1 / 52

Pondering Atherosclerosis Prevention in Primary Care

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.

jennis
Download Presentation

Pondering Atherosclerosis Prevention in Primary Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pondering Atherosclerosis Prevention in Primary Care Douglas H. James MD

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

  3. Seven Countries StudyAncel Keyes

  4. WHO Monica CAD Events

  5. ?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.

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

  7. Normal endothelium by scanning electron micrograph by Sir Michael Davies

  8. Stressed endothelium

  9. Endothelium erosion/apoptosis

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

  11. 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.

  12. 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

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

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

  15. 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

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

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

  18. 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

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

  20. Mortality Trends in the USA

  21. Trends in Obesity

  22. Metabolic Syndrome

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

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

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

  26. 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.

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

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

  29. 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.

  30. 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.

  31. 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

More Related