Prevention a Better Option

Happening Issue 66 Jul, 2010

Prevention of heart disease (coronary) can only be based on recognition of risk factors, early diagnosis and management of the established cases.  What are risk factors?  These are factors which have been shown to have an association with an increased risk of heart disease above that expected for the general population.  We should note that 25% of coronary heart disease related deaths are preventable by the application of existing knowledge.

The concept of risk factors constitutes a major advance for developing strategies towards preventing heart disease. The more the risk factors operating in an individual, the more likely he is to develop heart disease.  They are synergistic and not simply addictive so that having more than one risk factor multiplies the risk.  Some risk factors like smoking, obesity, diet and alcohol can be altered, while others like genetics and personality factors cannot.

The known risk factors can be grouped under several headings:

A. Hereditary/Genetic predisposing factors

  1. Family history of heart disease
  2. Hypertension
  3. Hyperlipidemia
  4. Obesity
  5. Diabetes Mellitus

B.    Lifestyle

  1. Unhealthy eating lifestyle
  2. Smoking
  3. Lack of exercise
  4.  Stress

C.    Personality Type A

  1. Intense/rigid
  2. Angry man
  3.  Ambitious/Obsession
  4.  Competitive
  5. Aggressive

AHA (American Heart Association) categorizes risk factors as major and minor.

The major risk factors are:
Diabetes Mellitus
Aging Process

The minor risk factors are:
Physical inactivity
Family history
Congenital/Genetic factors

People with low risk profiles have less than half the risk of the general population. This is true even for older people.  Lowering hypertension reduces blood vessel plaque thereby decreasing risk of coronary heart disease.  Smoking cessation and cholesterol lowering reduces plaque destabilization and thereby acute coronary events.  Studies have also shown that cholesterol levels measured in young adulthood is inversely associated with life expectancy. Under two headings namely, Primary and Secondary Prevention.

Primary prevention aims to stop disease developing.  It encourages everyone to be slim, non-smoking, on a healthy diet, taking plenty of exercise and a stress free life. Of course this remains an unrealistic ideal concept but remains the long term aim of WHO which states that ‘Health is a state of complete physical, mental and social well being and not, merely the absence of disease.’  It makes everyone responsible for one’s health.  In pure medical terms, primary prevention means the effort to modify risk factors or prevent their development with the aim of delaying or preventing new onset coronary heart disease.  The clinical and public health approaches to primary prevention are complimentary.  Primary prevention refers to guidance given to individuals with no known cardiovascular disease.  Physicians contribute through patient education.  Patient education is primarily family oriented.  Risk factor prevention begins in childhood.  Prevention of smoking by children/adolescent is a primary goal.  Counseling is important and if warranted, recent methods like nicotine patch/replacement strategy should be implemented.  Another major goal is prevention of overweight/obesity in children and weight gain in adults. Obesity lies at the heart of several risk factors.  Encouraging life habits that incorporate regular physical activity will decrease the intensity of risk factors.  We must promote the environmental factors conducive to health.  At a personal level, I have motivated several people to start golf (people in their late 40’s) and now they play more regularly than I do!  Diets rich in cholesterol should be avoided by using unsaturated vegetable oils instead of animal based fats and eating smaller portions/morsels instead of heavy meals should be encouraged.

Secondary prevention aims to identify those with early (pre-symptomatic) disease and to reverse or slow its progress.  It is important to regularly check for established risk factors like smoking, exercise, cholesterol and blood pressure.  A long-term physician-patient relationship is usually necessary for successful prevention and modification of risk factors. Secondary prevention implies screening or therapy to reduce recurrent coronary heart disease events and reduce mortality in established cases.  Strategy is aimed at both control of risk factors and direct therapeutic treatment.  Patients with low risk scores can be reassured.  Those with higher scores should be counseled to adopt risk reducing life habits.  It must be noted that low absolute risk at a young age doesn’t ensure a lifetime of low risk.  Risk factors like diabetes, hypertension and cholesterol tend to increase with age and thus risk factors should be periodically investigated.

Risk factor clustering also known as metabolic syndrome is referred to when one suffers from multiple risk factors.  It’s the tendency of risk factors to cluster in a single individual for example obesity and physical inactivity.  Risk factor modification in persons at high risk offers the best strategy for effectively reducing the prevention of coronary heart disease.  The general public has to be highly motivated and well informed.  Facilities (sports/gym) should be available and accessible.  Adverse factors like smoking and unhealthy habits should be discouraged.  Risk factor screening facilities (hospitals/clinics) should be accessible for this to be implemented.  Parents, teachers, journalists, health care workers, tobacco manufactures, food advertisers and politicians need to be actively involved.

In conclusion, every individual must take responsibility of his own health, lead a healthy life and be prepared to work in partnership with the professionals, should his condition require it.

Dr. Baral is the consultant cardiologist at Ganga Lal Heart Institute & NORVIC Hospital. Ph: 4436612/4437610, Mobile: 98510-53577