Nonpharmacologic therapy for coronary artery atherosclerosis: results of primary and secondary prevention trials

Primary prevention of cardiovascular disease by an occupational health service

BACKGROUND

Worksites are considered to be a key channel for the delivery of interventions to prevent cardiovascular disease. The aim of this study was to evaluate the effect on the blood cholesterol levels of an intervention program offered by an occupational health service.

METHODS

The intervention group consisted of 95 employees and the reference group consisted of 74 employees, in all, 169 subjects, with a serum cholesterol > or = 5.2 mmol/l. Both groups completed a standardized questionnaire. Occupational health nurses carried out the blood sampling before and after the program. The intervention group was then offered counseling on physical activity and a dietician offered individual counseling on healthy food habits. The reference group was not the subject of the intervention program.

RESULTS

The mean cholesterol level decreased by 0.3 mmol/l (5%) in the intervention group and for the men the decrease was 0.5 mmol/l, while the mean level of the reference group was unchanged. Furthermore, there was a nonsignificant decrease of the mean triglyceride level in the intervention group.

CONCLUSION

The results of this controlled trial indicates that risk factors for cardiovascular disease can be reduced by interventions at the worksite. Even modest reductions of cholesterol levels may reduce the risk to a tangible degree.

Prevention of coronary heart disease. Part II. Secondary prevention, detection of subclinical disease, and emerging risk factors

The prevention of CHD should be a major priority among primary care physicians and subspecialists who have any dealing with the cardiovascular system. There is ample evidence from epidemiologic studies for the impact of specific risk factors on CHD events. There is also ample evidence from observational studies and clinical trials that interventions of lifestyle and pharmacologic therapy can decrease morbidity and mortality from CHD before or after the first event. It behooves the physician who wishes to practice good medicine to understand the pathophysiologic roles of the risk factors and the evidence from epidemiologic studies and clinical trials for their association with cardiovascular disease. It is important to determine the efficacy of interventions, both lifestyle and pharmacologic, in modifying CHD risk. To be effective in doing so, the practicing physician has to have the motivation to determine target goals for risk factor modification in each patient, to understand the patient's own motivations in modifying risk factors, and to define clearly with the patient the expectations of such interventions. Although there are guidelines for risk factor modification in modification of cholesterol and in hypertension, the periodic renewal of these guidelines reflects the changing concepts of risk and its modification. A cardiovascular risk factor intervention categorization is presented in Table 12. The physician must be convinced that such intervention is beneficial to the patient, cost-effective, and thus fulfills the expectations of medical practice. The practice of medicine in the evaluation and treatment of coronary heart disease has always been challenging and stimulating. The prevention of CAD disease should ultimately provide the greatest accomplishment.

The future of best practice

Evidence from epidemiological and clinical studies continues to improve our understanding of the pathogenesis of coronary heart disease (CHD). However, despite major advances in the development of diagnostic methods and effective treatment, CHD remains the leading cause of mortality in the Western world. That cholesterol lowering is of major importance in lowering the risk of developing coronary artery disease (CAD) is now an accepted principle in medicine. Most patients with CAD will require drug therapy to achieve target lipid levels. Subgroup analyses of data from the landmark statin trials show that this benefit is seen in all patient groups: male and female, older and younger patients, diabetics and non-diabetics, and patients with and without myocardial revascularization. Recent evidence suggests that the extent to which cholesterol is lowered is also important and that the attainment of reduced low-density lipoprotein cholesterol levels is associated with greater reductions in the risk of cardiovascular events. Unfortunately, data from studies to date do not provide a definitive answer to the question of whether there is a benefit in lowering cholesterol to very low levels.

A perspective on hyperlipidemia: concepts of management in the prevention of coronary artery disease

The clinical benefits of lowering elevated serum cholesterol for both primary and secondary prevention of coronary artery disease are now well established. Reduction in clinical events occurs early and appears to be related to stabilization of atherosclerotic plaque. Despite these salutary findings, lipid-lowering therapy, both nondrug and pharmacologic, is still markedly underutilized in patients and high-risk individuals in the asymptomatic population. Recent practical and uncomplicated guidelines present a rational strategy for selection of patients for low-density lipoprotein (LDL) cholesterol reduction and have the potential to yield major clinical benefits if properly implemented. Preventive cardiology measures should be applied by matching the intensity of the intervention to the hazard for clinical events. We support the current guidelines of the expert panels described in this article and propose several extensions for cholesterol lowering in selected, high-risk populations.

Post-transplant hyperlipidaemia

The correction of post-transplant hyperlipidaemia warrants the judicious and timely use of pharmacological agents with dietary modification and exercise. Reduction in hyperlipidaemia may have some role in decreasing the incidence of chronic rejection of allografts. The awareness that the morbidity and mortality of atherosclerotic disease may be lowered by active intervention will result in a better quality of life for transplant recipients.