Recent Advances in
Preventive Cardiology
and Lifestyle Medicine
A Decade of Discovery
Barry A. Franklin, Ph.D., FAHA
Beaumont Health System
Royal Oak, Michigan
e-mail: bfranklin@beaumont.edu
No Disclosures
The First-Line Strategy
to Prevent Heart Disease
Death
Clinical
Endpoints
Coronary
Disease
Abnormal
Heart
Rhythms
Heart
Failure
Stroke
Cognitive
Decline
Early Vascular Disease
Disease
Progression
Established
& Novel
Risk Factors
Lifestyle
Risk Factors
Inflammation
Diabetes
Obesity
Poor Dietary Habits
Psychosocial
Stressors
High
Cholesterol
Physical Inactivity
Air
Pollution
Hypertension
Smoking
Mozaffarian, Wilson & Kannel, Circulation 2008
100
100
100
97
Percentage survival from age 35
94
Cigarette Smokers
91
81
80
Non-Smokers
81
60
59
58
10 years
40
26
24
20
4
0
40
50
60
70
80
2
90
2
100
Age (years)
BMJ 2004;328:1519
Outline
 Coronary Remodeling, Plaque Rupture, and
Traditional and Emerging Risk Factors
 Cardioprotective Medications
 Evidence-based Dietary Strategies
 Fitness, Sitting Time and Mortality
 Psychosocial Stressors
 Rehab: Modern-Day Mortality Benefit?
 Enhanced External Counterpulsation Therapy
 Medical Management versus Coronary
Revascularization
Angiographic studies on patients
before myocardial infarction show
that the majority of subsequent
events involve sites with < 70%
obstruction.
Falk E. et al. Circ 1995;92:657
The new picture of
atherosclerosis explains why
many heart attacks come
from out of the blue: the
plaques that rupture do not
necessarily protrude very far
into the blood channel and so
may not cause angina or
ischemic ST-segment
depression.
Libby S. Scientific American 2002;286:28
Efficacy of the Presently
Available Statin Drugs
TC ↓
LDL↓
HDL↑
22% - 47%
27% - 60%
7%
*Roberts WC. AJC 2006;78:1550
The Polypill as Part of a Global
Strategy to Substantially Reduce the
CVD Burden
The polypill could potentially be widely used in
secondary prevention and in selected high-risk
individuals without known CVD (e.g., those with
diabetes mellitus with additional risk factors).
In such individuals, a 50% to 75% proportional reduction
in risk can be anticipated from prolonged therapy.
By contrast, in individuals without CVD and not at high risk,
large trials are needed to quantify the benefits, potential
risks and cost-effectiveness of the polypill.
Lonn E et al. Circulation 2010;122:2078-2088
Polypill: User Directions
Take medication each day in the prescribed
dosage, followed or preceded by at least 30
minutes of moderate-to-vigorous physical
activity, in combination with a low-fat, lowcholesterol diet, weight management,
smoking cessation, and regular visits to your
physician.
Franklin BA et al. AJC 2004;94:162
Dietary Priorities Associated with
Cardioprotective Benefits
Consume more:
Consume less:
• Fish and shellfish
• Potatoes, refined grains, sugars
• Whole grains
• Processed meats
• Fruits
• Sweetened beverages, diet sodas
• Vegetables
• Grain-based desserts & bakery goods
• Nuts
• Fats, oil or foods containing partially
• Low-fat or no fat diary products
hydrogenated vegetable oils
• Vegetable oils*
• Salt
• Water
• Alcohol**
* Examples include flaxseed, canola, and soybean oil
** For adults who drink alcohol, no more than moderate consumption (i.e., up to 2
drinks/day for men, 1 drink/day for women) should be encouraged, ideally with meals.
CONCLUSIONS: Better CRF was associated with lower
risk all-cause mortality and CHD/CVD. Participants with
a MAC of 7.9 METs or more had substantially lower rates
of all-cause mortality and CHD/CVD events compared
with those with a MAC of less 7.9 METs.
Kodama S et al.
