Would 51-year-old James (Tony Soprano) Gandolfini or Tim ("If it's Sunday, it's Meet The Press") Russert be alive today if their docs had followed the new cardiovascular disease prevention guidelines just issued by the American College of Cardiology and American Heart Association?
This week, we asked that question to many of the docs with whom we work at the Wellness Institute. We just do not know enough about Gandolfini or Russert; however, you know enough about YOU—that's the key. And the likelihood is Gandofini and Russert both would have been taking statins if their docs had followed the new guidelines...and aspirin and exercising, losing weight and changing their diets (and Russert and Galdofini weren't doing food –perhaps the most important choice—right if observations and news reports are correct.) You might too—and we want you to stay alive.
There is some great news in the new guidelines: greater emphasis on diet and exercise (heck cardiologists need only zero hours of diet info to be board certified. That's right, zero).
"Why greater emphasis on inflammation and none on stress management?", you might ask. Inflammation, great! We think stress management is part and parcel of preventing cardiovascular disease and think the data strong enough to include it, but the guideline committee didn't...a weakness in committee membership? Perhaps. The not so great news is that the guidelines really highlight the lack of sufficient data to answer all our questions when counseling patients.
Discussions with most of the docs in our Cleveland branch of our Executive Health/Preventive Medicine Department and Wellness Institute Centers for Lifestyle Medicine and Center for Integrative Medicine have led us to the following conclusions about what the new guidelines mean for our patients - and might have meant for Galdofini and Russert.
YES, that's right. We feel that knowing your percent change of dying in the next ten years would motivate change, and that's one of the major changes the new guidelines recommends (yes we've been doing it for all patients we see in preventive medicine for many years now. Please note these are our personal opinions, and that they do not reflect official policy or guidelines of Cleveland Clinic or even our Wellness Institute)
Know that all the doctors mentioned above work to reverse or prevent cardiovascular disease, including arterial diseases that cause heart attacks, strokes, memory loss, kidney disease, impotence, and even wrinkles.
1. Most importantly, these ACC/AHA recommendations demonstrate the relative lack of data with which doctors are required make recommendations to patients on a daily basis. The lack of long term outcomes data for patients with LDLs of 100 or 70 does not mean these targets are invalid, but rather that no research has been conducted to confirm that their benefits. Like the current recommendations, the new revised targets are "best estimates." There is nothing wrong with either the previous or revised recommendations, but unfortunately there are still no data to indicate that these new recommendations generate better patient outcomes. .
2. The new recommendations do not account for a patient's other risk reducing behaviors, including medications and supplements, diet, exercise, and stress management, not to mention avoiding all tobacco, including secondhand smoke exposure. . Most physicians routinely calculate Framingham and Reynolds scores (for men and women, respectively), and most also discuss the use of statins (such as atorvastatin, brand-name Lipitor) with each patient in whom a calculated 10 year risk of heart attack exceeds 5%. For now, we do not plan to restrict our recommendation for instituting a statin to patients whose 10-year risk currently exceeds 7.5% even after they have achieved optimal risk-factor management. This might include the use of other medications and supplements for any or all of the following: blood pressure control, blood sugar control, diet, exercise, stress management, aspirin,water, DHA, purified omega-7, vitaminD3, 1/2 a multi twice a day, etc.
3. We will continue to implement intensive disease reversal programs (Ornish and Esselstyn, and Lifestyle180) as well as to coach patients to optimal blood pressures of 115/75, LDLs below 100, HDLs above 50, high-sensitivity c-reactive proteins under 1.0, waist measurements less than half one's height or a BMI (body mass index) between 21 and 27), non-smoking status, avoidance of , red meat,added sugars andsyrups, white flour (use only 100% whole grains), interval cardiovascular and weight resistance exercises, and active daily stress management, plus all indicated immunizations for our employees and patients. Of course, all of these are dependent on and modifiable by each patient's personal history, family history and other risk factors)
Here is the bottom line that we will tell our patients: Incorporate only healthful food choices, physical activity, and stress management programs identified in items #2 and 3 and do your own risk calculations (available for free on the Internet,and know your numbers). Then, if you have done all you can do to lower your risk but still see 10-year risk greater than 5%, talk to your doc (one of us in this case, and let's have more discussion about benefits and risks) about adding a statin, even a statin every other day, plus CoQ10.
Thanks for reading,
Mike Roizen MD, FACP (AKA The Enforcer)
Roxanne Sukol, MD, FACP