[New concepts of primary prevention require rethinking].

The decline in cardiovascular mortality over the past decades is due to improved survival of patients with clinical events rather than to a declining incidence of these events. As a result, an increased prevalence of chronic coronary artery disease and especially congestive heart failure has been described. Further substantial reductions in coronary artery disease morbidity and mortality can only be anticipated if coronary artery disease is treated before the manifestation of clinical disease. Modern concepts of primary prevention incorporate an individualized approach to risk assessment. Medical history, physical examination, and established laboratory tests are the basic instruments which allow for quantitative risk assessment. Tables and simplified algorithms derived from large clinical trials enable the calculation of intermediate and long-term ("life-time") probability of cardiac events. In this setting of quantitative risk assessment, the importance of some risk factors is increasingly recognized, namely diabetes. Noninvasive diagnostic testing is used to detect preclinical atherosclerotic plaque disease. Direct imaging of coronary and peripheral arteries, the ankle-brachial index, and measurements of C-reactive protein represent novel methods which have become available for further risk stratification. Because they consider the pathophysiology of atherosclerosis and coronary artery disease, these methods may facilitate decision-making regarding preventive treatment in patients who have an intermediate risk on the basis of the traditional risk factors. The modern concept of primary prevention is aimed at identifying subjects whose risk is similarly high as that of patients with clinically established cardiovascular disease. These subjects can then be treated efficiently, and the strict distinction between primary and secondary prevention is blurred.