Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. A descriptive epidemiological study

Abstract

OBJECTIVE: Our first objective is to describe total, age- and gender-specific prevalences of subjects in a well-defined population for whom medical follow-up is indicated due to unfavourably high blood pressure and/or cholesterol levels, as defined by the 2003 European guidelines on cardiovascular disease prevention in clinical practice. Our second objective is to highlight scientific questions and ethical dilemmas relating to implementation of the guidelines. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional population study comprising 62104 adult Norwegians aged 20-79 years who participated in The Nord-Tröndelag Health Study 1995--97. MAIN OUTCOME MEASURES: Total, age- and gender-specific point prevalences of individuals with total cholesterol > or =5 mmol/l and/or systolic blood pressure > or =140 mmHg and/or diastolic blood pressure > or =90 mmHg, or taking antihypertensive medication. MAIN RESULTS: In total, 76% of individuals aged 20-79 years have an "unfavourable" cardiovascular disease risk profile, according to guideline definitions. The point prevalence of individuals with cholesterol and/or blood pressure above the recommended cut-off points increases with age. By age 24, the prevalence reaches 50%. By age 49, it reaches 90%. Men below 50 years of age have higher combined risk prevalence than women. CONCLUSIONS AND IMPLICATIONS: Implementation of the 2003 European guidelines on CVD prevention would label a large majority of Norwegian adults as having unfavourably high cholesterol and/or blood pressure levels. The current biomedical standards appear to invalidate demographic health statistics. The theoretical basis on which the guidelines rest should thereby be scrutinized with regard to scientific methodology and consistency. Important ethical dilemmas arise at the point of guideline implementation, relating to risk labelling and medicalization, as well as resource allocation and sustainability within the healthcare system.