Dr. Fry will describe strategies to prevent cardiovascular disease earlier in the encounters with patients.
Sponsored by Ed Koolish
Program: Live and Zoom: Cardiovascular Prevention from a More Upstream Perspective Speaker: Edward Fry, MD, Cardiologist, Ascension St. Vincent, Carmel and more
Introduced By: Ed Koolish
Attendance: NESC: 106; Zoom: 27
Guest(s): Mary Conway, Terry and Cheryl Nofsinger, Ned and Kathy Sturner
Scribe: Benny Ko
Editor: Bill Elliott
View a Zoom recording of this talk at: https://www.scientechclubvideos.org/zoom/05122025.mp4
A 55y/o WM with hypertension, hyperlipidemia, smoker, obese, positive family history for cardiovascular disease, had not seen a primary care physician for three years, presented with sudden severe chest pain. EKG confirms myocardial infarction, and coronary angiography demonstrates stenosis of the anterior descending and posterior circumflex arteries near their junction. Under mechanical circulatory support, stents were placed to open up both stenoses. The patient did well and survived.
While this case illustrates success in intervention, it is a failure in prevention, as cardiovascular disease is preventable.
Currently, the burden of cardiovascular disease is increasing while resources to address it are declining.
Worldwide, cardiovascular disease (CV) cases have doubled to 523M between 1990-2019. CV deaths are up 50% to 18.6 M. 48% are women, and 60% are 30-70 y/o. Ischemic heart disease (IHD) accounts for 1/2 of all deaths, and disability-adjusted life years have doubled from 17.7 to 34.4 M. The death rates are increasing in both the U.S. and globally.
Associated prevalence trends such as hypertension, diabetes, obesity, coronary disease, heart failure, and atrial fibrillation are expected to rise in the future. Smoking is a decreasing trend. Aging also increases the risk for CV, and the US population is aging. The US life expectancy is 4.1 years less than other developed nations, and the impact is more pronounced among Black people and Hispanics. This is despite we spend twice as much as the others.
We are also facing a crisis in nursing and cardiologist shortages.
Prevention of Ischemic Heart Disease is a spectrum and can be divided into primordial, primary, and secondary phases.
The Top 10 Guideline Take-Aways from ACC/AHA are:
1. Promote a Healthy Lifestyle throughout life.
2. Strategy of Team-Based Care, address Social Determinants of Health.
3. Adults 40-75 should undergo 10-yr ASCVD risk assessment, consider CAC Score.
4. Healthy Diet. Minimize red meat, trans fat, and refined carbohydrates. Maintain ideal weight.
5. Exercise. Recommend 150 min/week of moderate intensity workout.
6. Type 2 Diabetes. Metformin, SGLT-2 or GLP-1 agents, keep A1c < 7.0
7. Smoking cessation. Never too late to quit.
8. Routine ASA? For certain risk groups?
9> LDL > 190mg/dl Statin therapy.
10. BP goal <130/80 mmHg.
Point of Care (POC) ASCVD Risk Calculation, e.g., the Pooled Cohort Equation is used to estimate a patient's risk (low, intermediate, high) of developing ASCVD in the coming ten years.
Among tools used for assessment: Coronary calcium score, Coronary CT Angiography, CCTA-FFR (fractional flow reserve), IVUS/OCT (Intravascular ultrasound/optical coherence tomography), QCPA (quantitative coronary plaque analysis), to assess total plaque burden and plaque composition.
Preventive Medication:
Lowering LDL cholesterol: Statin therapy is safe and beneficial in reducing risks and outcome.
The use of PCSK9 inhibitors also lowers LDL level. Drugs: Evolocumab, Alirocumab.
Lipoprotein(a) elevation is associated with ASCVD and aortic stenosis. It is elevated in 20% of the population.
Diabetes Drugs: Beneficial if one is diabetic.
Anti-hypertensives for hypertension.
Small Interfering RNAs to reduce cardiovascular risks, i.e. to treat PCSK9, Lp(a), hypertension. CRISPR gene editing to turn off the process of amyloidosis formation.
Polypill (a single pill containing multiple medications).
Myths (Items that do not work): Plant sterols, Niacin, Smokeless nicotine, Omega-3, Fish oil.
The Bogalusa Heart Study found that ASHD begins before age 20, according to autopsy results. Early behavior, genetics, and environment are causative factors.
Socioeconomic factors are determinants. Air pollution, especially microparticles and microplastics, and nano plastics, contribute to CVD and is harmful to health in general. Smoke cessation is beneficial to health and reduces death. Consumption of ultra-processed food increases mortality, with most of the deaths attributable to CVD. CVD correlates with the region of one's residence. Pregnancy and associated complications can contribute to the future development of CVD.
Edward Fry, MD.
