An Eye on Cardiovascular Prevention: Begin in Childhood, Identify All Risk Factors

For each level of cardiovascular risk, lifestyle factors remain a significant contributor that can be modified to reduce risk. However, some risk will remain nonmodifiable and require therapy, according to panelists during a session on cardiovascular prevention at the European Society of Cardiology Congress 2017, held August 26-30 in Barcelona, Spain.

Ulrich Laufs, MD, of the University of Leipzig, led the session with an approach to treat young patients with multiple risk factors. Images of human coronary arteries have shown that atherosclerosis can start as early as 7 years old, Laufs explained.

Cardiovascular disease (CVD) remains a main killer for people with atherosclerosis, but a significant part of the risk is preventable through early detection, healthy lifestyle, and therapies. Addressing the modifiable aspects requires an early detection of risk factors and then the implementation of a healthy lifestyle, but “for specific patients, there will be additional drug treatments needed,” Laufs said.

He highlighted that lowering low-density lipoprotein (LDL) cholesterol with statins leads to approximately a 25% risk reduction per year. However, it is important to understand that the effects are not as potent during the first year—the treatment takes some time to start working.

There are challenges to this long-term type of therapy. Studies have shown that when it comes to medication adherence for statins, only one-third of statins are taken as intended over the long term.

“We need therapies that are easier and advance adherence,” Laufs said.

One therapy under investigation is small interfering RNA, which only requires a few doses per year to lower LDL. Another is a vaccination. Patients can be immunized and see their LDL dramatically lowered. Vaccination is only currently being tested in animals and would not be available for humans until much further down the road.

Christos Lionis, MD, PhD, of the University of Crete, followed up with a presentation on how mental health factors into cardiovascular risk. While depression and anxiety can increase CVD risk, he noted that primary care physicians and cardiologists are not always prepared or able to recognize mental health disorders or frailty in the elderly.

For patients who are identified as having mental illness, they should be considered priority patients, Lionis said. It’s important to note that psychotropics used to treat patients with mental illness increase the risk of sudden death and ventricular fibrillation. Suggested interventions for these patients include exercise, mindful meditation, breathing exercises, medications, and cognitive behavioral therapy.

To facilitate changes in behavior, Lionis discussed motivational interviewing, which can be used to strengthen a patient’s commitment to change. This is a conversation style intervention that can help motivate patients to change behavior that increases CVD risk, such as to stop smoking.

“We need to always be thinking of mental health playing a role in … cardiovascular disease,” he said. “And it starts not in adulthood, but in childhood. Always think about the behavioral change technique, which does not need many hours,” to be successful.

Having comorbidities along with CVD is not unusual, explained Pavel Svitil, MUDr, during his portion of the presentation. He presented a number of cases from his practice to explain why he always keeps in mind 2 words when caring for patients using the guidelines: “however” and “nevertheless.”

There are always modified or calculated risks to keep in mind, such as family history, psychosocial risk factors, cancer treatment, and presence of autoimmune diseases.

In one example, Svitil presented the case of a 52-year-old male who was a nonsmoker, not obese, had no diabetes, experienced some stress at work, and was physically active. His blood pressure was normal, his cholesterol almost normal, and he had no symptoms of coronary artery disease (CAD). However, this man had a family history to keep in mind: his father had diabetes and hypertension and his first acute myocardial infarction when he was 50 years old, and the patient’s 2 brothers had hypertension.

The patient was treated for grade 1 hypertension, hypercholesterolemia, and dyslipidemia, and told to have an annual cardiologic follow-up. From 2012 to 2016, the patient saw improvements in hypertension and cholesterol. However, in 2017 his health started to worsen and he was diagnosed with multivessel CAD. So the patient had a percutaneous coronary intervention.

The point of this case, and the others Svitil presented, was to remind attendees that other factors may mean veering from guidelines.

In the case of the 52-year-old male, Svitil said, “an asymptomatic and low-risk patient with family history can become a high-risk patient.”