devices. The initial cost of procedures and devices is often quite high, but long-term follow-up is needed to assess the total net cost of the procedure relative to alternative therapies.
An expensive procedure may have some or all of its incremental costs recouped through prevention of costly adverse events, such as in the case of CABG relative to balloon angioplasty. The higher cost may be only partially offset by later savings e. These considerations emphasize the importance of a long-term perspective in the economic evaluation of devices and procedures, so that their full costs and benefits can be assessed.
Economically efficient management of a chronic disease such as heart failure is very different from that of an acute illness or a surgical procedure. In chronic diseases, the cost of care is spread over many years instead of being concentrated at the outset of treatment.
Similarly, the benefits of treatment accrue only over a period of prolonged follow-up. Improvements in clinical and economic outcomes may come either from better therapies or from better ways to deliver established therapies, or both. Angiotensin-converting enzyme ACE inhibitors have significantly improved survival of patients with heart failure in randomized trials.
An economic analysis based on the Survival and Ventricular Enlargement SAVE trial in patients with an ejection fraction less than 40 percent after an acute MI suggested that captopril therapy was economically attractive for this indication, with more favorable cost-effectiveness ratios in older patients than in younger patients.
The data from randomized trials of ACE inhibitors suggest that some of the cost of an intervention for heart failure may be offset by prevention of costly hospital re admissions. Epidemiological research has shown that most admissions for heart failure result from lack of patient adherence to drug or dietary regimens. In one study, a nurse-directed multidisciplinary intervention significantly reduced hospital admissions and lowered overall health care costs in patients with heart failure.
Disease prevention is very important from a clinical perspective. Some preventive measures are very effective and inexpensive, as exemplified by vaccination programs for common infectious diseases that cut risk by over 90 percent at the cost of only a few dollars. Most preventive measures are less effective in reducing the risk of disease and far more costly to implement.
Vaccines, in particular, are relatively inexpensive because they are given only two or three times, whereas drugs to lower serum cholesterol or high blood pressure are given daily for decades. Thus, the cost-effectiveness of preventive programs varies considerably according to the intervention, its effectiveness, and its cost. Hypercholesterolemia see Chap. The efficacy of cholesterol lowering in primary prevention i. The cost-effectiveness of HMG-CoA reductase therapy to prevent coronary heart disease varies from extremely favorable values in secondary prevention settings to quite unfavorable in some primary prevention settings.
In the 4S trial, [60] for example, the 6-year overall mortality was 8. The greater level of clinical efficacy in secondary prevention than primary prevention implies that lipid-lowering therapy is more economically attractive in the secondary prevention setting. Similarly, within the primary prevention setting, treatment of higher-risk patients i. These insights are supported by more formal cost-effectiveness studies. Other analyses have confirmed the basic observations that primary prevention with HMG-CoA reductase therapy in low-risk patients is economically unattractive, whereas treatment of higher-risk patients is quite cost effective.
Cigarette smoking see Chaps. Proper selection of diagnostic tests to evaluate various clinical problems has become more challenging as a result of the collision between the forces of technological innovation. Recognize the factors for prevention and risk stratification around cardiovascular disease and effectively delay the onset of disease and moderate the effects and complications, even for individual who are genetically predisposed.
Effectively navigate full range of considerations in prevention from epidemiology of heart disease, biology of atherosclerosis and myocardial infraction, risk assessment? Tap into the expertise of prominent leaders in cardiovascular disease prevention with guidance from Drs. Roger Blumenthal? JoAnne Foody, and Nathan Wong. Gain a deeper understanding of the pathogenesis of disease and the rationale for management through discussions of basic science.
Apply current clinical practice guidelines to ensure optimal outcomes in both primary and secondary prevention.
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