Recent Advances in Preventive Cardiology and Lifestyle Medicine

1. Recent Advances in Preventive Cardiology and Lifestyle Medicine A Decade of Discovery Barry A. Franklin, Ph.D., FAHA Beaumont Health System Royal Oak, Michigan e-mail: bfranklin@beaumont.edu No Disclosures

2. The First-Line Strategy to Prevent Heart Disease Death Coronary Disease Abnormal Heart Rhythms Heart Failure Stroke Cognitive Decline Clinical Endpoints Early Vascular Disease Disease Progression Inflammation Air Pollution Diabetes Psychosocial Stressors Established & Novel Risk Factors Obesity High Cholesterol Hypertension Lifestyle Risk Factors Poor Dietary Habits Physical Inactivity Smoking Mozaffarian, Wilson & Kannel, Circulation 2008

3. 10 years BMJ 2004;328:1519

4. 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

5. 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

6. 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

7. Efficacy of the PresentlyAvailable Statin Drugs

8. The Polypill as Part of a Global Strategy to Substantially Reduce the CVD Burden 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. The 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). Lonn E et al. Circulation 2010;122:2078-2088

9. 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

10. Dietary Priorities Associated with Cardioprotective Benefits

11. 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. Kodama S et al. JAMA 2009;301:2024

12. CHD/CVD Overall 100.00 0.85 (0.82-0.88) Kodama S et al. JAMA 2009;301:2024

13. 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

14. LVEF And Exercise Capacity As Predictors Of 2- And 5-year Mortality 2-year data 5-year data p = 0.038 p = 0.0025 p = 0.019 p = 0.0007 Mortality (%) LVEF Exercise Capacity * Only significant p-values are shown Dutcher J, Franklin B, et. al – Am J Cardiol 2007;99:436-441.

15. Warning: Sitting for Extended Periods May be to Your Health Hazardous Manson JE et al. NEJM 2002;347:716 Hamilton, MT et al. Diabetes 2007;56:2655 Hamilton, MT et al. Curr Cardiovasc Risk Rep 2008;2:292 Katzmarzyk, PT et al. Med Sci Sports Exerc 2009;41:998

16. 100 95 Almost None of the Time ¼ of the Time ½ of the Time ¾ of the Time 90 85 Cumulative Survival (%) Almost All of the Time 80 75 70 0 2 4 6 8 10 12 14 Follow-up Years Katzmarzyk PT et al. Medicine & Science in Sports & Exercise 2009;41:998

17. Missing Puzzle Pieces? Social Isolation Depression Hostility Anxiety Stress Anger Vital Exhaustion Type-A Behavior Pattern

18. Psychosocial stressors Behavioral risk factors (e.g., depression, social isolation) (e.g., smoking, poor diet) ATHEROSCLEROSIS CLINICAL EVENTS (e.g., angina, MI) Recurrent cardiac events Rozanski A et al. Circ 1999;99:2192

19. 30 25 20 15 10 5 0 % Mortality 0 1 2 3 4 5 6 Months Post-MI Depressed (n=35) Nondepressed (n=187) Cumulative mortality for depressed and non-depressed patients. MI indicates myocardial infarction.

21. 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

22. Enhanced External Counterpulsation Therapy:A Noninvasive Approach to Treating Coronary Disease* *Arora R et al. JACC 1999;33:1833

23. Ochoa AB et al. AJMS 2003;May/June

24. COURAGE: Cumulative Event Rates at 4.6 Years

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

26. Evolutionary Treatment of Heart Disease Interventional Devices 1990 2012 Preventive Cardiology Coronary Thrombolysis 1960 1980 Coronary Angioplasty Lifestyle Modification 1970 Bypass Surgery Pharmacologic Therapy