What Is the Best Mix of Population‐Wide and High‐Risk Targeted Strategies of Primary Stroke and Cardiovascular Disease Prevention?

I n arguably the most influential public health article ever written, “Sick Individuals and Sick Populations,” Geoffrey Rose described and appraised 2 mainstream strategies for primary prevention of disease: (1) the “high-risk” strategy, where the preventative strategy seeks to identify high-risk susceptible individuals to offer them some individual protection; and (2) the population “mass” strategy aimed to reduce the mean level of the determinants of disease, and thereby the incidence of disease, in the population as a whole. He concluded that a “high-risk” strategy is needed only as long as the underlying causes of incidence remain unknown or uncontrollable, and the priority in primary prevention should always be the discovery and control of the causes of incidence to shift the whole distribution of exposure in a favorable direction via a population strategy. For the primary prevention of stroke and cardiovascular disease (CVD), the value of population screening to identify individuals at high risk of CVD was first publicly debated almost 20 years later. Jackson et al, the proponents of the high-risk strategies argued that the key for preventing CVD is well-targeted treatment with safe, inexpensive and effective drugs for patients at high risk and that this approach is more effective than population-wide interventions, such as reducing salt intake and managing obesity. However, it was argued by Capewell, the opponent of the high-risk strategy, that the “high-risk” approach lacks effectiveness and is associated with low uptake of the screening, inaccuracy of the CVD risk scoring systems in estimating an individual patient’s risk, low adherence to treatment, medicalization of individuals, and high cost. He warned that perhaps the greatest harm arising from the “high-risk” strategies is misleading health professionals and politicians into thinking they can tick the box “mission accomplished” (screening completed) and the problem of CVD prevention is solved. Therefore, the best strategy for preventing CVD is policy interventions aimed at reducing key modifiable CVD risk factors across whole populations. However, at the time of the debate there was no robust evidence for or against either of these strategies. As the global burden and cost of stroke and CVD is increasing, it is timely and necessary to critically review the current strategies of stroke and CVD prevention in light of the available evidence to inform future directions in primary stroke and CVD prevention (see Tables 1 and 2 for “Aims of This Viewpoint” and “Search and Selection Criteria”). From the National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand (V.L.F.); Department of Neuroscience and Preventive Medicine, President of the World Stroke Organization, Danube University Krems, Austria (M.B.); Department of Clinical Sciences, Department of Neurology, Sk ane University Hospital, Lund University, Lund, Sweden (B.N.); Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.B.G.); Population Health Research Institute, McMaster University of Health Sciences and Hamilton University, Hamilton, Ontario, Canada (P.B.G.); Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universit€at LMU, Munich, Germany (M.D.); Munich Cluster of Systems Neurology (SyNergy), Munich, Germany (M.D.); Beijing Neurosurgical Institute, Capital Medical University, Beijing, People’s Republic of China (W.W.); National Office for CVD Prevention and Control, National Health Commission, Beijing, China (W.W.); Department of Neurology, Christian Medical College, Ludhiana, Punjab (J.D.P.); Brazilian Stroke Network President, Hospital de Cl ınicas de Porto Alegre, Hospital Moinhos de Vento, Porto Alegre, Brazil (S.C.O.); Center for Genomic and Precision Medicine, University of Ibadan, Ibadan, Oyo, Nigeria (M.O.O.); University College Hospital, Ibadan, Oyo, Nigeria (M.O.O.); Blossom Center for Neurorehabilitation, Ibadan, Nigeria (M.O.O.); National Heart and Lung Institute, Imperial College London, London, United Kingdom (D.A.W.); National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Ireland (D.A.W.); Medical School, The University of Western Australia, Perth, Australia (G.J.H.). Correspondence to: Valery L. Feigin, MD, PhD, FAAN, FRSNZ, FRAS, National Institute for Stroke and Applied Neurosciences, School of Public Health and Psychosocial Studies, Faculty of Health and Environmental Sciences, AUT University, 90 Akoranga Dr, Northcote, Auckland 0627, New Zealand. E-mail: valery.feigin@aut.ac.nz and Michael Brainin, MD, PhD, Department of Neuroscience and Preventive Medicine, President of the World Stroke Organization, Danube University Krems, Krems, Austria. Email: michael.brainin@donau-uni.ac.at J Am Heart Assoc. 2020;9:e014494. DOI: 10.1161/JAHA.119.014494. a 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.