Steven Nissen, MD: Balancing Therapy & Lifestyle in Guidelines


With cardiovascular drug classes inhibitors owning discussion, how will recent or upcoming guideline updates address their use alongside lifestyle management?

The new American College of Caridology (ACC) and American Heart Association (AHA) guidance on cardiovascular preventive care, presented at the ACC 2019 Scientific Session in New Orleans, LA, this weekend, put emphasis on how physicians should manage their patients’ diet, exercise, and tobacco consumption—as much as they do their pharmacotherapy.

In an interview with MD Magazine® while at ACC 2019, Steve Nissen, MD, chairman of the Department of Cardiovascular Medicine at the Cleveland Clinic, discussed the significance of the guidelines, while also teasing out some therapy-related studies being developed by the clinic.

MD Mag: How important are updated guidelines and protocols in an era of advancing therapies?

Nissen: Well, you know, it's important in all of these things—and this also important in the prevention space: there is a tendency to emphasize pharmacology, when in fact we also need to understand the role of lifestyle. And right now, tobacco cessation and exercise—exercise probably has as big an effect on outcomes as any drug we've ever had.

So, getting people to exercise an appropriate amount every week—which generally is considered 150 minutes of moderate exercise or 75 minutes of intensive exercise—is critically important along with diet. You know, we tend to recommend the Mediterranean diet, because we have the best evidence for that. And so I hope that, as we think about prevention, that we not just focus on the pharmacology.

You know, there's a there's a sign somewhere in the Cleveland Clinic by the stairs that says, “This is a free therapy, just walk up the stairs.” It's great advice, and we get more patients to do that.

I'm very worried about the obesity epidemic. That's the one where we haven't made any progress, so we've got to keep our eye on the ball. Yes, we need better drugs and we're getting there because of the new guidance, but we also need to really emphasize lifestyle. And physicians have to be better and more proactive. We need effective strategies for getting people to change their lifestyles. So far we haven't been very successful.

The obesity epidemic is getting worse, which is why diabetes is continuing to increase in our developed countries, and now in the developing world.

What work is the Cleveland Clinic presenting at ACC 2019?

Well, we have some clinical trials that we're completing now. One of them is a trial of a highly modified omega-3—a fish oil-type product that's designed to be better absorbed. We have a recent trial called REDUCE-IT which had promising results.

We have a somewhat larger trial that we're completing sometime in the next year or so, and we're looking forward to the results because these drugs are targeted at lowering triglycerides, and triglycerides are now emerging as a very important risk factor. It is not just about LDL cholesterol—triglycerides are important in cardiovascular risk. And we're now developing therapies that will target elevated triglyceride levels.

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