HEART HEALTH
Dr. Bert Scharff
Doctor and patient need to identify risk factors that increase cardiovascular disease
WE ARE bombarded with media messages daily touting the best pill on the market to cure all our ills. It can become overwhelming and confusing at times.
One such area deals with the variety of drugs on the market designed to battle elevated cholesterol levels. The problem is serious–cardiovascular disease is the number one cause of death in the United States and is estimated to be the number one cause of death in the world by 2025. The course of action chosen demands an equally serious perspective. The most useful bit of information that accompanies the ads for vitamins, herbs, programs, pills, etc. is the advice, “Consult your physician before…’’
Simply dealing with the disease and not the causes offers some help, but to truly attack this disease, the doctor and patient need to identify what risk factors exist in a person’s life that increase the possibility or severity of cardiovascular disease. The treatment can then be more tailored to counter those risk factors in an effort to decrease morbidity and death from cardiovascular disease. The intensity of treatment must be matched with the intensity of cardiovascular risk factors.
Risk Factors
A risk factor is a characteristic that is present early in life and is associated with an increased risk of disease. These include:
• Habits such as smoking
• Age (men greater than or equal to 45 or woman greater than or equal to 55)
• Genetic conditions such as inherited forms of hyperlipidemia (higher than normal cholesterol levels)
• Hypertension (blood pressure exceeding 140/90)
• Family history of premature atherosclerosis (a first degree relative who is male and less than 55 or a female less than 65 years of age)
• High low-density lipoprotein (LDL)
• Low (less than or equal to 40) high density lipoprotein (HDL)
• Obesity • Physical inactivity
• Diet rich in fats
Also included are emerging risk factors like inflammatory proteins such as hsCRP, subclinical atherosclerosis noted incidentally during CAT scan, or thrombotic factors such as fibrogen. Of the emerging risk factors that I just described the only one that seems to fit the bill as a potentially useful screening tool at this time is hsCRP.
It is important to note that not all risk factors can be modified. If your father or mother had a history of premature atherosclerosis, you cannot change that risk factor. Genetic factors, at least at this time, cannot be altered.
Discussions between the doctor and patient will expose these risk factors and will determine the best course available to modify or eliminate the risks. Because 20 percent or more people suffering cardiovascular events may have none of the traditional risk factors, I recommend that all aspects of lifestyle habits and emerging risk factors be considered.
Current Health Status
The next step is to determine the current health condition of the patient. Certainly, treatment approaches will be different for persons who have had a cardiovascular event and those who have varying levels of risk factors. The evaluation of a person for probability of a cardiovascular event should be considered whether or not coronary disease (or its equivalent) or only risk factors for coronary heart disease exist.
The person with coronary heart disease or the coronary heart disease equivalent is at the highest risk. Coronary heart disease equivalent is defined as diabetes mellitus or the presence of two or more risk factors which would indictate a greater than or equal to 20 percent risk of cardiovascular event occurring within 10 years. Naturally, the person with zero risk factors has the lowest risk. Intensity of treatment will vary directly with risk.
PREVENTION: Diet, exercise, and weight reduction are very important in the initial steps of treating elevated lipids in patients who are at risk for coronary heart disease. The intensity of treatment must be matched with the intensity of cardiovascular risk factors.
Treatment
The first step in treatment includes evaluation and adjustment of diet and exercise–what is known as therapeutic lifestyle changes. These include weight reduction, exercise, and adjustment of diet, often including counseling by a dietitian. Diet and exercise have had favorable effects on total cholesterol, triglycerides, HDL, low-density lipoproteins (LDL), blood pressure, weight, and sense of well being. Current recommendations concerning calorie intake and diet have been published and are readily available on line at the web links cited in this article.
Dyslipidemia (abnormal lipid profile) is a very important risk factor and is the risk factor most addressed in the media. It is modifiable and studies have shown that reduction of lipids, particularly LDL, reduces the frequency of cardiovascular events.
Before discussing prescription medicines to control cholesterol and their role in the treatment and prevention of cardiovascular disease, I would like to review some over-the-counter products that are frequently discussed at office visits. Patients are very interested in vitamins, especially B, C and E, as well as products such as Coenzyme Q, Fish Oils, nuts, phytosterols, legumes, whole grain products, polycosanol, and red yeast rice. Many of these have been recommended at one time or another by research studies and in newspaper articles or advertisements. Most are considered useful in reducing weight and improving glucose tolerance and reducing triglycerides; however, there is lack of data in a controlled scientific study.
LDL can be easily treated in comparison to other risk factors. In evaluating a patient for treatment or prevention, the degree of risk is first determined and the goal of therapy is therefore decided based on that risk. Treatment always includes lifestyle changes, including diet, weight loss and exercise. The need for medicine depends upon the probability level of a cardiovascular event based upon the analysis of LDL levels with other risk factors. The higher the probability then the more likely the patient will need medicine. Current recommendations for lipid management are based on a series of statements that have been published over the years. The most recent guidelines were published in 2002 with an update in 2004 when several important clinical trials were released. The most recent statement is known as ATP III, which stands for Adult Treatment Panel III.
Based on these current guidelines, if a medicine is needed to treat elevated lipids, statins play a major role. Interestingly, this class of drugs played no significant role in the ATP II guidelines published in 1994. The ATP III guidelines recommend that physicians assess the risk of the patient. This calculation places patients into three major categories namely: (1) high-risk patients which include coronary heart disease or its equivalent, (2) moderate risk patients which include patients with two or more risk factors and a less than 10-20 percent risk of cardiovascular event over the next 10 years, (3) low risk meaning zero to one risk factor and in general have a less than 10 percent risk for an event over the next 10 years. Goals for diet and the need for medication such as statins, niacin, and fenofibrates are outlined in the ATP III guidelines.
In summary, it is recommended that lipoproteins be checked every five years beginning at age 20. Diet, exercise, and weight reduction are very important in the initial steps of treating elevated lipids in patients who are at risk for coronary heart disease. As physicians, we must assess risk and then assess the patient’s response to lifestyle changes. If the patient does not reach recommended goals, we must consider medications and adjust the medicines following current published guidelines. Regular follow-up with a physician is necessary to take advantage of recommended changes in treatment of cardiovascular disease reflecting current research.
Dr. Scharff is board-certified in internal medicine and cardiovascular disease, and a fellow of the American College of Cardiology. After receiving a BS in biology from St. Joseph University and his MD from Jefferson Medical College in Philadelphia, he completed his post graduate training in Cardiology at the National Naval Medical Center in Bethesda, Maryland. In 1986 he joined Dr. Don Messersmith and formed the Brevard Cardiology Group in Brevard County, Florida. An avid angler, he enjoys off-shore fishing with Linda, his wife of 35 years, his two children, Bert and Jeanne and two grandchildren.
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