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Physicians Update

 
Fall 2012: Men's Health

Evidence-Based Strategies Help Prevent Heart Disease

Physician looking at monitorWhile heart disease is the leading cause of death among all U.S. adults, men frequently present with cardiovascular disease at an earlier age than women. This is due, it is thought, to the greater incidence at a younger age of some cardiovascular risk factors in men.

According to the Framingham Heart Study, conducted by the National Heart, Lung and Blood Institute and Boston University, an average man between the ages of 60 and 64 has a 21-percent chance of developing heart disease in the next 10 years; the risk for an average woman is 12 percent. The risk is even greater at younger ages. Men between the ages of 40 and 44 are more than three times more likely than women to suffer serious heart disease within the next 10 years.

But a large percentage of cardiovascular conditions could be prevented by addressingsuch modifiable risk factors such as blood pressure and low-density lipoprotein (LDL or so-called "bad") cholesterol, which tend to be higher in men. The primary barrier to reducing morbidity and mortality from heart disease, experts say, is inconsistent application of evidence-based strategies in practice to reduce these factors.

"By knowing just a few simple factors about patients, we can predict their 10-year and lifetime risk for developing cardiovascular disease," says cardiologist Gregg C. Fonarow, M.D., co-director of the UCLA Cholesterol, Hypertension, and Atherosclerosis Management Program (CHAMP). In addition to blood pressure and cholesterol, the key variables associated with heart disease include age, blood pressure, glucose, physical activity, smoking behavior and family history. 

With this information, physicians can calculate a Framingham Risk Score, which reflects an individual's risk for having a heart attack or dying from heart disease within a certain time frame. This information is frequently collected but not consistently analyzed and used to support informed decision-making about risk-factor modification and the benefits of protective therapies. "Death from cardiovascular disease remains prevalent in the U.S. because there is a lot more that could be done to modify risk," Dr. Fonarow says.

Patient compliance with recommended therapies represents a major challenge. For example, blood-pressure-lowering medications reduce the risk for heart attack and stroke by as much as 40 percent, but approximately one-third of patients will stop taking prescribed medications within a year, before their blood pressure is well-controlled, Dr. Fonarow says. Many of these patients will later experience heart failure, stroke, renal disease or other preventable cardiovascular deaths.

"Many patients start therapy and then stop it within a few months not because of side effects or intolerance but because they were not sure why they were put on the medications in the first place," he adds. A large proportion of patients who have cardiac events were on one or more cardiovascular therapies at one time but stopped taking them, according to Dr. Fonarow.

Checking blood pressure To address this problem, he recommends that physicians explain and reinforce the benefits of prescribed therapies and establish mechanisms to monitor patient adherence. Some studies have demonstrated the effectiveness of reminders and feedback regarding medication compliance, such as electronic health records at the point-of-care and automated notices when patients fail to fill or refill prescriptions. Other studies have shown that establishing incentives or rewards, such as reduced co-payments or premium discounts, for achieving health goals are associated with increased risk factor modification and control, Dr. Fonarow says.

"We've learned a great deal about implementing programs to help manage heart disease, such as CHAMP and Get With The Guidelines," says cardiologist Karol Watson, M.D., co-director of CHAMP and the Cholesterol and Lipid Management Center at UCLA. Get With The Guidelines is a hospital-based program sponsored by the American Heart Association - based on the CHAMP model created at UCLA - that uses national, evidence-based guidelines to help manage risk factors in patients with cardiovascular disease. "Unfortunately, many risk factors are left uncontrolled despite these programs because patients received usual care rather this enhanced system of care," Dr. Watson says.

Statins, for example, can lower LDL cholesterol and the risk for fatal and nonfatal cardiovascular events by 50 to 60 percent but remain dramatically underutilized. Statins not only reduce lipids but also reduce inflammation, prevent platelets from sticking and improve epithelial function, Dr. Watson says. 

"Many of the medications that were initially developed to treat cholesterol have demonstrated benefits far and above their initial function," she says. New agents, such as PCSK9 monoclonal antibodies, which may work alone or together with statins to further lower cholesterol, are also being investigated in clinical trials. Reducing LDL cholesterol to below levels of 40 to 60 mg/dL substantially lowers the risk for developing cardiovascular disease across a broad range of individuals. Addressing behavioral risk factors, including lack of physical activity, poor nutrition, tobacco use and excessive alcohol consumption, are also key priorities in managing heart disease. 

"We know what works," Dr. Watson says. "Getting the right strategies into practice is the difficult part."

Drs. Fonarow and Watson note that the American Heart Association has developed an online tool to enable individuals to perform their own cardiovascular-health assessment, identify modifiable risk factors and learn more about heart health.

For more information about the American Heart Association's online tool, go to: http://mylifecheck.heart.org





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