COMMENTARY

Let's Stop the Unnecessary Treatment of Heart Disease

John Mandrola

Disclosures

October 03, 2014

Editor's Note: This blog entry originally posted at drjohnm.org.

There are many reasons doctors suffer from burnout and compassion fatigue. One of the least-mentioned of these reasons is that much of what we do is so damned unnecessary. In the US, the land of excess everything, caregivers, especially cardiologists, spend most of our time treating human beings who didn't need to have disease.

Let's be clear and honest: Lifestyle-related disease is largely unnecessary.

These days, there is so much unnecessary disease that caregivers, especially cardiologists, rarely see it. We look past the obesity right to the cholesterol number and ECG. And then we pull out the prescription pad for the guideline-directed pills. Just typing that causes me angst.

A man gets referred for AF ablation for symptomatic AF. Indeed, he has many AF episodes. But he also drinks alcohol excessively, weighs 300 pounds, and refuses to wear his sleep-apnea mask. You refuse to do a $100 000 procedure, and soon the reputation arrives: you are too conservative an ablationist. Mandrola won't do procedures.

My interventional-cardiology colleagues have it much worse. They are roused from sleep and family time to rush in and save people from mostly unnecessary MIs. One way to see the chorus of emergency PCI treatment of acute MI is with awe. Another is with utter frustration—because in most cases it was unnecessary.

The Study

A recent population-based prospective study of Swedish men suggested almost four of five MIs in men could be preventable.[1] (That's not a typo.) Researchers from the Institute of Environmental Medicine in Stockholm, Sweden, followed 20 721 men from 1997 to 2009. They specifically asked about five modifiable lifestyle behaviors: a healthy diet, moderate alcohol consumption, no smoking, being physically active, and having no abdominal fat (waist circumference.) There were 1361 cases of MI in the 11-year follow-up period.

heartwire journalist Michael O'Riordan recaps the details of the study here. The short story was that each of the five low-risk behaviors independently reduced the chance of having a heart attack. Not smoking was the strongest risk reducer. Men who combined all five behaviors were 86% less likely than those who had zero behaviors to have a heart attack.

The wake-up call

I realize everyone knows lifestyle is important to prevent heart disease. It's so obvious that we (patients and doctors) have grown numb to it. But pause for a moment and think about the finding that four of five heart attacks could be prevented with simple achievable lifestyle behaviors. That is something.

My electrophysiology colleague Dr Prash Sanders (Adelaide, Australia) stands in front of audiences of doctors and says risk-factor modifications, such as weight loss and blood-pressure control, are easy. The key word, he says, is motivation.

The challenge for caregivers, especially us cardiologists, is to stop suppressing the idea that heart disease can't be prevented—that people won't do it. The first definition of the noun motivation is the reason or reasons one has for acting or behaving in a particular way. That's our job as caregivers.

My experience in the AF clinic in the past few years of lifestyle-enlightenment is that people can change. I've posted the lifestyle studies in the exam room. I discuss the biology of how lifestyle disease relates to the atria. I make the case that AF is (largely) unnecessary. I talk about atrial stretch and fibrosis, rotors, and inflammation.

We can do the same with vascular disease and diabetes and high blood pressure. Being active, eating well, not smoking, and carrying less body fat work because they favorably affect oxidative stress, inflammation, endothelial function, insulin sensitivity, and blood pressure. These are the reasons people should eat less, move more, and reduce their belt size. Reasons and expectations equal motivation.

The low-hanging fruit is right there. I say we reach up and grab it. Just thinking about doing fewer unnecessary things for unnecessary disease is soothing.

JMM

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