May 10, 2004

A little TLC can improve cardiovascular health      

By Sherry Baker

High blood pressure, high cholesterol levels (hyperlipidemia) and elevated blood sugar (hyperglycemia) are serious risk factors for cardiovascular disease. Physicians frequently prescribe a host of medications to treat these problems and reduce these risks.

But research presented at the American College of Cardiology’s 53rd Scientific Sessions in New Orleans in March concluded that many patients with classic cardiovascular disease risk factors can achieve risk-reduction goals without medications and within three months by initiating therapeutic lifestyle changes (TLC).

“National clinical guidelines recommend TLC as a standard of care in the management of cardiovascular disease risk factors, but the value of TLC in actual contemporary medical practice is often discounted by clinicians and health insurers who instead frequently turn to widely available pharmacotherapeutic agents,” said Neil Gordon, clinical professor of medicine, who presented the research. “This study was designed to evaluate the precise role of TLC in helping patients achieve goal risk-factor levels—and our conclusions refute the notion that intensive lifestyle intervention is not worth the effort.

In this prospective, multicenter study of 2,390 patients, researchers evaluated the clinical effectiveness of 12 weeks of TLC in helping individuals with hypertension, hyperlipidemia or impaired fasting glucose (diabetes mellitus) to achieve their goal risk-factor levels without drug therapy. TLC included exercise training, nutrition counseling and other appropriate lifestyle interventions based on established behavior-change models.

The results showed that 64 percent of patients achieved their systolic blood pressure goal (less than 130 mmHg for patients with diabetes and/or chronic renal disease, and less than 140 mmHg for others), and 67 percent achieved their diastolic blood pressure goal (less than 80 mmHg for patients with diabetes and/or chronic renal disease, and less than 90 mmHg for others).

LDL cholesterol levels also decreased, with 23 percent of patients achieving their goal for this metric. In reducing fasting glucose, 39 percent of patients achieved the goal of blood sugar levels under 110 mg/dl; and 37 percent of patients with baseline blood-sugar levels compatible with diabetes (more than 126 mg/dl) achieved their goal (under 126 mg/dl).

“More study is needed to see if this approach will be as successful with patients who have more marked elevations in cardiovascular risk factors than the participants in this study,” said Emory Heart Center cardiologist Laurence Sperling, co-author of the study. “However, the findings clearly have important implications for helping physicians and patients translate national clinical guidelines on risk-factor management into medical practice and personal behavior change.

“With the current concern over rising health care costs, it is also important to note that TLC can generally be implemented less expensively than most medications and, unlike single-drug therapy, favorably impacts multiple cardiovascular disease risk factors,” Sperling continued. “We believe the data from this study could have important policy implications for health care payers, including the federal government, who often do not provide reimbursement for TLC but either currently provide or intend to provide more costly prescription drug coverage.”

In a related project, Sperling and his colleagues studied the results of the STARR (Steps to Achieve Risk Reduction) program at Emory Hospital designed to improve patient knowledge of cardiac risk factors and promote TLC changes.

“Despite significant evidence that secondary preventive strategies benefit patients with coronary disease, registry data and literature reviews suggest that a majority of the patients are still not in compliance with the American Heart Association/
American College of Cardiology guidelines,” Sperling said. “The STARR program offers inpatient strategies to implement these guidelines and close the gap between physician knowledge and practice.”

The STARR program uses an algorithmic approach to identify individual cardiac risk factors and modulate them through a multifactorial team approach. Patients are educated about their individual risk factors and their management; this education is reinforced with educational booklets, magnets, stickers, and patient contracts.

“Our pilot data suggests that the STARR inpatient program can improve patient knowledge of TLC and help promote improved adherence to these goals, especially with regards to diet and exercise,” Sperling said. “The impact of such a program could have enormous significance if implemented nation-wide when you consider that the majority of recurrent heart attacks could be prevented and five-year mortality significantly decreased if there were strict patient adherence to secondary prevention guidelines and therapeutic lifestyle changes.”