Coronary heart disease (CHD) is the most frequent cause of deaths in middle age (and beyond) in the UK. Many of these premature deaths are preventable. Practical prevention measures are well known and have been the subject of committee reports in many countries. In the UK there were major reports from the Department of Health and Social Security (1974) and from the Joint Working Party of the Royal College of Physicians and the British Cardiac Society (RCP/BCS) in 1976. Little action has followed either report and their simple recommendations on diet, smoking and lifestyle have not been implemented. Thus these avoidable premature deaths continue in epidemic proportions, causing family misery, loss of productive working life and a high cost to the Health Service.
In response to this inaction, the Coronary Prevention Group (CPG) has been formed. Its members and supporters include two doctors who were on the Joint Working Party, as well as agriculturalists, nutritionists, economists, educationists and participants in industry and commerce.
The CPG aims to promote action on the prevention of CHD.
Objectives
- To implement the recommendations of the Joint Working Party of the RCP/BCS and similar recommendations aimed at the prevention of CHD.
- To promote a reduction in smoking, healthier diets, more exercise and a life style more conducive to a low risk of CHD and to better health.
- To encourage the early diagnosis and better treatment of high blood pressure.
- To introduce a national food policy conducive to healthy eating patterns.
- To become a centre for discussion with the government, the food and agricultural industries and others interested in the production of food, its consumption and health.
- To encourage doctors and other health workers to practise and promote prevention of CHD.
- To promote research into both the causes of CHD and the most practical and efficient means of its prevention and control.
| Enough is already known to justify preventive action. There is no reason to delay action. | The CPG has sound reasons which justify immediate action on the prevention of CHD. There remain areas of incomplete knowledge, but this provides no basis for delaying action. More can be learned of the causal mechanisms, the measurement of individual risks and of the efficacy of different preventive measures. However, such information, if available, can only improve the success of prevention; it is not necessary before action is started. |
How big is the problem of CHD?
The facts are formidable.
| CHD is caused by arteries, carrying blood to the lleart being blocked by fatty deposits or a blood clot. | i Most heart attacks are due to disease of the coronary arteries which is caused by deposition of a fatty substance (cholesterol) in the wall of the arteries. This narrows the arteries and, often, with the added complication of a thrombus (blood clot), obstructs the flow of blood. This can cause severe damage to the heart muscle and often sudden death. |
| CHD is the biggest cause of deaths. One man in three or four will die prematurely front heart attack or stroke. | ii CHD is now the commonest cause of death in men after the age of 35, with an increasing death rate in the age group 35-44. Over thirty per cent of deaths from CHD occur before retirement; one man in three or four can expect a heart attack or stroke before the age of 65. Many of these premature deaths are preventable. |
| CHD has increased in yonger men and women. | iii Since the second world war, CHD death rates in the UK have increased, especially in younger men and women. |
| Death rates from CHD vary between and within countries | iv Death rates from CHD vary between and within countries. Scotland and Northern Ireland have among the highest death rates from CHD in the world and are followed closely by England and Wales. Death rates in Japan and the Mediterranean countries are much lower than those of the UK. |
| Some countries’ death rates are falling. | v In the USA, Australia, Canada, Belgium and Finland death rates from CHD are falling, but not in the UK. |
| Intensive study of evidence has shown smoking, raised levels of blood fats and high blood pressure as the major risk factors. | No medical subject has undergone more intensive scrutiny in recent years. A large volume of evidence exists which identifies, strong associations between the incidence of CHD and particular risk factors: smoking, raised levels of blood fats induced by faulty diets, and high blood pressure. This evidence is supported by epidemiological and clinical studies, and by laboratory experiments which have identified and tested possible mechanisms.These associations, however strong and repeatedly found, do riot represent absolute certainty of causation. Such certainty cannot be obtained, even through scientific experiments. However, careful evaluation of accumulating evidence provides increasing confidence that these are valid causal links. |
Cumulative effect of cigarettes, raised cholesterol, and hypertension on the incidence of all CHD – fatal and non-fatal – in men 30-59 years (data from Pooling Pro]ect in USA)
What do other countries’ scientists believe?