JAMA 2009;301:2024
CHD/CVD
Overall
100.00
0.85 (0.82-0.88)
Kodama S et al. JAMA 2009;301:2024
Prognostic Significance of Peak Exercise
Capacity in Patients with CAD*
• 527 men with CVD who were referred
to an outpatient rehabilitation program
• Measured peak VO2 during cycle ergometer
testing
• Average follow-up of 6.1 yrs, 33 and 20 pts
died of cardiovascular and noncardiovascular
causes, respectively.
Highest mortality in pts who averaged ≤ 4.4 METs; There
were no deaths in pts who averaged ≥ 9.2 METs.
*Vanhees L et al. JACC 1994;23:358
LVEF And Exercise Capacity As Predictors
Of 2- And 5-year Mortality
2-year data
5-year data
p = 0.038
p = 0.0025
p = 0.019
Mortality (%)
30
p = 0.0007
20
< 40 %
10
> 40 %
0
< 4 METs > 4 METs
* Only significant p-values are shown
LVEF
< 4 METs > 4 METs
Exercise Capacity
Dutcher J, Franklin B, et. al – Am J Cardiol 2007;99:436-441.
Warning: Sitting for Extended
Periods May be Hazardous to Your
Health
Manson JE et al. NEJM 2002;347:716
Hamilton, MT et al. Diabetes 2007;56:2655
Hamilton, MT et al. Curr Cardiovasc Risk Rep 2008;2:292
Katzmarzyk, PT et al. Med Sci Sports Exerc 2009;41:998
100
Cumulative Survival (%)
95
Almost None of the Time
¼ of the Time
90
½ of the Time
85
¾ of the Time
80
Almost All of the Time
75
70
0
2
4
6
8
10
12
14
Follow-up Years
Katzmarzyk PT et al. Medicine & Science in Sports & Exercise 2009;41:998
Missing Puzzle Pieces?
Social Isolation
Hostility
Depression
Anxiety
Stress
Anger
Vital
Exhaustion
Type-A Behavior Pattern
Psychosocial
stressors
Behavioral
risk factors
(e.g., depression, social isolation)
(e.g., smoking, poor diet)
ATHEROSCLEROSIS
CLINICAL EVENTS
(e.g., angina, MI)
Recurrent
cardiac events
Rozanski A et al. Circ 1999;99:2192
30
% Mortality
25
20
15
Depressed (n=35)
10
5
Nondepressed (n=187)
0
0
1
2
3
4
5
Months Post-MI
6
Cumulative mortality for depressed and non-depressed
patients. MI indicates myocardial infarction.
Major Findings
 Compared with usual care, CR ↓ total mortality
by 20% and cardiac mortality by 26%.
 There were also substantial ↓s in TC, TGs, SBP,
and self-reported cigarette smoking in the CR
group, but there were no differences in HDL-C
and LDL-C, DBP, or health-related QOL.
 The effect of CR on total mortality was
independent of whether the trial was published
before or after 1995, suggesting that the
mortality benefits of CR persist in modern
cardiology.
Taylor RS et al. Am J Med 2004;16:682
Enhanced External Counterpulsation
Therapy: A Noninvasive Approach to
Treating Coronary Disease*
*Arora R et al. JACC 1999;33:1833
Ochoa AB et al. AJMS 2003;May/June
COURAGE: Cumulative Event Rates
at 4.6 Years
PCI Group
Outcome
Medical Tx Group
p Value
#
%
#
%
Death, nonfatal MI
211
19.0
202
18.5
0.62
Death, MI, Stroke
222
20.0
213
19.5
0.62
Death
85
7.6
95
8.3
0.38
Nonfatal MI
143
13.2
128
12.3
0.33
Stroke
22
2.1
14
1.8
0.19
Hospitalization*
135
12.4
125
11.8
0.56
Revascularization **
228
21.1
348
32.6
<0.001
* for ACS; ** PCI or CABG
BARI 2D Study Group. NEJM 2009;360:2503
Evolutionary Treatment
of Heart Disease
Interventional Devices
1990
Coronary
Thrombolysis
1980
Coronary
Angioplasty
Pharmacologic
Therapy
2012
Preventive
Cardiology
1960
Lifestyle
Modification
1970
Bypass Surgery