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The forgotten majority: unfinished business in cardiovascular risk reduction
1Donald W. Reynolds Cardiovascular Clinical Research Center, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA. plibby@rics.bwh.harvard.edu
Insights
Cardiovascular disease deaths are rising globally due to obesity and diabetes. While statins and lifestyle changes help, many patients still experience events, necessitating a balanced approach to drug therapy and personal behavior.
Area of Science:
- Cardiology
- Metabolic Disorders
- Public Health
Background:
- Cardiovascular disease (CVD) mortality is increasing globally, driven by obesity, metabolic syndrome, and type 2 diabetes.
- Despite advancements in risk factor identification and clinical tools, a significant number of patients experience cardiovascular events.
- Pharmacologic interventions like statins have shown benefits but do not fully eliminate cardiovascular events.
Purpose of the Study:
- To review the current landscape of cardiovascular disease risk factors and treatment efficacy.
- To highlight the persistent occurrence of cardiovascular events despite established therapies.
- To emphasize the importance of integrating lifestyle modifications with pharmacologic treatments.
Main Methods:
- Review of major clinical trials on statins (e.g., Scandinavian Simvastatin Survival Study, Cholesterol and Recurrent Events trial) and fibric acid derivatives (e.g., Helsinki Heart Study).
- Analysis of findings from follow-up studies (e.g., Heart Protection Study) reinforcing treatment outcomes.
- Consideration of the impact of lifestyle modifications on metabolic syndrome and insulin resistance.
Main Results:
- Large clinical trials indicate that statin therapy, while reducing cholesterol and mortality, does not prevent cardiovascular events in all patients.
- Fibric acid derivatives show mixed results, with some studies demonstrating reduced events and others less encouraging outcomes.
- Lifestyle modifications offer general health benefits but face challenges in patient adherence.
Conclusions:
- A significant unmet need remains in preventing cardiovascular events, even with current pharmacologic and lifestyle interventions.
- Physicians must educate patients on the necessity of balancing effective drug therapy with personal behavior changes.
- Optimizing patient outcomes requires a comprehensive strategy addressing both medical treatment and lifestyle adherence.
Abstract:
Despite meaningful progress in the identification of risk factors and the development of highly effective clinical tools, deaths from cardiovascular disease continue to increase worldwide. Sparked by an obesity epidemic, the metabolic syndrome and the rising incidence of type 2 diabetes have led to an upsurge of cardiovascular risk. Although pharmacologic treatments with the statin class of drugs have reduced cholesterol levels and lowered mortality rates, several large controlled clinical trials, including the Scandinavian Simvastatin Survival Study, the Cholesterol and Recurrent Events trial, the Air Force/Texas Coronary Atherosclerosis Prevention studies, and Long-term Intervention with Pravastatin in Ischemic Disease study, have indicated that cardiovascular events continue to occur in two thirds of all patients. Follow-up studies, such as the Heart Protection Study and the Pravastatin or Atorvastatin Evaluation and Infection Therapy/Thrombolysis In Myocardial Infarction-22 trials, reinforced these earlier results. Although therapy with gemfibrozil, a fibric acid derivative, showed reduced occurrence of cardiovascular events in the Helsinki Heart Study and the Veterans Affairs HDL Intervention Trial, results of other studies, e.g., the Bezafibrate Intervention Program and the Diabetes Atherosclerosis Intervention study, showed less encouraging results. Although lifestyle modifications, such as improved diet and increased exercise levels, benefit general health and the metabolic syndrome and insulin resistance in particular, most people continue to resist changes in their daily routines. Thus, physicians must continue to educate their patients regarding an optimal balance of drug therapy and personal behavior.
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