Ileana L. Piña, MD, MPH


December 10, 2015

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Editor's Note:
Mark A. Creager, MD, president of the American Heart Association (AHA), gave the opening address at the 2015 Scientific Sessions, titled "The Crisis of Vascular Disease and the Journey to Vascular Health." His speech emphasized that peripheral arterial disease (PAD)is not a disease of the legs, but rather a clinical manifestation of a systemic disease. Preventing vascular disease is a personal cause for Dr Creager because his father (a longtime smoker) developed PAD in his 60s and benefited from early diagnosis and treatment. Ileana L. Piña, MD, MPH, interviewed the AHA president in Orlando, Florida.

Dr Piña: Hello. I'm Ileana Piña, from Montefiore Medical Center in the Bronx, New York. This is my blog [Heart Failure and Transplantation with Dr Ileana Piña], but more than that, it's a fun interview for me. I am here at the AHA 2015 Scientific Sessions. We are in Orlando, Florida—where it's been a lot warmer than up north where I work—and we have tons of energy. In this program, clinical trials have been presented—some that may actually change medical practice and that we feel are very impactful.

I'm very happy to welcome Mark Creager, president of the AHA and recently the head of the Dartmouth-Hitchcock Heart and Vascular Center. Thank you, and welcome. I'm happy that you found some time. This is a busy time for you.

Dr Creager: Thank you, Ileana. It's a pleasure to be here.

Dr Piña: Thank you. In your opening address, you delivered the message of cardiovascular disease awareness and treatment and are really trying to push our field forward. Tell me a little bit about that.

Dr Creager: The theme of my opening address was the crisis of vascular disease and our need to develop systems to improve vascular health. As you know only too well, Ileana, we talk about cardiovascular disease, but in doing so, people really focus on—importantly—the cardiac components.

But vascular disease affects all of us. Vascular disease affects arteries; it affects veins; it comes in the form of atherosclerosis or thrombosis; it's very, very prevalent. Yet, the public is not sufficiently aware of vascular disease, and providers are not sufficiently aware of what needs to be done to detect and treat vascular diseases so that we can make an impact. By properly and appropriately diagnosing and treating vascular disease, we will reduce death and disability from these problems.

Importantly, and the point I wanted to emphasize: We can avoid dealing with the treatment of these vascular diseases if we can simply prevent them.

Dr Piña: Which is the right way to do things—preventing. My mother always said, "Prevention: better than the cure."

Dr Creager: Well, your mother was right.

Dr Piña: How can we get that message to practicing physicians? Some of these patients don't sit with me; I only see them when they're really ill. They go to the primary care offices. How can we get that message out?

Dr Creager: The primary care office is a terrific opportunity to have a discussion with the patients about ways the patient can preserve [his or her] vascular health. It's obvious to us, but it's not obvious to the public: good nutrition; avoiding fatty foods; low salt in the diet; exercise; and, importantly, smoking cessation and programs to prevent individuals from beginning to smoke, particularly our youth. We have to aim early in life. We have to get to people before problems develop, and our youth, of course, is the perfect place to engage and get them involved.

Dr Piña: I worry about those college kids who are starting smoking and about the vaporizer cigarettes that are now being advertised. It's a concern.

Dr Creager: It is a concern, and as I mentioned during that address, there are advertisements that are directed to the youth market. This is not to get individuals or help them to stop smoking; these advertisements are actually bringing young people into the marketplace. Start with e-cigarettes, and there's a potential [that] you transition from e-cigarettes to tobacco.

Dr Piña: And flavors, which attract the youth.

Dr Creager: All types of those things. Advertisements, which are indeed attractive. In the office, physicians and other healthcare providers can have the conversation with their patients about these important health issues. Of course, the physician has the opportunity to bring up blood pressure, check the blood pressure, measure the cholesterol, measure the blood sugar, talk about weight—all these other important health factors that contribute to vascular diseases.

