A 40-year-old Caucasian man presents to your preventive cardiology clinic. He has no personal history of cardiovascular disease (CVD), is asymptomatic, and is not taking any medications. His parents are both alive and free from CVD, diabetes, or lipid disorders. He started smoking five to 10 cigarettes per day at age 14 and currently smokes 10 to 20 cigarettes per day. He has thought about giving up smoking several times, but never tried it seriously.
He has worked in the same office for 15 years, with growing levels of responsibility. This resulted in increasing daily time devoted to work, quick meals, and reduced leisure time, especially after his divorce. Every morning he likes to have a copious breakfast often including eggs, bacon and/or sausages, cookies, and a cup of coffee with cream. For lunch he eats a meal delivered by a local restaurant at his office desk, and for dinner he tends to eat homemade pasta or a sandwich. On Saturdays, he works at home following a similar dietary pattern, and on Sundays, he likes to relax with friends having dinner at a restaurant or watching a game of their favorite teams while having a pizza. Because of his job, he spends long periods of time sitting, and his engagement in leisure-time physical activities had diminished progressively. He sleeps about five hours a night. In this context, he reports having gained about 22 pounds in the last five years.
It is after one of his friends had a myocardial infarction at age 42 that he decides to present to your clinic concerned about his personal risk for having a myocardial infarction.
On exam, blood pressure is 136/86 mm Hg, body mass index (BMI) 27.6 kg/m2, waist circumference 107 cm. The rest of the physical examination is normal. The laboratory studies show total cholesterol of 202 mg/dL, high-density lipoprotein cholesterol (HDL-C) 35 mg/dL, triglycerides 158 mg/dL, HbA1c 5.6%.
The patient's 10-year absolute atherosclerotic cardiovascular disease (ASCVD) risk according to the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Pooled Cohort Equations is 7.0%.
The correct answer is: C. Comprehensive lifestyle intervention: quit smoking + physical activity + dietary intervention + optimize BMI.
Answers A and F are incorrect, as there is currently no strong evidence-based indication for aspirin treatment in asymptomatic, primary prevention patients with such a risk profile. Potential benefits must be weighed against risk of bleeding, and the net benefit of aspirin for ASCVD prevention is uncertain in this patient.
Answer B is also incorrect because the patient's blood pressure is <140/90 mm Hg.
Answer D is incorrect because in primary prevention, current ACC/AHA clinical practice guidelines suggest considering moderate statin treatment in the context of a patient-physician risk discussion, which should address patient preferences, potential for CVD risk reduction benefits, potential adverse effects, alternative interventions such as a heart-healthy lifestyle and the management of other risk factors, and further risk assessment.1 Therefore, the patient should not be automatically placed on a statin. Moreover, this option does not include physical activity, dietary intervention, and weight management.
Answer E is a reasonable option for further CVD risk assessment; however, the indication for further testing should be individualized and may not apply to all patients. Moreover, the clinician may want to consider a different test (e.g, coronary artery calcium [CAC]) for further risk assessment.2 Indeed, current ACC/AHA guidelines note that recent evidence3 supports "the contention that measuring CAC is likely to be the most useful of the current approaches to improving risk assessment among individuals found to be at intermediate risk after formal risk assessment."4 Furthermore, answer E fails to include important lifestyle changes (physical activity, diet, optimize BMI) as part of the essential risk management intervention.
Current clinical practice guidelines emphasize the notion of lifestyle modification as an essential component of CVD risk reduction, "both prior to and in concert with the use of cholesterol-lowering drug therapies."1 The patient in this case has no relevant family history of risk factors or CVD, nor a personal history of medical conditions that would predispose him to develop CVD risk factors. Instead, he exhibits a risk profile in which lifestyle factors such as tobacco, physical inactivity, unhealthy diet, overweight, sleep deficiency, and stress play a central role. Therefore, an essential intervention for CVD risk management in this patient is a comprehensive lifestyle intervention:3,4 answer C is correct: A comprehensive lifestyle intervention without medication or futher testing.
