<International Circulation>: It seems that in China the two options would be salt substitution and then screening. Could you comment on what screening would entail?

　　《国际循环》：看起来中国的两个做法是使用盐替代品和筛查。关于筛查您是怎么看的？
　　Dr. Gaziano：We looked at screening frequencies anywhere from yearly to every five years evaluating patients between the ages of 25 and at least 74 for risk factors that are non-laboratory based so it could be done in the village with a community health worker or a physician or a nurse， but it doesn’t require lab testing. We assess blood pressure， assess any history of diabetes， smoking status， measure BMI and age for both males and females. Using a physician’s or nurse’s time， that can be from ＄3 to ＄5. You can do self-assessment， if someone can fill in a form and has access to an electronic blood pressure cuff. In higher income countries or in urban centers in developing countries you will find people who have automatic blood pressure devices attached to pharmacies. So it is anywhere up to ＄5 for a screening. Those people who were identified at high risk， a 25%-30% ten-year risk， would be recommended for therapy for blood pressure. Currently， 40% of the global population in the developing countries is aware of hypertension. That is by gaining access to screening. We would like to increase that up to 60% or 70% in the high income countries， ideally 100% where there is screening for at least one of these risk factors at least once a year. The rule of thumb in developing and developed countries has been that for every person that is aware of their diagnosis， about half of them are treated. Once initiating that treatment， the effectiveness of that treatment is about 50% achieving goal. They don’t have to achieve the goal mind you. Even with reductions in 5mmHg or 10mmHg where their overall risk is quite high， they still get significant reduction in risk; maybe a 5-10 times reduction in blood pressure than they would get from the salt strategy we have analyzed. It is a little more expensive to do the screening strategy but in identifying the high risk people， the gains are far more significant. And it is politically less sensitive. Most countries have adopted the WHO/ISH Guidelines on screening for blood pressure and cardiovascular disease as part of their national guidelines as is the case in China. We think the best option is for a non-lab strategy of identifying people and allowing it to be done at the same site as the visit because if you measure someone’s cholesterol， they may never come back or there may not be the availability of a lab at the particular site whether it be in rural China or somewhere in Africa. This allows for easy identification of people and for the decision regarding treatment to be made on the spot at that visit. That will improve compliance on treatment. These are two of the strategies. We didn’t talk about adding cholesterol-lowering medication among these high-risk people. It would have the same screening cost and if you identify someone and added a statin， you get a further reduction of 20% or more in those high-risk individuals. That would give you another 2-3% towards the 25% goal if you added that in a polypill form or as separate medication. Even in the US， statins have fallen in price from ＄1000 to ＄90 and in developing countries such as India for example， you can get a year’s supply of statin for under ＄10. It makes a big difference. It is not quite in line with antihypertensive prices but it is close.

　　Gaziano博士：我们在观察筛查频率是多少更为合适。我们观察了各地25-74岁人群的危险因素，筛查频率为每年一次到每五年一次。所观察的危险因素不需要实验室检查，因此我们能够在社区健康工作者、医生或护士的帮助下在村庄里完成筛查。我们评价了男性和女性的血压、糖尿病史、吸烟情况，测定了体重指数，记录年龄。我们付给医生或护士的劳务费从3美元到5美元不等。如果有人能够自己填表，同时又电子血压计的话，也可以完成自我评估。在高收入国家或发展中国家的城市，药房设有自动血压仪。筛查一次的费用最多是5美元。那些被检查出心血管风险较高的患者，即10年心血管风险为25~30%，会被推荐进行降压治疗。当前，发展中国家40%的人群知晓高血压。这是得益于心血管风险的筛查。在高收入国家，我们期望这一比例能够提高到60~70%，理想情况下是达到100%，至少每年一次筛查至少一个危险因素。对于发展中国家和发达国家来说，经验都是让每一个人都知晓自己患了病，其中半数的人得到治疗。一旦开始治疗，血压达标的患者比例为50%。需要注意的是，高血压患者不是非得达标才能获益。即便是血压降低只有5或10 mm Hg，此时风险还是相当高，但是患者的风险已经下降很多了。降压的心血管获益是限制盐摄入时获益的5~10倍。实施筛查的花费要高一些，但是通过筛查发现高危人群的获益更为显著。筛查在政治上也不那么敏感。大多数国家将世界卫生组织/国际高血压学会（WHO/ISH）的高血压和心血管疾病筛查指南融为国家指南的一部分，中国也是如此。
　　我们认为，最理想的方法是采用非实验室手段来筛查人群，在与随访相同的地点开展筛查，因为如果筛查的是血脂的话，被筛查的人有可能永远也不会再来同一个地点就诊。另外，无论在中国农村还是在非洲的某些地区，可能不设有实验室。采取非实验室手段完成筛查使得我们能够轻松地检出有风险的人群，还能使我们在随访的现场做出相应的治疗决策。我们这里说的不是给高危人群处方降脂药。事实上，筛查的花费是相同的。如果发现一个高血脂的人并给他服用他汀的话，可以使心血管风险高的人风险进一步降低20%或更多。如果处方的是含他汀的复方制剂的话，还可以使风险再降低2~3%，这样就离风险降低25%的目标值更近了一步。即使是在美国，他汀的价格已经从最初的1000美元降低到90美元。在印度等发展中国家，吃一年他汀的花费还不到10美元。吃他汀会带来很大的改变。他汀的费用虽然不是与降压药物相同的，但是两者的费用是接近的。

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