New Guidelines for Heart Disease

More than 17 million Americans have coronary arteries with blockages from plague (atherosclerosis). Over the past few decades a patient with chest pain typically received further cardiac testing. This can include a 12-lead EKG, a monitored exercise stress test or a chemical stress test. Cardiac catheterization with the possibility of cardiac stent placement or even open-heart surgery would follow for any significant abnormalities. The concern is that people with stable heart disease could be treated with medications instead of quickly having the more advanced procedures.

Of course, stent placements and surgeries have risks and they are very expensive. In addition, a person that has had stent placements must be on an anticoagulant medication from 6-12 months, which also carries a risk. The surgery takes a considerable amount of recovery time as well.

A recently completed study that spanned 37 countries had a budget of $100 million. The study resulted in new guidelines for the treatment of heart disease. This study did include patients with severe cardiovascular disease. Researchers found that the risk of having a heart attack or dying over the years was not reduced following heart surgery or having a stent implanted in an artery of the heart.

The study found that after one year the invasively treated group (7%) had a cardiac event as compared to 5% of those on medication alone. In 4 years 15% of the group on medications had a cardiac problem, while only 13% of the group who had procedures had a cardiac event.

Treadmill exercise tests were given to 5,179 participants who had problems with cardiac blood flow. All of the participants were given medications to improve their heart health, and they were also given healthy lifestyle advice. Approximately one half of these participants were given a CT scan to rule out blockages that were dangerous.

The people who showed more severe blockages had a cardiac catheterization, and they were treated with angioplasties, cardiac stents or surgery if necessary. Additionally, if a person had a heart attack they received a procedure immediately to restore blood flow.

New York University’s Dr. Judith Hochman stated that non-emergency cases do not need to rush into having any invasive testing and medications should be given a chance to work. Another result of this large study found a higher rate of more severe heart problems or death in those participants who had a cardiac procedure during the past year.

The medical procedures for a blocked artery in the heart include:

1. Angioplasty - a cardiac catheterization that uses a tube to push through the blockage while inflating a balloon that expands the plague to open the artery
2. Stent placement - during a cardiac catheterization a stent is placed in the blocked artery to restore blood flow
3. Open heart surgery - the surgery uses the mammary artery or other arteries harvested from the legs to bypass the blocked section of the coronary artery

There was study completed 12 years ago which showed that angioplasty was not more effective than treating patients with medications. Many doctors did not agree with the methods of this study, so treatment overall did not change.

An effective strategy includes a team-based care approach to prevent cardiovascular disease. Each individual should be evaluated for cardiac disease risk factors.

Recommendations include:

• Statin therapy is considered the first line of defense as high cholesterol, particularly low-density lipoprotein (LDL) that should be below 190 mg/dl for those with diabetes mellitus between 40 and 75 years of age.
• Aspirin is used infrequently as a routine primary prevention aid.
• Blood pressure ideally is 120/80. If your blood pressure consistently runs above 130/80 medication is used to lower it to a healthier level.

You might wonder why medication works better than a cardiac procedure in reducing future cardiac events. The reason is a stent or angioplasty only treats a small section of a coronary artery, so if you have plaque in your arteries other areas of the artery may present a problem in the future.

There are numerous new and improved medications to treat the problems with heart disease. Cardiac procedures do improve chest pain, but not longevity. Chest pain improved after procedures alone, but it may be a placebo effect.

Cardiac risk factors include:

• A family history, which cannot be changed (ASCVD for males under 55 years and females under 65 years that may include high cholesterol)
• Metabolic syndrome where your waist circumference is increased, including elevated triglycerides above 150 mg/dl, an elevated blood pressure and a low good cholesterol (HDL) below 40 for men and 50 for women.
• Chronic kidney disease (eGRF 15-59 mL/min) with or without albuminuria untreated with dialysis or kidney transplant
• Chronic inflammatory diseases, such as RA, psoriasis, systemic lupus or HIV/AIDS
• History of premature menopause (before age 40 yr)
• Adults with type 2 diabetes mellitus
• Race/ethnicity risk factor (South Asian ancestry)
• Consistent elevated hypertriglyceridemia (above 175 mg/dL, nonfasting)
• Obesity as it promotes other diseases, such as diabetes type 2

The American College of Cardiology (ACC) and the American Heart Association (AHA) have set clinical practice guidelines since 1980, which are based on scientific evidence. First, counseling and caloric restriction is recommended for overweight adults.

1. Exercise of 150 minutes a week of moderate-intensity or 75 minutes of "vigorous-intensity” is recommended.
2. Adults with type 2 diabetes mellitus are evaluated for lifestyle changes, such as dietary habits and exercise recommendations.
3. Adults will be assessed for tobacco use, and they will be strongly advised to quit.
4. Statin medication is a first-line medication for elevated cholesterol.
5. Aspirin is infrequently used for the routine primary prevention.

It is important to promote a healthy lifestyle and a “team-based approach” is considered the most effective way to prevent cardiovascular disease. Adults from 40 to 75 years of age will be evaluated for cardiovascular disease prevention by undergoing a risk estimation for cardiovascular disease prevention. The patient should have a discussion with their physician before any pharmacological therapy is started, such as statins, aspirin or antihypertensive medications. The physician will also assess for other risk factors, and they may order coronary artery calcium scanning if warranted as it is a non-invasive test.

Other recommendations include:

1. A healthy diet for an adult should include vegetables, fruits, nuts, legumes, whole grains, lean meats and fish. The diet should minimize processed meats, trans fats, sweetened beverages and refined carbohydrates.
2. Blood pressure should be less than 130/80, so non-pharmacological treatment will be tried before prescribed medications.

Cardiovascular disease should be treated in a more conservative fashion. Procedures will be scheduled as necessary but medications will be the first line of defense. It is still important for patients to know the signs of a heart attack and report any symptoms to their physician.

• https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention
• https://www.hopkinsmedicine.org/heart_vascular_institute/clinical_services/centers_excellence/ciccarone/
• https://www.ahajournals.org/doi/10.1161/CIR.0000000000000677
• https://professional.heart.org/professional/ScienceNews/UCM_503728_Top-Ten-2019-CVD-Primary-Prevention-Guideline.jsp
• https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000678