Pondering Atherosclerosis Prevention in Primary Care

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Pondering Atherosclerosis Prevention in Primary
Care

• Douglas H. James MD

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Reddy, KS, NEJM 350242438-2440, 2004
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Seven Countries StudyAncel Keyes
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WHO Monica CAD Events
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?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.

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The Culprit. How Does it Work? More Than Just
Fat
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Normal endothelium by scanning electron
micrograph by Sir Michael Davies
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Stressed endothelium
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Endothelium erosion/apoptosis
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Little, WC, et al, Circulation 1988781157-66
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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.

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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

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Mortality in the UK and US. What made the
difference?
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Causes of Mortality Change Unal, B et al,
Circulation. 20041091101-1107
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Cardiovascular Health Promotion in Schools, AHA
Scientific Statement, Circ.20041102266-2275

• 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

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AHA Statement on Omega-3 Fatty Acids in Heart
Disease. Kris-Etherton et al, Circ.
20021062747-2757
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Diet vs. Lovostatin on LDL and CRP Jenkins, DJA,
JAMA 2003, 290502-510
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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

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Reduction of Progression to Diabetes NEJM
2002346393-403
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Mortality Trends in the USA
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Trends in Obesity
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Metabolic Syndrome
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Reilly, MP and Rader, DJ, Circulation
20031081546-51
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Katzmarzyk, PT et al, Arch Int Med,20041641092-9
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Farrell, SW, et al, Obesity Res. 200412824-30
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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.
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Effects of TherapySdringola, S. et al, JACC,
200341263-72
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Cardiac Rehab in Olmstead Co. Witt, B. et al,
JACC.2004, 44988-96
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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.

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How to Achieve Full Prevention?

• See 33rd Bethesda Conference, Preventive
  Cardiology How can we do better?, JACC
  2002579-651
• 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 physicians
  office.

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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.
  Dont 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

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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

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