Cardiovascular diseases: prevention is the best treatment
Preventive cardiology
Speaking of cardiology, we mean here cardiovascular diseases in general. In a broad sense, they include not only myocardial infarction, but also stroke, and heart failure, and fatal cardiac arrhythmias.
The importance of preventing these conditions is primarily due to the fact that they are extremely difficult to treat when they have already developed. When we approach a patient who is already in an urgent (acute) state, it is usually very difficult to do something. The healthcare system spends huge resources of all kinds to help in this situation. Therefore, after medical science developed new methods of prevention, it became clear that the well-known principle "it is much easier to prevent than to treat" is especially true for heart diseases.
Throughout the history of mankind, the main causes of human death have changed. Initially, people died due to lack of food, due to wars and violence, in later periods thousands of lives were claimed by epidemics of infectious diseases.
If you look at the graph of mortality from diseases as a whole, you will see that it has been going down almost in a straight line since the beginning of the twentieth century. Oddly enough, mortality declined sharply in the 20s. This was not due to the invention of some medicine, but to the introduction of hygiene principles, thanks to which people became much less likely to die from infections. Even the decline in mortality since the beginning of the era of antibiotic use was not so significant.
Mortality from infectious diseases in the XX centuryOver the past 40 years, there has been a serious paradigm shift in the concepts of health, life and death.
Currently, the risk factors for death are smoking, poor nutrition (primarily hyper-calorie fatty foods), alcohol, stress, and insufficient physical activity. That resource-saving phenotype, which made it possible to survive in times of scarcity, plays a cruel joke with people in conditions of food prosperity. Our "selfish" brain, doubting the availability of resources tomorrow, requires the consumption of fatty foods even when it is not necessary. This behavior "calms" us, but at the same time puts the vessels and the liver at risk. Preventive cardiology provides the keys to effective management of such a completely new profile of risk factors, setting the main goal of prevention of cardiovascular disasters.
- Preventive Cardiology: Insights Into the Prevention and Treatment of Cardiovascular Disease, Humana press, 2006
- Editorial, Diabetology, 2004, 47: 1339-1342
Preventive cardiology is a whole range of approaches that covers all levels of prevention, starting with genetic risk factors and ending with changes in dietary patterns and behavior. When choosing an impact strategy, both modifiable risk factors (such as smoking and high blood pressure) and unmodified ones (for example, age and male gender) are taken into account.
The first achievements of preventive cardiology can be attributed to the middle of the XX century. Then began the decline in mortality from heart disease, associated by scientists with the fact that society began to actively adopt new principles of maintaining the health of the cardiovascular system.
In practice, there are two ways to implement preventive cardiology methods.
The first one can be conditionally called Northern European. In Finland, which adored a cold sandwich table and fatty food, in the 70s, cardiovascular mortality was the highest in Europe. Then the Finns and other northern peoples, who perceive the words of doctors well, were roughly explained that if they eat less fatty foods, smoke less, drink less, they will die less from heart disease. An extensive educational campaign quickly bore fruit – the Finns managed to dramatically reduce the death of people from heart disease and reach one of the first places in Europe in reducing mortality (the so-called North Karelia Project, the North Karelia project).
Finnish experience: reduction of mortality from coronary heart disease (CHD)The USA followed the second path.
There, people do not really want to change their usual way of life, but at the same time they oppose new risk factors with medications that break the link between risk factors that continue to act and pathological changes in blood vessels leading to death. American scientists have estimated that from 1980 to 2000, mortality from heart disease decreased by about 2 times, which in absolute numbers corresponds to about 200 thousand saved lives. But against this background, there was an increase in mortality due to the progression of diabetes and obesity, which indirectly testified in favor of the fact that Americans, unlike Finns, could not overcome their cravings for fatty and high-calorie foods.
Nations that have not been able or will not be able to adapt to the changed profile of risk factors and adopt the concepts of preventive cardiology are apparently doomed to extinction.
- P. Puska. The North Karelia Project - Chronic disease management, 2008 - idf.org
- Ford et al., Explaining the Decline in U.S. Deaths from C(A)D, 1980-2000 NEJM, 356; 23, 2007
Preventive cardiology consists of several main links. The first is the upbringing of children, the social basis. This includes a lot of methods that generally prepare society for a more relaxed lifestyle and proper nutrition. At the second level, preventive cardiology deals with patients who have the same risk factors with a high probability to be found tomorrow: these are young men and women who already have minimal damage in the vessels caused by inhaling tobacco smoke or fats in a slice of smoked sausage. Today's society is simply oversaturated with risk factors. The most initial atherosclerotic vascular injuries are noted even when opening the coronary vessels of the fetus (for example, if a young pregnant woman dies in a car accident). It's not exactly like what we see in older people, it's a reversible process. Nevertheless, atherosclerosis has been living in us since birth, so a certain preventive benefit is also needed in the population of young people: first of all, it is the prevention of smoking, the formation of an active lifestyle, weight loss. And the higher the risk of patients becomes in the future, the more aggressive preventive action is necessary. The third level of preventive cardiology includes a set of the most effective measures to prevent the development of a heart attack or stroke in those people who are already ill or literally on the verge of death. Moreover, a person may not even guess about the severity of the condition – in some cases, unstable atherosclerotic plaques that cause death do not manifest themselves at all, and can only be diagnosed by a very experienced cardiologist.
