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EAS 2018 report from Sunday plenary session on "Cardiovascular health should be the priority"

Monday 7 May 2018   (0 Comments)
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Sunday’s Plenary session questioned whether the focus for cardiovascular prevention needs a rethink. In his lecture, Professor Valentin Fuster (Mount Sinai Heart, New York, USA)highlighted the need for renewed focus on promotion of cardiovascular health, based on primordial preventive approaches. Such an approach makes sense both from the individual and societal viewpoint, given that as atherosclerosis is a chronic disease, targeting intervention to individuals with cardiovascular disease – even subclinical – is already too late.

This change in thinking has been prompted by findings from the PESA (Progression of Early Subclinical Atherosclerosis) study, in about 4,000 middle-aged individuals without cardiovascular risk factors, and thus considered to be at low risk for atherosclerosis.1 Despite this, subclinical atherosclerosis (either atherosclerotic plaque or coronary artery calcification) was present in nearly half of these individuals, even in those with LDL cholesterol levels considered normal in accordance with European guidelines.  Moreover, the vascular risk profile also impacts cerebrovascular health, and thus merits consideration when rethinking preventive strategies to avoid the long-term consequences of cognitive impairment and dementia. For example, evidence from the Young Finns Study shows that an increasing number of cardiovascular risk factors (such as high blood pressure, elevated cholesterol, and smoking) from childhood is a factor in the development of midlife cognitive impairment.2

A switch to targeted health promotion in the young, appropriate to the local culture, is therefore likely to prove more effective and less costly. Indeed, there is evidence that intervention during early childhood can translate into lifelong benefits. For example, the Columbia study has used age-specific targeted health promotion focusing on how the body works, health food habits, physical activity and emotional habits (to avoid future addictions), intervening at ages 3-5, 6-8 and 9-14 with follow-up planned at age 20 years. The programme has now expanded to include more than 25,000 children across the world, targeting children at preschool, primary and secondary school ages.   

However, cardiovascular health strategies may need more thinking in lower and middle-income countries, due to a number of issues including inadequate access to information and limited public investment in health services. In support, data show that the prevalence of ideal cardiovascular health, as defined by the American Heart Association, may be <1% in regions where poverty is prevalent.3,4  As highlighted by Professor Salim Yusuf (Population Health Research Institute, Hamilton, Canada), this is not surprising given issues relating to the (un)affordability of healthcare in less affluent regions. In the secondary prevention setting, data from the PURE (Prospective Urban Rural Epidemiologic) study shows that 40% of individuals living in rural areas in lower middle-income countries are unable to afford four generic medications recommended for cardiovascular disease prevention (antiplatelet therapy, beta-blockers, angiotensin receptor blockers and statins) and this figure is even higher in low income countries.

Furthermore, as discussed by Professor Yusuf, beyond consideration of traditional cardiovascular risk factors –or ideal cardiovascular health – it is also important to take account of environmental determinants of risk, such as ambient air pollution, which even at levels below current standards, is significantly associated with increased risk of cardiovascular disease.5 Moreover, this is recognized as an issue across the economic divide, when including both household air pollution emitted from inefficient cooking stoves in lower income countries, as well as outside air pollution from traffic, industry, and other sources The UK is a clear example, with London already attaining legal air pollution limits for 2018 by January this year.6 London is not alone, however, as there is also evidence of ongoing failure by a number of EU countries to meet legal targets to cut air pollution and take action to reduce the problem.

References

1. Fernández-Friera L, Fuster V, López-Melgar B, Oliva B, García-Ruiz JM, Mendiguren J, Bueno H, Pocock S, Ibáñez B, Fernández-Ortiz A, Sanz J. Normal LDL-cholesterol levels are associated with subclinical atherosclerosis in the absence of risk factors. J Am Coll Cardiol 2017;70:2979-2991.

2. Rovio SP, Pahkala K, Nevalainen J, Juonala M, Salo P, Kähönen M, Hutri-Kähönen N, Lehtimäki T, Jokinen E, Laitinen T, Taittonen L, Tossavainen P, Viikari JS, Rinne JO, Raitakari OT. Cardiovascular risk factors from childhood and midlife cognitive performance: the Young Finns Study. J Am Coll Cardiol 2017;69:2279-2289.

3. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586–613.

4. Brant LCC, Ribeiro ALP. Cardiovascular health: a global primordial need. Heart 2018 Jan 19. doi: 10.1136/heartjnl-2017-312562. [Epub ahead of print].

5. Cai Y, Hodgson S, Blangiardo M, Gulliver J, Morley D, Fecht D, Vienneau D, de Hoogh K, Key T, Hveem K, Elliott P, Hansell AL. Road traffic noise, air pollution and incident cardiovascular disease: A joint analysis of the HUNT, EPIC-Oxford and UK Biobank cohorts. Environ Int 2018;114:191-201.

6. New Scientist. 30 January 2018. https://www.newscientist.com/article/2159875-london-has-already-reached-air-pollution-limits-for-2018/


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