Recent Advances in Preventive Cardiology and Lifestyle Medicine Barry A. Franklin, Ph.D., FAHA Beaumont Health System Royal Oak, Michigan A Decade of Discovery No Disclosures

Death Coronary Disease Abnormal Heart Rhythms Heart Failure Stroke Cognitive Decline Early Vascular Disease Inflammation Diabetes Psychosocial Stressors Air Pollution Obesity High Cholesterol Hypertension Poor Dietary HabitsPhysical InactivitySmoking Clinical Endpoints Disease Progression Established & Novel Risk Factors Lifestyle Risk Factors The First-Line Strategy to Prevent Heart Disease Mozaffarian, Wilson & Kannel, Circulation 2008

10 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:

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, low- cholesterol 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

Kodama S et al. JAMA 2009;301:2024 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.

CHD/CVD Overall ( ) 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 Mortality (%) LVEF Exercise Capacity p = * Only significant p-values are shown p = p = p = Dutcher J, Franklin B, et. al – Am J Cardiol 2007;99:

Warning: Sitting for Extended Periods May be 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 H HH Hazardous

Cumulative Survival (%) Follow-up Years Almost None of the Time ¼ of the Time ½ of the Time ¾ of the Time Almost All of the Time Katzmarzyk PT et al. Medicine & Science in Sports & Exercise 2009;41:998

Missing Puzzle Pieces? Social Isolation Hostility Anxiety Anger Type-A Behavior Pattern VitalExhaustion Stress Depression

Psychosocialstressors (e.g., depression, social isolation) Behavioral risk factors (e.g., smoking, poor diet) ATHEROSCLEROSIS CLINICAL EVENTS (e.g., angina, MI) Recurrent cardiac events Rozanski A et al. Circ 1999;99:2192

Cumulative mortality for depressed and non-depressed patients. MI indicates myocardial infarction % Mortality Months Post-MI Depressed (n=35) Nondepressed (n=187)

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 GroupMedical Tx Groupp Value Outcome#%#% Death, nonfatal MI Death, MI, Stroke Death Nonfatal MI Stroke Hospitalization* Revascularization ** <0.001 * for ACS; ** PCI or CABG

BARI 2D Study Group. NEJM 2009;360:2503

Evolutionary Treatment of Heart Disease Interventional Devices 2012 LifestyleModification 1970 Bypass Surgery 1990 CoronaryThrombolysis 1980CoronaryAngioplasty PharmacologicTherapy 1960 PreventiveCardiology