Heart disease is the leading cause of death in the Western world: it is responsible for 44% of all deaths in Italy. There is a wide range of heart disease risk factors: smoking, diabetes, obesity, sedentary lifestyle, high cholesterol and high blood pressure. The probability of developing heart disease depends on the seriousness of each risk factor and the combination they come in. Knowing how many people are affected by these conditions and disseminating effective ways to tackle them enable the introduction of public health measures geared towards defending the sub-groups of people most at risk.
People aged 40-59 years old are a prime target group for analysis and preventive action. Intervention models are being tested with the purpose of:

1. reducing death and illness caused by heart disease;
   
2. gauging the risk of heart disease in the population;
   
3. raising people's awareness and perception of risk;
   
4. organising integrated healthcare between hospitals, districts and prevention departments in order to prevent heart disease and to fight controllable risk factors (diet, smoking, exercise, etc.);
   
5. promoting a rational approach to treatment and ensuring the right medicine is prescribed;
   
6. monitoring and assessing the above measures along the way.
   

The primary heart disease prevention programme is organised along the same lines as cancer screening, i.e. people are called for a test, a network is built of prevention departments, GPs, specialists, hospitals, patient associations, local authorities and universities in order to put public health expertise at the service of a wider population; also envisaged are epidemiology and intervention evaluation, education and the development of clinical governance.
The programme introduces into the GP network a carta del rischio, a risk map, and the ensuing personal counselling service; it also launches cooperation and health measures shared between health services, and between these, municipalities and local associations.
The aim is to put the GP at the centre of this system by proposing that the target population is screened for the major heart disease risk factors and then bespoke, effective treatment is offered to anyone potentially at risk. GPs will provide their patients with a "health report" and should patients be at risk, GPs will follow guidelines that direct patients towards programmes that help them exercise, quit smoking, correct unbalanced diets and start treatment.
Local authority prevention departments are required to coordinate and support preventive and second-phase activities for those potentially at risk (e.g. stop-smoking centres, affiliated gyms, initiatives by associations and bodies that promote health through exercise, counselling with a dietician) and promote cooperation with municipalities, bodies and associations so that services can be made available for the promotion of healthy lifestyles.
The change in behaviour proposed by healthcare personnel is introduced in accordance with the person's own commitments and preferences. Choices include individual measures, informal groups, more structured situations, as well as additional alternatives or a combination of choices. One example is exercise, which can be taken in a gym, but the gym may be a make-shift one such as a parish or school hall where people would feel more at ease; people can also use fitness trails or join walking groups, which get them out into the local countryside. Additional options can also be suggested as progress is made.
The options for quitting smoking are strengthened by starting weekly open-to-all groups, training local primary healthcare unit (UTAP) workers to give short-term counselling, the possible prescription of nicotine replacements by GPs, provision of self-help material and better use of secondary-phase GP surgeries. Healthy diet is encouraged by participating in self-help groups, cooking courses, theory and practice meetings on healthy diet, encouraging healthy menus in restaurants, as well as promoting and disseminating healthy food-and-exercise itineraries.
All of these local opportunities, both old and new, are reviewed and put into a handbook available to GPs, local communities and individuals. Before the project is launched, municipal administrations are encouraged to draw up exercise plans that are suited to the project's criteria. Updates on local health-improvement opportunities are sent to healthcare workers so that they can provide useful information to anyone potentially interested in the project.

At present, this primary prevention programme involving risk assessment for heart disease in healthy people in Veneto is underway in Local Health Authorities (Aziende ULSS) no. 4 in Thiene, no. 9 in Treviso and no. 17 in Este-Monselice. These three Aziende ULSS chose their own organisation models, which were integrated with primary healthcare specifically geared towards the local area; these models are still being assessed in order to establish which can be best reproduced and sustained in other areas.
The experiences in all three, however, do have some common lines of action. At the beginning, they choose the people who will benefit from the action by their age and by their lack of any underlying illness. Citizen are invited to the local health authority where a suitably trained nurse or health worker studies their lifestyle, measures their weight, height, waist and blood pressure, and gives them a blood sugar test. All of the results are compiled in a computerised "preventive health report". On the basis of the assessment, users are subdivided into: GROUP A - healthy lifestyle with normal parameters; GROUP B - unhealthy lifestyle with normal parameters; GROUP C - high blood pressure and high blood sugar; GROUP D - excluded because already have major illness.
People classified in Groups B or C are invited to take part in one or more measures to improve their lifestyle, but if no change occurs, they are sent back to their GP to be prescribed medication.
The results in the table are from work carried out until the date in the column by each Azienda ULSS and are not for the entire cycle of activity, which ends in the first half-year period of 2011. The people who have been invited up to now are a percentage of the people who will be asked to attend (Table 13.1.1).
Initial results are extremely promising as screening has revealed a major share of people with high blood pressure and high blood sugar who were not aware of their problem; even if they are unable to change their lifestyle, they will be able to be treated effectively with medication.
In addition, figures point out that it is feasible to use a primary heart disease screening model which not only uses screening expertise, but also the same instruments and organisational model, as well as part of the personnel. This enables economies of scale to be achieved, as well as high-quality intervention which uses proven management resources and mechanisms. Involving GPs with the UTAP was also found to be an excellent approach. Having the first part carried out by a health worker or nurse is the key to the project as it enables people to be screened before being sent to a GP, thus ensuring the GP does not have to deal with all of the target population.
In light of this, it is necessary to ensure integration between the Azienda Ulss and the local area: the strength of this organisational model is based on the coordinated pooling of a range of health services in association with GPs, local public bodies-mainly municipalities-and private bodies (e.g. walking groups, gyms etc.).