Editor's Corner | Lifestyle and Cardiovascular Health
At the last several national and international cardiology meetings, we saw several reports on improving long-term health by paying more attention to lifestyle changes. This past year witnessed the first data on coronary incidence reduction: a PCSK9 inhibitor produced striking reductions in LDL cholesterol that apparently, after a long wait, resulted in a reduction in the incidence of subsequent coronary events in people with existing coronary disease.
But we already have data going back 20 years that shows a reduction in coronary incidence in patients taking long-term statins. Perhaps long-term heart health can be reduced to simply taking a pill or injection for lipid lowering, another for blood glucose control and something else to keep blood pressure normal.
Controversies arise over how low should LDL cholesterol go, what is a normal A1c level and what constitutes normal blood pressure. One assumes that when these three measures for cardiovascular health are normal, usually through medication therapy, cardiovascular risk is thereby managed properly and nothing else needs to be addressed. In particular, adding lifestyle components that incorporate physical exercise and dietary discretion, even when the key measures of risk are at normal levels with medications, moves the individual into the realm of lifestyle changes that also contribute to long-term health, longevity and overall well-being.
Given the continuing epidemic of obesity, it doesn’t appear that we’re doing a good job as health care providers in improving overall health and especially lowering the risk of cardiovascular disease. At the AHA meeting this year, while hypertension was the dominant theme, several papers presented the results of clinical trials examining the benefit of a healthy lifestyle on cardiovascular health. The results, as expected, showed reduced mortality in those who followed a healthy lifestyle.
But would a patient with normal risk that was achieved by medications opt to avoid exercise and other lifestyle measures? Is a pill an adequate surrogate for walking a mile? What added benefit accrues from the exercise when the usual risk measures are normalized with medications? I’ve been a runner for more than 50 years and find some pleasure in being outside, sensing the motion and the physical activity involved. Will such attributes motivate others to adopt exercise to reduce their risk?
The highlight of this year’s AHA meeting was the report of the ACC/AHA guideline on high blood pressure. The guideline makes strong recommendations to lower the upper boundary for diagnosis of hypertension to below 120 mm Hg, and treatment should be considered when blood pressure is consistently above that level. The data are based on several clinical trials that demonstrate a definite reduction in mortality when blood pressure is below 120 mm Hg. Consideration based on age as well as a variety of comorbidities are included in the guideline.
It’s also important to use a standard protocol when measuring blood pressure. Recommendations from the ACC/AHA high blood pressure guideline includes use of a validated measurement device, use of proper cuff size and allowing the patient to rest quietly for a few minutes before making the measurement. Self measurement or assisted measurement do not affect the measurement. There’s also a significant effort to improve treatment adherence to both medications and to lifestyle behaviors that lower overall cardiovascular risk. Team-based care is one means for achieving blood pressure goals through medication adherence and adherence to improved lifestyle. Bariatric surgery appears to be a useful tool for both weight reduction and blood pressure control.
We’re witnessing an increased awareness of the value of prevention in the overall treatment of cardiovascular disease. This can range from prevention measures in younger individuals with no evidence of cardiovascular disease, who have a relatively low incidence of cardiovascular disease, to secondary prevention to reduce the frequency of subsequent cardiovascular events in patients with established cardiovascular disease.
Most cardiologists are involved with patients with existing coronary disease or patients without overt disease but who are at risk. Thus, we should pay significant attention to this latter patient population. This is predominantly made up of older patients with risk factors or comorbidities who need to receive specific guidance and encouragement to follow a healthy lifestyle to minimize risk. Many of these patients already have other non-cardiac comorbidities, are often under treatment and may have already had a cardiovascular event.
No matter what the situation, we need to focus attention on the preventive and lifestyle aspects of the care of our patients. In general, we’ve been more involved with new drugs and devices. The application of the new medications and devices has made important contributions to health care. But they cannot provide the broad base of care that’s needed for significant advances in population health — accomplishing this goal requires a commitment by health systems and government to provide the resources. These commitments are essential to achieving large-scale improvements in population health. Contributing to improved health care for our individual patients and for larger populations of patients should be a part of our care goals. Physician contributions to these population goals cannot be ignored.
Alfred A. Bove, MD, PhD, MACC, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and a former president of the ACC.
Keywords: ACC Publications, Cardiology Magazine, Cholesterol, LDL, Blood Pressure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Risk Factors, Secondary Prevention, Blood Glucose, Goals, Hemoglobin A, Glycosylated, Incidence, Walking, Medication Adherence, Pleasure, Longevity, Weight Loss, Life Style, Obesity, Hypertension, Exercise, Bariatric Surgery, Coronary Disease, Comorbidity, Patient Care Planning
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