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Physicians Update

 
Summer 2010

Evidence-Based Guidelines Reduce Deaths from Atherosclerosis

07/14/2010

PU-Summer10-Reduce Deaths from AtherosclerosisAtherosclerosis is the primary culprit in promoting coronary heart disease (CHD), the leading cause of death in the United States. Addressing key risk factors is important to preventing and treating the disease, but experts say earlier intervention with medication may also be warranted.

“Instead of watching some patients fail to follow diet and exercise recommendations and miss their blood pressure, cholesterol and glucose targets year after year, we now intervene much sooner with statins, beta blockers, ace inhibitors and aspirin,” says UCLA cardiologist Alan Fogelman, M.D., chair of the UCLA Department of Medicine. “It’s important to identify the patients at risk and treat the underlying inflammatory disease as opposed to waiting until patients experience arterial blockage that will result in chest pain, heart attack or other problems.”

Laboratory and clinical studies suggest that inflammation, the process by which the body responds to infection or injury, is associated with the rupture of atherosclerotic plaque in the arteries. This damage triggers blood clotting that may eventually block blood flow to the heart.

Though atherosclerosis is often asymptomatic, physicians can utilize significant evidencebased predictors to estimate with a high degree of accuracy patients at risk for developing cardiovascular diseases, Dr. Fogelman says. These risk factors include smoking, hypertension, diabetes and obesity, as well as elevated levels of LDL (“bad” cholesterol), triglycerides and glucose in the blood. In recent, large clinical studies, high-sensitivity C-reactive protein (hs-CRP), a marker for inflammation, has also been shown to be a significant predictor of cardiovascular disease in patients who otherwise appear healthy. Test results for hs-CRP in patients with recent illness, injury, infection or general inflammation should be interpreted carefully because CRP levels are elevated in sick patients. According to Dr. Fogelman, physicians should not automatically rule out prescribing medications in patients with normal LDL levels, particularly when they have high CRP levels and other risk factors.

PU-Summer10-Heart Blockage“Some physicians are reluctant to order a statin because the patient has a relatively low LDL level, or hesitate to prescribe a beta blocker or ace inhibitor because they think there will be side effects,” Dr. Fogelman says. “But we want people to understand that atherosclerosis is an inflammatory condition, and these medications can act as antiinflammatory agents.”

“Implementation of evidence-based cardiovascular medicine across the country is still suboptimal,” says cardiologistKarol Watson, M.D., co-director of the UCLA Center for Cholesterol and Lipid Management. “We really need to work at educating patients and physicians about the benefits of newer therapies and bring everyone into compliance with evidence-based guidelines.”

According to numerous published studies, national initiatives such as the American Heart Association’s Get with the Guidelines (GWTG) and the American College of Cardiology’s Guidelines Applied in Practice (ACC-GAP) programs, which were modeled after the UCLA Cholesterol, Hypertension, and Atherosclerosis Management Program (CHAMP), have significantly helped to improve treatment and reduce mortality from cardiovascular disease. The death rate from coronary heart disease declined 36.4 percent from 1996 to 2006, according to the American Heart Association. But cardiovascular disease still causes one in nearly every three deaths in the U.S. each year, with some racial and ethnic groups experiencing significantly higher morbidity and mortality than others. Dr. Watson says there is still much to learn about the effect of cardiovascular disease risk factors in diverse populations.

PU-Summer10-Management“There are strong genetic and environmental components to atherosclerosis,” says Dr. Watson, who is the principal investigator of the Multi- Ethnic Study of Atherosclerosis (MESA) currently being conducted at six sites across the country. According to Dr. Watson, MESA will advance what is known about cardiovascular diseases by examining the relationship between geography, race/ethnicity and other demographic characteristics and certain cardiovascular risk factors. The MESA cohort is comprised of approximately 25 percent each of Caucasian, African-American, Hispanic and Asian populations, in contrast to the Framingham Heart Study, which includes a primarily Caucasian cohort.

“We are now able to manage lipids and other risk factors better than ever before, but about 10 percent of people need more intensive symptom management,” Dr. Watson says. “To get control of this disease, we need to close the knowledge gaps related to how various risk factors impact people from different racial/ethnic, cultural, economic and geographic backgrounds.”





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