Coronary artery disease: primary prevention measures

Regular physical activity provides cardiovascular benefits and should be recommended for patients in a program of at least 30 minutes of physical activity per day. Weight control to prevent obesity is a strong avoidable cause of CAD. Development of obesity contributes to hypertension, dyslipidemia, and insulin resistance, which eventually leads to diabetes mellitus and development of metabolic syndrome. Healthcare providers should encourage patients to have an ideal BMI between 19 and 25. Patients who consume heavy amounts of alcohol have high rates of morbidity and mortality associated with CVD. Small amounts of daily alcohol consumption regardless of type of alcoholic beverage have been shown to decrease the rates of morbidity and mortality associated with CVD.

Dyslipidemia significantly contributes to the development of CAD and should be treated according to the National Cholesterol Education Program (NCEP) recommendations. Reduction of LDL with statin therapy has been associated with the greatest outcomes. Control of hypertension is an essential factor in reducing risk of CAD. Control of blood pressure reduces myocardial oxygen consumption and reduces angina, and it also lowers the incidence of cardiovascular disease.⁶

Optimal blood pressure management is about <140 mm Hg systolic and < 90 mm Hg diastolic, with goals slightly different in patients with a chronic disease such as chronic kidney disease and diabetes mellitus. Blood pressure control should be promoted through use of antihypertensive and nonpharmacologic measures such as weight reduction, reduced sodium intake, exercise, and avoidance of alcohol. Glycemic control in patients with diabetes continues to be an important risk factor in the development of both macrovascular and microvascular complications. According to the American Diabetes Association,⁷ optimal glucose control should include a hemoglobin A1c of 7% or lower to prevent the development of CAD and reduce the risk of cardiovascular events.

Revascularization procedures

Aside from primary prevention measures and reducing risk factors, the primary treatment for CAD entails revascularization procedures such as PCI and CABG. The procedures work by producing revascularization to the heart by opening blocked vessels as with PCI or bypassing blocked vessels as with CABG. Neither PCI nor CABG is performed without risk, and neither offers a permanent fix to CAD, as patients still have to live with the burden of the primary disease and are at risk for myocardial infarction, restenosis, and death associated with the procedures. Percutaneous coronary artery intervention is more effective than medical therapy in relieving angina, but it confers no greater survival benefit.⁶

Healthcare providers must educate patients that postprocedure care still includes management of risk factors, aggressive statin therapy, and antiplatelet therapy to reduce the risk of restenosis at the intervention site. CABG produces better survival rates than does medical therapy in selected circumstances and is recommended for symptomatic patients with left main coronary artery disease, 3-vessel CAD, or 2-vessel CAD marked by stenosis of the proximal left anterior descending artery.⁶ CABG is an effective procedure for management of CAD; however, benefits of the procedure begin to decline at about 10 years postprocedure, and the procedure still does not stop the progression of atherosclerosis. Healthcare providers must inform patients that after surgery aggressive treatment of the underlying CAD along with treatment of risk factors is essential to stop the progression of CAD in the future.

Conclusion

Overall, CVD continues to pose a significant health burden not only in the United States but worldwide and accounts for the leading cause of global deaths. CAD is the leading form of CVD and accounts for substantial amounts of morbidity, mortality, and expenditure of healthcare dollars. Healthcare providers must work with patients to decrease the disease burden in the US. Primary prevention efforts such as exercise, weight control, cessation of smoking, and alcohol intake can greatly affect the development of CAD. Healthcare providers must also assess risk factors in patients and treat such factors as hypertension, diabetes, and dyslipidemia according to medical standards to prevent and accelerate CAD in patients. Alleviation of symptoms associated with the disease is done via PCI and CABG; however, these procedures do not cure or lessen the burden of the disease. Healthcare providers should emphasize primary prevention and aggressively assess and treat arising risk factors to reduce the disease burden.

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Kelsey Onder, CRNP, is a family nurse practitioner in Johnstown, Pa.

References

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3. CDC. Heart disease facts. November 28, 2017. Available at: http://www.cdc.gov/heartdisease/facts.htm
4. Frost & Sullivan. Coronary heart disease and the cost effectiveness of omega-3 and b vitamin dietary supplementation. 2013. Available at: https://www.crnusa.org/sites/default/files/pdfs-hccs/03-CRNFSHCCS-CHD%2BOmega-3sandBVitamins-SP.pdf
5. Behnke LM, Solis A, Shulman SA, Skoufalos A. A targeted approach to reducing overutilization: use of percutaneous coronary intervention in stable coronary artery disease. Popul Health Manag. 2013;16:164-168. doi: 10.1089/pop.2012.0019
6. Rimmerman CM. Coronary artery disease. Cleveland Clinic, Center for Continuing Education. February 2013. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/coronary-artery-disease/
7. American Diabetes Association. A1C and eAG. Updated September 29, 2014. Available at: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/a1c

From the March 01, 2018 Issue of Clinical Advisor