Pondering Atherosclerosis Prevention in Primary Care

Douglas H. James MD

Reddy, KS, NEJM 350;24:2438-2440, 2004

Seven Countries StudyAncel Keyes

WHO Monica CAD Events

?How to Explain the Variation? Lipids Necessary but not Sufficient

• The most plausible explanation is in cultural/lifestyle variation making some cultures a “risk factor”. The lifetime risk in our culture is at least 50% and may be as high as 75%.

• Diet is probably the most important variable. • Physical activity is increasingly important• Smoking – not as important as it was.• ? Genetics. Japanese who move to our culture

acquire our disease incidence in about 10 years.

The Culprit. How Does it Work? More Than Just Fat

Normal endothelium by scanning electron micrograph by Sir Michael Davies

Stressed endothelium

Endothelium erosion/apoptosis

Little, WC, et al, Circulation 1988;78:1157-66

Paradigm Shift• Epidemiology suggests that the disease is largely

preventable except for stronger genetic risks.• It follows that the complications of the disease are

also preventable – MI, sudden death, congestive heart failure, vascular disease etc.

• We need to figure out how to intervene before the fatty streak becomes a plaque as well as before the complications have happened.

• Our culture puts us at high risk (at least 50% chance of dying of atherosclerosis during our lifetime), “primary” prevention is really early secondary prevention.

What to Do? Multiple targets in Addition to Lipids: Diet, Exercise, Smoking, BP, Weight

• Cultural, societal intervention. Shift the paradigm from repair to prevent. Take advantage of the cost effectiveness of life style change in the entire population. Still meet lipid goals.

• Intervene earlier before cultural patterns are established. We need more data on early drug intervention using additional risk factors.

• Intervene on multiple fronts since risk reductions are additive.

• This is difficult to do but even small changes have significant impact.

• Take advantage of group settings and support

Mortality in the UK and US. What made the difference?

Causes of Mortality Change Unal, B et al, Circulation. 2004;109:1101-1107

Cardiovascular Health Promotion in Schools, AHA Scientific Statement, Circ.2004;110:2266-2275

• Teach Health; especially nutrition.

• Provide adequate exercise: 2-3 hrs./wk

• Food served should be healthy. School should be free of unhealthy commercial food products.

• Provide a tobacco free environment.

• Establish links to community programs

AHA Statement on Omega-3 Fatty Acids in Heart Disease. Kris-Etherton et al, Circ. 2002;106:2747-2757

Diet vs. Lovostatin on LDL and CRP Jenkins, DJA, JAMA 2003, 290:502-510

Issues in Exercise• Duration matters more than intensity. Pedometer

approach. More is better but even a little works• Enhances dietary effects• Maintains cardiac function as well as skeletal

muscle function• Enhances general well being• Improves prognosis• Enables weight control• Enhances glucose control and ?insulin sensitivity• Improves endothelial function• Reduces inflammation/CRP

Reduction of Progression to Diabetes NEJM 2002;346:393-403

Mortality Trends in the USA

Trends in Obesity

Metabolic Syndrome

Reilly, MP and Rader, DJ, Circulation 2003;108:1546-51

Katzmarzyk, PT et al, Arch Int Med,2004;164:1092-97

Farrell, SW, et al, Obesity Res. 2004;12:824-30

Diet and exercise are the most effective therapy for the

metabolic syndrome and obesity. Long term weight loss is only

achieved through calorie restriction and exercise. The

earlier this is instituted, the more effective it will be.

Effects of TherapySdringola, S. et al, JACC, 2003;41:263-72

Cardiac Rehab in Olmstead Co. Witt, B. et al, JACC.2004, 44:988-96

Summary

• Lipid management with medication is very important but lifestyle management is equally important if we are to reverse the epidemic of cardiovascular disease. We need to develop community and healthcare resources and structures to achieve the best results. It will not be easy. It will require the participation of primary and specialty physicians, nurses, hospitals, schools and community leaders.

How to Achieve Full Prevention?• See 33rd Bethesda Conference, “Preventive

Cardiology: How can we do better?”, JACC 2002:579-651

• Cardiac Rehabilitation is the best multidisciplinary model which needs to expand its impact but the name no longer fits. It has actually become a program for cardiovascular health with strong educational resources. It could broaden its impact as a coordinating center for multidisciplinary effort with AHA, exercise facilities, businesses etc. in a community effort. It is difficult to do in the physician’s office.

What can I do in my Office?

• Refer to Cardiac Rehab and support it.• Measure abdominal girth and BMI• Screen earlier with positive family history. Don’t

just check cholesterol, check full lipids.• Consider pedometers• Develop good diet resources and ask about diet• Ask about exercise and smoking• Set strong health goals in all areas

Cost Issues• Present costs for treatment of established disease

and secondary prevention with drugs strain the system; e.g. estimated additional cost of meeting original NCEP III guidelines will be $500 billion over the next 20 years. (Krumholz) Little is left to support primary care and prevention.

• Poor support for nutrition management.• Poor support for public health programs in

communities. • Poor support for cardiac rehab, wellness,

prevention programs