Call to action: more emphasis needed on prevention

There is overwhelming evidence that aggressive, comprehensive risk factor modification reduces cardiovascular events, improves survival, and improves the quality of life if adults become more physically fit.

However, rates of obesity are on the rise. This is leading to an epidemic of metabolic syndrome and diabetes. We are spending far too much money on drug-eluting stents, implantable cardioverter-defibrillators and other expensive therapies that treat the complications of atherosclerotic vascular disease.

Cardiovascular specialists need to put a much greater emphasis on prevention in order to halt the often rapid progression of atherosclerosis. Physicians need to understand that the traditional risk stratification can be improved by selective use of atherosclerosis imaging and measurement of hs-CRP. The Framingham score is limited by the omission of family history of premature CVD, triglycerides, waist size, and dietary and exercise habits. While an adult with a glucose .125 mg/dl is automatically considered to be at very high risk, that same individual with a slightly lower glucose often does not qualify for aspirin or lipid-lowering therapy. We need to do better in order to determine which of our middle-aged and older patients are really at high risk for future CVD events.

For each of our patients, we need to determine how low their BP, LDL, triglycerides and glucose should be. We also need to determine whether a medication to raise HDL should be employed. Few clinicians are aware that a year ago the latest American Heart Association Advisory on Hypertension recommended a target BP of ,130 mm Hg/80 mm Hg for those with a >10% Framingham risk estimate of an MI/CHD death. The NCEP guidelines cite diabetes and peripheral arterial disease as a CHD risk equivalent. Is it time to add chronic kidney disease and advanced subclinical atherosclerosis to the list?

We need to promote guideline adherence and reduce the gap in utilization of proven lifestyle and medical therapies in order to optimize cardiovascular care. The cornerstones of prevention are a healthy diet and regular brisk physical activity. Prevention does not need to be complicated.

As a profession, we all need to live healthier lifestyles and set better examples for our patients. In addition, we also need to decide when atherosclerosis imaging may help refine risk assessment to change our clinical management. We also await the publication of the landmark JUPITER study, which will change the way many of us manage adults aged 60 and up.

I look forward to working with Cardiology Today to provide my perspective on preventive cardiology and CHD management. With our redesigned, combined CHD and Prevention section, you’ll find that over time, some of the answers to the questions I’ve posed will be found here, and commented on by myself or the esteemed colleagues who serve on this section of the Editorial Board. Stay tuned.

Roger S. Blumenthal, MD, is Professor of Medicine and Director of The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease.