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.”
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