Between January 2007 and December 2012, we conducted a screening campaign in the western suburbs of Paris (the CARVAR 92 study). The target population was men aged 40 to 65 years and women aged 50 to 70 years. The social insured inhabitants of the western suburbs of Paris matching the age and sex requirements were sent a form inviting them to a free medical visit in one of the participating centers. They were asked about their personal and family history of CVD, and whether they were taking any medication. To determine current cigarette smoking, respondents were asked if they smoked at least one cigarette per day for at least 6 months over the last three years. Weight and height were measured by a standard protocol and used to calculate body mass index (BMI); i.e, weight in kilograms divided by the square of height in meters. Systolic and diastolic blood pressure (BP) was measured according to standard protocols in a supine position. Screening included blood tests for total cholesterol, low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), triglycerides and glucose with 12 hours of fasting prior to the blood draw using standardized methods. During the examination and face-to-face interview, physicians completed an online questionnaire including information about previous and discovered CVRFs and the results of the blood tests. The software (http://www.cpam92-si.com/site/frcv/frcv.php) calculated the participants’ 10-year risk for CVD (coronary, cerebrovascular, and peripheral arterial disease and heart failure) using the d’Agostino-method[19] and the European Systematic COronary Risk Evaluation (SCORE) [20] estimation of 10-year risk of fatal CVD. The access to the website was freely available to calculate the 10-year risk scores, but recording of data was protected by access codes. It was used for educational/information purposes, reinforced with possible simulation in the presence of the person at risk. Printed results were given to the participants and sent to their general practitioner (GP). High-risk patients were offered further care at the university hospital while low- and medium-risk patients were advised to visit their GP. An interview with a nutritionist and a smoking cessation specialist were offered to all study participants, who were encouraged to answer a satisfaction survey. The study was approved by the National Commission for Data Protection and Liberties (CNIL-France). The Comité de Protection des Personnes reviewed the study and provided a formal statement declaring this study to be exempt from the requirement for human research ethics approval.

Diabetes mellitus was defined as fasting plasma glucose value ≥7 mmol/L, hypertension as BP exceeding 140 over 90 mmHg in nondiabetics and 130 over 80 mmHg in diabetic patients, obesity as a BMI ≥30 kg/m² and high LDL-Cas a fasting plasma value ≥4.14 mmol/L[21–23]. Current smoking was defined as a positive answer to the question above. Subjects who stopped smoking for at least 3 years were considered non-smokers. For the Framingham 10-year risk for CVD, low risk was defined as < 10%, intermediate risk as 10% to 20%, and high risk as > 20%, while for the European 10-year risk of fatal CVD, low risk was defined as < 2%, intermediate risk as ≥ 2% and < 5%, and high risk as ≥ 5%.

Three populations were defined. Population A consisted of the total participants who presented to the medical visit and for whom data were complete. Population B consisted of the total participants who presented to the medical visit and for whom data were complete and who were not taking any antihypertensive or lipid-lowering agents or drug treatment for diabetes. Since the screening program addressed older people with social insurance in the early years and younger ones in the later years, we adjusted the results according to gender and ± 5-year age groups for the study participants who were not taking any antihypertensive or lipid-lowering agents or drug treatment for diabetes. Population C represented the age- and sex-adjusted untreated population. We used direct methods for adjustment and matched each study subject in 2007 by sex and age (± 5 years) with other study subjects in 2008, 2009, 2010, 2011 and 2012 successively. Quantitative data are expressed as mean ± standard deviation and qualitative data as frequency and percent. Comparisons of means were performed using the Student t test and Analysis of Variance. Linear trends were verified using the Cochran-Armitage trend test for linearity for categorical data (diabetes, hypertension, high LDL-C, current smokers, obesity), and regression lines for parametric data (10-year risk of fatal CVD and 10-year risk of CVD). A p value less than .05 was considered statistically significant. All statistical analyses were performed with the use of SAS statistical software (version 9.3, SAS Institute Inc., Cary, North Carolina, USA).

