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Heart Month – very sensible messages

National Heart Month – reducing the prevalence of heart disease

From BHF

Heart disease needs to remain high on our agenda. It remains the leading cause of death in the world1 and second only (and then only just) to cancer in the UK as of 2013.

Advances in recent years have improved outcomes after a cardiac event. Primary percutaneous coronary intervention heart attack and better management of risk factors have translated into meaningful mortality benefits.

A concern for many doctors has been the progressive medicalisation of what many consider normal ageing. Nothing demonstrates this better than statin use for primary prevention of heart disease.

The American Heart Association and American College of Cardiology now recommend statin use from a 7.5% CVD risk over 10 years compared to 20% in current UK guidelines. This would include the majority of men over 50 and over half of all women over 60 years old.

While medications have an important role in managing heart disease, most risk factors such as smoking, obesity, and even high blood pressure and cholesterol to some extent, can be attenuated without drugs and the resulting iatrogenic risk.

Obesity
Obesity contributes significantly to cardiovascular disease, with increased risk of hypertension and diabetes. In England, 24% of adult males and 26% of adult females are obese, and 41% and 33% are overweight. There are now more overweight adults than those with a normal BMI.

For the morbidly obese, there are significant benefits of weight reduction. A 15% reduction in body mass can lead to normalisation of glucose and insulin metabolism, even in people who have developed type 2 diabetes recently – effectively “curing” the condition.

How can this be achieved? Bariatric surgery is very effective at sustained weight loss in the morbidly obese but there is neither funding nor the manpower to use this on such a numerous group.

Low-energy liquid diets used in combination with other measures may provide the answer. Pilot studies have demonstrated that 6-8 weeks of a very low-energy liquid diet, followed by a gradual re-introduction of normal food within a 1-year supported programme leads to comparable weight loss to bariatric surgery at 1 year. For the same cost three times more patients achieved significant weight loss than with bariatric surgery. The question will be if this loss can be sustained for longer periods.

For those simply overweight or obese, evidence supports using commercial weight loss programmes over NHS ones (particularly for women) with more weight loss sustained at 1 year. Popular diets with the public generally have a weak evidence base which limits their recommendation.

Hypertension
There is a linear association between blood pressure and cardiovascular events, starting at a systolic of 115 mmHg. A number of lifestyle factors influence blood pressure: obesity, alcohol intake and, of course, salt.

A recent meta-analysis shows that reducing daily salt intake to 6 g/day, from a Western intake of 8-12 g/day, significantly reduces systolic blood pressure in hypertensives by 10 mmHg.   Data also shows that increasing the consumption of dietary potassium modestly reduces blood pressure by around 4/2 mmHg.

The majority of salt is hidden in processed foods. The public needs to become familiar with examining the salt content of food they purchase. Potassium-rich foods include fruit, vegetables, pulses, oily fish and chicken.

Another approach is the DASH (Dietary Approaches to Stop Hypertension) diet – high in vegetables, fruit and low in fat – which shares many features of the Mediterranean diet. Compared with the standard Western diet, but where sodium intake is equal, the DASH diet still reduces blood pressure by 11.4/5.5 mmHg. Reducing salt intake has additional benefits.

Exercise
Evidence supports the role of exercise, not simply as a mechanism for weight loss, but to improve multi-system function.

One of the key messages in the latest NICE guidance on secondary prevention of MI is that patients should be offered and encouraged to attend cardiac rehabilitation. This is safe, even in those with significant herat dysfunction, and should start within 10 days of discharge from hospital. It improves quality of life and reduces morbidity and mortality.

Smoking
Smoking remains the single most important modifiable risk factor for an individual.

Most smokers want to quit. The most effective intervention to aid quitting is offering support with a combination of behavioural and pharmacological therapy – compared to no advice, the rate of stopping smoking was 217% higher.

Combination nicotine replacement therapy (eg long-acting patches with short-acting gum for residual cravings) or varenicline are the most effective pharmacological agents; bupropion is also commonly used which has similar efficacy to nicotine replacement therapy monotherapy. They are all safe in patients with heart disease.

Conclusion
The challenge remains to engage patients with lifestyle change. We can start by being positive – for example, explaining that reducing salt intake can have the same benefit as an antihypertensive medication is a powerful message.

People need to understand that they can have a direct and substantial impact on their long-term health; doctors need to understand that empowering patients rather than progressive medicalisation will be the answer.

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