ACC NEWS
President’s Page: Prevention’s Place in Cardiology: What the Future Holds
Pamela S. Douglas, MD, FACC, President, American College of Cardiology* and
Roger S. Blumenthal, MD, FACC, Chair, ACC Prevention Committee
* Address correspondence to: Dr. Pamela S. Douglas, American College of Cardiology, c/o Cathy Lora, 9111 Old Georgetown Road, Bethesda, Maryland 20814-1699.
It would seem, at first blush, that we should have the prevention of heart disease well in hand. Simply put, there is ample evidence to support the positive impact of aggressive risk factor management in reducing cardiovascular events, improving quality of life, and facilitating long-term survival. Tools such as the upcoming 2005 American College of Cardiology/American Heart Association (ACC/AHA) Guideline Update of the ACC/AHA Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease provide excellent reviews of the lifestyle changes and pharmacologic therapies that should be employed in individuals with established atherosclerotic vascular disease.
Yet, despite this abundance of knowledge and clear clinical direction, we are facing an uphill battle. A growing percentage of the U.S. population is entering an age where cardiovascular disease is commonplace. Rates of obesity are on the rise, particularly—and sadly—among young children and adolescents. Participation in regular forms of exercise is disappointingly low. Not surprisingly, rates of dyslipidemia, diabetes mellitus, and metabolic syndrome also are on the rise. As such, we predict an increased use of drug-eluting stents, implantable cardioverter-defibrillators, and other expensive therapies that will continue to escalate costs in our health care system.
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What can we do?
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As the American College of Cardiology (ACC), our approach to atherosclerotic vascular disease needs to change. We must put a greater emphasis on attempts to prevent, slow, or ideally halt the progression of heart disease. Our focus should be to develop and help caregivers to implement prevention strategies for every individual at risk for cardiovascular disease, as well as to redefine what is meant by prevention.
Traditionally, prevention has been classified as either primary or secondary, based on the presence of a defining cardiovascular event (e.g., myocardial infarction). We are now entering an era, however, where identification of subclinical atherosclerosis is a reality. Recently, Dr. David Celermajer coined the term "primary-and-a-half prevention" for asymptomatic individuals with no history of a cardiac event who, on the basis of blood tests (e.g., high-sensitivity C-reactive protein, lipids, and so on) or imaging modalities (e.g., cardiac computed tomography, carotid intima media thickness), can be identified as candidates for more intensive preventive strategies (1). We also have data that exercise treadmill testing to determine exercise capacity and heart rate recovery may be quite useful in predicting mortality in intermediate-risk adults (2,3).
Unfortunately, the intensity with which risk factors or evidence of asymptomatic disease in such individuals should be treated remains unknown. How low should their blood pressure be? To what level should their low-density lipoprotein cholesterol (LDL-C) be reduced? As technology provides us with a better look inside our patients, we need to be prepared with answers as to how best to treat them.
One strategy is to develop cost-effective methods of identifying patients who are considered to be "low" or "intermediate" risk by the traditional Framingham risk score but who would likely benefit from additional blood tests or imaging tests to see if they might qualify for more aggressive risk factor modification. Further, the Framingham score may underestimate risk in some individuals because it does not take into account waist circumference, triglyceride levels, elevated fasting glucose, or family history, and it tends to overemphasize age. Moreover, while an adult with diabetes is classified as high risk, that same adult with a slightly lower glucose level may not qualify for any type of pharmacologic therapy.
There are many questions to be answered: Asymptomatic adults can now be diagnosed with moderate or advanced coronary or carotid atherosclerosis. Should such a person be treated to standard primary or secondary prevention goals, or should we aim for the more aggressive "optional" LDL-C and non–high-density lipoprotein cholesterol (HDL-C) targets to help arrest the progression of his or her atherosclerosis? The National Cholesterol Education Program guidelines termed diabetes and peripheral arterial disease as coronary heart disease risk equivalents. Should we add chronic kidney disease and advanced subclinical atherosclerosis to this list?
Although we may believe these conditions do warrant aggressive secondary prevention strategies, we are not adequately treating the risk factors of patients with known coronary artery disease or diabetes, in whom the imperative to prevent recurrent disease is clear. Patients, physicians, and other health care providers are not fully utilizing the knowledge and tools available to lower cardiovascular disease (CVD) risk. A major focus of the ACC, in particular, should be improving guideline adherence, reducing the gap in utilization of proven therapies, and promoting strategies to sustain the use of risk reduction therapies in order to optimize cardiovascular care.
