Cardiovascular disease remains the number one cause of death in United States during 2014. The underlying cause of cardiovascular disease relates to atherosclerosis. This begins as an inflammatory process involving our blood vessels. Many risk factors and therapeutic interventional modalities are currently available to address this issue. The continued high morbidity and mortality from this disease process is indeed unfortunate as there is great potential for treatment and especially prevention. Employing our current understanding and use of available tools and preventative resources should essentially preclude anyone from having a stroke or heart attack who is currently in generally good health. Although the disease manifestations of atherosclerosis often present during our 60s, 70s and 80s+ it is a process that often begins in our 20s and 30s. Effective prevention should be initiated based on risk with a 15 to 20 year lead-time to be highly successful.
During the American Heart Association (AHA) scientific session in November 2013, the AHA and American College of Cardiology (ACC) released new guidelines for the prevention and treatment of coronary artery disease (CAD). The guidelines focused on the assessment of cardiovascular risk and treatment of blood lipids and received a great deal of attention from both the media and professional journals. These organizations set the standard for clinical medical practice. Most of the attention focused on updated cardiovascular risk calculation using race, sex, age, cholesterol levels including HDL and LDL, blood-pressure, diabetes mellitus and smoking status.
New guidelines recommended statins for people with a lower risk of cardiovascular disease then had previously been advised. The new guidelines used calculated risk rather than LDL levels to determine statin therapy. The lay press has focused on the potential overuse of statins.
Unfortunately, exercise and fitness, that have been shown to be highly relevant CVD risk factors, are often not included in risk calculation. It is especially important to note for women aged 30 years and older, that physical inactivity has a greater impact on the risk of developing heart disease than any other major risk factor. It may be prudent to ask the question, is lifelong use of statins a better investment of our healthcare dollars than sessions with an exercise physiologist and/or a nutritionist to encourage healthier nutrition, weight loss, and an improvement in fitness?
Studies have found that statin therapy may reduce the risk of future cardiac events up to 25%. The level of evidence in support of statin use from clinical trial data is undeniably strong. However, well documented adverse effects of statins include a higher incidence of diabetes, liver damage, muscle pain, inflammation, myopathy, and an attenuation of the effects of exercise training. Furthermore, some have expressed the view that statins provide false reassurances that may discourage patients from making the lifestyle changes that reduce cardiovascular disease. Physicians and patients have been taught to be overly focused on lipids rather than behavior modification to prevent heart disease. Data from major studies have shown that 80% or more of CVD cases can be attributed to smoking, lack of exercise, and an unhealthy diet. Although inherited genetics plays a role, it should be considered the "loaded gun" while lifestyle is the "trigger".
The Mayo Clinic Proceedings, June 2014, reports meta-analysis studies reveal that physically active individuals had pooled risk reductions of 35% for cardiovascular mortality and 33% for all cause mortality when compared to inactive individuals. Regular exercise was statistically as effective as drug interventions for the secondary prevention of coronary heart disease and prediabetes. Among patients who have experienced a stroke, physical activity interventions were more effective than drug treatment. The combination of statin treatment and moderate exercise reduced risk more than either alone. Among individuals that achieved a high level of fitness, the risk was lowered more than 70%.
Surprisingly, few data are available that relate healthcare costs to objective measures of fitness. The Cooper Center Longitudinal Study has reported that fit individuals had a 38% lower healthcare costs than the least fit individuals during a roughly 20 year follow-up. An important and consistent finding across multiple studies is the fact that the greatest difference in health outcome benefits is observed between the least fit and the most fit groups. The health benefits of fitness are most evident in the low end of the fitness spectrum. Even moderate efforts to improve fitness result in measurable health benefits and reduce overall health costs.
-Dr. Paul Block