After decades of decline, heart disease mortality is on the rise again.
New approaches to the prevention of heart disease could help counter a disturbing trend in the number of cardiovascular deaths occurring in the US, according to Karol E Watson, MD, PhD, professor of medicine/cardiology, and co-director of the UCLA Program in Preventive Cardiology.
Control of hypertension, cholesterol levels, and obesity, and recommendations for diet and exercise, were all part of Watson’s presentation at Pri-Med’s West Annual Conference in Anaheim, California. Watson’s talk began with a review of the tremendous progress that has been made over the past few decades in reducing mortality from the two most deadly conditions in the US — heart disease and cancer. However, after decades of decline, heart disease mortality rates flattened from 2011 to 2014 and increased in 2015, she said.
Addressing hypertension, in particular, changes made by the 8th Joint National Committee (JNC 8) in 2014 to relax the previous blood pressure goal of less than 140/90 for patients over the age of 60, Watson explained that a minority of the JNC 8 disagreed with the new recommendation and wrote their own, separate guidance: “We, the panel minority, believed that evidence was insufficient to increase the SBP goal from its current level of less than 140 mg Hg….partially undoing the remarkable progress in reducing cardiovascular mortality in Americans older than 60 years.”
At about the same time as these recommendations were being made, Watson said, data from a study (SPRINT) of hypertensive high-risk patients (130 to 180 mm Hg) over the age of 50 was published. It contrasted intensive (goal < 120 mm Hg) versus standard (goal <140 mm Hg) control of hypertension.
“The intensively treated group showed a 25% relative risk reduction [RRR] for the primary outcome [myocardial infarction, stroke, heart failure, acute coronary syndrome, and CV death]. Even more amazing, they had a 27% reduction in total mortality,” she said.
Watson also reviewed serious adverse events in the SPRINT study — including hypotension, syncope, electrolyte abnormalities, and acute kidney injury/renal failure – that were seen significantly more often with the intensively treated patients.
She was not put off by this safety data.
“When they looked at the risk-benefit ratio, they still favored treating to the more intensive level of goal to reduce cardiovascular events,” she said. “In general, the more intensive the pharmacological therapy, the more side-effects you are going to get. That’s true with everything, not just hypertension — dyslipidemia, diabetes, whatever.”
Watson used a fictional case study of a 61-year-old white male with hypertension (149/82), a BMI of 35, and gout to illuminate her points on prevention of heart disease. Speaking of whether intensive treatment would be warranted for the patient in the fictional case study, she said, “You have to make sure that the risk/benefit balance still favors treatment. In this case, it definitely did, so my recommendation would be to treat this patient intensively with amlodipine to control his hypertension.”
Watson concluding her presentation with a broad discussion of the importance and challenge of preventive medicine.
“Prevention is where medicine gets hard. To prevent something that may or may not happen in the future is difficult,” she said. “Preventive medicine also requires us to treat people who are not sick, so the first principle is to do no harm. The good news is that prevention works. And many preventive therapies that reduce risk of heart disease also work on dementia and cancer.”