The population strategy of prevention is characterized. The role of population and high-risk strategies in the primary prevention of cardiovascular diseases. Why is overall risk assessment important?

For citation: Emberson D., Uinkup P., Morris R., Walker M., Ebraim Sh. The role of population strategy and high-risk strategy in the primary prevention of cardiovascular diseases // BC. 2008. No. 20. S. 1320

Introduction

There are two main strategies for primary prevention of cardiovascular diseases (CVD) - the so-called "high-risk strategy", in accordance with which prevention activities are carried out among people at high risk of the disease, and the "population strategy", which implies exposure to risk factors throughout population. For physicians dealing with specific patient cases in their practice, a high-risk strategy is more natural. But more often CVD occurs not in a small cohort of maximum risk, but among a much larger group of people with a lower risk, and here the population strategy becomes relevant. Since both approaches were formulated, their potential relevance has changed. So, the high-risk strategy allows, on the one hand, to assess the absolute risk of CVD (and not the only 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 ) an independent decrease in the likelihood of CVD in a cohort of high-risk patients. However, it is now clear that the effectiveness of the population strategy was previously underestimated. This is because dilution bias in regression was not taken into account (underestimating the significance of risk factors that occurs when used in baseline analyzes), and as a result, even a slight decrease in the level of 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, for the purposes of primary prevention of CVD, a high-risk strategy is more often chosen than a population-based strategy. For example, in the UK, particular emphasis is placed on identifying individuals with a 10-year predicted CVD risk of 30% or more (according to the CVD risk formula used in the Framingham Study). On the contrary, very little attention is paid to lowering blood cholesterol and blood pressure in the population as a whole. However, so far only a few researchers have attempted to assess the potential value of different high-risk and population-based strategies, given both the benefits of preventive CVD treatment and the underestimation of the population strategy associated with dilution bias regression. Below is an analysis and comparison of the potential effectiveness of the high-risk strategy (aimed both at controlling individual risk factors, in particular, the level of cholesterol in the blood and blood pressure, and at identifying individuals with a high total risk of CVD) and the population strategy (the purpose of which is to control BP and blood cholesterol) in a representative sample of middle-aged British people. Since the emphasis is on primary prevention, patients with verified CVD who almost certainly received pharmacotherapy were excluded from the study, and their risk of subsequent cardiovascular events was especially high.

To examine the effect of population-based and high-risk strategies on the incidence of the first major cardiovascular event (myocardial infarction (MI) or stroke, with or without fatal outcome) in middle-aged men without prior CVD and their symptoms, we took data from a prospective observational study on CVD (British Regional Heart Study) and meta-analyzed results of randomized clinical trials concerning the reduction of the relative risk of CVD.

CVD prevention strategies

Considered several high-risk prevention strategies: (1) identification and control of individual risk factors: (a) determination of the threshold blood cholesterol level 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 indicator according to the Framingham study data (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. In the course of an auxiliary analysis, the possible effectiveness of the prophylaxis regimen was assessed, according to which, depending on age, combined treatment with ASA, β-blocker or diuretic, ACE inhibitor and statin was prescribed. And although more and more scientists are inclined to believe that the calculations according to the formulas of the Framingham Study overestimate the real risk indicators among Europeans, in the conduct of this study these initial formulas were used so that the results were understandable from the standpoint of modern guidelines (correction of the overestimated indicators will lead to a decrease in the size of the group high risk, and this, 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 with statin therapy reduces the risk of MI by 31%, and stroke by 24%. A decrease in 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, ASA treatment reduces the risk of MI and stroke by 26 and 22%, respectively, and treatment with ACE inhibitors - by 20 and 32%, respectively. If we assume that the ratio between the incidence of the first episodes of 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 values of the decrease in two different indicators of relative risk (i.e. 4 / 5 reduction in the relative risk of MI plus 1/5 of the reduction in the relative risk of stroke), it is possible to calculate how much the relative risk of combined CVD outcomes decreases. The effectiveness of treatment increases, and ultimately the combined reduction in the relative risk against the background of taking ASA, statins, ACE inhibitors and β-blockers / diuretics is 68% (1-0.75 [ASA] × 0.70 [ statins] x 0.78 [ACE inhibitors] x 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 general population; (b) a decrease in the average value of blood pressure in the population as a whole; (c) a combined decrease in mean cholesterol level and mean blood pressure in the general population.

British regional
heart examination

British Regional Heart Survey ( BRHS) is a prospective CVD study conducted at the level of general practitioners in 24 British cities from 1978 to 1980. The study included patients aged 40-59 years. The indicators of general mortality and structural morbidity for CVD were monitored; less than 1% of participants dropped out of the trial. The baseline data of the physical examination and biochemical analyzes are presented in detail earlier. In two cities (with high and low CVD mortality rates), patients were reexamined after 16 and 20 years of follow-up, while BP was measured and blood lipids were assessed. This allowed us to evaluate the effect of intrapersonal deviations (coefficient of 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 pectoris, or severe chest pain lasting at least 30 minutes, which would have prompted medical attention. In addition, patients filled out the WHO questionnaire (Rose questionnaire) on angina pectoris, which made it possible to identify obvious or latent symptoms of angina pectoris. Persons with a history of myocardial infarction, angina pectoris or stroke, severe chest pain, overt or latent symptoms of angina pectoris were excluded from the study based on the results of answers to Rose's questionnaire.

