Preventive Cardiology Companion to Braunwald’s Heart Disease PDF

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 Multi- Ethnic 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.