CVD: the present situation
Cardiovascular diseases (CVDs) are non-communicable diseases that affect the cardiovascular system (i.e., the heart and blood vessels). These diseases include heart attack and stroke.a CVDs are ranked as the leading cause of mortality and morbidity in the world. The CVD-related mortality rate ranges from 4% in high-income countries to 42% in low-income countries . The mortality rates from stroke are higher in Central and Eastern Europe than in Northern, Southern and Western Europe . Overall, CVD is estimated to cost the EU economy 192 billion EUR a year, 57% of which is due to healthcare costs, 21% to productivity losses and 22% to informal care . However, with proper primary care, CVDs are highly preventable [1, 3].
The identified risk factors for CVDs include the following: heredity, socio-economic changes, cultural changes and behaviour. To a certain extent, one can decrease or increase the risk of CVD by modifying these factors. While heredity cannot be changed and the socio-economic situation is difficult for an individual to change, individual behaviour can easily be modified and doing so can yield good results for CVD prevention.
There are many consequences of CVD. For the individual, these consequences can range from death to dramatic changes in lifestyle (e.g., disability and decreased productivity), increased costs of long-term medical treatment and rehabilitation and even impoverishment. For the community, an individual recovering from CVD necessitates managing a less productive worker and supporting extended healthcare costs because part of the treatment costs are supported by the state.
There are two methods of treating CVDs: treatment of the risk factors that are present before a severe CVD occurs and treatment of the consequences of a severe CVD. Treating (or managing) the risk factors implies prevention of the disease (i.e., primary care). Countries that have implemented prevention programs have reduced the rate of CVDs in the last two decades [1, 3]. Treating the effects implies treating the disease and managing its consequences as they occur. This practice prevails in countries that have not implemented a prevention program. Economic studies have been performed both to evaluate the effectiveness of combat strategies and interventions in low- and middle-income countries  and to provide a better method of resource allocation .
The cultural differences between Westernb and Easternc Europe were deepened by the socio-economic and political development of both regions during the last century . Western European countries have been more successful in implementing health policies than Eastern European countries have and the national health indicators therefore reflect a healthier population with a healthier lifestyle and healthier dietary habits. Additionally, there is a significant difference in lifestyle habits and dietary habits between countries in the west and east. The Eastern European countries, which have a poorer lifestyle and dietary habits, do not score well on many national health indicators . Once admitted to the EU, an Eastern European country is committed to implementing the Union’s policies, thus it must implement the Union’s health policies and achieve the health standards of the Union.
The socio-economic situation in Romania is similar to that of other Eastern European countries and the average Romanian faces the same challenges and the same health problems as the average Eastern European. This situation has a direct influence on the habits of the population and hence the national health indicators in Romania are representative of Eastern European countries as a whole. Thus, the effects of a health policy on the average Romanian are similar to the effects on the average Eastern European individual.
Even if Romania is viewed as a developed country  and the health status indicators present a positive trend, these indicators remain below the EU and regional averages. In Romania in 2010, 3466547 individuals from a total population of 21431298 were affected by various forms of CVD (16175.16 per 100000 population). Additionally, 90608 people died from a CVD (422.78 per 100000 population). Out of 259723 deaths in Romania in 2010, 34.89% were caused by a CVD [8, 9]. This figure can be compared with constantly time-decreasing CVD mortality rates of less than 200 per 100000 population in countries such as France, Spain, the Netherlands, Italy, Denmark and Norway . Another indicator of the CVD burden is the percent of the total healthcare costs allocated to CVDs : in France and Spain, only 7% of the individual healthcare costs are generated by CVDs; in Cyprus and Denmark, this percentage is the lowest (5%); however, in Romania and Estonia, 15% of the individual healthcare costs are generated by CVDs. The only EU country with a worse status is Poland (17%).
The economic impact of stroke, including its psychological and social aspects, was studied in the Netherlands . Little information about the effectiveness of physical activity enhancement strategies is provided for developing countries, while this information is highly documented in developed countries . In 2006, the economic burden of CVD in the enlarged EU was investigated . Although that study has important limitations, it found that productivity losses and informal care represented 21% and 17% of CVD-related costs, respectively.
Since signing the European Heart Health Charter in 2007, Romania has been committed to fighting CVD and its effects . The goals of this campaign are to reduce the morbidity and mortality rates to levels comparable to the EU averages: under 4000 per 100000 population for morbidity and under 400 per 100000 population for mortality. However, because the morbidity and mortality rates do not decrease dramatically overnight, the achievement of these goals takes a period of time that depends on the number of people who pay attention to their heart health. An additional issue is the problem of coverage (i.e., the number of patients with severe CVD that can be treated given the healthcare budget). With a fixed healthcare budget, the rate of coverage should increase as the CVD-related morbidity rate decreases.
The economics of primary care was investigated in  and the conclusion was that little is known about the economic impact of health promotion interventions compared to clinical prevention activities. The authors also highlighted the importance of governmental engagement in economic evaluations of prevention activities.
Our study aims to document the economic importance of CVD prevention compared with treatment of the disease. To this end, we considered the database of the EUROASPIRE III Romania Follow Up and we computed the costs in the following manner. The minimum costs in the case of a fatal heart disease were estimated for different scenarios that corresponded to various levels of both the patient’s interest in his/her health state and the severity of the CVD consequences. At the beginning of the study, the Heart SCORE  was computed, yielding the probability of fatal heart disease for the next 10 years. The lowest standardised cost of disease was computed as the minimum cost of heart disease multiplied by the SCORE probability. Then, the prevention costs over a period of 1.5 years were estimated. The SCORE probability was again computed after a period of 1.5 years. The lowest standardised costs of fatal heart disease were estimated for the remaining 8.5 years. These values were compared with the number of recommendations followed by the patients. Our approach emphasises that with a proper primary care program, there is no need to identify (or allocate) additional resources for the enhancement of the healthcare budget.