Analysis of CVD cases

The standard “tagging” procedure provided by the Southport (England and Wales) and Edinburgh (Scotland) NHS registries was used to collect information on the time and cause of death. Fatal coronary events were defined as death due to coronary heart disease (the main cause), including sudden deaths presumably due to heart problems (ICD-9 410-414), and fatal strokes 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 based on the information provided by the attending physicians, and supplemented by the results of systematic examinations every 2 years until the end of the trial. The diagnosis of non-fatal heart attack was made on the basis of criteria approved by the WHO. All cerebrovascular events accompanied by the development of neurological deficits, which persisted for more than 24 hours, were referred to non-fatal strokes. With regard to this work, the group of major CVDs included deaths due to coronary heart disease or stroke, as well as MI and non-fatal strokes.

Methods of statistical
processing results

The correlation between baseline risk exposure and 10-year risk of major CVDs was studied using logistic regression; during the analysis, adjustments were made for age, blood cholesterol level, blood pressure, smoking status (now, in the past, never), body mass index, level of physical activity (absence, episodic, insignificant, moderate), presence / absence of sugar diabetes and place of residence (counties south, midlands and Wales, northern counties, Scotland). The associative effect of blood cholesterol levels (total cholesterol and cholesterol / HDL ratio), as well as systolic (BP sist.) and diastolic (BP diast.) BP for predicting the risk of major CVD was assessed in a fully adjusted model in terms of likelihood ratio χ 2 (HDL content was not taken into account, since it was measured only in 18 cities out of 24). It was assumed that the level of cholesterol and blood pressure were measured with an error, and over time these indicators underwent intrapersonal deviations. The effects of these deviations were analyzed over 4 years (using observational data after 16 and 20 years) in order to describe the true correlations in the first 10 years of observation in comparison with empirical "baseline" correlations (to calculate the usual expected exposure level and true values of the regression coefficients calibrated it).

Taking into account the greatest informativeness of the blood cholesterol level and blood pressure value for predicting the risk of CVD (and after introducing the correction of the regression coefficients for its displacement due to dilution), the potential informativeness of each of the high-risk prevention strategies was predicted using logistic regression (the results of measurements of the level of cholesterol in the blood and BP values were recalibrated). If the prediction for the sample was made on the basis of data obtained from the same individuals, errors in the calculations of the difference in risk indicators could occur (and sometimes quite significant). Therefore, the risk was predicted using the so-called. the "folding knife" method, which eliminated these errors. The mean of the predicted risk scores was the expected absolute 10-year CVD risk in the population prior to the implementation of the prevention strategy (which is exactly the same as the empirical CVD risk score). In cases where the empirical level of risk exposure turned out to be high enough to make a positive decision to initiate preventive treatment (i.e., in a high-risk group), the predicted risk indicators were recalculated taking into account the effects of therapy. Then the average of the predicted risk indicators after the implementation of the prevention strategy was calculated, which made it possible to obtain the value of the expected reduction in the risk of major CVDs due to the implementation of the high-risk prevention strategy. With regard to population strategies, the expected decrease 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 the subjects of the same sample after an absolute decrease in blood cholesterol levels and blood pressure. When these strategies were applied, the reduction in the incidence of major CVDs corresponded to the predicted reductions that would occur if the blood cholesterol and BP values in this sample remained low throughout their lives.

results

Of the 7735 men selected during the baseline screening, 1186 (15.3%) had baseline signs of CVD, and another 210 people initially took antihypertensive or lipid-lowering drugs. For 5997 patients (of the remaining), a complete set of risk factor data was available. The baseline characteristics of these subjects are presented in Table 1. In 165 individuals without baseline CVD symptoms who were not taking any antihypertensive or lipid-lowering drugs at the time of examination after 16 or 20 years, there were results of repeated measurements of cholesterol and blood pressure for 4 years (between 16 and 20 years). The dilution regression bias coefficient for total cholesterol was 0.79; for the logarithm of the ratio of cholesterol / HDL - 0.88; for blood pressure sist.- 0.75; for blood pressure diast. - 0,65.

In the first 10 years of follow-up, 450 men (7.5%) developed an episode of major CVD. The "relative informativeness" of the effect of different cholesterol and blood pressure levels on the predicted CVD risk was assessed using a fully adjusted logistic regression model with respect to likelihood ratio χ 2. Compared with total cholesterol in serum, the HDL / cholesterol ratio was 55% less informative, and compared to garden sist. and HELL diast.- by 67%. Therefore, for predicting the risk of CVD, two criteria were recognized as the most informative - the content of total cholesterol and blood pressure. sist..

Effectiveness of the strategy
high risk prevention

Table 2 presents data on the estimated efficacy of each high-risk prophylaxis regimen depending on the specific thresholds at which treatment is initiated, and Figure 1 shows the relationship between these thresholds, treatment efficacy, and the proportion of people in the population receiving treatment in accordance with the selected scheme. When the threshold is lowered (i.e., the proportion of people treated increases), the expected decrease in the incidence of CVD in the population becomes more pronounced. If we talk about a single type of treatment, the effectiveness of detection based on the risk of the disease as a whole (calculating the indicator using the risk equation of the Framingham Study) is higher than when identifying based on a single risk factor, and as the threshold decreases, this difference becomes more pronounced. From the point of view of prevention, combination therapy brings much more benefits than prescribing only antihypertensive or lipid-lowering drugs. However, even when taking several drugs, the reduction in the incidence of the first episode of major CVD, expected against the background of the implementation of the 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 decrease in the incidence of the first episode of major CVDs will be 34%, and with a decrease to ≥15% - 49% ... Thus, at these thresholds, one quarter and half of the population without CVD symptoms, respectively, would need to receive combination prophylactic treatment.

