Clinicum, Department of Public Health, University of Helsinki, Helsinki, Finland.
Clinicum, Department of Public Health, University of Helsinki, Helsinki, Finland; Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland.
Lancet Public Health. 2019 Apr;4(4):e189-e199. doi: 10.1016/S2468-2667(19)30023-4.
Clinical guidelines suggest preventive interventions such as statin therapy for individuals with a high estimated 10-year risk of major cardiovascular events. For those with a low or intermediate estimated risk, risk-factor screenings are recommended at 5-year intervals; this interval is based on expert opinion rather than on direct research evidence. Using longitudinal data on the progression of cardiovascular disease risk over time, we compared different screening intervals in terms of timely detection of high-risk individuals, cardiovascular events prevented, and health-care costs.
We used data from participants in the British Whitehall II study (aged 40-64 years at baseline) who had repeated biomedical screenings at 5-year intervals and linked these data to electronic health records between baseline (Aug 7, 1991, to May 10, 1993) and June 30, 2015. We estimated participants' 10-year risk of a major cardiovascular event (myocardial infarction, cardiac death, and fatal or non-fatal stroke) using the revised Atherosclerotic Cardiovascular Disease (ASCVD) calculator. We used multistate Markov modelling to estimate optimum screening intervals on the basis of progression rates from low-risk and intermediate-risk categories to the high-risk category (ie, ≥7·5% 10-year risk of a major cardiovascular event). Our assessment criteria included person-years spent in a high-risk category before detection, the number of major cardiovascular events prevented and quality-adjusted life-years (QALYs) gained, and screening costs.
Of 6964 participants (mean age 50·0 years [SD 6·0] at baseline) with 152 700 person-years of follow-up (mean follow-up 22·0 years [SD 5·0]), 1686 participants progressed to the high-risk category and 617 had a major cardiovascular event. With the 5-year screening intervals, participants spent 7866 (95% CI 7130-8658) person-years unrecognised in the high-risk group. For individuals in the low, intermediate-low, and intermediate-high risk categories, 21 alternative risk category-based screening intervals outperformed the 5-yearly screening protocol. Screening intervals at 7 years, 4 years, and 1 year for those in the low, intermediate-low, and intermediate-high-risk category would reduce the number of person-years spent unrecognised in the high-risk group by 62% (95% CI 57-66; 4894 person-years), reduce the number of major cardiovascular events by 8% (7-9; 49 events), and raise 44 QALYs (40-49) for the study population.
In terms of timely preventive interventions, the 5-year screening intervals were unnecessarily frequent for low-risk individuals and insufficiently frequent for intermediate-risk individuals. Screening intervals based on risk-category-specific progression rates would perform better in terms of preventing major cardiovascular disease events and improving cost-effectiveness.
Medical Research Council, British Heart Association, National Institutes on Aging, NordForsk, Academy of Finland.
临床指南建议对具有高估计的 10 年内发生主要心血管事件风险的个体进行预防干预，如他汀类药物治疗。对于低或中估计风险的个体，建议每 5 年进行一次风险因素筛查；该间隔是基于专家意见而不是直接研究证据。利用心血管疾病风险随时间进展的纵向数据，我们根据及时发现高危个体、预防心血管事件和医疗保健成本，比较了不同的筛查间隔。
我们使用了英国白厅二期研究（基线时年龄为 40-64 岁）参与者的重复生物医学筛查数据，这些参与者每 5 年进行一次筛查，并且在基线（1991 年 8 月 7 日至 1993 年 5 月 10 日）和 2015 年 6 月 30 日之间将这些数据与电子健康记录相链接。我们使用改良的动脉粥样硬化性心血管疾病（ASCVD）计算器估计参与者发生主要心血管事件（心肌梗死、心源性死亡和致命或非致命性卒中）的 10 年风险。我们使用多状态马尔可夫模型来估计最佳筛查间隔，该间隔基于从低风险和中低风险类别进展到高风险类别（即，主要心血管事件风险为 7.5%以上的 10 年）的进展率。我们的评估标准包括在检测到之前处于高风险类别的人年数、预防的主要心血管事件数和获得的质量调整生命年（QALY）以及筛查成本。
在 6964 名参与者（基线时平均年龄为 50.0 岁[SD 6.0]）中，有 152700 人年的随访（平均随访 22.0 年[SD 5.0]），有 1686 名参与者进展到高风险类别，617 名参与者发生主要心血管事件。采用 5 年筛查间隔，参与者有 7866（95%CI 7130-8658）人年未被识别出处于高风险组。对于低、中低和中高风险类别的个体，21 种替代风险类别为基础的筛查间隔优于 5 年筛查方案。对于低、中低和中高风险类别的个体，7 年、4 年和 1 年的筛查间隔将使处于高风险组的未被识别的人年数减少 62%（95%CI 57-66；4894 人年），减少 8%（7-9）的主要心血管事件数，并且提高 44 个质量调整生命年（40-49）的研究人群。
在及时的预防干预方面，5 年的筛查间隔对低风险个体过于频繁，对中风险个体则不够频繁。基于风险类别特定进展率的筛查间隔在预防主要心血管疾病事件和提高成本效益方面将表现更好。
医学研究委员会、英国心脏协会、美国国立老化研究所、北欧研究与合作基金会、芬兰科学院。
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