Azra Mahmud, MRCPI, PhD, FBHS, FESH, FASH

Transcription

1 Azra Mahmud, MRCPI, PhD, FBHS, FESH, FASH

2 Disclosures AtCor Medical, Sydney, Australia Pfizer Ireland. Menarini Ireland. Astra-Zeneca, Ireland/UK. Omron Corporation, Tokyo, Japan. Novartis, Ireland/KSA. MSD, Ireland

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4 Cardiovascular Disease is a Man Made Disease?

5 Global Burden of Cardiovascular Disease Cardiovascular disease deaths as a percentage of all deaths in each region and total regional population, (From Global Burden of Disease Study 2010.

6 Top Ten Selected Risk Factors of Cause of Death

7 HUMPETY DUMPETY HAD AN M.I. Sit all day Eat Up BP Physicians of the Utmost Fame Were called at once; but when they came They answered, as they took their Fees, 'There is no Cure for this Disease.' H. Belloc 'Henry King', in Cautionary Tales for Children (first published 1907), (1908 edition), Dr. Do Little Patient, too little, too Late!!

8 Cardiovascular Disease: A diagnosis too late

9 Suspects in Cardiovascular Neglect Case Family Practitioner - see no evil, too busy Cardiac Surgeon waiting for patients

10 CHD mortality fall in Ireland explained by (a) treatments in CHD patients and (b) population risk factors [Bennett et al. J. Epid Comm Health 2006;60:322]

11 Name Medicines Reflect Societies ills! % of Scheme Total 1 Atorvastatin Nutritional Products Pravastatin Omeprazole Olanzapine Lansoprazole Amlodipine Clopidogrel Beclomethasone Esomeprazole Risperidone Salmeterol and OAD Salbutamol Budesonide Pantoprazole Citaolpram Paroxetine Venlafaxine Doxazosin Ramipril of the top 20 drugs are life saving cardiovascular drugs, the rest are for - Dyspepsics - Picky eaters Sadness - Madness

12 High Pill Burden!

13 Do What the Doctor Says! Patients with good compliance (> 80%) whether on active therapy or placebo have better survival (A) from all causes and fewer admissions to hospital Patients adherence to statins 30% stopped within three months (CHARM, Lancet 2005;366:2005) Coronary Drug Project (NEJM 1980; ) with lipid lowering and betablocker in Heart Attack Trial (Lancet 1990;336:542) showed similar results

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15 Our Patients Are Only Human- Life Before Attending the Clinic

16 Depression & Cardiovascular Disease For every affection of the mind that is attended with either pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart, and there induces change from the natural constitution, in the temperature, the pulse and the rest William Harvey Lesperance et al. Circulation 2002

17 Our Patients Are Reading This; Are We?

18 Or This?

19 The Unmet Needs In Cardiovascular Prevention Have We Missed the Boat? Adherence Issues Unhealthy Diet Lack of Exercise Obesity Smoking Stress & depression Social isolation Poor Patient- Physician Relationship Dissatisfaction with health care systems Side effects of drugs High health costs Looking for Cures Sense of Empowerment

20 Complementary & Alternative Medicine It is a Group of Diverse Medical and Health Care Systems, Practices, and Products That are Not Presently Considered Part of Conventional Medicine National Center for Complementary and Alternative Medicine

21 What s on Offer in CAM? Alternative Medical Systems Ayurveda, Chinese, Native American, Aboriginal, African, Middle Eastern, Tibetan, Central and South American cultures, Homeopathy, Naturopathy Mind-Body Interventions Biological Based Therapies Manipulative And Body- Based Methods Energy Therapies Cognitive-behavioral approaches, meditation, hypnosis, dance, music, art therapy, prayer, mental healing Dietary supplements, herbs, orthomolecular (varying concentrations of chemicals, such as, magnesium, melatonin, and mega-doses of vitamins), individual biological therapies (use of laetrile, shark cartilage, bee pollen). Chiropractic, osteopathic manipulation, massage Qi gong, Reiki, therapeutic touch, bioelectromagnetic-based therapies (pulsed fields, magnetic fields, or alternating current or direct current fields)

22 Why? What is Mainstream Medicine Not Offering Our Patients? In the United States, an estimated 15 million individuals use some form of CAM therapy at an annual cost of almost $30 billion. Patient expenditure for CAM services in the United States is comparable to out-of-pocket patient expenses for conventional medical services and prescription drugs. Health care professionals are more likely to use CAM therapies than the general public (76% versus 63%, P < 0.001). Only 14% of patients who use CAM therapies discussed their choice with a physician. 600 Million Visits a Year to CAM Providers More Than to Primary Care Providers

23 82% of cardiology patients attending a Cardiology Outpatient Dept. used CAM Of these patients, 44% used CAM for cardiac symptoms. The most frequently used CAM modalities were: 1. Dietary supplements (75%), 2. Chiropractic (32%), 3. Massage (19%), 4. Relaxation techniques (13%). In a survey of more than 1000 cardiology outpatients, 75% reported the use of some form of supplement or herbal product. The most common OTC products included: 1. Multivitamins (53%), 2. Fish oil (45%), vitamin C (36%), 3. Vitamin E (29%), fiber (27%), 4. Folic acid (18%), 5. Coenzyme Q10 (CoQ10) (12%), 6. Garlic (12%).

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26 w-3 Fatty Acids Evidence: Primary and Secondary Prevention Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS) 18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a statin or a statin alone for 5 years Yokoyama M et al. Lancet. 2007;369: Years A meta-analysis of 20 studies of omega-3 fatty acids that included 68,680 patients showed no overall benefit in reducing all-cause mortality, sudden death, cardiac death, or myocardial infarction.

