Norway's new principles for primary prevention of cardiovascular disease: age differentiated risk thresholds

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Abstract
Norway decided not to follow European guidelines on preventing cardiovascular disease and instead developed its own with age based thresholds. Ole Norheim and colleagues explain the rationale behind them European Society for Cardiology guidelines on preventing cardiovascular disease in clinical practice classify most elderly people at high risk of cardiovascular disease and lead to widespread prescription of drugs for prevention.1 General practitioners in the Nordic countries have repeatedly expressed concern at this advice for reasons including increased workload for physicians, time and prescription costs, the risk of medicalisation of healthy people, and the risk of undermining patients’ informed choice.2 3 4 5 6 On the other hand, cardiologists and other specialists point to the overwhelming evidence supporting use of statins and other drugs for prevention in terms of lower morbidity and mortality.7 During the past decade, various guidelines for cardiovascular prevention were presented in Norway, with diverging recommendations on the thresholds for starting drug treatment. General practice specialist organisations and hospital specialists held contradictory views, both in Norway and within Europe.2 The Norwegian health directorate found this situation unsatisfactory and invited key stakeholders to develop new national guidelines for general practitioners and other specialists prescribing primary prevention. The guidelines, published and implemented in 2009, adopt a new approach using differentiated risk thresholds according to age.8 This article describes the process and reasons underlying the choices made. The Norwegian primary prevention guidelines group was established in 2004 and agreed on key principles for the development of new recommendations. We agreed that the process should be evidence based and combined with a systematic and transparent approach. To clarify disagreement, all stakeholders were asked to explain their arguments and acknowledge medical evidence, evidence on cost effectiveness, and health policy and ethical concerns. Recommendations on treatment thresholds are arguably …