Selection of therapy based on age only

Of 450 patients who had the first episode of CVD during 10 years of follow-up, 296 (65.8%) were over 55 years old at the time of the onset of the phenomenon. If from the age of 55 the subjects start taking 4 drugs for prophylactic purposes, then 201 first episodes of CVD (296x 0.68) can be prevented. Therefore, approximately 45% of all first episodes of major CVDs within 10 years (201/450) can be prevented by implementing this specific high-risk prevention strategy (at 100% prescribing frequency and as strictly adherence to the regimen as in clinical trials). If preventive therapy is carried out from the age of 50, then 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 performance of each of the population-based approaches. A 5% decrease in total serum cholesterol and systolic blood pressure (by 0.3 mmol / L and 7 mm Hg, respectively) over a long period of time leads to a 26% decrease in the incidence of the first episode of major CVD over 10 years. and a decrease in the values of these indicators by 10% - by 45%.

Influence of Regression Bias
due to dilution

Regression bias by dilution has no effect on the expected performance of high-risk strategies, while its effect on the performance of population-based approaches is significant. The adjusted indicators presented in Table 2 and Figure 2 turned out to be 20-30% higher than the unadjusted ones.

Discussion

When analyzing the potential efficacy of various high-risk CVD primary prevention strategies and population strategies, it is necessary to take into account inaccuracies arising in the measurement of blood cholesterol and blood pressure, as well as intrapersonal deviations (regression bias due to dilution). The data obtained in this study indicate that a tangible change in the incidence of CVD occurs only against the background of widespread implementation of high-risk primary prevention strategies involving combination therapy (at a level of less than 3% of the expected risk per year according to the recommendations accepted in the UK and less than 2% of the expected risk). risk per year according to the recommendations accepted in Europe). A potentially relatively small reduction in the two key risk factors (blood cholesterol and blood pressure) across the population can lead to a significant reduction in the incidence of major CVDs.

Assumptions

The validity of assumptions about high-risk strategies is determined by the hypothetical effectiveness of treatment and the appropriateness 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 the calculations made during the cohort analysis, because cohort analysis allows us to assess the impact of the difference between risk scores that arises from long-term changes in the level of risk exposure, while clinical trials provide an opportunity to reveal how much such epidemiological correlations are reversible during therapy. In addition, in the course of clinical trials, non-adherence to the treatment plan is also taken into account when calculating, 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 can be overestimated, since often subjects who did not follow the drug regimen were excluded during the preparatory phase of the study, and patients were monitored more closely). As a rule, the effectiveness of the 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 on the effectiveness of which is based mainly on the results of studies conducted in patients with a verified diagnosis of CVD. When prescribing statins and ASA, this assumption looks more reasonable, because indicators of relative risk decrease rather steadily in a wide range of patient groups. Further, if we assume that the 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 drug combinations (including several low-dose drugs), you can expect a more tangible reduction in the risk of CVD compared with the data presented in this article, but even if this is the case, this assumption is unlikely to seriously affect the results of our study (for example, if, while taking a combination pill, the decrease in the true relative risk is 85%, then treating patients with a risk of ≥30% according to the Framingham study formula will reduce the incidence of major CVD by 14% compared with the value of 11% given in Table 2).

The effectiveness of population-based prevention strategies depends primarily on the severity of population-wide changes that can actually be achieved in practice. The decrease in the average level of total cholesterol and blood pressure in the range from 5 to 15% in the scale of the entire population (Table 2) is very insignificant; by a similar amount, the values of these indicators may decrease if a certain diet is followed. If we talk about the content of total cholesterol, then in the course of a study on the island of Mauritius, it was found that after switching to the consumption of soybean (rather than palm) oil and the introduction of programs aimed at promoting a healthy lifestyle, for 5 years the level of total cholesterol in the population as a whole decreased by 15%. Meta-analysis of research results conducted in the so-called. the metabolic chamber, indicates that if 60% of the consumed saturated fats are replaced by other fats, and the amount of cholesterol supplied with food is reduced by 60%, then the same decrease in the values of indicators can be achieved. Limiting salt intake leads to a population-wide decrease in blood pressure by about 10%, although in clinical practice this approach is less effective. And although when comparing 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 do not decrease significantly, our assessment of the potential effectiveness of population strategies is quite safe. Long-term trends in blood pressure are also subject to pronounced fluctuations over fairly short periods of time; Thus, in the period from 1948 to 1968, the average value of systolic blood pressure in Glasgow students decreased by 9 mm Hg. , and regardless of antihypertensive therapy, the same data were obtained from the results of clinical examination in England. Finally, the implementation of prophylaxis regimens aimed at reducing the cholesterol content and blood pressure in the population has an additional positive effect on other cardiovascular risk factors, such as body mass index and physical activity level.

In the present study, it was mainly about the content of cholesterol, the level of blood pressure and the corresponding methods of pharmacological correction of these indicators, and the questions regarding the effect of smoking on the risk of CVD were not raised. If this aspect is also taken into account, then the effectiveness of both high-risk and population-based strategies becomes even more obvious (for example, a decrease in the number of deaths associated with CVD over the past two decades by about one third is associated with smoking cessation). But even taking into account smoking, the ratio of the potential effectiveness of both prevention strategies remains unchanged.

Influence of Regression Bias
due to dilution

In the analysis, corrections were made for regression bias due to dilution (underestimation of the correlation between the level of common risk factors and disease risk due to intrapersonal deviations). In the case of the implementation of the high-risk strategy, this phenomenon did not affect the effectiveness of the approach (since the data on the effectiveness of treatment were taken from the results of clinical trials), however, when the population strategy was implemented, this 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 extremely important to correct for regression bias due to dilution. Otherwise, it is highly likely that the effectiveness of the approach will be largely underestimated.