On December 31, 2012; 177,000 (51%) of the 347,396 inhabitants of the western suburbs of Paris with social insurance matching the age and sex requirements had already received a form inviting them to a free medical visit in one of the participating centers. A total of 30,646 answers were obtained and 23,643 social insured presented to the medical visit. Data were complete for 20,324 participants (S1 Table) of whom 14,709 did not receive any antihypertensive or lipid-lowering agents or drug treatment for diabetes. Fig 1 shows the selection of the study populations (flow chart). The characteristics of population A are summarized in Table 1 and the characteristics of population B are shown in Table 2. In population A, the sex ratio (male/female) was 0.89 and the mean age was 51.5 ± 7.9 years in men and 58.1 ± 7.2 years in women. Hypertension was found to be the most common CVRF (34.6%) followed by high LDL-C (34.4%), current smoking (20.7%), and obesity (18%). Diabetes was found in 8.7% of the total population. In population B, the sex ratio (male/female) was 1.01 and the mean age was 50.1 ± 7.7 years in men and 56.9 ± 7.1 years in women. High LDL-C was found to be the most common CVRF (24.3%) followed by current smoking (22.5%), hypertension (17.4%) and obesity (13.4%). Diabetes was found in only 2.1% of the untreated participants.

There were no statistically significant differences between population B and population C (adjusted model) concerning the distribution of the CVRFs (S2 Table).

In population B, 42.5% were found to be free of all major CVRFs, 56.8% had between 1 and 3 CVRFs and only 0.7% had four or more CVRFs. The predicted 10-year risk for CVD ranked men significantly more at high risk than women (12.8% vs 1.5%, p <0.0001). Similarly, according to the European SCORE estimation of the 10-year risk of fatal CVD, the prevalence of high-risk individuals was significantly higher in men than in women (1.0% vs 0.4%, p <0.0001).

Changes in CVRFs and the 10-year risk scoring systems between 2007 and 2012 are represented in Fig 2 and S3 Table for population A, in Table 3 and Fig 3 for population B and Table 4 and Fig 4 for the adjusted model (population C). Fig 2 shows the line graphs of the changes in CVRFs and the 10-year risk scoring systems in population A between 2007 and 2012. In the male population, we observed a decrease in the prevalence of all CVRFs and in both 10-year risk for CVD and fatal CVD scores. In women, all but high LDL-C prevalence decreased. Fig 3 shows the line graphs of the changes in CVRFs and the 10-year risk scoring systems in population B between 2007 and 2012. In the male population, we observed a decrease in the prevalence of all CVRFs and in both 10-year risk for CVD and fatal CVD scores. In women, all but obesity and diabetes prevalence decreased.

In the adjusted model (Fig 4), the prevalence trend over the six years of the study was statistically significant for hypertension in men from 25.9% in 2007 to 21.1% in 2012 (trend test, p = 0.002) and from 23% in 2007 to 12.7% in 2012 in women (trend test, p <0.0001). Similarly, the prevalence trend of current tobacco smoking decreased significantly from 38.6% in 2007 to 27.7% in 2012 in men (trend test, p = 0.0001). It decreased from 22.6% in 2007 to 16.8% in 2012 in women, but the trend over the six years of the study was not statistically significant (trend test, p = 0.113).

We observed a significant decrease in the mean 10-year risk for CVD from 13.3 ± 8.2% in 2007 to 11.7 ± 9.0% in 2012 in men and from 8.0 ± 4.1% in 2007 to 5.9 ± 3.4% in women (both p <0.0001). The 10-year risk of fatal CVD showed a significant decrease in men and in women (1.2 ± 1.1% in 2007 and 0.6 ± 0.7% in 2012, p <0.0001). In the male population, we observed a significant decrease in obesity and diabetes mellitus but not in high LDL-C. Moreover, high LDL-C, diabetes and obesity did not vary significantly in women.

Responses to statements regarding to the study showed a high level of agreement with the need for screening. The great majority of service users (92%) had a positive experience of the screening service, agreeing that they were given enough time and attention.