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Implications for clinicians and policymakers

The current approach combines the absolute risk rule captured by the overall benefit expected from the application of the 2007 ESH/ESC guidelines used as a constraint to design the PB strategy with the application of the peers’ risk previously suggested. Other indices could also serve as constraints, such as the resources allocated to cardiovascular prevention at the scale of a country population, thus determining the maximum allowed number of eligible subjects to be distributed across the pertinent categories of individuals according to the proportional benefit definition.

The PB strategy is based on the discrimination ability of the risk equations used and, similarly to the risk age approach[1], calibration is indeed irrelevant to the rule application. Discrimination has been shown to be consistent across populations despite their different absolute risks[33–40] extending interestingly the potential applications of our methodology to other populations, disregarding the risk estimation system used as long as it has reasonable discriminatory power. Adapting the treatment rule needs to identify the CVD risk thresholds class-specific that lead to save a prefixed proportion of life-years in the years of potential life lost across the categories of individuals; even if the risk equation overestimates or underestimates CVD risk, this proportion would be unaffected. The CVD risk of the individual patient could be referred to the treatment rule established for that risk predictor in the whole country population until suitable coefficients are identified to calibrate the prediction.

Perspectives

Our approach has the merit to highlight several dimensions in the decision process, which can be considered as independent: 1) effectiveness, 2) economics, which is combined with the first dimension into efficiency aspects; and 3) level of evidence: this dimension is illustrated by the fact that when guidelines promoted treating people with BP between 140/90 mm Hg and 160/95 mm Hg, any good level of evidence was lacking[41]. Our modelling approach should take this dimension into account in further developments. In next steps, we envisage demonstrating the generalizability of our approach by adapting the current recommendation to identify the individuals eligible to treatment in the Chilean population.

Conclusion

We propose a new strategy to identify the individuals eligible to treatment defined in terms of the proportional benefit desired (or allowed) both at the scale of a country population and within each category of gender and age of that population. This method allows adapting recommendations to the risk factors profile and the incidence of cardiovascular events of a particular country or region. The PB strategy deals with the risk differences between genders and across ages taking into account the relative weight of CVD events according to the demographic structure instead of the overall population events only.

The Proportional Benefit strategy appears to be less efficient than the 2007 ESH/ESC guidelines. However, it offers an intermediate position with regards to the efficiency expected with the application of the latest ESH/ESC guideline version. Opposite to the treatment preference towards oldest men resulting from historical European recommendations, the PB strategy distributes fairly the benefit expected from treatment to all individuals from a population, regardless their age or gender. These contradictory pictures add new evidence to be balanced in decision-making: which price are we willing to pay for equity?

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