Preventive Cardiology: A Companion to Braunwald’s Heart Disease 1st Edition 2011

For nearly a century, atherosclerotic cardiovascular disease has been the leading cause of death in industrialized countries. It often remains clinically silent for decades before resulting in an acute ischemic syndrome, myocardial infarction, stroke, or sudden cardiac death. Since atherosclerosis is a progressive disease that starts early in life, it challenges us to be more aggressive in our efforts regarding prevention.

Early identification of cardiovascular risk and modification of risk factors reduce the incidence of future cardiovascular events and improve peoples’ quality of life. Unfortunately, rates of obesity and related conditions such as metabolic syndrome and diabetes are on the rise, in both developed and developing countries. Instead of prevention, significant health care dollars are spent on the end-stage complications of atherosclerotic vascular disease, such as drug-eluting stents, implantable cardioverter-defibrillators, and surgical revascularization.

Physicians, nurses, and other health care providers need to emphasize preventive strategies to slow or halt the progression of atherosclerosis. Health care providers need to understand how to optimize cardiovascular risk stratification. The Framingham and other global risk algorithms serve as an important starting point in risk assessment, but have limitations and often exclude key risk factors such as a family history of premature cardiovascular disease, glucose intolerance, triglycerides, waist size, and lifestyle habits. For example, although an adult with a glucose level of 126 mg/ dL or higher is automatically placed into a very high risk category, a similar individual with a slightly lower glucose level but who may have additional risk factors or evidence of advanced subclinical atherosclerosis for their age may actually be at higher risk, but would not necessarily qualify for aspirin therapy, antihypertensive therapy, or lipid-lowering therapy.

A great need also exists for better understanding of the significance, clinical utility, and cost-effectiveness of more novel risk factors and screening for asymptomatic cardiovascular disease. Atherosclerosis imaging and measurement of biomarkers such as hs-CRP are now fairly widely performed, and there is a need for understanding how to incorporate into clinical practice the findings from large-scale epidemiologic studies (e.g., Cardiovascular Health Study and the MultiEthnic Study of Atherosclerosis) and clinical trials such as JUPITER. However, there are clear limitations to the data that we have so far on biomarkers such as hs-CRP and increasingly popular multimarker approaches, and imaging measures such as coronary artery calcium and carotid intima-media thickness. Experts are clearly split on how to incorporate emerging risk factors and subclinical disease into clinical practice.

The medical community needs to promote guideline adherence and reduce the gap in use of proven medical and lifestyle therapies. Moreover, federal, state, and local governments, education departments and schools, and the corporate sector need to play a greater role in ensuring environments conducive to promoting heart health. The cornerstone of prevention is based on therapeutic lifestyle changes, including regular brisk physical activity and a healthy diet, and strategies to better support these measures need to be developed and implemented at the health care and community level.

In this companion to Braunwald’s Heart Disease, we approach cardiovascular disease prevention in a convenient ABCDE framework. In 2002 the AHA and ACC produced a guideline statement on the management of patients with chronic stable angina and arranged their recommendations into an ABCDE format. This approach has also been used as the basis for the training of fellows in preventive cardiology.1 It has also been used in several evidence based reviews on primary and secondary prevention of CVD, management of non–ST-segment elevation myocardial infarction (NSTEMI) and management of metabolic syndrome.2-4

Prevention needs to be a central feature of a sustainable health care system, but implementation of preventive practices remains suboptimal. The ABCDE approach arranges prevention guidelines into an easy-to-remember framework that can be used by clinicians with each patient to ensure comprehensive care. The principal sections of this textbook include: (A) assessment of risk from a clinical and genetic perspective, atherothrombosis and antiplatelet therapy; (B) blood pressure management; (C) cholesterol and dyslipidemia; (D) diet and lifestyle issues (diabetes mellitus ,metabolic syndrome; disparities in care; diagnostic testing to help improve risk prediction); and (E) exercise prescriptions, cardiac rehabilitation and emotional aspects of preventive cardiology.

This text is meant to serve as a guide for those interested in prevention of cardiovascular disease. It provides an overview of the epidemiology and risk factors for cardiovascular disease, and the importance of risk stratification. It underscores the evidence base for the management of cardiovascular risk factors and provides recommendations for clinical care. It our hope that armed with the tools provided in this text we may achieve the promise of the prevention of most cardiovascular disease events in our lifetimes.