The comprehensive intervention should be provided by trained professionals, engaging the patient in a cardiovascular-healthy lifestyle including tobacco cessation; regular physical activity; a dietary modification restricting sodium, saturated and trans fats, low-fiber foods and sugar-sweetened beverages, and emphasizing intake of vegetables, fruits, and whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and a sustained weight loss. Moreover, the providers should set an appropriate follow-up plan, considering on-site interventions during at least the first six months, and advising the patient to participate in a long-term weight loss maintenance program5,6. These interventions may result in reductions in blood glucose, HbA1c, blood pressure, and improve LDL and HDL cholesterol levels, and have an important impact in the cardiovascular health of our patient.7
All answers included tobacco cessation. Studies on the CVD benefits of "low-risk lifestyles"8 have shown smoking avoidance as one of the most powerful single interventions for improving CVD health.8-11 Indeed, a non-smoker with otherwise the same risk profile would score a 2.1% 10-year CVD risk using the 2013 AHA/ACC Pooled Cohort Equations. However, that same patient would have a 46% lifetime risk, underscoring the need and potential benefits of a more comprehensive lifestyle intervention. Instead of taking a smoking break, the patient could be encouraged to replace this habit with a 10 minute walk.
Observational studies12 and randomized trials have shown that a Mediterranean diet can improve mediators of cardiovascular risk such as glucose levels and insulin resistance, lipid levels and blood pressure13, and reduce the incidence of CVD events in both primary and secondary prevention14,15. Moreover, the concept of the "Mediterranean lifestyle" has evolved, and beyond providing recommendations on nutrients, the Mediterranean Diet Foundation has developed a pyramid that also includes recommendations on physical activity, serving size, as well as having adequate rest and engaging in relaxing activities, covering a broad range of preventable cardiovascular risk factors and supporting the notion of comprehensive lifestyle interventions16.
Thus, our patient could reduce the presence of saturated fat in his breakfast and emphasize the intake of fruits, nuts and low-fat milk. While in his office, he could try to take advantage of phone calls to walk, using a hands-free headset or his cell phone. He may buddy up with a coworker to go on walking breaks in place of smoking breaks. Physical activity could be tracked with a pedometer, aiming for a goal such as 10,000 steps per day. For lunch, he could try to walk to the closer local market and buy dishes consisting mainly of vegetables and legumes. Once at home, he could try to find time to engage in some physical activity, as well as for cooking dishes including fish rich in omega-3 fatty acids (e.g, salmon), whole-grain pasta and white meat, often adding extra virgin olive oil. In the weekends, he should try to spend time with his family and friends, prioritizing leisure-time activities involving physical activity and avoiding unhealthy foods.
References
- Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.
- Blaha MJ, Budoff MJ, DeFilippis AP, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet 2011;378:684-92.
- Peters SAE, den Ruijter HM, Bots ML, Moons KG. Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: a systematic review. Heart 2012;98:177-84.
- Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB Sr, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129(suppl 2):S49-S73.
- Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2960-84.
- Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines and TheObesity Society. J Am Coll Cardiol 2014;63:2985-3023.
- Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586-613.
- Ahmed HM, Blaha MJ, Nasir K, et al. Low-risk lifestyle, coronary calcium, cardiovascular events, and mortality: results from MESA. Am J Epidemiol 2013;178:12-21.
- Daviglus ML, Stamler J, Pirzada A, et al. Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality. JAMA 2004;292:1588-92.
- Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013;368:341-50.
- Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med 2014;370:60-8.
- Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 2003;348:2599-608.
- Serra-Majem L, Roman B, Estruch R. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Rev 2006;64:S27-47.
- Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279-90.
- De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, et al. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction:final report of the Lyon Diet Heart Study. Circulation 1999;99:779-85.
- Bach-Faig A, Berry EM, Lairon D, et al. Mediterranean diet pyramid today. Science and Cultural updates. Public Health Nutr 2011;14:2274-84.
Log in to MyACC
