Recent Advances in Preventive Cardiology and Lifestyle Medicine

Barry A. Franklin, Ph.D., FAHA

Beaumont Health SystemRoyal Oak, Michigane-mail: bfranklin@beaumont.edu

A Decade of Discovery

No Disclosures

Death

CoronaryDisease

AbnormalHeart

Rhythms

HeartFailure Stroke Cognitive

Decline

Early Vascular Disease

Inflammation

Diabetes PsychosocialStressors

AirPollution

Obesity HighCholesterol Hypertension

Poor Dietary Habits Physical Inactivity Smoking

ClinicalEndpoints

DiseaseProgression

Established& Novel

Risk Factors

LifestyleRisk Factors

The First-Line Strategy to Prevent Heart Disease

Mozaffarian, Wilson & Kannel, Circulation 2008

10094

81

58

26

4 2

10097

91

81

59

24

20

20

40

60

80

100

40 50 60 70 80 90 100

Age (years)

Pe

rce

nta

ge

su

rviv

al

fro

m a

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35 Cigarette Smokers

Non-Smokers

10 years

BMJ 2004;328:1519

Outline Coronary Remodeling, Plaque Rupture, and

Traditional and Emerging Risk Factors

Cardioprotective Medications

Evidence-based Dietary Strategies

Fitness, Sitting Time and Mortality

Psychosocial Stressors

Rehab: Modern-Day Mortality Benefit?

Enhanced External Counterpulsation Therapy

Medical Management versus Coronary Revascularization

Angiographic studies on patients

before myocardial infarction show

that the majority of subsequent

events involve sites with < 70%

obstruction.

Falk E. et al. Circ 1995;92:657

The new picture of

atherosclerosis explains why

many heart attacks come

from out of the blue: the

plaques that rupture do not

necessarily protrude very far

into the blood channel and

so may not cause angina

or ischemic ST-segment

depression.Libby S. Scientific American 2002;286:28

Efficacy of the PresentlyAvailable Statin Drugs

TC ↓ LDL↓ HDL↑

22% - 47% 27% - 60% 7%

*Roberts WC. AJC 2006;78:1550

The Polypill as Part of a Global Strategy to Substantially Reduce the

CVD BurdenThe polypill could potentially be widely used in secondary prevention and in selected high-risk individuals without known CVD (e.g., those with diabetes mellitus with additional risk factors).

In such individuals, a 50% to 75% proportional reduction in risk can be anticipated from prolonged therapy.

By contrast, in individuals without CVD and not at high risk, large trials are needed to quantify the benefits, potential risks and cost-effectiveness of the polypill.

Lonn E et al. Circulation 2010;122:2078-2088

Polypill: User Directions

Take medication each day in the prescribed

dosage, followed or preceded by at least 30

minutes of moderate-to-vigorous physical

activity, in combination with a low-fat, low-

cholesterol diet, weight management,

smoking cessation, and regular visits to your

physician. Franklin BA et al. AJC 2004;94:162

Dietary Priorities Associated with Cardioprotective Benefits

Consume more: Consume less:

• Fish and shellfish

• Whole grains

• Fruits

• Vegetables

• Nuts

• Low-fat or no fat diary products

• Vegetable oils*

• Water

• Potatoes, refined grains, sugars

• Processed meats

• Sweetened beverages, diet sodas

• Grain-based desserts & bakery goods

• Fats, oil or foods containing partially

hydrogenated vegetable oils

• Salt

• Alcohol**

* Examples include flaxseed, canola, and soybean oil

** For adults who drink alcohol, no more than moderate consumption (i.e., up to 2 drinks/day for men, 1 drink/day for women) should be encouraged, ideally with meals.

Kodama S et al.JAMA 2009;301:2024

CONCLUSIONS: Better CRF was associated with lower risk all-cause mortality and CHD/CVD. Participants with a MAC of 7.9 METs or more had substantially lower rates of all-cause mortality and CHD/CVD events compared with those with a MAC of less 7.9 METs.

