Valentin Fuster, MD, PhD, MACC 2015-11-17 05:20:07
When we are trying to establish goals toward improved cardiovascular health or health promotion on a population-wide scale, it is important to remember that we need unique strategies at different stages of our lives, depending on the varied scientific/ physiopathological background and educational/behavioral tools appropriate for each stage. Because significant challenges exist, I am proposing a strategy for sustaining health throughout a lifetime, which involves a stratified approach at three different age ranges that could be most effective in promoting cardiovascular health or preventing the progression of disease – even among those at highest risk for cardiovascular events. This strategy cannot be employed in the same way at the same time for every individual. These are strategies pertaining to health promotion that my colleagues and I have learned through recent studies and trials across the globe. As the first approach to stratified health is within the first 25 years of life, it is reasonable to assume that at that stage there is no significant cardiovascular disease yet in most individuals. We have learned that the optimal period of time to motivate behavior in favor of health is between the ages of three to five years. Indeed, there is evolving evidence that our behavior as adults has its roots in the environment that we grew up in from age three to five years. Furthermore, unhealthy diets begin to influence cardiovascular disease markers early in life. Conditions such as dyslipidemia, high blood pressure, impaired glucose tolerance, as well as obesity and metabolic syndrome may become rooted as early as three to five years of age, increasing the risk of development of atherosclerosis in adolescence and early adulthood. During these ages, educational topics can include how the body and heart work, healthy food habits, physical activity and emotional habits to avoid addictions. In the SI! Program for Cardiovascular Health Promotion in Early Childhood, for example, intervention was designed to be applied at all preschool levels in 24 Madrid, Spain, schools for the purpose of promoting cardiovascular health among children using their proximal environment (school, teachers and families). Improvement was initially demonstrated during the first year of intervention. This program translated into a beneficial effect on adiposity, with maximal effect when started at the earliest age and maintained over three years. The results presented in the Madrid SI! Program align well with those obtained previously in a Colombian initiative. After intervention, Colombian preschoolers were followed-up for 36 months, sustaining the effect toward healthier behaviors and ultimately leading to a nationwide expansion of the program. The critical question will be answered when these children are 15 to 20 years of age. In other words, can intervention at age three to five years affect health behaviors when these children reach adulthood? For the second opportunity for stratified health, the age range of 25 to 50 years appears to be the right time to evaluate subclinical disease, about which we have been learning a significant amount through noninvasive imaging techniques. In two recent bioimaging studies, we assessed approximately 10,000 asymptomatic adults >40 years of age using multimodality vascular imaging of the coronary arteries with electron-beam computed tomography for calcification and of the carotid arteries with 3-D ultrasound. We found that subclinical atherosclerosis was highly prevalent, detectable in both the coronary and carotid vascular territories (more recently also in the ilio-femoral region) in close to 60 percent of participants. Thus, we concluded that incorporating detection of subclinical atherosclerosis irrespective of anatomic territory, in addition to cardiovascular risk factors, would motivate patients to change their lifestyle. Through the use of advanced imaging technologies, we are now testing in such adult populations with manifested subclinical disease whether addressing risk factor profile through “group therapy” or an intensified and “aroundthe- clock” personalized approach is more beneficial in terms of changing lifestyle and preventing progression of the disease than the usual conventional means. The third opportunity for stratified health is for individuals >50 years, when cardiovascular disease has often begun to manifest itself symptomatically or by an adverse event. It is of value to approach this population by taking into account the total body vasculatures, including the heart and the brain. It has been increasingly recognized that degenerative brain disease is intimately linked to the vasculature and overall burden of atherosclerosis disease. Specifically, the heart-degenerative brain disease axis is perceptible across a very broad spectrum of disease, from macrovascular large-vessel coronary, carotid or ilio-femoral diseases leading to myocardial infarction or stroke, to microvascular small vessel changes causing dementia. Thus, we must make a transition from primarily considering the coronary vessels to looking at the entire individual in terms of systemic cardiovascular disease, which includes the neurovascular region. Furthermore, in the elderly population with already manifested disease, two pharmacological challenges need to be addressed: Can adherence to medication be improved? Can medication be simplified such as with the use of a polypill? In summary, at every age range, there are specific scientific/ physiopathological backgrounds and educational/behavioral tools available to best intervene. Although there have been external pressures to make “medicine” more personalized or precision-based – terms that have yet to be clearly defined – those of us who are actually entrusted to keep people healthy need to start approaching the population with a stratified health strategy. Fuster is director of Mount Sinai Heart; physician-in-chief of Mount Sinai Hospital; and editor-in-chief of the Journal of the American College of Cardiology. He spoke on these approaches during ACC’s Population Health Policy retreat in July and received an award from the Population Health Policy and Health Promotion Committee at the retreat for his leadership in changing the landscape and improving patient health through the lifespan.
Published by American College of Cardiology. View All Articles.
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