Kosteneffektivität der Prävention der koronaren Herzkrankheit in Deutschland

CARRISMA: a new tool to improve risk stratification and guidance of patients in cardiovascular risk management in primary prevention

AIMS

Risk stratification is important for decisions about the intensity of treatment in primary prevention. Risk factors and lifestyle factors are responsible for over 80% of cardiovascular morbidity and mortality. However, body mass index (BMI), physical activity and smoking (cigarettes/day) are not or not quantitatively represented in the risk stratification system.

METHODS AND RESULTS

CARdiovascular RISk MAnagement (CARRISMA) is a software program considering the prognostic impact of BMI, physical activity and cigarettes per day adjusted for age and sex based on multivariate regression analyses from the literature on top of one of the three major scores to improve risk stratification. The 10-year European Society of Cardiology Systematic COronary Risk Evaluation (SCORE) cardiovascular mortality risk for an intermediate risk region, e.g. increases from 3 to 6% by considering smoking of 30 cigarettes per day instead of just 'smoking' and by taking into account a BMI of 34. Whereas the 10-year ESC cardiovascular mortality risk of a 55-year-old active individual decreases from 5 to 3%, by considering a physical activity equivalent of 2100 kcal/week, the Framingham or PROspective CArdiovascular Münster (PROCAM) risks change accordingly.

CONCLUSION

CARRISMA facilitates the application of knowledge of the current literature in the individual patient in a user-friendly manner allowing a more detailed and yet time-efficient risk stratification and risk management in primary prevention, particularly in the intermediate risk range.

Cardiovascular prevention in clinical practice (ESC and German guidelines 2007)

Preventive efforts should be guided by the patient's global cardiovascular (CV) risk. A risk stratification should be done in every person > age 35 with more than a single risk factor. Recommendations for improved lifestyle are applicable to all persons with CV risk factors: smoking cessation, daily exercise, normal body mass index, Mediterranean diet, blood pressure < 140 mmHg systolic, and LDL cholesterol < 130 mg/dl are beneficial. If the 10-year risk is > or = 20% for CV events or > or = 5% for CV death, additional drug interventions are usually necessary: acetylsalicylic acid 100 mg daily, statins to lower LDL cholesterol to < 100 mg/dl or, in diabetics with coronary artery disease, to < 70 mg/dl, blood pressure should be < 130 mmHg systolic, e.g., in patients with diabetes or renal disease. After bare-metal stent implantation clopidogrel should be given for > or = 4 weeks and after drug-eluting stents for > or = 6 months. In patients after myocardial infarction with an ejection fraction of < 40%, ACE inhibitors and beta-blocker should be started. Influenza vaccination improves prognosis in high-risk patients.

[Health in older age: cost of illness and cost-effectiveness of prevention]

The objective of prevention is to avoid or to delay health impairments and diseases. For older people it is important to maintain their independence and to avoid and reduce the need for external help such as nursing care. Good starting points are the strategies for healthy life-style. Physical activity, smoking abstinence, and normal weight have proven to have their positive medical and economic effect on many chronic diseases such as type 2 diabetes mellitus, cardiovascular diseases, and certain types of dementia. The potential of prevention increases as those diseases affect one another. As for other health care, the cost-effectiveness of preventive measures must also be examined. There are few German studies addressing the cost-benefit of the non-medication prevention. Results from international studies can only partly be transferred to the German context. The cost-effectiveness for prevention for elderly people has been very rarely researched. Research in the field of prevention is so far not very well developed as for other health fields. There is a need for more specific research for methods, interventions and target groups. In health economics major challenges arise from different time schedules and various purchasers, as well as from the evaluation of human capital for elderly.