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ACC leadership in the field of prevention
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In the spring of 2005, the ACC convened a task force to develop a background paper on the organization’s future role in the area of prevention. The Prevention Task Force was charged with developing a 10-year outlook on the field with respect to diagnosis and treatment of asymptomatic disease, improving adherence to guidelines, and the potential impact of emerging fields of genomics, proteomics, and metabolomics. This task force’s recommendations build on a substantial record of involvement in setting quality standards for prevention.
Over the past decade, the ACC has substantially increased prevention content in its programs and activities, such as in its flagship general cardiology self-primer ACC Self-Assessment Program (SAP). For example, in 1999, the ACC/AHA/American College of Physicians (ACP) guidelines for the management of chronic stable angina included the "ABC" treatment mnemonic of Aspirin and anginals, Beta-blocker and blood pressure, Cholesterol and cigarettes, Diet and diabetes, Education and exercise (4). A modified version of the ABC approach is now the cornerstone of an evidence-based approach to primary and secondary prevention of CVD (5).
The 2005 ACC Prevention Task Force firmly holds that we should advocate for improved reimbursement for disease detection and prevention activities, promote multidisciplinary teams through advocacy and education, and develop simplified guidelines on prevention. It also calls for greater advocacy for prevention research and the creation of training modules on prevention for cardiovascular medicine trainees and other health care providers. These priorities were adopted by the Board of Trustees at its most recent meeting.
By the end of this decade, we hope to achieve major pharmacologic advances in the areas of HDL-C–raising drugs, smoking cessation, and weight loss medications. In the next decade, targeted therapies based on genetic, proteomic, and metabolic diagnostic testing may become a reality. As these new technologies gradually emerge, new continuing education programs and updates to existing guidelines will be needed to deal with the knowledge gaps of the cardiovascular specialist. Our new and expanded Cardiosource Website is a great source of reliable clinical information about emerging technologies and other advances in the area of prevention. The Prevention Committee will be expanded to include new members with expertise in emerging technologies, vascular biology, and genetics.
The ACC plans to continue its work with other organizations such as the AHA, the American Society of Hypertension, and the American Diabetes Association to develop unified guidelines for prevention that will update the recent collaboration between several major organizations (6). We will also actively work to align ourselves with organizations and campaigns focused on primordial prevention (promotion of healthy behavioral patterns to prevent risk factor development), such as those targeting childhood obesity. We hope to promote more widespread use of multidisciplinary teams (nurses, nutritionists, exercise physiologists) through ACC Cardiac Care Associates, as well as greater cooperation with organizations such as the Preventive Cardiology Nurses Association.
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Call to action
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The cornerstones of a healthy heart are indisputably a healthy diet and regular activity. A healthy diet is one that is low in saturated fats, trans-fatty acids, and simple sugars, with an increased amount of vegetables, fruit, and whole grains. And all children, adolescents, and adults should be encouraged to accumulate 30 min of brisk activity most days of the week. These simple measures, following the "ounce of prevention is worth a pound of cure" paradigm, are all we need to remember as we implement the ABCs of prevention for our patients and for ourselves (5). Prevention does not have to be complicated, and the ACC is committed to getting the message out to all through education, increased support for research and training, and partnerships with other organizations.
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References
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- Celermajer DS. Primary and a half prevention. Can we identify asymptomatic subjects with high vascular risk? J Am Coll Cardiol 2005;45:1994-1995.[Free Full Text]
- Mora S, Redberg RF, Sharrett AR, Blumenthal RS. Enhanced risk assessment in asymptomatic individuals with exercise testing and Framingham risk scores Circulation 2005;112:1566-1572.[Abstract/Free Full Text]
- Kraus WE, Douglas PS. Where does fitness fit in? N Engl J Med 2005;353:517-519.[Free Full Text]
- Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable anginaa report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 1999;33:2092-2197.[Free Full Text]
- Gluckman TJ, Baranowski B, Ashen MD, et al. A practical and evidence-based approach to cardiovascular risk reduction Arch Intern Med 2004;164:1490-1500.[Abstract/Free Full Text]
- Eyre H, Kahn R, Robertson RM, et al. Preventing cancer, cardiovascular disease, and diabetes Circulation 2004;109:3244-3255.[Abstract/Free Full Text]
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What can we do?
ACC leadership in the...