Practical
application of results

The results obtained indicate that the 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 Framingham Study's Risk Score generally provides a more accurate estimate of the treatment regimen from which a single risk factor is taken into account, such as total cholesterol or blood pressure (although these differences do appear only in the case when the therapy is carried out in a sufficient sample size; Table 2). These facts do not contradict previously published data concerning the effect of antihypertensive and lipid-lowering treatment on the risk of CVD. But even if drugs are prescribed in combination to reduce the risk of CVD, the impact of a high-risk primary pharmacological prevention strategy will still be limited until these strategies are introduced much more actively than now (according to, for example, the recommendations adopted in the UK ). To obtain benefits comparable to those of a population-wide 10% reduction in cholesterol and blood pressure, it is necessary to treat more than a third of middle-aged men without clinical symptoms of CVD with all 4 drugs. The same is discussed in the revised report of the Third Joint Committee on CVD Prevention, according to the provisions of which the key attention should be paid to patients with a 10-year risk of CVD with a fatal outcome of at least 5% (based on the results of the SCORE project); with this value of this criterion, 36% of participants in the BHRS study initially fall into the high-risk group. However, treatment in 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, decreases, since the absolute risk threshold decreases. At the same time, population strategies are highly effective in economic terms, and in addition (more importantly), they are focused not only on eliminating the influence of risk factors, but on identifying the determinants of their distribution. Population-based approaches are more able to stop the progression of atherosclerosis, while high-risk strategies ensure the prolongation of treatment in middle-aged patients requiring pharmacotherapy.

The data presented indicate a tangible hypothetical advantage of population-based high-risk prevention strategies. Compared to international standards, the average level of total cholesterol and blood pressure among residents of the UK remains high, and over the past decade, the values of these indicators have decreased very little. The current UK national health policy on CVD prevention takes into account the need to reduce total cholesterol and blood pressure levels across the population only marginally, and does not attach decisive importance to government action as a key tool for influencing these changes (which could be expressed, for example, in the adoption of a law to restrict the content of salt and fat in groceries). Apparently, if we prioritize population-based approaches to lowering cholesterol and blood pressure, it will be possible to preserve the noticeable successes that have been achieved in the prevention of CVD over the past two decades, especially given the sharply increased incidence of obesity and diabetes mellitus. as well as a sedentary lifestyle.

The abstract was 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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Oganov R.G.

Arutyunov Grigory Pavlovich,Doctor of Medical Sciences, Professor:

On the agenda, we are pleased to 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 Oganov Rafael Gegamovich.

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

Dear colleagues.

Today we are going to talk about the main strategies for the prevention of cardiovascular disease. I must say that, of course, the results of prevention are not as bright and emotional as the results of surgical treatment. The surgeon, having successfully performed the operation, often sees the results immediately. This does not happen in prevention. But we still cannot do without prevention.

One of the achievements of the 20th century was to obtain scientific evidence that the epidemic of cardiovascular disease is mainly due to the peculiarities of the lifestyle and associated risk factors. Lifestyle modifications and lowering 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 any role. Undoubtedly, they play a role. But the main one is a way of life. This is well proven by observations of migrants. We are well aware that in Japan the prevalence of atherosclerosis and related diseases is not great. This is due to the Japanese lifestyle. When the Japanese move to the United States, after a while they start to get sick and die like real Americans.

Such examples can be cited with other diasporas as well. But I think this example quite clearly shows that genetics, of course, plays a role, but the main thing is still a way of life.

Sometime in the 1960s, it became obvious that only by improving the methods of diagnosing treatment, we would not be able to cope with the problem of cardiovascular diseases.

The rationale for the need for the prevention of cardiovascular diseases was expressed. Firstly, the pathology is usually based on atherosclerosis, which proceeds secretly for many years and, as a rule, is already strongly pronounced when symptoms appear.

It is now well known from epidemiological studies that even in adolescents who died from some accidents, the first manifestations of atherosclerosis are already being found.

The second is death, myocardial infarction, stroke. They often develop suddenly when medical care is unavailable, so many treatment interventions are inappropriate. From time to time we hear speeches in the media that a person who looks full of 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 methods of treatment (medication, endovascular, surgical) do not eliminate the cause of cardiovascular diseases. After all, we act here on the effect, and not on the cause, therefore the risk of vascular catastrophes in these patients remains high, even though they subjectively may feel absolutely healthy.

What are the necessary conditions for successful actions to prevent cardiovascular diseases. First, there must be an evidence-based prevention concept. Then the creation of the infrastructure for action to promote health and prevent cardiovascular disease. The staffing of this structure with professional personnel and the provision of material, technical and financial resources.

In principle, we have all this, but it does not work at full strength, while it remains to be desired the best effect.

Do we have a scientific basis? Yes there is. 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 this very 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, reduce. They are conventionally divided into three subgroups. These are behavioral and social, biological and environmental.

This is not to say that unmodified factors are of no interest to us. If we take two known unmodified factors: age and gender, then, fortunately or unfortunately, we cannot change them yet. But we use them well when developing forecast tables or instruments.

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

There are many risk factors. There were more than 30 - 40 of them, so you always have to choose a priority, that is, which risk factors should be given priority. What risk factors first of all we need to pay attention to.

The first is the factors that have been proven to be associated with diseases. Second, this connection must be strong. The prevalence of risk factors should be high. Factors affecting several diseases, not 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 decrease in cardiovascular diseases, but also to many more diseases. Such factors are of particular interest to us from a practical point of view.

