A Public Health Action Plan to Prevent Heart Disease and Stroke

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Section 1. Heart Disease and Stroke Prevention: Time for Action

Evolution of Prevention Policy

As our knowledge about CVD has grown during the past half–century, our policies for preventing heart disease and stroke have also advanced.³ The first recommendations appeared in 1959 in A Statement on Arteriosclerosis: Main Cause of "Heart Attacks" and "Strokes," which was signed by five past presidents of the American Heart Association.²⁶ Citing studies published in the 1950s, this report identified most of the same risk factors discussed here as the focus for preventive measures to be taken by patients and their physicians. 

A wealth of recommendations has appeared subsequently. For example, the 1972 report from the Inter–Society Commission for Heart Disease Resources, Primary Prevention of the Atherosclerotic Diseases, recommended "a strategy of primary prevention of premature atherosclerotic diseases be adopted as long–term national policy for the United States and to implement this strategy that adequate resources of money and manpower be committed to accomplish: changes in diet to prevent or control hyperlipidemia, obesity, hypertension and diabetes; elimination of cigarette smoking; [and] pharmacologic control of elevated blood pressure."²⁷ 

The Cardiovascular Disease Unit of the World Health Organization and the International Heart Health Conferences also have issued recommendations, usually addressing international and global concerns.^3,28 Recommendations have been published by the American Heart Association/American Stroke Association, the American College of Cardiology, and the National Heart, Lung, and Blood Institute, including clinical practice guidelines for detecting and treating risk factors and preventing heart disease and stroke.³ 

In 1994, an important predecessor to the present plan was published by the CVD Plan Steering Committee,* Preventing Death and Disability from Cardiovascular Diseases: A State–Based Plan for Action.²⁹ This document was a call to the states to expand their capacity and obtain additional resources so they could develop the infrastructure needed to achieve the year 2000 objectives for CVD prevention and control. By outlining basic functions for CVD programs and strategies for building capacity, this report contributed directly to implementation of CDC's state heart disease and stroke prevention program in 1998. It also indicated the value of partnership and collaborative in producing a policy document with broad support, based on the contributions of participating members. 

In this extensive body of policy documents, what is advised for preventing heart disease and stroke? Two main approaches have been recommended—interventions addressing individuals and interventions addressing whole populations.³⁰ The individual or "high–risk" approach centers either on people with CVD risk factors but no evident disease or on those with CVD, including survivors of CVD events. For people with risk factors but no recognized disease, "primary prevention" is intended to prevent a first heart attack or stroke by detecting and treating risk factors. For people with known CVD, "secondary prevention" is intended to reduce the risk for subsequent heart attacks or strokes by treating CVD and the risk factors. Both aspects focus on individual risk. The "population–wide" approach, which focuses on a whole population or community, recognizes that the excess risk for heart disease and stroke is widely distributed in the population, with most victims having moderate, rather than extreme, risk. Therefore, even modest change in average risk in the whole population, achievable through means such as public education, can markedly reduce the risk for CVD events. 

A third approach aims to prevent CVD risk factors in the first place. Sometimes called "primordial prevention," this plan uses the term "CVH promotion."³¹ This approach is most widely applicable in populations where social and economic development has yet to progress to the point of fostering epidemic occurrence of the major risk factors. CVH promotion also encompasses interventions aimed at individuals at any age who have not yet developed treatable levels of CVD risk factors because the interventions occur before the risk factors begin to cause or accelerate atherosclerosis. Such intervention should occur in childhood or even, as recent research suggests, during gestation (to improve the fetal environment).³² These interventions should continue throughout adulthood to prevent risk factors from ever developing. 

Despite the many policy recommendations made since the 1950s, practice has lagged far behind. Assessments in recent years have consistently shown that doctors and patients have not adhered well to treatment guidelines for secondary prevention.³³ Although well–supported and detailed policies for preventing heart disease and stroke have long been available, the actions recommended in these policies have, to a large degree, not been followed. Action is needed to support their effective implementation.

* Members represented the American Heart Association/American Stroke Association, the Association of State and Territorial Directors of Health Promotion and Public Health Education, the Association of State and Territorial Public Health Nutrition Directors, CDC, the Chronic Disease Directors, and the National Heart, Lung, and Blood Institute.

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Date last reviewed: 05/12/2006
Content source: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion