C. Richard Conti, MD, MACC

Some diseases other than cardiac disease can be“prevented”, but the purpose of this communication written by a clinical cardiologist, not as a prevention specialist, is to focus strictly on cardiovascular disease. The de finition of preventive medicine in simplest terms means keeping your patient healthy.In addition to maintaining health, of course, we want to prevent the disability associated with cardiac disease as well as death in the younger person.

When the term “preventive medicine” is used,we generally mean that whatever methods are used,they hopefully will delay the onset of the major adverse cardiac events, e.g., myocardial infarction,stroke, or cardiac death. In general, these endpoints are related to atherosclerosis, either of the heart,brain, or peripheral arteries.

In 2016, I seriously doubt that we prevent most major cardiovascular events in patients with known cardiovascular disease. The term “delay” seems more appropriate than prevention to me.

Thus, the term “preventive medicine” is probably a misnomer.

Once the cardiac disease is evident, most of what cardiovascular physicians do is palliation.Of course, there are a few exceptions: e.g., in most instances an ICD will prevent sudden cardiac death if it is due to ventricular fibrillation or ventricular tachycardia. Another exception is the ablation of an accessory pathway to control tachycardia. In contrast, “prevention” slows down (palliates) progression of most other untoward conditions, even when utilizing advanced cardiovascular medicine and surgery.

However, despite palliation, and not cure, most Americans who have cardiac disease are living a good deal longer than they have at the turn of the 20th century. I think this is the result of aggressive risk factor modi fication in patients with known cardiovascular disease. e.g., early diagnosis of cardiac disease and aggressive medical and surgical therapy.

Categories of “Prevention”

In 2016 it has become fashionable to use the term primordial prevention of cardiovascular disease risk factors [1]. One of the de finitions of primordial is“relating to or occurring near the beginning of a process”. In cardiovascular terms, this could mean the earliest detection of risk factors associated with the development of cardiovascular disease. The earliest detection of risk that I know of is the detection of fatty streaks in the aborted fetuses of hypercholesterolemic mothers. It can’t get much earlier than that [2].

I like to think that “preventive” measures are divided into three separate categories:

1.Primary Prevention– In my opinion primary prevention means the prevention of the development of the usual risk factors for cardiovascular disease, such as smoking, hypertension, hyperlipidemia, diabetes, and obesity; and we do this by promoting smoking cessation programs,increased exercise activity, control of weight using dietary methods, and possibly prevention of hypertension by decreasing salt intake and preventing obesity. I am not quite sure how we can prevent diabetes, but I suspect controlling obesity with appropriate diet, may play a role.

2.Secondary Prevention– By this I mean controlling patient risk factors i.e., smoking cessation, hypertension, hyperlipidemia diabetes, obesity, lack of exercise in order to delay the onset of major adverse cardiac events.i.e., myocardial infarction, stroke, sudden cardiac death.

3.Tertiary Prevention– This is what most cardiologists practice since most of our patients have cardiovascular disease, i.e., Ischemic heart disease,arrhythmias, and heart failure. In these patients physicians make an attempt to delay death and disabling conditions such as, myocardial infarction, and/or stroke by treating the patient aggressively with medicine, surgery, angioplasty, or with electrophysiologic techniques.

In summary, in 2016, primary prevention addresses the prevention of the probable cause of a disease,i.e. risk factor whereas secondary prevention aims to detect and treat patients with known risk factors prior to any end organ damage, e.g., hypertension.Tertiary prevention focuses on preventing untoward complications from established disease e.g., myocardial infarction and its resultant possible disabilities such as heart failure, arrhythmias etc.

The Language of “Preventive Cardiology”

As implied, the reader can detect that I am not a great fan of the term “prevention”. The language of“preventive cardiology”, in my opinion, is somewhat confusing. I like to think of the prevention or delay of major adverse cardiac events in patients with known cardiac disease asTertiary Prevention. If that term is used, thenSecondary Preventionbecomes the prevention or delay of cardiac disease in patients with known risk factors andPrimary Preventionbecomes the prevention or delay of the development of risk factors which may lead to cardiovascular disease.

