Six Areas of Consensus – Coronary Artery Disease

00:00 infarction increases. So, evidence based medicine does work. A number of the evidence based medicines, and I’m going to show you some data briefly that supports the idea, I’m going to show you, in other words, the evidence that patients can do well if they take the medicines. Number one of the evidence based medicines of the Statins, I’m going to show you data, that you can decrease recurrent myocardial infarction that is another heart attack or death by 30% to 40% if you take your Statins. I’m going to show you about platelet... Anti-platelet agents to prevent blood clots from forming.

00:33 I’m going to show you about Beta Blockers and ACE inhibitors. I’m going to show you about a whole variety of different chemicals that will help to prevent another heart attack.

00:44 The former surgeon general in the United States Everett Koop said, “Drugs don’t work that patients don’t take.” Obviously, it’s important to try and talk the patient into taking their medicines as prescribed and regularly and follow up with their doctor. When they do that, the outcome is usually good. When they don’t do it, sometimes the outcome is good, but more frequently, the outcome is not good, there's further injury to the heart. So, let’s look at some of this evidence base. First of all, here you see a composite from a number of Statin trials in which the lighter color is recurrent myocardial infarction and the darker color is death. And you can see these are reduction in each of these events in a variety of different subgroups. On individuals, who've had angioplasty - PTCA, individuals who had a previous MI, individuals who had coronary bypass and so forth, in every subgroup, there's a reduction, you can see 30%, 40%, even 50% reduction in recurrent MI and a smaller, but very large reduction in death. So, Statins are sort of number one on the list of evidence based medicine that is really important for patients to take after a myocardial infarct.

02:00 Here are Beta Blockers, there's also significant improvement, not as dramatic as with Statins, but again, across all subgroups a remarkable decrease in further events, further events being another heart attack, MI or the worst outcome, death. Here we see for the taking of Aspirin. Again, this is an older article from the Lancet because we've had Aspirin for a very long time as an evidence based medicine and you can see here again, reduction… significant reductions in events with the use of Aspirin versus placebo - a control.

02:38 So, evidence based medicine does work. I’m now going to show you six areas where there's a consensus among cardiologists about how to manage these patients. I'm then going to show you four controversial areas where there's still work going on and where there's some debate among the experts. The first consensus I've already shown you, evidence based medicines really work, they really do reduce recurrent myocardial infarction and they reduce death, including sudden death. And you see listed here what I just showed you in earlier slides, Statins, the Beta Blockers and the platelet agents. I didn’t show you the data for ACE inhibitors, but I’m going to show that to you in just a moment in the next slide. But also, secondary prevention measures in lifestyle have been shown to reduce events. Here's exercise, diet, appropriate smoking cessation, so forth, cardiac rehab intervention such as lifestyle have also been shown to decrease the death rate. Here, is the slide showing you the ACE inhibitor reductions just like in the same sub-groups that we had before with the Beta Blockers and with the Statins. You can see again marked reductions in events when patients are placed on ACE inhibitors and inhibit the rennin-angiotensin system that we’ve talked about in the past. So, again, what are the evidence based medicines? Statins, Beta Blockers, Anti-platelet agents, ACE inhibitors or in the newer version, angiotensin receptor blockers that do the same thing, that inhibit the rennin-angiotensin system.

04:23 All of them work in patients who've had an acute ischemic event to prevent a second ischemic event and to prevent death. So, what’s the second consensus agreement? Cigarette smoking, public enemy number one. Cigarette smoking is the cause of a huge number of deaths, not just from coronary heart disease, but from a variety of cancers and end-stage lung disease. I take care of a number of these patients when I'm on the internal medicine service. I think the worst way you can die is from respiratory that is lung failure, where you’re drowning all the time, you’re constantly short of breath even with the most minimal activity. Commonest cause of severe end-stage lung disease - cigarette smoking, public enemy number one. If you continue to smoke after you've had a heart attack, you have a six times increased risk of dying in the next 10 years. And there's a variety of techniques for smoking cessation, usually one works on a com-, in particularly in severely addicted smokers, a combination of behavioral modification techniques and there are some drugs that also help patients to stop smoking. It’s really important that this be told to patients. I tell them the first thing in the hospital that cigarette smoking is absolutely the best way that they can have another heart attack, they really have to stop. We'll help them in any way we can, but smoking cessation is absolutely critical and has been shown to make a big difference when patients who've had myocardial infarct stop smoking.

05:59 Well, let’s look at the next consensus. One can predict in a statistical manner, patients who are high risk for developing coronary disease. There are a number of different indices that can be calculated. The European Society of Cardiology has one, the Framingham study form is used often in the United States and basically, what we're doing is we're looking at risk factors and for each risk factor the patient has, you get a certain number of points.

06:28 The higher number of points you score, the greater your likelihood of developing coronary disease. Now, these statistics don’t predict the future, they can’t tell you for sure you’re going to have a heart attack or not, they just tell you the risk. I always tell my patients, it’s like going out to the horse races. You can bet on the favorite or you can bet on the hundred-to-one long shot. The hundred-to-one long shot almost never wins, once in a hundred, but the 2-to-1 favorite usually wins. I want you to follow the evidence based medicine rules so you can be the favorite, the to 2-to-1 shot to survive. I can’t tell the future, but I can tell you the odds of you being here from ten years… ten years from now, if you follow with our program or if you don’t follow with our program. And again, here are the factors. Again, you've heard them again and again. Of course, age, there's nothing we can do about yet, but there's all the other things, hyperlipidemia, hypertension, cigarette smoking and so forth. When patients eliminate these factors, the chances of another heart attack or death are markedly reduced and when we eliminate them even before a heart attack, we can help to decrease the chance that a patient will eventually even develop a heart attack or need angioplasty. So, let’s talk about consensus number four, that is patients with chronic coronary disease are surviving longer than they did in the past. There's a variety of reasons, people are taking to heart the lifestyle changes, they're on evidence based medicines, they're seeing their doctors and theyre following through. And what we see from that is, in fact, the public health statistics show in the United States and also now in Western Europe, a decline in the death rate from coronary heart disease. It’s a combination of lifestyle changes and also, evidence based medicine.