The most important thing. When giving priority to a certain risk factor, one must clearly understand that there are effective methods of prevention and correction of this risk factor.

If we talk about common risk factors, for which there are scientifically grounded and accessible methods of detection and correction for health care, 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 decrease 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 general in the world). This is overweight, obesity. Impaired carbohydrate tolerance, diabetes mellitus. Metabolic syndrome, as these two factors - obesity and diabetes - are components of metabolic syndrome.

It is of interest to examine the extent to which risk factors can actually predict mortality from ischemic disease or from chronic noncommunicable diseases.

In our center, such an analysis was carried out by Professor A. 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 really happened, that is, what the observed risk was. If you look at the slide "Mortality from coronary heart disease", then there the two "curves" practically merge. It is even surprising how accurate it is.

If you look at the slide "Mortality from chronic noncommunicable diseases" ("predicted risk" and "observed risk"), although the "curves" diverge somewhat, they run very parallel.

Today we have learned very well to predict 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 such a level of risk factors, 50% will die in 10 years. But who will be these 50%, we cannot personally name today.

Risk factors that did not meet expectations. What do I mean when I talk about risk factors that did not live up to expectations. This is oxidative stress. They talk about him endlessly, especially when they talk about dietary supplements. This is hyperhomocysteinemia. In the United States and Canada, B vitamins and folic acid have even been added to foods in order to reduce hyperhomocysteinemia among their populations.

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 brackets it is indicated which clinical trials were, which drugs. These clinical studies, unfortunately, either did not give any result (they were nil) or even turned out to be negative.

Does it mean that these factors do not play a role in the development and progression of diseases? Of course it doesn't. Most likely, we are doing something wrong in terms of our intervention. This is well shown by the situation with female sex hormones, with hormone replacement therapy. There have been several meta-analyzes that have shown that hormone replacement therapy after menopause leads to an increased risk of vascular catastrophes. This led to the conclusion that they can be used very carefully.

When analyzed more closely, 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 have passed 10-15 years after menopause, then these results were poor.

Actions of structures providing preventive care. What needs to be done to provide preventive care. There are only three very simple things. This is the identification of risk factors (screening). Risk assessment using tables or using some kind of computer program.

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

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-language literature they call. We translate it literally. This is an examination of everyone who seeks a 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 kind of risk factor. For example, we want to identify individuals with diabetes. Naturally, if we take people with overweight, obesity, or people who have a dietary predisposition to diabetes mellitus, then there we will identify significantly more of these patients.

These two types of screening are based on this. Depending on the task, one or the other is used.

Diagnostic methods, which are very rapidly improving, today allow us to identify the so-called subclinical markers of increased risk. In particular, the defeat of atherosclerosis or arterial hypertension.

We can determine the thickness of the intima-media (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, or you can simply do this using the phonendoscope cuff). Plaque in the carotid or peripheral arteries (ultrasound).

This is the carotid-femoral velocity of the pulse wave propagation. A method that has been known for a very long time, but now devices have appeared that allow it 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 better predictive power, predictive quality, than the predictive value of such scales as the Framingham or 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 may move to another group. Ultimately, imaging atherosclerosis can improve patient adherence to preventive measures. This is not easy because non-adherence is the main problem.

A strategy for the prevention of cardiovascular disease. We are now getting to the point for which I am giving this lecture today. It all depends on what task we set. The long term goal is population strategy. It is the impact on those lifestyle and environmental factors that increase the risk of developing cardiovascular disease in the entire population. To put it simply, this is what we call a "healthy lifestyle."

This strategy largely lies outside the health sector. However, this is one of the main strategies that has a number of benefits. This positive effect will reach a large part of the population, including those at high risk or suffering from non-communicable diseases.

The implementation cost is very low. There is no need to extensively strengthen the health care system, as this strategy is largely outside the health care system. It has now been well established that well-planned prevention programs can have a significant impact on lifestyle and the prevalence of risk factors. Lifestyle changes and lower risk factor levels do lead to lower cardiovascular and other chronic noncommunicable diseases.

A systematic analysis was carried out that examined the possibility of reducing mortality through lifestyle and dietary changes in patients with coronary heart disease and in the general population.

(Slide demonstration).

The bar on the left is the reduction in mortality in patients. On the right is the decrease in mortality in the population. Smoking cessation gives 35 - 50%. Increasing physical activity by 25 - 30% reduces mortality. Reasonable use of alcohol also reduces mortality. Diet changes. With the help of a lifestyle, you can achieve results that are no worse than with the help of medications.

I talk about population strategy all the time and emphasize that this strategy mainly lies outside the health care system, nevertheless, the role of doctors is quite high. Physicians should be initiators, if I may say, catalysts, analyzers, informants of processes that contribute to the prevention of cardiovascular diseases.

Physicians must initiate these processes. They should excite society and our political decision-makers, analyze and inform both the population and the authorities about what is happening. It is not entirely correct when they say that this strategy lies outside the boundaries of health care, there is nothing for doctors to do there.

Physicians play a very large role in this strategy. However, its implementation really mainly lies outside of health care.

The medium term 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 latent period between the impact on factors and the result. If everyone quits smoking tomorrow, this does not mean that mortality from coronary heart disease or lung cancer will decrease in 2-3 months. It will take some time for the risk to disappear.

The contribution of risk factors is well understood. Contribution of the seven leading risk factors to the lost years of healthy life for Russia. The risk factors we know are: hypertension, alcohol, smoking, hypercholesterolemia, overweight, nutrition and physical inactivity.

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

The SCORE table, which I already mentioned, which determines the risk of death. But it must be borne in mind 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 persons at high risk. You don't need to use any table. These are individuals at high and very high risk.