CHD/CVD

Overall 100.00 0.85 (0.82-0.88)

Kodama S et al. JAMA 2009;301:2024

Prognostic Significance of Peak Exercise Capacity in Patients with CAD*

• 527 men with CVD who were referred to an outpatient rehabilitation program

• Measured peak VO2 during cycle ergometer testing

• Average follow-up of 6.1 yrs, 33 and 20 pts died of cardiovascular and noncardiovascular causes, respectively.

Highest mortality in pts who averaged ≤ 4.4 METs; There were no deaths in pts who averaged ≥ 9.2 METs.

*Vanhees L et al. JACC 1994;23:358

LVEF And Exercise Capacity As Predictors Of 2- And 5-year Mortality

0

10

20

30

< 4 METs > 4 METs < 4 METs > 4 METs

> 40 %

< 40 %

2-year data

5-year data

Mo

rtal

ity

(%)

LVEF

Exercise Capacity

p = 0.019

* Only significant p-values are shown

p = 0.0007

p = 0.0025

p = 0.038

Dutcher J, Franklin B, et. al – Am J Cardiol 2007;99:436-441.

Warning: Sitting for Extended Periods May be to Your

Health

Manson JE et al. NEJM 2002;347:716Hamilton, MT et al. Diabetes 2007;56:2655Hamilton, MT et al. Curr Cardiovasc Risk Rep 2008;2:292Katzmarzyk, PT et al. Med Sci Sports Exerc 2009;41:998

Hazardous

100

95

90

85

80

75

70

0 2 4 6 8 10 12 14

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mu

lati

ve S

urv

ival

(%

)

Follow-up Years

Almost None of the Time

¼ of the Time

½ of the Time

¾ of the Time

Almost All of the Time

Katzmarzyk PT et al. Medicine & Science in Sports & Exercise 2009;41:998

Missing Puzzle Pieces?Social Isolation

Hostility

Anxiety

Anger

Type-A Behavior Pattern

VitalExhaustion

Stress

Depression

Psychosocialstressors

(e.g., depression, social isolation)

Behavioralrisk factors

(e.g., smoking, poor diet)

ATHEROSCLEROSIS

CLINICAL EVENTS(e.g., angina, MI)

Recurrentcardiac events

Rozanski A et al. Circ 1999;99:2192

Cumulative mortality for depressed and non-depressed patients. MI indicates myocardial infarction.

30

25

20

15

10

5

0

% M

orta

lity

0 1 2 3 4 5 6Months Post-MI

Depressed (n=35)

Nondepressed (n=187)

Major Findings Compared with usual care, CR ↓ total mortality

by 20% and cardiac mortality by 26%.

There were also substantial ↓s in TC, TGs, SBP, and self-reported cigarette smoking in the CR group, but there were no differences in HDL-C and LDL-C, DBP, or health-related QOL.

The effect of CR on total mortality was independent of whether the trial was published before or after 1995, suggesting that the mortality benefits of CR persist in modern cardiology.

Taylor RS et al. Am J Med 2004;16:682

Enhanced External Counterpulsation Therapy: A Noninvasive Approach to

Treating Coronary Disease*

*Arora R et al. JACC 1999;33:1833

Ochoa AB et al. AJMS 2003;May/June

COURAGE: Cumulative Event Rates at 4.6 Years

PCI Group Medical Tx Group p ValueOutcome # % # %

Death, nonfatal MI 211 19.0 202 18.5 0.62

Death, MI, Stroke 222 20.0 213 19.5 0.62

Death 85 7.6 95 8.3 0.38

Nonfatal MI 143 13.2 128 12.3 0.33

Stroke 22 2.1 14 1.8 0.19

Hospitalization* 135 12.4 125 11.8 0.56

Revascularization ** 228 21.1 348 32.6 <0.001

* for ACS; ** PCI or CABG

BARI 2D Study Group. NEJM 2009;360:2503

Evolutionary Treatmentof Heart Disease

Interventional Devices

2012

LifestyleModification

1970Bypass Surgery

1990

CoronaryThrombolysis

1980Coronary

Angioplasty

PharmacologicTherapy

1960

PreventiveCardiology