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Pondering Atherosclerosis Prevention in Primary Care. Douglas H. James MD. Reddy, KS, NEJM 350;24:2438-2440, 2004. Seven Countries Study Ancel Keyes. WHO Monica CAD Events. ?How to Explain the Variation? Lipids Necessary but not Sufficient.
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Pondering Atherosclerosis Prevention in Primary Care Douglas H. James MD
?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.
Normal endothelium by scanning electron micrograph by Sir Michael Davies
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
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
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.
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