If not, then this table can be used. It's pretty simplistic, of course. However, it is now widely used for such mass screening. There are few indicators. These are: by age, cholesterol, smoking and blood pressure. Based on these factors as a percentage, the risk can be predicted. Accordingly, monitor the effectiveness of ongoing activities.

A specific feature for Russia is that, against the background 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.

Of the psycho-social factors for which their influence on the development of disease progression has been proven, the following can be named:

Depression and anxiety;

Work-related stress: low job performance 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 are well studied and that influence the development and progression of diseases.

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

Among the non-prescription drugs, Afobazol is the most popular - it is the original domestic anxiolytic of the non-benzodiazepine series. It reduces anxiety, sleep disturbances, and various autonomic disturbances. What is very important - it is not addictive, does not cause sedation.

Despite the fact that this is an over-the-counter drug, of course, I advise, before buying it in a pharmacy, to consult a doctor about how useful it is in this situation.

There was a fairly large study that showed that indeed its anxiolytic effect, that is, the effect on anxiety, was in 85% of patients. This is an effective drug that can be used in consultation with a doctor (emphasize).

Third strategy. This is a short-term task, a strategy that has a quick effect. This is secondary prevention - early detection and prevention of disease progression.

A systematic analysis that shows what can be achieved with the complex treatment of patients with coronary heart disease or other vascular diseases. Acetylsalicylic acid - up to 30%. Beta blockers - up to 35%. ACE inhibitors - 25%, statins - 42%. Smoking cessation is quite effective - 35%, it is not worse than all medications and there is no need to spend money especially.

The goals of treatment of patients with coronary artery disease. Why I stopped at ischemic heart disease. This is one of the main forms of cardiovascular disease. Drugs that are used to improve prognosis, to prevent complications. These are antiplatelet agents Aspirin, Clopidogrel. New antiplatelet agents are now emerging. But so far, these two drugs occupy a leading position. Lipid-lowering therapy, here statins beat all other drugs. Although, perhaps, this is not entirely correct. These are beta blockers (especially after myocardial infarction). ACE inhibitors. The largest evidence base has Perindopril, Ramipril.

Interest in omega-3 polyunsaturated fatty acids has grown again 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 appear to have antiarrhythmic effects. Due to this, it is possible to achieve good results in secondary prevention.

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

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

Nitrates;

Beta blockers;

Calcium antagonists;

Metabolic drugs;

Ivabradin (Coraksan).

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 constantly in a state of discussion. There is a lot of discussion about them, how effective they are.

We have two most popular drugs - Preductal and Mildronate. Why are these discussions going on. First, these drugs are usually used in combination with other antianginal drugs. It is often difficult to isolate the extent to which this effect is related to metabolic drugs. Then their effect is still not as strong as from other antianginal drugs. To identify and prove it, a lot of research is needed.

Third. There are no clear surrogate points. For hypertension - the level of blood pressure or hypercholesterolemia - the level of cholesterol. There are no such points here, so such a discussion is constantly going on.

A major study on mildronates has recently been completed. International research. A large number of patients. His task was to assess the effect of mildronate at a dose of 1000 mg (that is, these are two capsules) on the symptoms of coronary heart disease, using indicators of exercise tolerance in patients with stable angina pectoris against the background of standard therapy for 12 months.

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

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

(Slide demonstration).

The results were as follows. Orange bars - due to risk factors. Greens are due to treatment. I was more amazed that the rather high contribution of treatment to the reduction of mortality. 46%, 47%, 38%, 35%. We often hear that treatment is not very effective on health. But these analyzes show that prevention is ahead. You cannot do without it, but the treatment is also quite effective. It is not necessary to oppose them, but to use them together.

Another clearer analysis is in England and Wales. Again, we see a 58% reduction in coronary heart disease mortality by reducing risk factor levels and 42% by treating coronary heart disease patients. It is necessary to combine these two types of intervention, and not oppose them against each other.

Regardless of advances in medical technology, the main reduction in mortality and disability from noncommunicable 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. Unfortunately, this is often the case here.

In clinical medicine, there is a “prophylactic dose”. In preventive medicine, there is also such a “preventive dose”. For prevention to be effective, the “prophylactic dose” must be optimal, which means doing the right thing, targeting the right number of people, over the right time frame, 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 - it is clear, now it is your turn to act. Unfortunately, we talk a lot and act much less.

I thank you for your attention.

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Diseases Prevention is a system of medical and non-medical measures aimed at preventing, reducing the risk of developing abnormalities in health and diseases, preventing or slowing down their progression, and reducing their adverse consequences.

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

1. Improving the work of the institution for the provision of primary health care to the population, improving the material and technical base.
2. Improving the quality of medical care, raising the qualification level of doctors and nurses.
3. Increasing the health index of children, women of fertile age, high-quality conduct, implementation of the plan of preventive medical examinations.
4. Carrying out work to stabilize and reduce socially significant diseases.

clinical examination health adult population

5. Decrease in premature mortality of the adult population, infant mortality; prevention of child, maternal mortality.
6. Decrease in the level of primary access to disability.
7. Promotion of a healthy lifestyle as a strategic implementation.

Medical prevention is a system of preventive measures implemented through the health care 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 is a complex of medical and non-medical measures aimed at preventing the development of health abnormalities 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 food, working conditions, life and rest, the level of psychosocial stress and others affecting the quality of life), environmental and sanitary and 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, the possibilities of its reduction;

b) health education - hygiene education;

c) measures to reduce the prevalence of smoking and consumption of tobacco products, reduce alcohol consumption, prevention of drug and drug use;

d) encouraging the population to 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 illnesses and injuries, including occupationally caused, accidents, disability and deaths from unnatural causes, road traffic injuries, etc.

