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Preventing Cardiovascular Disease
PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S XX ( 2 0 1 6) XXX – XXX
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Preventing Cardiovascular Disease Cardiovascular (CV) disease (CVD) is the leading cause of death in the Western world. Certainly, both nutritional and medical interventions are important for the primary and secondary prevention of CVD. However, there is considerable controversy in both fields regarding what are the current best strategies to reduce CV risk, morbidity, and premature mortality. Nutrition should always be considered in the overall CV prevention and treatment protocol. However, the best nutritional strategies in order to reduce CV risk are debatable. In the 1980s, Americans were told to restrict total and saturated fat in the hopes that this would lead to a reduction in obesity and CVD. Paradoxically, the situation has seemingly become worse, particularly in regard to an increase in diabetes and obesity, whereas better diagnostic tools and treatments (both medical and surgical) for CVD seem to have reduced the overall rate of death from this complication. Current dietary demons (such as saturated fat) may actually not be as harmful to health as once thought; and recommendations to restrict saturated fat may misdirect us toward eating a more detrimental dietary substance (refined sugar). Whereas sugar was once thought of as empty calories, recent data suggest that its calories are potentially harmful when compared to other types of calories due to the unique consequences that occur during its metabolism, leading to increased inflammation, oxidative stress, and visceral fat accumulation. There has been a long and heated debate regarding what is the best strategy to inhibit the renin–angiotensin aldosterone system (RAAS) for reducing CV risk. While most guidelines and clinicians consider angiotensin-receptor blockers (ARBs) to be equivalent to angiotensin-converting enzyme inhibitors (ACEIs), recent meta-analyses suggest otherwise. ARBs are associated with fewer side effects compared to ACEIs (such as a lower risk of cough), but ACEIs seem to have the advantage when it comes to reducing major CVD endpoints, such as myocardial infarctions, as well as all-cause and CV mortality.
This may in part be due to the fact that ARBs were tested in an era of better background medical therapy, but even certain direct comparison trials suggest that ACEIs are indeed more cardioprotective compared to ARBs. Surprisingly, the use of non-contrast computed tomography (CT) for detection of coronary artery calcium (CAC) remains a controversial issue. CT screening for CAC is a highly sensitive, non-invasive, and inexpensive test that is among the strongest clinically available predictors of future risk of adverse CV events among primary prevention patients. The presence of CAC is associated with up to a 10-fold higher risk of adverse CVD events, even after fully adjusting for the standard CVD risk factors. In contrast, the absence of CAC confers a very low risk of major CVD events. This simple test enables us to focus on the individuals who will benefit most from aggressive preventive strategies, whereas those with a zero CAC score may be able to avoid or defer daily aspirin therapy and pharmacological therapy for cholesterol management, and instead work on therapeutic lifestyle changes. Thus CT CAC screening can be thought of as a “mammogram for the heart”, a screening test that can lead to more or less aggressive testing and interventions. In this issue of PCVD, we review current topics from both the nutrition and medical field that have important implications for reducing the risk of CVD. We also review certain diagnostic tools that may help in the early identification of those who are at particularly high risk of CVD events in the near future.
James J. DiNicolantonio⁎ James H. O’Keefe Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA ⁎Address reprint requests to James J DiNicolantonio, PharmD Saint Luke’s Mid America Heart Institute, Kansas City, MO E-mail address: [email protected] Available online xxxx
Please cite this article as: DiNicolantonio JJ., O’Keefe JH. Preventing Cardiovascular Disease. Prog Cardiovasc Dis (2016), http:// dx.doi.org/10.1016/j.pcad.2016.02.002
Available online at www.sciencedirect.com
ScienceDirect www.onlinepcd.com
Preventing Cardiovascular Disease Cardiovascular (CV) disease (CVD) is the leading cause of death in the Western world. Certainly, both nutritional and medical interventions are important for the primary and secondary prevention of CVD. However, there is considerable controversy in both fields regarding what are the current best strategies to reduce CV risk, morbidity, and premature mortality. Nutrition should always be considered in the overall CV prevention and treatment protocol. However, the best nutritional strategies in order to reduce CV risk are debatable. In the 1980s, Americans were told to restrict total and saturated fat in the hopes that this would lead to a reduction in obesity and CVD. Paradoxically, the situation has seemingly become worse, particularly in regard to an increase in diabetes and obesity, whereas better diagnostic tools and treatments (both medical and surgical) for CVD seem to have reduced the overall rate of death from this complication. Current dietary demons (such as saturated fat) may actually not be as harmful to health as once thought; and recommendations to restrict saturated fat may misdirect us toward eating a more detrimental dietary substance (refined sugar). Whereas sugar was once thought of as empty calories, recent data suggest that its calories are potentially harmful when compared to other types of calories due to the unique consequences that occur during its metabolism, leading to increased inflammation, oxidative stress, and visceral fat accumulation. There has been a long and heated debate regarding what is the best strategy to inhibit the renin–angiotensin aldosterone system (RAAS) for reducing CV risk. While most guidelines and clinicians consider angiotensin-receptor blockers (ARBs) to be equivalent to angiotensin-converting enzyme inhibitors (ACEIs), recent meta-analyses suggest otherwise. ARBs are associated with fewer side effects compared to ACEIs (such as a lower risk of cough), but ACEIs seem to have the advantage when it comes to reducing major CVD endpoints, such as myocardial infarctions, as well as all-cause and CV mortality.
This may in part be due to the fact that ARBs were tested in an era of better background medical therapy, but even certain direct comparison trials suggest that ACEIs are indeed more cardioprotective compared to ARBs. Surprisingly, the use of non-contrast computed tomography (CT) for detection of coronary artery calcium (CAC) remains a controversial issue. CT screening for CAC is a highly sensitive, non-invasive, and inexpensive test that is among the strongest clinically available predictors of future risk of adverse CV events among primary prevention patients. The presence of CAC is associated with up to a 10-fold higher risk of adverse CVD events, even after fully adjusting for the standard CVD risk factors. In contrast, the absence of CAC confers a very low risk of major CVD events. This simple test enables us to focus on the individuals who will benefit most from aggressive preventive strategies, whereas those with a zero CAC score may be able to avoid or defer daily aspirin therapy and pharmacological therapy for cholesterol management, and instead work on therapeutic lifestyle changes. Thus CT CAC screening can be thought of as a “mammogram for the heart”, a screening test that can lead to more or less aggressive testing and interventions. In this issue of PCVD, we review current topics from both the nutrition and medical field that have important implications for reducing the risk of CVD. We also review certain diagnostic tools that may help in the early identification of those who are at particularly high risk of CVD events in the near future.
James J. DiNicolantonio⁎ James H. O’Keefe Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA ⁎Address reprint requests to James J DiNicolantonio, PharmD Saint Luke’s Mid America Heart Institute, Kansas City, MO E-mail address: [email protected] Available online xxxx
Please cite this article as: DiNicolantonio JJ., O’Keefe JH. Preventing Cardiovascular Disease. Prog Cardiovasc Dis (2016), http:// dx.doi.org/10.1016/j.pcad.2016.02.002