27 An Evidence-Based review of Herbal Medications Used in Cardiovascular Medicine Asian ginseng (Panax ginseng) Red Yeast Rice(Monocolin) Flaxseed oil (Linum usitatissimum) Garlic (Allium sativum) Ginkgo (Ginkgo biloba) Grape (Vitis vinifera) seeds Green tea (Camellia sinensis) Hawthorn (Crataegus) Soy (Glycine max)

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29 Mind-Body Medicine- The Most Promising CAM Deep Breathing Biofeedback Tai Chi Guided imagery

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31 Integrative Preventive Medicine Integrative Preventive Medicine Combines Mainstream Medical Therapies and CAM Therapies for Which There is Some High-Quality Scientific Evidence of Safety and Effectiveness. Integrative Preventive Medicine Recognizes the central role of Nutrition and Lifestyle for prevention and treatment of heart disease, combined with Diverse, Scientifically Validated Modalities of CAM all within the Framework of Guideline-based Conventional Cardiology Care.

32 Age-standardized Prevalence Estimates for Poor, Intermediate and Ideal Cardiovascular Health for each of the Seven Metrics of Cardiovascular Health in the AHA 2020 Goals, among US Adults 2010 American Heart Association, Inc. All rights reserved. Roger VL et al. Published online in Circulation Dec. 15, 2010

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35 CHD Patients with Metabolic Syndrome, while Deriving Incremental Benefit from High Dose Atorvastatin, irrespective of Diabetes, or Treatment Assignment, have more CV Events than those Without the Syndrome (Lancet 2006;368:925)

36 Different Strokes for Different Folks!

37 The Hunter & Gatherer- The Early Man

38 O Dea 1991, Royal Society of London. Hunter Gatherer diet

39 CARDIOLOGY

40 The Ideal Diet? Atkins Ornish Duken Mediterranean diet

41 The Mediterranean Diet was associated with a reduced risk of a new CV event including acute MI, stroke or Death compared with a standard Western Diet NEJM, 2013 vol. 368 no. 14

42 NEJM, 2013 vol. 368 no. 14

43 Disclaimer While the characters depicted in this presentation are based on real people resemblance to any members of the audience is purely coincidental

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45 There is a Dose Response Relationship between level of Physical Activity & CHD Risk Health Professionals Follow-up Study (2002).

46 Intensive lifestyle intervention results in greater improvements in lipid parameters Look AHEAD Trial 5,145 patients aged years with type 2 DM and BMI 25 kg/m2 (27 kg/m 2 if taking insulin) randomized to an intensive lifestyle intervention (ILI) involving group and individual meetings to achieve and maintain weight loss through decreased caloric intake and increased physical activity versus diabetes support and education (DSE) ILI DSE P value LDL (mg/dl) -5.2 ± ± HDL (mg/dl) 3.4 ± ± 0.1 <0.001 Triglycerides (mg/dl) ± ± 1.8 <0.001 % Metabolic Syndrome ± ± 0.7 <0.001 Look AHEAD investigators. Diabetes Care 2007;30:

47 Most Useful Integrative Strategies for Prevention of Coronary Disease Nutrition Mediterranean diet led to a 72% reduction in cardiac events. Healthiest diet linked to a 35% reduction in cardiovascular mortality. Exercise Meditation Comprehensive lifestyle intervention Walking 30 min 5 days/wk reduces risk for coronary heart disease by 14%. Twice-daily meditation reduced cardiovascular events by 48%. The combination of a low-fat, plantbased diet, exercise, and stress management led 74% of patients with angina to become asymptomatic Red yeast rice Red yeast rice resulted in a >20% reduction in LDL-C and was often tolerated in patients with previous statin-related myalgias

48 Why do Patients Not Tell the Physician About Their CAM Use? Between 40 and 70% of CAM users do not disclose their use to their physician. WHY? 60% - My doctor never asked. 60% - It wasn t important for my doctor to know. 20% - My doctor wouldn t understand. 14% - My doctor would disapprove. 70% of patients see their Physician before or concurrent with their visits to a CAM provider! Eisenberg DM. Ann Int Med 2001;135(5):344-51

49 Why Would Patients Not Trust Us? Percorlan

50 Why Would We Not Trust CAM? Difficulties With CAM Research Sham Acupuncture Non Standardized Herbal Formulations Difficult to Blind Patients and Practitioners Treatments Very Individualized Difficult to Formulate Protocols Legislation Issues- None required for CAM! Do not need to be approved before CAM enters the market, and do not have to be proven safe or effective in the treatment of a given condition. Do not require clinical studies before their approval and can be found unsafe only after they have caused harm. Drug Interactions!

51 Cardiovascular Drug Interactions with Herbals Liperoti et al, JACC 2016

52 The Future of Integrative Medicine The Term Integrative Medicine Will Die o o o Our Patients Will Demand Integrative Medicine From All of Us Training Will Be Demanded by Medical Students Training Will Be Demanded by Residents Integrative Medicine Will Be A Skill Set Added on Just Like: o o o o Electronic Health Records New Medications New Procedures What Cannot Be Added On is Empathy and Open-mindedness The integrated approach requires a paradigm shift from the disease-centered approach of conventional biomedicine to an approach in which patient values and participation of patients are central and account the whole person (body, mind, and spirit), including all aspects of lifestyle.

53 Guidelines Need Teeth "Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein ( )

54 Imagine a world - oriented toward healing rather than disease, where physicians believed in the natural healing capacity of human beings, and emphasized prevention above treatment. In such a world, doctors and patients would be partners working toward the same end.

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