- Braunwald’s Heart Disease, 8e, Saunders, 2008
The set of risk factors is constantly changing. As a rule, it expands with age, and there is also a certain clustering: for example, a man with obesity and sits on the couch all the time, and drinks beer, and smokes, and even gets stressed from scandals with his wife. At this moment, there is an exceptionally powerful multifactorial pathological effect on the walls of blood vessels. Their walls are remodeled, thicken and become tougher, which leads to an increase in blood pressure. In parallel, inflammation occurs in certain areas of the vessels, fats rush there, forming the same atherosclerotic plaque.
A very important role here belongs to such a factor as chronic mental stress. Evolutionarily, our bodies are well adapted to acute stress, followed by discharge. Constant chronic stress due to complex and not fully understood mechanisms dramatically reduces the ability of the vascular membrane to resist traditional damaging factors, repeatedly potentiating their action.
Such people need to be lured to doctors who are able to find an approach to them, so that they donate the lipid spectrum, periodically measure blood pressure, blood glucose levels, do not smoke, and also use suitable techniques of emotional unloading.
If the situation takes its course, then in the future the risk increases even more, patients develop symptoms of heart disease: at first it may be barely noticeable pain behind the sternum ("like a bath leaf stuck on the skin for a few minutes"), which many men tend to ignore.
- Contributions toward evidence-based psychocardiology: a systematic review of the literature, 2007
It is particularly necessary to highlight the combination of high blood pressure with the presence of atherosclerotic plaques in the vessels of a patient who has not yet had time to develop a heart attack or stroke. This is a situation where a "fire" in the vessels (i.e. thrombosis) can start at any moment. The match that ignites it is usually acute stress, which is impossible to predict. In such patients, the use of the most aggressive preventive therapy is justified. Sometimes it is up to 6 different medications taken at the same time, for example, statin, antiplatelet, hypoglycemic agent, beta-blocker, ACE inhibitor and calcium channel blocker. To understand when the time comes for such measures, you need a doctor's flair, but there are also cardiological charts – tables, substituting age, gender, cholesterol level, blood pressure level and other indicators into which you can calculate the risk level. In difficult cases, new methods of radiation diagnostics can clarify the situation.
- Preventing future acute coronary events: is the target the so-called vulnerable plaque or the high-risk or vulnerable patient? Current Opinion in Cardiology: September 2009 - Volume 24 - Issue 5 - p 483-489
Unfortunately, there is an opinion in society that a few years before the development of a heart attack, a person's heart should begin to hurt. Alas, for many men it does not hurt until the last moment. When surveys are conducted of young men who have suffered a heart attack in a hospital, it turns out that 2/3 of men did not feel any symptoms associated with heart failure in the previous two months. Doctors have recently realized what is the matter: elderly people, as a rule, have large plaques in their vessels that block the flow of blood; patients "feel" them because the heart lacks oxygen. Such plaques "ripen" for a long time to rupture, while the heart hurts, but also adapts to life in conditions of oxygen starvation. Young people who experience high levels of stress develop small plaques with a very thin and unstable fibrous covering. Often they are silent, their appearance is not associated with pain in the heart, but they can suddenly burst against the background of imaginary well-being, immediately manifesting themselves as a massive heart attack.
The concept of unstable plaques and the management of risk factors in a patient with the probable presence of such plaques is one of the key issues of modern preventive cardiology.
- The thin-cap fibroatheroma: a type of vulnerable plaque: The major precursor lesion to acute coronary syndromes Current Opinion in Cardiology: September 2001 - Volume 16 - Issue 5 - pp 285-292
The question of whether we know everything about the risk factors that lead to the development of heart diseases is quite important, and whether all the principles of lifestyle modification and prevention of acute life-threatening conditions have been studied. The main ones are certainly known: these are maintaining blood pressure at a level not higher than 130 and 80 mm Hg; prevention of obesity; control over the content of lipids and glucose in the blood; reduction of salt, fatty foods and alcohol intake with an increase in the content of vegetables, fruits, whole grains, nuts and fish in the diet; complete smoking cessation; increased physical activity and, of course, methods of achieving mental well-being.
The active study of risk factors for cardiovascular diseases continues at the present time. And in the near future we will learn a lot about them.
- Preventive Cardiology: Companion to Braunwald's Heart Disease: Expert Consult, 2011
The author is a candidate of medical sciences, a practicing cardiologist.
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