What is the effectiveness of systematic population-level screening programmes for reducing the burden of cardiovascular disease? Summary

iWHO HEALTH EVIDENCE NETWORK SYNTHESIS REPORT 71 What is the effectiveness of systematic population-level screening programmes for reducing the burden of cardiovascular diseases? Christian Ulrich Eriksen | Oxana Rotar | Ulla Toft | Torben Jørgensen The Health Evidence Network The Health Evidence Network (HEN) is an information service for public health decision-makers in the WHO European Region, in action since 2003 and initiated and coordinated by the WHO Regional Office for Europe under the umbrella of the WHO European Health Information Initiative (a multipartner network coordinating all health information activities in the WHO European Region). HEN supports public health decision-makers to use the best available evidence in their own decision- making and aims to ensure links between evidence, health policies and improvements in public health. The HEN synthesis report series provides summaries of what is known about the policy issue, the gaps in the evidence and the areas of debate. Based on the synthesized evidence, HEN proposes policy considerations, not recommendations, for policy-makers to formulate their own recommendations and policies within their national context. The Noncommunicable Diseases Integrated Prevention and Control programme The Noncommunicable Disease Integrated Prevention and Control programme of the WHO Regional Office for Europe has three main functions: leading the integrated response of policies to address noncommunicable diseases (NCDs) at the regional and country levels; managing the major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) across the continuum of care from prevention to early detection, screening, diagnosis, treatment, rehabilitation, secondary prevention and end-of-life/palliative care; and leading the NCD health systems response. It focuses on priority action areas and interventions in order to achieve regional and global targets to reduce premature mortality, reduce the disease burden, improve the quality of life and make healthy life expectancy more equitable, as called for in the WHO strategies and action plans for NCD prevention and control in particular and for sustainable development in general. WHO Health Evidence Network synthesis report 71 What is the effectiveness of systematic population-level screening programmes for reducing the burden of cardiovascular diseases? Christian Ulrich Eriksen | Oxana Rotar | Ulla Toft | Torben Jørgensen © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Eriksen CU, Rotar O, Toft U, Jørgensen T. What is the effectiveness of systematic population- level screening programmes for reducing the burden of cardiovascular disease? Copenhagen: WHO Regional Office for Europe; 2020 (WHO Health Evidence Network (HEN) Evidence Synthesis Report 71). Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Printed in Luxembourg Document number: WHO/EURO:2020-1708-41459-56525 vSUMMARY The issue Cardiovascular diseases (CVDs) are the main cause of death in the WHO European Region, accounting for nearly 4 million deaths (43% of all deaths) in 2016. Population- level screening is a public health strategy to reduce the burden of disease in society by identifying and managing preclinical disease or the risk factors of disease. In the screening pathway, early identification in people who have not sought medical attention for CVD symptoms is followed by appropriate management of positive cases. Several studies that examined systematic screening programmes for reducing the CVD risk in general populations have questioned their effectiveness. Therefore, a comprehensive analysis of the current evidence on the CVD burden and the impact and potential adverse effects of screening for CVD risk factors and preclinical CVDs (including health economic considerations) is needed to inform national and regional decision-makers about feasible interventions for national screening programmes. The synthesis question The objective of this report is to address the question: "What is the effectiveness of systematic population-level screening programmes for reducing the burden of cardiovascular diseases?" Types of evidence A systematic review of peer-reviewed and selected grey literature in English and Russian was conducted between March and May 2020 to identify population-level randomized controlled trials (RCTs) examining the impact of screening for CVD risk factors (both behavioural factors (smoking, harmful use of alcohol, unhealthy nutrition and physical inactivity) and biological factors (high blood pressure, raised blood sugar, dyslipidaemia and raised body mass index)) preclinical CVD conditions (abdominal aortic aneurysm (AAA), atrial fibrillation (AF), peripheral arterial disease (PAD), coronary artery calcification (CAC) and carotid plaques (CPs)) on reducing the CVD burden (mortality, morbidity and costs) in general populations. No geographical or time limits were applied and only RCTs that included randomization, interventions related to CVD risk factors and/or preclinical CVD conditions and impact analysis at a population level were considered. WHAT IS THE EFFECTIVENESS OF SYSTEMATIC POPULATION-LEVEL SCREENING PROGRAMMES FOR REDUCING THE BURDEN OF CARDIOVASCULAR DISEASES? WHO HEALTH EVIDENCE NETWORK SYNTHESIS REPORT vi Results A total of 33 studies were identified; these related to 22 RCTs, of which 14 focused on screening for CVD risk and CVD risk factors (two ongoing), four on AAA, two on AF (both ongoing) and two on a combination of preclinical CVDs (one ongoing). Following an assessment of methodological quality, all studies were included in a narrative synthesis, and a subset of studies with appropriate outcome data were included in a series of meta-analyses. In addition, one case study from Sweden was selected to illustrate a possible model for a population-level screening programme for AAA. Based on several high-quality RCTs that included a large number of participants, the overall results clearly showed that screening for CVD risk and CVD risk factors has had no impact on lowering CVD morbidity and mortality in the general population. Moreover, serious adverse effects were identified (e.g. increased mortality). These studies were primarily conducted in western European countries, and the evidence can be difficult to transfer to other settings, such as south-eastern Europe and the Commonwealth of Independent States (CIS), owing to differences in national health-care systems and disease burdens. However, no high-quality RCTs have been conducted in these parts of the WHO European Region. There is, therefore, no evidential basis to recommend population-level screening for CVD risk and CVD risk factors in Member States of the Region. At present, the benefit of screening for AAA is uncertain. Although some studies have reported reductions in AAA-related negative outcomes, there was no reduction in total mortality. However, recent changes in risk factors and less traumatic treatment may negate the apparent effects of AAA screening. Similarly, the results of ongoing population-level RCTs are needed to establish whether screening for AF can lower the CVD burden. Although one study on screening for a combination of preclinical CVDs showed promising results for reducing mortality, more evidence is needed to determine the effect of such programmes. Policy considerations Based on the review findings, the main policy considerations for Member States of the WHO European Region are to: • review existing systematic population-level screening programmes for CVD risk and CVD risk factors (if such already exist), avoid initiating new vii screening programmes for CVD risk and CVD risk factors, and consider alternative methods to achieve the desired outcomes in reducing the CVD burden; • re-evaluate current systematic population-level programmes for screening for AAA, taking into account the changes in risk factors and improved treatment; and • await the results of population-level RCTs on the effectiveness of screening for AF and other preclinical CVDs before considering the implementation of such programmes. World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int WHO/EURO:2020-1708-41459-56525