Prevention of Coronary Heart Disease 2020: If Not Now, When?
Division of Cardiology, University of Arizona, Arizona, USA
*Correspondence to: Charles Katzenberg, Division of Cardiology, University of Arizona, Arizona, USA, E-mail: firstname.lastname@example.org
Prevention of Coronary Heart Disease remains an urgent challenge. We have made progress over the past 50 years, but in the last few years coronary heart disease mortality curves have flattened and begun to trend upwards coincident with worldwide epidemics of diabetes and obesity.
We understand the problem. We know what to do. We understand the multiple paths toward prevention. What is missing is uniform acknowledgement from medical practitioners, hospitals, insurers, government and the general public that a problem exists, followed by unified commitment of financial, educational and program resources commensurate with shining a bright light on Prevention. Why are we so complacent with treating disease rather than preventing it? The answer may lie in the current economics of healthcare where financial incentives are not aligned with prevention and health promotion.
The Hippocratic Oath contains the clause,
I will prevent disease whenever I can, for prevention is preferable to
The incidence and consequences of coronary heart disease (CHD)
have been well defined.
• Someone in the U.S. has a heart attack every 40 seconds
• 805,000 heart attacks/yr, 365,914 of which result in death (2017)
• 2/10 deaths from CHD happen in adults<65 yrs old
Risk factors involved in CHD have been well characterized . The
INTERHEART Study compared 12,461 people having their first heart attack with 14,820 matched controls in 52 countries, concluding that 90% of heart attacks were associated with at least one risk factor
Since the 1960's, mortality from Coronary Heart Disease has been dropping (Figure 1). Нis fall in mortality predated both the First Dietary Goals for the United States which came out of Senator George McGovern's Select Committee in 1977, as well as the introduction of
statins (lovastatin) in 1987. Нe general consensus is that this fall in mortality was multifactoral, related to improvements in earlier diagnosis, improved treatments, medications, and studies such as Framingham which identified targetable risk factors like smoking, hypertension and elevated cholesterol . But alas, over the last 10 years, the mortality curve has flattened and recently begun climbing.
Heart Disease deaths, the majority being coronary heart disease, increased from 596,577 in 2011 to 614,348 in 2014 . This trend reversal is arguably fueled by the current obesity and diabetes epidemic.
What should be our prevention strategy(s) in 2020?
Traditional Cardiac Rehabilitation
Traditional Cardiac Rehabilitation is primarily exercise-based and has shown improvement in risk profile and outcomes, including survival in individuals with known CHD. Traditional Cardiac Rehabilitation reduces the chances of being rehospitalized or depressed
after a coronary event, and helps patients recover strength and build skills in managing medications and activities. A challenge for Traditional Cardiac Rehabilitation is suboptimal referral and participation. Women, minorities, older people, and people with comorbidities are less likely to be referred and/or attend Traditional Cardiac Rehabilitation. A strong recommendation by the patient’s physician may be the most significant factor in a patient's decision to participate.
Intensive Cardiac Rehabilitation (ICR)
The Medicare definition of Intensive Cardiac Rehabilitation is “a physician- supervised program that furnishes cardiac rehabilitation services more frequently and often in a more rigorous manner (than Traditional Cardiac Rehabilitation).”
One of the first Intensive Cardiac Rehabilitation programs was developed by Dean Ornish during his groundbreaking studies on the effٴects of lifestyle on CHD. The benefits in terms of risk factor modification and prognosis with Intensive Cardiac Rehabilitation are generally superior to Traditional Cardiac Rehabilitation, but, both Traditional Cardiac Rehabilitation and Intensive Cardiac Rehabilitation are underutilized.
We conduct an Intensive Cardiac Rehabilitation program in Tucson called the Heart Series. It is a twelve week program. Each participant group meets weekly for 3 hours. Each week has a different theme, covering risk factors, pathophysiology, nutrition, safe and effective exercise, yoga, stress management, communication, food label reading, creating resiliency, eوٴective communication, supplements, and medications. The sessions are designed around active engagement and participation. Each weekly session includes evidence-based education, the practice of Tai Chi, and the sharing of a whole-food, plant-based potluck meal.
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Prevention; Coronary heart disease; Cardiac rehabilitation
© 2020 Katzenberg C. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
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