Dr Tejas Patel, a world-renowned interventional cardiologist and endovascular therapist, highlights cardiovascular disease, a leading cause of disability and premature death around the world
Cardiovascular disease is a leading cause of disability and premature death around the world, accounting for around 3.9 million deaths per year in Europe. Atherosclerosis is a slowly developing process and has long and minimally symptomatic latent period, but it results in sudden and catastrophic events like myocardial infarction and stroke. These catastrophic events can lead to death even before hospital arrival and this reiterates the importance of modification of risk factors which have shown to reduce both mortality and morbidity.
Atherosclerotic cardiovascular disease is not curable. Palliation is the aim of even the most advanced treatments, like the placement of coronary stents or bypass grafts. The old proverb, ‘prevention is better than cure’ is perfect in its description of cardiovascular disease. Cardiovascular diseases, even though considered a disease of old age, begins quite early in life and it is this long latent period which is amenable to preventive measures.
The age at which atherosclerotic cardiovascular disease becomes present, in turn, depends on the rate of progression of atherosclerosis. This is influenced by cardiovascular risk factors: tobacco consumption (both chewable and inhalation), abnormal blood lipids (dyslipidemia) and elevated blood glucose (diabetes), elevated blood pressure (hypertension), an unhealthy diet and sedentary lifestyle. Obesity, particularly abdominal obesity (high waist-hip ratio) and a family history of premature cardiovascular disease (cardiovascular disease in a first-degree relative before the age of 55 years for men and 65 years for women) can also modify cardiovascular risk. Continuing exposure to these risk factors leads to the progression of atherosclerosis, resulting in unstable atherosclerotic plaques leading to narrowing of blood vessels and obstruction of blood flow to vital organs, such as the heart and the brain. This can result in myocardial infarction and stroke.
Prevention of cardiovascular disease via modification of risk factors is a much more practical approach than just the treatment of disease. Preventive measures will decrease the burden of disease in the community, while standalone treatment measures will make the population live for longer living. In addition, while the effects of drug therapy cease within a short period of discontinuation of treatment, the impact of lifestyle modification are longer standing. Stopping smoking, a healthy diet and regular physical exercise comes at no added cost and has no known adverse effects. So, lifestyle modification should take priority in the formulation of policies for cardiovascular diseases.
Cessation of tobacco consumption has shown to decrease cardiovascular mortality and morbidity. There is evidence to believe that the risk of CAD is mitigated 10 years after stopping smoking. People who continue to smoke albeit in reduced quantity have greater mortality risk than people who stopped smoking as shown by the Interheart study. A long-term follow-up study of British doctors demonstrated that smokers who quit smoking between 35-44 years had the same survival rate as that of a non-smoker.
The estimated health care costs for unhealthy diets ranged from €3.5 per capita in China to €63 in Australia and €156 in the United Kingdom. For low physical activity, the estimated annual per capita health care costs ranged from €3 in the Czech Republic to €48 in Canada.
A cardioprotective diet is defined as the one which is an overall healthy diet, results in acceptable body weight and improves lipid profile, as well as blood pressure. Recommendations are to reduce total fat intake to less than 30% of calories, saturated fat to less than 10% of calories and salt to less than 5 grammes per day and also increasing fruit and vegetable intake to 400–500 grammes daily. Fruit and vegetable intake may promote cardiovascular health through a variety of micronutrients, antioxidants, phytochemicals, flavonoids, fibre and potassium. Two major forms of diet have been recommended for improvement of cardiovascular outcomes. DASH diet includes lots of whole grains, fruits, vegetables and low-fat dairy products.
The DASH diet also includes some fish, poultry and legumes and encourages a small number of nuts and seeds a few times a week. The Mediterranean diet has shown to improve cardiovascular outcomes. This kind of diet is characterised by high intake of plant-based food (fresh fruits, vegetables, cereals and nuts) and extra-virgin olive oil, moderate intake of fish and poultry and low intake of dairy products, red and processed meat and sweets. Other important elements of the Mediterranean diet are being physically active, sharing meals with family and friends and sometimes enjoying a glass of red wine.
A sedentary lifestyle is associated with an increased risk of heart disease. ESC guidelines recommend at least 150 minutes a week of moderate aerobic physical activity or 75 minutes a week of vigorous aerobic physical activity or a combination of the two intensities. Importantly, there is almost a linear relationship between the amount of physical activity and cardiovascular benefit.
Even though moderate alcohol consumption has been shown to improve cardiovascular outcomes, this should not be recommended for non-alcoholics.
Alcohol consumption is associated with a lot of social evil and is implicated in the pathogenesis of many cancers. Consequently, from both the public health and clinical viewpoints, there is no merit in promoting alcohol consumption as a preventive strategy.
With the rapid modernisation and increasing stress as a part of lifestyle some psychosocial factors, such as depression and anxiety, lack of social support, social isolation and stressful conditions at work, hostility and type A behaviour patterns and anxiety or panic disorders, have also been contributing to the cardiovascular risk. Rapid identification and treatment of these conditions might improve cardiovascular outcomes.
In addition to these lifestyle modifications, pharmacological treatment of hypertension, diabetes and dyslipidemia has been shown to reduce cardiovascular morbidity and mortality.
The recent digital revolution has sparked new possibilities in the field of medicine. Digital health interventions include use of telemedicine, email, smartphones, mobile applications and monitoring sensors for diagnosis and management of various heart conditions and these could prove to be a landmark event in the field of medicine by involving digital world and the patient himself in the diagnosis and management of heart disease. This could also help in the individualisation of therapy which could improve health outcomes. Wearable watches such as Apple, Fitbit, etc. have numerous functions like step count, calculation of calorie consumption, distance travelled and heart rate monitoring. Such data might help us to plan individualised therapy and can also provide information regarding basic hemodynamics preceding an event which might increase our understanding of the disease process.