CARDIOVASCULAR HEALTH LIVING A HEART HEALTHY LIFE. Matt Handley MD Group Health Physicians

Transcription

1 CARDIOVASCULAR HEALTH LIVING A HEART HEALTHY LIFE Matt Handley MD Group Health Physicians

2 WILLIE SUTTON Add together your risk of dying from breast cancer and colon cancer (women), or prostate cancer and colon cancer (men) Multiply by 10 That s your risk of heart disease

3 MAKING SENSE OF SCIENCE Every week there is conflicting advice in the lay press about risks and benefits of different health issues So how do we manage this information to lead healthy lives? First - understand the basics about medical studies

4 Understanding Medical News What Different Studies are Good For Observational trials Look at what happens to people without influencing what care they get Good for identifying prognosis/risk, bad for understanding the effectiveness of treatments

5 Understanding Medical News What Different Studies are Good For Randomized trials - true experiments Take one population of patients and use random selection to determine what treatment they get (active or placebo) Known and unknown risks are equally distributed between the groups, so that the observed difference is from the treatments, not differences in other characteristics between the two groups Bad for understanding risk (very selected populations), good for understanding the effectiveness of treatment Challenges Expensive, often have non-generalizable populations or interventions

6 STUDY OUTCOMES POEMs Patient Oriented Evidence that Matters Mortality, heart attack, functional capacity, quality of life DOE Disease Oriented Evidence BP, cholesterol, tumor size

7 Lies, Damned Lies, and Statistics Benjamin Disraeli Look for the Absolute difference in outcomes, Example not the Relative difference 100 patients at risk take drug A - 2% have heart attack 100 patients at risk take Placebo - 3% have heart attack Relative risk reduction (the newspaper statistic) is (3%-2%) 3% Absolute risk reduction (what you need to know) is 3% - 2% = 1% = 33%

8 THE NUMBER NEEDED TO TREAT How many patients would need to be treated for a period of time for one patient to avoid a specific outcome? Relative Risk Reduction 33% Absolute risk reduction 1% NNT = 100

9 UNDERSTANDING RISK The likelihood of any treatment helping you is determined mostly by your baseline risk of the heart disease Example: two people, same treatment, different benefits 60 yo man, smokes, high BP, diabetes cholesterol 220, HDL 50-5 year risk is about 30%. Treatment that lowers risk by 30% NNT = yo woman, nonsmoker, normal BP, same cholesterol, 5 year risk is about 1% Treatment that lowers risk by 30% NNT = 300

10 ESTIMATING RISK Cholesterol is not a measure of risk (or health) - it is one risk factor Risk factor counting systems do not work well Framingham equation is the best way to estimate risk Includes: age, gender, BP, chol/hdl, diabetes, smoking Does not include: family history of early CAD, diet, exercise, treatment

11 CONTROVERSIES IN ESTIMATING CVD RISK C reactive Protein Sub-fractions of cholesterol Heart Scam - calcium scoring The Metabolic Syndrome Tests are only useful if they provide information that would change a recommendation for care

12 CHOLESTEROL MEASUREMENT What cholesterol lab tests make sense? Total cholesterol and HDL are undeniably the best Do you need to know Triglycerides or LDL?

13 DIET AND HEALTH The micronutrient theory of diet Looking at components of food, rather than food itself (% calories from x and y) What does it build back into? Has yet to yield effective interventions

14 DIET STUDIES Observational studies Vegetables are good Lots of saturated fats are bad Mediterranean Diet is good and a miss... Vitamins are good for you Experimental studies - looking for POEMs Low fat diets - no benefits, and little adherence Mediterranean diet - 1/3 reduction in heart attacks and strokes, cancer and mortality and good adherence

15 EXERCISE Fitness Matters Weight, vascular disease, probably cancer, and most every aspect of QOL Exercise/Physical activity is a reasonable marker for fitness Dose response - diminishing returns after moderate fitness - more is better, but not much better The gym is not the answer - it is a bonus rather than the solution Successful improvements in physical activity usually include walking and social connection

16 TOBACCO The most important modifiable risk factor. Period

17 ASPIRIN There are risks and benefits For unknown reasons, aspirin prevents heart attacks in men and strokes in women 15% RRR, NNH is about 300 (GI bleeding) If your baseline risk is over 5%, there is a net benefit

18 BLOOD PRESSURE BP increases with age - most people develop HTN Lower is better if you aren t on treatment Only about 40% of people diagnosed are in good control, because: We overestimate impact of diet and exercise on BP We do not adjusts medications in the ways that have been shown to work best

19 STATINS While people focus on cholesterol, statins treat CVD risk Patients at equal CVD risk with high and low cholesterol have the same benefit Patients with large and small reductions in cholesterol on statins have the same benefit Statins are twice as effective as aspirin, and safer

20 CHOLESTEROL LOWERING DRUGS Five medications that have been shown to improve cholesterol effectively, but increase risk of CVD and death Combination therapy in the quest to treat the number has not been shown to be helpful in decreasing CVD

21 ALCOHOL & CHOCOLATE People who drink alcohol in moderation have less heart disease and live longer Most if not all of the effect is from alcohol (vs red wine) Alcohol causes enormous damage to health Chocolate may be beneficial - and tastes great

22

23