Identification during preventive medical examinations of factors harmful to health, including behavioral ones, for taking measures to eliminate them, in order to reduce the level of action, risk factors. Article 46. Medical examinations, clinical examination provides for:.

1) A medical examination is a complex of medical interventions aimed at identifying pathological conditions, diseases and risk factors for their development.
2) The types of medical examinations are:
1. Preventive medical examination, carried out for the purpose of early (timely) detection of pathological conditions, diseases and risk factors for their development, non-medical consumption of narcotic drugs and psychotropic substances, as well as in order to form groups of health status and develop recommendations for patients;
2. A preliminary medical examination, carried out upon admission to work or study, in order to determine the compliance of the employee's state of health with the work entrusted to him, the student's compliance with the training requirements;
3. Periodic medical examination, carried out at a specified frequency, in order to dynamically monitor the state of health of workers, students, timely detection of the 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 the state of health workers, students, in order to form risk groups for the development of occupational diseases, to identify medical contraindications to the implementation of certain types of work, to continue their studies;
4. Pre-shift, pre-trip medical examinations conducted 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 impede the performance of work duties, including alcohol, drug 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) hazardous 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 stipulated by the legislation of the Russian Federation, in relation to certain categories of citizens, in-depth medical examinations may be carried out, which are periodic medical examinations with an expanded list of specialist doctors and examination methods participating in them.
4) Conducting immunoprophylaxis of various population groups.
5) Rehabilitation of individuals and groups of the population under the influence of unfavorable factors for health with the use of medical and non-medical measures
6) Clinical examination of the population in order to identify the risks of developing chronic somatic diseases and improve the health of individuals and populations under the influence of adverse factors with the use of medical and non-medical measures.

Article 46. Medical examinations, clinical examination.

7) Conducting prophylactic medical examination of the population to identify the risks of developing chronic somatic diseases and improve the health of individuals and populations under the influence of factors unfavorable to health, using medical and non-medical measures.

Secondary prevention (seondaryprevention) is a complex of medical, social, sanitary-hygienic, psychological and other measures aimed at early detection and prevention of exacerbations, complications and chronicity of diseases, disabilities that cause maladjustment 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 the state of health, 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 medical nutrition, physiotherapy exercises, medical massage and other therapeutic and prophylactic methods of health improvement, spa treatment.
4. Carrying out medical and psychological adaptation to changes in the situation in the state of health, the formation of correct perception and attitude to 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, maintaining residual working capacity and the ability to adapt in a social environment, creating conditions for optimal life support for patients and disabled people (for example: architectural and planning solutions and the creation of appropriate conditions for persons with disabilities, etc.).

Tertiary prophylaxis - rehabilitation (syn. Health restoration) (Rehabilitation) - a complex of medical, psychological, pedagogical, social measures aimed at eliminating or compensating for disabilities, lost functions in order to restore social and professional status as fully as possible, prevent relapses and chronic disease ...

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

1. Teaching patients and their family members knowledge and skills related to a specific disease or group of diseases.
2. Conducting clinical examination of patients with chronic diseases and invalids, including dispensary medical examinations in order to assess the dynamics of the state of health and the course of diseases, the implementation of permanent monitoring of them and the implementation of adequate treatment and rehabilitation measures.
3. Carrying out medical and psychological adaptation to changes in the situation in the state of health, the formation of correct perception and attitude to the changed capabilities and needs of the body.
4. Carrying out measures of state, economic, medico-social nature, aimed at reducing the level of influence of modified risk factors; preservation of residual working capacity and the ability to adapt in the social environment; creation of conditions for optimal support of the life of patients and disabled people (for example, the production of medical food, the implementation of architectural and planning solutions, the creation of appropriate conditions for people 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.

Population strategy is about changing the lifestyle and environmental factors associated with diseases, as well as their social and economic determinants. The main areas of activity are monitoring of HNIZs and their risk factors, policy, legislation and regulation, intersectoral cooperation and partnership, public education, involvement of the media, and the formation of healthy lifestyles. The implementation of this strategy is primarily the task of the government and legislative bodies of the federal, regional and municipal levels. The role of physicians comes down mainly to initiating these actions and analyzing the ongoing processes.

The formation of a healthy lifestyle, which presupposes a well-organized propaganda of medical and hygienic knowledge in combination with some organizational measures, is a highly effective measure that makes it possible to reduce the level of morbidity and associated labor losses, contributes to an increase in the body's resistance to various adverse influences.

One of the leading directions in the formation of a healthy lifestyle is the fight against smoking. Smokers are sick more often and for a longer time, among them the level of temporary and permanent disability is significantly higher, they use inpatient and outpatient treatment more intensively. It is necessary to pay great attention to such problems as the use of alcohol and drugs. Therefore, measures to promote mental and sexual health are important components of a healthy lifestyle. Chronic fatigue is also an urgent problem in our society, people should undergo regular medical examination and treatment of chronic fatigue.

A prerequisite for a healthy lifestyle is a proper balanced diet. The basic principles of good nutrition must be followed:

energy balance of the diet (compliance of energy consumption with energy consumption);

balance of the diet for the main components (proteins, fats, carbohydrates, trace elements, 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 massive - primary health care for the population.

The success of a population strategy to reduce smoking, excess alcohol consumption and road traffic accidents can be achieved with improvements and strict adherence to 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, staying in extreme conditions, etc.)

