The impact of clinical and population strategies on coronary heart disease mortality: an assessment of Rose’s big idea

BACKGROUND: Coronary heart disease (CHD), the leading cause of death worldwide, has declined in many affluent countries but it continues to rise in industrializing countries. OBJECTIVE: To quantify the relative contribution of the clinical and population strategies to the decline in CHD mortality in affluent countries. DESIGN: Meta-analysis of cross-sectional and prospective studies. DATA SOURCES: PubMed and Web of Science from January 1, 1970 to December 31, 2019. METHOD: We combined and analyzed data from 22 cross-sectional and prospective studies, representing 500 million people, to quantify the relative decline in CHD mortality attributable to the clinical strategy and population strategy. RESULT: The population strategy accounted for 48% (range = 19 to 73%) of the decline in CHD deaths and the clinical strategy accounted for 42% (range = 25 to 56%), with moderate inconsistency of results across studies. CONCLUSION: Since 1970, a larger fraction of the decline in CHD deaths in industrialized countries was attributable to reduction in CHD risk factors than medical care. Population strategies, which are more cost-effective than clinical strategies, are under-utilized.