The Worsening Landscape of Cardiovascular Disease

Suzanne Hughes, MSN, RN; Alfred A. Bove, MD, PhD, F.A.C.C.

Disclosures

Cardiosource 

While we have witnessed a decline in the number of deaths from cardiovascular disease (CVD) in the last 20-30 years, the trends for the future look much less bright. For some years, the increasing incidence of obesity was considered to be a consequence of prosperity, and obesity was even debated as an acceptable lifestyle. However, as the epidemiology of obesity became more apparent and the incidence began to reach astronomic levels, the consequences of obesity with its accompanying metabolic derangements, sometimes in the form of type 2 diabetes, or in the form of the metabolic syndrome, and now being understood as an obesity-induced rise in insulin resistance, have become more apparent. Numerous studies are confirming the contribution of metabolic syndrome to increased risk and incidence of CVD.[1] Hypertension, hyperlipidemia, and diabetes are well documented to be the major risk factors for CVD, and they contribute to the quantitative measures of CVD risk embodied in the Framingham score.[2] One has only to enter hypothetical values for these measures in the Framingham Risk Calculator (https://www.itsmyhealthfile.com/ITSLive/ACCRiskForm.lasso) to understand how rapidly the incidence of CVD rises when these factors are abnormal. Selvin et al.[3] showed from a meta-analysis of several CVD studies that A1C levels are directly related to risk for CVD. Also, Sukhija et al. demonstrated a relation between microalbuminuria, a measure of organ effects of diabetes, and the extent of coronary disease (Abstract, http://www.ajconline.org/article/PIIS0002914906007077/abstract). It is clear that the metabolic derangements associated with obesity are creating a future population of adults who will become diabetic early in life, develop cardiovascular complications by middle age, and become disabled well before retirement age. The study by Kivipelto et al., recently published in The Lancet, has now shown that these patients will be more prone to dementia later in life when they are hypertensive and diabetic in middle age (Abstract, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
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). All of these findings create a scenario that suggests that we will have a large number of middle-aged adults who will be disabled by CVD, who will require increased health care with its associated costs, and who are likely to require chronic care, unable to afford health insurance, and unable to be gainfully employed. As they grow into later life, there will be a greater number of disabled senior citizens who will demand intensive care, and in some cases, will require long-term care institutions. At present, overweight subjects constitute more than half of the population of the United States,[4] and in some groups, particularly minorities and underserved people, the incidence reaches 65% with obesity incidence greater than 50%, and extreme obesity reaching significant proportions. Similar experience is reported in European countries, and in other parts of the world.

True solutions to the obesity epidemic are lacking. Anyone who practices clinical cardiology witnesses the efforts physicians and other care providers make to encourage weight loss, only to find that reductions in weight are commonly not sustained. Intense programs seem to have the same result: early weight reduction, followed in 6-12 months by a return to original weight. It is a sad fact that the most sustainable method of weight reduction appears to be bariatric surgery. One can imagine the cost of performing the procedure on proportions of the population that can reach 35-50% of all adults.

When faced with the monumental size of the task before us, it may be helpful to look at a parallel initiative that began in 1964 with the surgeon general's first report on smoking and health. The reduction in tobacco use associated with the now 40-year effort has been labeled "one of America's 10 greatest public health achievements of the 20th century." This achievement is attributed to clinical, educational, regulatory, and economic approaches in combination.[5] It is clear that strategies to combat the obesity epidemic will require the same forces.

The role of the cardiovascular specialist (physician and care associate) seems uncertain. However, our goal as cardiologists should be to improve the health of patients by preventing CVD, and by providing optimal care to those with CVD. Prevention, therefore, should be part of our day-to-day patient care, but the demands for care of patients with existing CVD already have become overwhelming, and leave little time for a true effort at prevention. Because of the clear link between CVD, diabetes, and obesity, prevention of obesity should be part of the care programs within cardiology.

The fact that obesity and diabetes management programs for prevention of CVD are lacking in the cardiology community is the result of inadequate reimbursement for such preventive programs, and the lack of professional resources to support such programs. A true investment in obesity and diabetes prevention is likely to require a significant cost impact on our society before a national investment is made to reverse the obesity epidemic.

The ACC has taken important strides in the last few years in the form of both public and professional education campaigns. One such public awareness initiative is the "Make the Link!", http://www.acc.org/education/outreach/diabetes/diabetes.htm) campaign, developed by the American Diabetes Association and the ACC to raise awareness that CVD is the leading cause of death for persons with diabetes.

On the professional education front, under the leadership of Dr. Alan Brown, the College sponsored a series of regional programs developed to support the cardiology community in better implementing secondary prevention, including a focus on managing type 2 diabetes (http://www.acc.org/education/programs/brochures/dei.htm). Most important for today's goals in this effort should be to provide education to children and adolescents regarding proper and acceptable body weight or BMI, understanding of optimal diets for health maintenance, role of exercise, and avoidance of high-risk lifestyles such as cigarette smoking and use of recreational drugs. Much of this education could be accomplished in the schools by funding intensive educational programs in the area of behaviors to maintain long-term health. Even this approach has not been developed, and surgeons are proposing the extension of bariatric surgery to children and adolescents without good data on the long-term effects on growth and maturation when absorption of nutrients is limited by alterations in the usual absorptive pathways through the gastrointestinal tract.

At first glance, this epidemic looks like job security for cardiologists who might see the very large population of patients with CVD as a benefit. However, we are soon to be overwhelmed by the increasing demand for cardiovascular care and the lack of expansion of the cardiology work pool. Workloads are already high enough to make early retirement an attractive option for cardiologists. Shortening the working time for cardiologists will further aggravate the shortage and bring a major health crisis to our patients with CVD.

These readily predicted scenarios point to the cardiology community to help in prevention of obesity and diabetes. Perhaps new drugs or gene therapies will allow obese patients to avoid CVD risk, but the wait for such solutions is likely many years away.

It behooves us in the cardiology community to advocate for prevention and treatment programs for obesity and diabetes. Failing to embrace this initiative threatens to roll back the progress we have made in understanding the pathophysiology of atherosclerosis and in developing preventive strategies. "We must in parallel seek ways to reverse the epidemic of obesity, metabolic syndrome, and diabetes...should we fail in this regard ...its complications threaten to undo the advances of atherosclerosis of the past decades."[6] We will need a continued focus on growing the workforce and assuring that they are trained for the looming challenges. Being a cardiovascular clinician may become an increasingly taxing role in 10 or 15 years if we fail to join forces against the epidemic and allow ourselves to be overwhelmed with massive numbers of patients with CVD.

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