What Must be Done to “Prevent”Heart Disease?

In the born child, the earliest risk factors which should be prevented include hypertension, diabetes,obesity, cigarette smoking and lack of exercise. In my way of thinking, this should be considered asPrimary Preventionof the known risk factors and needs to be started early in childhood. Of course,neither adult cardiologists nor pediatric cardiologists are asked to evaluate (and counsel the parents)of a normal child. This group of “well” children are principally seen and evaluated by general physicians principally, general pediatricians who in my opinion have the responsibility to counsel the parents of the young child regarding good health practices and the parents have the responsibility of promoting good health practices for their children. If that is accomplished, good health practices may eventually have a young child evolve into a healthy adolescent and young adult without developing risk factors for cardiovascular disease. If that is not accomplished then the children are at risk for developing risk factors for cardiovascular disease. e.g., fat, and cigarette smoking children become fat and cigarette smoking adults [3].

Can Cardiologists Prevent the Development of Risk Factors

Most cardiologists do not see children who might go on to develop risk factors for cardiac disease.How then, are we, as cardiologists, going to practice primary prevention? Perhaps a way to answer that question is to use the family history as an entrée to identify the child or adolescent who might have a genetic or an environmental disposition to develop any of the risk factors. When an adult patient is seen by an internist or adult cardiologist, questions about family history usually relate to the patient’s siblings,parents, or other adult relatives. Despite the presence of multiple risk factors, rarely are the patient’s children considered unless the patient has one of the classic genetic-based diseases, (e.g., hypertrophic cardiomyopathy, long QT syndrome, Brugada syndrome), or very premature onset of acute myocardial infarction, (i.e., age 30).

The typical patient seen by adult cardiologists has some form of cardiac disease and multiple risk factors, such as hypertension, hyperlipidemia, diabetes,obesity, perhaps cigarette smoking, etc. I think we have an obligation to explain to the patient that their adolescent and adult children may be at increased risk for cardiovascular disease. Family history may be related to genetics, environment or a combination.

We do not do a good job of focusing on the offspring of patients with a detrimental family history and we need help from others: e.g., schools and teachers need to promote no smoking, dietary instructions which include decreasing salt intake,sugar intake, fat intake, encourage activities such as gym and after-school sports, etc. This is obviously not easy to do and, for those of us who have children or grandchildren, it is necessary to discuss these issues with pediatricians and with school authorities, since this is not only a medical problem,it is a societal problem.

Conclusion

If the goal is to prevent disease, which is not easily done, one must first prevent the risk factors that are responsible for the disease; thus, primary prevention is really different than tertiary prevention in which we treat the disease to prevent or slow down the progression of that disease and its major adverse cardiac events. If one can prevent hypertension, hyperglycemia, diabetes, hypercholesterolemia, prevent the individual from smoking, and increase the exercise of that individual, then one may be able to prevent the onset of the risk factors that are eventually responsible for the development of cardiovascular disease.General pediatricians and parents, school of fi-cials and society in general need to buy into the concept of the good health practices for the children, especially, diet, smoking cessation, weight control and exercise. To me this is real “prevention medicine”.

If, in addition to secondary and tertiary prevention, primary prevention, as outlined above,is accomplished, then maybe, this will lead to the elimination or decrease of cardiac disease and prolong useful life of our children and grandchildren.

REFERENCES

1. Gillman MW. Primordial prevention of cardiovascular disease. Circulation 2015;131:599–601.

2. Napoli C, D’Armiento FP, Mancini FP, Postiglione A, Witztum JL, Palumbo G, et al. Fatty streak formation occurs in human fetal aortas and is greatly enhanced by maternal hypercholesterolemia. J Clin Invest 1997;100(11):2680–90.

3. Berenson GS, Bogalusa Heart Study Investigators. Bogalusa heart study: a long-term community study of a rural biracial (Black/White) population. Am J Med Sci 2001;322(5):293–300.