| 20 expert committes from many countries have reached a consensus on the risk factors in CHD and have recommended changes to life style. | Since 1968, twenty expert committees from many countries have considered the available evidence and have made recommendations. ions. These committees, which include two front the UK, concluded that sufficient was known of the causes of CHD for them to make recommendations on prevention. These recommendations include action to reduce the risks from smoking, dietary composition, high blood pressure, and physical inactivity. There is a remarkable degree of agreement between the different committees. |
What is the justification for prevention?
| The causes of CHD are environmental thus can be modified. | CHD is due largely to life style. The major risk factors are environmental and can be modified. Such features of CHD as the rapid changes in death rates over time, the differences both between and within countries, and the evidence of changes in death rates in migrant populations all confirm the environmental character of the disease. The scientific basis of, and opportunity for, prevention are clear. Because CHD is the major cause of deaths in the UK, it has a significant impact on the economy. It reduces productive working life and the cost of treatment and rehabilitation are borne by the National Health Service. CHD also leads to much misery in families as a result of the increase in premature deaths. |
| Because the damage to artaries begins in childhood before symptoms appear, prevention must be directed at the whole population and not only to those at high risk. | The damage to arteries begins in childhood. The disease develops slowly over many years, usually without any symptom appearing until the occurrence of a heart attack or sudden death. Prevention should, therefore, be directed at the whole population and not only those who are identified as at high risk. In children, it is possible to prevent the disease from starting. For adults, prevention is aimed at halting the development of the disease. Individuals or groups at high risk f`rom one or more risk factors should receive additional emphasis or attention. |
Should there be proof before preventive action?
| Proof or absole certainty of the causes of CHD cannot be obtained. Action should be based on the best scientific judgement available. The risks are now well accepted, but there are no known risks from simple preventive measures being recommended. | Some argue that preventive action should be delayed until there is proof of both the causes of CHD and the benefits of prevention. However, proof in the sense of absolute certainty can never be obtained, even from scientific experimentation. Further research increases knowledge and the subjective assessment by expert scientists identifies the best of the available knowledge. Most decisions in medicine have to he based on sound judgment on incomplete knowledge. The conclusions and recommendations of the international committees which considered CHD represent the best available scientific judgment and, therefore, represent the most certain knowledge about the causes of CHD. For this reason they are a sufficient basis for action, although it is accepted that further research may contribute new knowledge to modify and improve the present position.The decision to take particular forms of action should be based on an assessment of the risks of CHD and of-any risks from prevention. The evidence clearly indicates high risks from smoking, diet, high blood pressure and inactivity. There is certainly no evidence of unacceptable risks to health which would follow from simple preventive measures. recommended for the prevention of CHD. In countries where the adoption of prevention has been encouraged, death rates have fallen in recent years. |
- An international conference on the prevention of coronary heart disease with co-sponsorship of the World Health Organisation and the International Society and Federation of Cardiology planned back in the spring of 1983. To beheld in the UK.
- A treatise on the scientific evidence for causation and prevention of CHD is being written by the group.
- Research into the economics of CHD and its prevention is being planned in co-operation with departments of’ economics and community medicine in universities.
- The group is being assisted to prepare and make available films for both scientific and lay audiences on the prevention of CHD.
- A regular bulletin and newsletter.
- General education and information leaflets are being prepared I-or distribution in schools, offices and factories, supermarkets, etc. Topics will include the nature and prevention of CHD, who is at risk, changing diets, etc.
- In collaboration with established cookery writers, a book on cat ing for coronary prevention is being written.
- A readily accessible information and reference library for use by professionals and the general public interested in prevention of CHD is being established in the CPG London offices and on HealthPro website.
- In all activities to work closely with related organisations, to include Action on Smoking and Health (ASH), the Health Education Council (HEC), British Heart Foundation (BHF), Chest, Heart and Stroke Association and the International Union of Health Education.