cardiovascular%20disease%20prevention
CARDIOVASCULAR DISEASE PREVENTION
Patients 18 years old and above should receive a risk factor assessment for cardiovascular disease (CVD) at every routine physician visit.
Cardiovascular disease development is closely related to lifestyle characteristics and associated risk factors.
There is an overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a cardiovascular event.
Very high-risk group refers to patients with documented CVD, by invasive or non-invasive testing, and with presence of risk factors.
High-risk patients are those who have already experienced a cardiovascular event or have very high levels of individual risk factors.
Moderate-risk patients require monitoring of risk profile every 6-12 months.
Low-risk patients may be given conservative management, focusing on lifestyle interventions.

Patient Education

  • Counseling should be part of the patient encounter as they tend to respond more favorably
    • Inform the patient that multiple risk factors contribute to atherosclerosis which causes CVD; therefore, the aim is to decrease the total risk from all these factors
    • If a goal with a risk factor cannot be reached, this can be remedied by more reduction in other risk factors
  • Lifestyle counseling is the foundation of primary prevention and has the potential to either reduce or prevent the development of risk factors
  • It would help to include family members in the educational process so they can assist the patient in achieving lifestyle modifications
  • Develop a plan with the patient and hold discussions over time so that patient is not overwhelmed by changing several behaviors all at one time (examples smoking, diet, exercise, etc)
  • Re-educate the patient about food selection and stress the importance of physical activity
  • Monitor progress through follow-up contact and have regular re-evaluation and behavioral interventions to maintain adherence

Lifestyle Modification

  • Medical nutrition therapy, physical activity and comprehensive lifestyle approaches have been shown to improve the control of risk factors and intermediate markers of cardiovascular disease risk

Diet Modification

  •  Counsel the patient on a diet consisting of fruits, vegetables, low-fat dairy products, fiber, whole grains and protein sources that are low in trans-fat, saturated fat and cholesterol:
    • Total dietary intake of fats 25-35% of calories consumed
    • Intake of saturated fats <7% of the total calories
    • Intake of polyunsaturated fats <10% of the calories
    • Monounsaturated fatty acids <20% of the caloric intake
    • Limit trans fats <1% of total calories
    • Intake of dietary cholesterol <200 mg/day
    • Dietary options can be added (plant stanols/sterols 2 g/day; soluble fiber 30-45 g/day)
  • Replace saturated fats with monounsaturated and polyunsaturated fats from vegetable or marine sources
    • Polyunsaturated fat showed slightly greater LDL-C reductions compared to monounsaturated fat
  • Minimize intake of beverages and foods with added sugar
  • The Prospective Urban Rural Epidemiology (PURE) study recently showed that high carbohydrate intake (>60% of energy) was associated with an adverse effect on total and non-cardiovascular disease mortality whereas a high fat intake (including saturated and unsaturated fatty acids) was associated with lower risk of total mortality, non-cardiovascular disease mortality and stroke
    • Limit overall carbohydrate intake especially from refined sources 
  • Recommended intake of sodium is <5 g/day for the general population
    • Advise about the hidden salt content in processed foods
  • Consumption of unsalted nuts by 30 grams per day may help reduce CVD risk
  • Increase consumption (≥2 servings per week) of fish high in omega-3 fatty acids
    • Intake of 2-4 g daily of fish oil can reduce triglycerides by ≥25%
    • The American Heart Association finds it reasonable to give Omega-3 polyunsaturated fatty acid supplementation for the secondary prevention of cardiac heart disease and sudden cardiac death in patients with prevalent cardiac heart disease or heart failure
  • Patients with cardiovascular disease or identified risk factors, such as diabetes, dyslipidemia, hypertension or obesity, may benefit from personalized diet advice or referral to a dietitian

Increased Physical Activity

  • Contributes to weight loss, glycemic control, improved BP, lipid profile and Insulin sensitivity
  • All should be encouraged to have moderate intensity aerobic activity (such as brisk walking) at least 30-60 minutes per day, 5-7 days a week, or 15 minutes per day for 5 days/week of high intensity aerobic activity, or a combination of the two, in addition to increase in daily lifestyle activities (like household work, gardening andwalking breaks during work)
    • Resistance training may be advised at least 2 days a week
  • Patients with cardiovascular disease or cardiovascular disease equivalents should be assessed prior to beginning a vigorous physical activity for conditions that might contraindicate certain types of exercise or predispose to injury

Moderation of Alcohol Consumption

  • Alcohol consumption above 3 units per day increases blood pressure, risk of cardiac arrhythmias, cardiomyopathy and sudden death
  • Patients should be advised to reduce alcohol consumption
  • Goal: Limit alcohol intake to <2 glasses per day or 20 g/day of alcohol for men and one glass per day or 10 g/day for women

Smoking Cessation

  • Studies have shown that smoking accelerates coronary plaque development and may lead to plaque rupture,dangerous in patients with advanced coronary atherosclerosis
  • Smoking cessation has been shown to significantly increase HDL-C
  • Evidence supports the beneficial effect of smoking cessation on cardiovascular disease mortality
  • All smokers should be strongly encouraged to quit smoking by a health professional and be supported in their efforts to do so
  • Assess the tobacco user’s willingness to quit
  • Assist by counseling and developing a plan for quitting
  • Pharmacologic intervention (such as Nicotine replacement therapy, Bupropion or Varenicline) should be given to motivated smokers who failed to quit by counseling
  • Several studies showed that the use of electronic cigarettes for relapse prevention and smoking cessation is comparable to Nicotine replacement therapy but data is limited
  • Arrange follow-up and referral to special programs
  • All nonsmokers should be encouraged not to start smoking
  • Goal: Complete smoking cessation and no exposure to environmental tobacco smoke
  • See Smoking Cessation Disease Management Chart for more details

Weight Management

  • Weight reduction results in lower BP, lower LDL-C and TG, higher HDL-C and improvements in hyperinsulinemia and hyperglycemia; it is recommended in overweight and obese patients
    • Initial target for weight loss is 5-10% for patients with BMI 20-25 kg/m2
  • Goal BMI for Asian adults: 18.5-22.9 kg/m2
  • Weight control can be achieved by restriction of total caloric intake, increase in physical activity, structured exercises and behavioral programs
  • Successful weight reduction requires sustained personal and family motivation, and with long-term professional support
  • Risk of coronary disease and mortality is increased in obese patients
    • Obesity also contributes to other chronic heart disease risk factors (such as hypertension, dyslipidemia, type 2 DM)
    • The presence of abdominal obesity particularly raises and independently predicts cardiovascular risk and waist circumference along with waist:hip ratio should be evaluated
    • Waist:hip ratio is indicative of central obesity
    • Gender-specific waist circumference cutoff points for increased cardiovascular disease risk have been established in Asians:≥80 cm in women and ≥90 cm in men
  • Pharmacological intervention is an option for patients who are determined to lose weight and will be able to incorporate the therapy with comprehensive lifestyle intervention strategies

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