08:24 Here you see some statistics that show between 50 years ago and now, the marked decrease in the number of patients who have coronary heart disease and all heart disease mortality, they are markedly down. Let me show you a diagram that demonstrates the same thing.

08:45 Here you see the curve going up to right around a little after year 2000, you can see a marked decrease in all forms of heart disease, in coronary heart disease and in stroke deaths in the United States. Similar statistics are now being seen in many Western European countries and again, it’s a result of two things - lifestyle changes on the part of the patient that accounts for approximately 50% and evidence based drugs that accounts for the other 50%.

09:18 To continue the argument that atherosclerosis and coronary artery disease deaths are decreasing, there are, as I mentioned, a number of factors. There's both lifestyle changes on the part of the patients and also evidence based medicine. One thing we've seen in the United States is that over recent decades, the mean serum cholesterol for a large number of patients’ sample has actually decreased. This implies both drug therapy with Statins and also lifestyle changes. But, maybe it isn’t all that, there may be a selection factor. The same thing was noticed with tuberculosis in the early years of the 20th century well before there were effective antibiotics, there was a decline in tuberculosis deaths. Again, probably because of better living conditions, better nutrition, in other words public health measures. It can be seen from autopsy studies in servicemen killed in action over recent American wars that actually, atherosclerosis is decreasing. So, it is automatic that anyone killed in action in the military has an autopsy and of course, one of the things that are looked at is the coronary arteries. You can see that there is a decline in the incidence of mild and severe coronary artery disease from individual study at the time of the Korean War 50 - 60 years ago, at the time of the Vietnam War 30 years ago and more recent experience in Iraq and Afghanistan. There is a definite decline in individuals of the same age in atherosclerotic findings. So, I think the public health statistics of a declining serum cholesterol, the public health statistics of a declining mortality are being reflected here as well, that there is declining coronary atherosclerosis. This should not be cause for contentment. There's still a lot of people, as I gave you the statistics earlier, who are having heart attacks and who are needing coronary bypasses and angioplasties and drugs. So, this disease has not gone away. Nevertheless, there is reason for some optimism and hope except for what’s in the next slide. This slide shows the incidence of diabetes mellitus in the United States. I don’t have to tell you what it shows. It shows a remarkable increase in the incidence of diabetes in Americans.

11:43 Part of this is due to increasing obesity and unfortunately, in Western Europe, the same pattern is being seen and by the way, in China and India, the same pattern is being seen. Increasing gross national product, increasing well being and income, results in better diets, more cigarette smoking, more rich foods, less activity as people drive cars around and what’s the result? You can see marked increase in diabetes. Diabetes is a major risk factor for coronary disease and we worry that maybe we’re going to see a reversal of the trend that we’ve seen for the last 50 years. Maybe, we’re going to start to see coronary artery disease go up again with the increasing incidence of diabetes. At the moment, in the United States, there are major programs that are seeking to try and stem this remarkable increase in diabetes in the US. Let me show it to you in another way. I’m going to show you three maps of the United States. The darker the color means the more diabetes as you can see. So, here we are in 1990, some whites and some greys, a few darkened areas.

12:51 Uh-oh, here's 1995, a lot more dark and look, here’s 2001, even more dark and I can tell you having seen recent statistics, it’s even worse. So, diabetes is a major issue to worry about. Now, let’s talk about another consensus and that is a good physician can make a big difference in the life of a coronary disease patient. Since a lot of the improvement in the risk for coronary disease relates to taking evidence based medicine, it’s really the good physician that can convince the patient why they need to continue to take these medicines. It’s a frightening statistic in the US that 50% of people who have had an ST-elevation myocardial infarct have stopped their Statin drug within a year. When they interview patients "Oh," they said, “Well, I thought I didn’t need to keep taking it or I don’t like to take chemicals, I would rather treat myself with natural product,” and so forth. Obviously, when these people stopped their Statins, their increased risk for having another myocardial infarction or dying goes up. So, evidence based medicine is an important component and having a physician who can make a difference in your life and convince you to take your medicines is very, very important. Not only will this physician convince you to take your medicines, but will also work with you to increase the likelihood that you’re gonna adhere to a healthy lifestyle, which will also decrease your likelihood of having a myocardial infarct.

14:22 And the final consensus then relates to the physician, it’s the cardiac rehab program.

14:27 By the way, often run by nurses and exercise physiologists, there have been a variety of studies that show statistically significant decrease in recurrent myocardial infarction and death in patients who go to cardiac rehab programs. Cardiac rehab programs do work and of course, what do they do? They consist of exercise, encouragement of the patient take their medicines and they’re indicated for all forms of coronary artery disease - myocardial infarction, patients with stable angina pectoris, patients who are at high risk, patients who had angioplasty or bypass. Any manifestation of coronary disease, patient’s benefit by going to cardiac rehab, by learning about exercise and diet and smoking cessation and taking their evidence based medicines and being encouraged to continue to follow that. This is a definite… definite positive and a good physician will encourage the patient to follow through on cardiac rehab interventions. Well, let’s look at controversies now. I've