The high-risk strategy consists of identifying individuals at high risk of disease by primary health services, assessing the degree of risk and correcting this risk through recommendations for improving lifestyle or the use of medication and non-medication.

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

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

Human health is largely determined by his behavioral habits and the response of society to personality behavior in relation to health. Behavioral change intervention can mobilize enormous resources and is one of the most effective ways to improve health.

Reducing the incidence of disease can be achieved by using several approaches. Medical Approach is aimed at the patient, its goal is to prevent the exacerbation of the disease (for example, emergency care for patients with coronary artery disease). Group-centered approach high risk , identifies individuals at high risk and provides intensive prophylaxis in this group (eg, hypertension screening and follow-up treatment). Primary prevention is an attempt to reduce morbidity by targeting a large number of people with a relatively low level of risk (for example, popularizing a low-fat diet). An individual approach is implemented through direct contact with the patient on lifestyle issues and covers the entire spectrum of problems (nutrition, physical activity, etc.).

Using the set strategies increases the effectiveness of prevention programs. Different approaches are needed to ensure systemic and individual changes. Using only one strategy is not enough, since many factors affect health.

The main strategies in the field of disease prevention and health promotion are:

- changing conditions and social norms (participation of the press, local organizations, leaders);

Gain health promotion policies(prohibition of smoking, ensuring safety in the workplace, etc.);

- economic incentives(taxes on cigarettes, fines for violation of workplace safety rules, etc.);

- increasing the level of knowledge and skills(educational campaigns, screening and follow-up);

Health care system ( education of the population on health issues using the developed recommendations);

- educational institutions, workplaces (educational programs for children and adults on healthy lifestyles);

- public organizations(organize meetings, gatherings, press appearances on health protection and promotion);

Other possibilities.

The use of various programs is not complete without participation in them medical professionals, so at nurses / paramedics a basic understanding of the possible scope of programs and the role of health workers in them must be formed. Nurses / paramedics for participation in the programs should be trained in health promotion and protection, psychology, communication, special attention is paid to such issues as planning, communication skills.

The experience of implementing many programs in various countries has demonstrated effectiveness of prevention in reducing morbidity and improving the health of the population.

A document was developed for Russia “ To a healthy Russia: Policy and strategy for the prevention of non-communicable diseases ”(M., 1994), which presents an analysis of the health status of the population according to official statistics, presents recommendations for the prevention of diseases for various groups of the population. The document states that educating the population on a healthy lifestyle should be carried out with the help of differentiated information programs, addressed and adapted to certain groups of the population, taking into account age, education, social status and other characteristics.

An international group of experts developed and adapted a guideline for Russia "Prevention through primary health care", which presents material on various studies in the field of factors affecting health, and also contains recommendations that need to be considered when working with the population. These recommendations are published in the journal "Disease Prevention and Health Promotion" (scientific and practical journal).

Risk factors

RISK FACTOR(risk factor) - a characteristic feature, such as a person's habit (for example, smoking) or exposure to harmful substances in the environment, as a result of which the likelihood of developing a disease in a person increases. This relationship is only one of the possible causes of the development of the disease, therefore, it should be distinguished from the causative factor. (Big explanatory medical dictionary. 2001)

Cause

1) reason, pretext for some action

Example: The serious reason; Laugh for no reason; For this reason ..; for the reason that .., union (book.) - due to the fact that.

2) a phenomenon that causes, causes the occurrence of another phenomenon

Example: Cause of fire; The reason for the rush is that there is not enough time.

The concept of risk factors is one of the most important principles underlying modern ideas about the possibilities and directions of preventive medicine. Apparently, such factors that are associated with a high frequency of certain diseases should be called risk factors. These are factors, the fight against which is aimed at reducing the incidence of diseases, reducing the severity or eliminating certain disease processes. From the huge number of factors, it seems advisable to single out two main groups of risk factors that are important for the implementation of preventive measures.

The first group of socio-cultural risk factors include:

sedentary (inactive) lifestyle, including in free time from work;
conditions of modern life saturated with stresses and conflicts;
poor nutrition;
ecological imbalance;
unhealthy lifestyle, including bad habits.

The second group - internal risk factors represent certain physiological and biochemical changes in the human body (obesity, high blood pressure, increased blood cholesterol, etc.). The manifestation of many of these intrinsic factors can be associated with genetic characteristics (hereditary predisposition).

Some features of risk factors:

their effect on the human body depends on the degree, severity and duration of the action of each of them and on the reactivity of the organism itself;
some of the risk factors are in causal relationships in the formation of diseases. For example, poor nutrition, being a risk factor, contributes to the emergence of another risk factor - obesity;
many risk factors start to affect in childhood. Therefore, preventive measures should be carried out as early as possible;
the likelihood of developing the disease increases significantly with the combined effects of risk factors. Example: if smoking increases the likelihood of oncological diseases by 1.5 times, and alcohol abuse - by 1.2, then their combined effect - by 5.7 times;
identification of risk factors is one of the main tasks of preventive medicine, the purpose of which is to eliminate the existing risk factor or weaken its effect on the human body;
usually, the same person has not one, but a combination of risk factors, in connection with which we are often talking about multifactorial prevention.

There are quite a few risk factors. Some of them are specific for the development of certain diseases, for example, an excess of table salt with hypertension or an excess of high-calorie food, rich in cholesterol, with atherosclerosis. The most practically significant risk factors include:

heredity;
stressful influences;
poor nutrition;
low physical activity;
ecological imbalance;
Unhealthy Lifestyle;
bad habits;
obesity.

Disease risk factors - these are factors that increase the likelihood of a particular disease. The main risk factors are given in table. 1.