Dr Piña: I always like the analogy of the tree. When I'm making rounds with the residents and somebody comes in and says, "...with their myocardial infarction (MI)" or "with heart failure" and it's ischemic, I say, "Where's the rest of the tree?" One tree, many branches—the heart, the kidneys, even the renal disease—are vascular in origin. That's a cute analogy to think about. Many branches of one tree.

Dr Creager: You asked what else we can do to help clinicians. We need to enhance our educational efforts, and we do so at scientific conferences, such as this one. At the AHA Scientific Sessions, we have an entire program, an entire track, dedicated to vascular diseases, to really increase the knowledge that we are transmitting to our clinicians so they can take that back to their offices and utilize it.

Dr Piña: You used the words "blood pressure," and I think one of the exciting things at this meeting has been the presentation of SPRINT. I had patients asking, "Oh, we saw this in the news; there's a new study out. What medicine is it?" It's not a medication; it's a strategy.

Dr Creager: It is indeed a strategy. SPRINT, as many of your viewers know, was an NHLBI [National Heart, Lung, and Blood Institute]-sponsored trial of individuals over the age of 50 with hypertension. The intent was to study whether lowering the systolic blood pressure to 120 mm Hg resulted in better outcomes than targeting a systolic blood pressure of 140 mm Hg.

Dr Piña: Which has been pretty common in practices: to look at 140 mm Hg.

Dr Creager: It has been, in part because of the notion—probably wrong—that there's a sudden cutoff at 140 mm Hg. So, if your blood pressure is 138/88 mm Hg, you're fine, don't worry. But if your blood pressure is 142/90 mm Hg, [then you are at risk]. Obviously, it's a continuum. We know from epidemiologic studies, population-based studies, that it is a continuum. Certainly, as your blood pressure increases—for example, above 120 mm Hg—your risk for a cardiovascular event increases proportionally.

Dr Piña: We have so many drugs that are available with good safety profiles, and even some [are given] once a day to improve compliance because people with hypertension feel well. You're telling them they have a problem.

Dr Creager: Right. There's so much we can do. As I spoke earlier about vascular diseases, it's important to detect them. It's important to detect high blood pressure so you know to treat it, and we need programs where people will get their blood pressure measured and then they'll have conversations and develop a treatment strategy with their physicians.

In any case, the SPRINT trial compared these two groups and found that in the group in which the target systolic blood pressure was 120 mm Hg (vs 140 mm Hg), there was a 25% reduction in cardiovascular events—

Dr Piña: And a reduction in heart failure.

Dr Creager: That was certainly included in the composite. A very, very important observation, and one that I think will be taken into consideration as our guidelines committee—there is an AHA/American College of Cardiology writing committee—looks at updating the new high blood pressure guidelines. I anticipate that they will take findings from SPRINT and formulate recommendations.

Dr Piña: To take it one step further, on my blog I have often talked about HF-PEF, or heart failure with preserved ejection fraction. Many of those patients have [had hypertension] all their lives; how can we prevent that HF-PEF from occurring in later years? Blood pressure reduction is one of them.

Dr Creager: Absolutely.

Dr Piña: I want to encourage my audience to think about exercise. Exercise is also a treatment of blood pressure. Not the only one, but it really can help. Weight loss, exercise, and taking your meds.

Dr Creager: Clearly, Ileana, we have a lot of options: lifestyle modifications to prevent and treat high blood pressure and, if we need it, medications. But when we start using medications—and we need to engage the patient in these conversations—we have to be able to use medications in the appropriate doses and the appropriate combinations to bring that blood pressure down.

Dr Piña: And we can do that. I want to thank you for taking the time. I'm very proud of the AHA, and I'm happy to be here.

I hope our audience takes a look at the New England Journal of Medicine paper published today on the SPRINT trial.[1] That issue has several other papers concerning blood pressure. Something so simple, so common, that I think we can do something about.

This is Ileana Piña, signing off. Thank you for joining me.

Disclosure: Mark A. Creager, MD, has reported no relevant financial relationships.


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