THE FIFTH COMMANDMENT

Thou shalt treat according to level of risk and not to level of risk factor

Treating asymptomatic individuals to prevent future adverse events requires a different and longer process of information sharing than treating uncomplicated acute illness. It needs to be based on more rigorous evidence about benefits and harms, especially as these apply to each individual.
Lifelong intervention should be determined by the importance of the outcome to each person, not by the extrapolated reduction of events in the population as a whole. People vary widely in their attitudes to the avoidance of death, myocardial infarction, stroke, or various kinds of cancer, and also in how they weigh the adverse effects of treatment.
The offer of preventive treatment — whether primary or secondary — needs to be made in the context of these individual goals, which can change over time. It should not be addressed to the reduction of a single risk factor but to the totality of risk for a particular outcome. For example, if a person is interested in avoiding coronary heart disease, risk factors need to be explored individually and then aggregated (approximately) using a scoring system. This can then inform a discussion about the various elements of this risk and how it can be reduced using a variety of non- drug and drug interventions. Moreover, such estimates may come up with curious findings; for example, that a statin might provide the best strategy in a high-risk person with a ‘normal’ LDL-cholesterol level.
All drug interventions to reduce risk factors have potential harms and rarely reduce risk in simple relation to reductions in the risk factor (or surrogate marker).

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The Absolute CVD Risk/Benefit Calculator

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