Real life issues & answers: the cardiovascular rehabilitation patient

Dr Scott Murray (BACPR President, Consultant Preventive Cardiologist, Royal Liverpool University Hospital)

What are the clinical issues?

Dr Scott Murray gave a wide ranging and challenging presentation on the future of cardiovascular disease prevention. He was formerly an interventional cardiologist and gave a powerful argument for the need for health services to stop being reactive in cardiovascular disease and put more resources into prevention. His comment was that, “We are putting metal stents into an inflammatory disorder – we have to think wider”.

Although total CVD mortality has been decreasing, obesity, diabetes and reduced exercise levels are beginning to have an impact on life expectancy and heart disease is rising.  People tend to be living longer with more disease.  Dr Murray reminded delegates of the findings of the INTERHEART Study (Yusuf S et al. Lancet 2004) that showed nine modifiable risk factors that account for >90% of the population attributable risk:

  • Abnormal lipids
  • Diabetes
  • Abdominal obesity
  • Inadequate consumption of fruit and veg
  • Lack of regular physical exercise
  • Smoking
  • Hypertension
  • Psychological factors
  • Excess alcohol

 What are the implications and answers?

The solution to the cardiovascular disease issue lies in a combination of improved nutrition and increased exercise and Dr Murray quoted Edward Smith-Stanley saying that, “Those who do not find time for nutrition and exercise will have to find time for illness”. He added that unless improvements in public health policy and societal lifestyle are not made, we will face a ‘tsunami’ of heart failure, diabetes, obesity and associated diseases.

He described a number of trials looking at different ways to tackle these issues:

  • The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) is currently investigating the value of high intensity exercise as a partial solution to some of these issues.
  • Lower carbohydrate diets in patients with type 2 diabetes. Current studies demonstrate intensive glucose lowering but also significant improvements in weight, liver function, lipids and blood pressure. Available trial results suggest at 10-15% reduction in CVD events for a 0.9% (10 mmol/mol) reduction in HbA1c

 Key points to make best practice everyday practice

  1. Residual risk in CVD patients is a combination of genetic, environmental and lifestyle and we need to pay urgent attention to these issues.
  2. ‘Cholesterol’ is complex and there is no such thing as “good and bad cholesterol”.
  3. Lipoprotein abnormalities are a sign of residual metabolic or genetic issues. Do we give room for drugs and lifestyle changes?
  4. Hyperinsulinaemia as a compensatory mechanism for lifestyle or genetic insulin resistance is the ‘elephant in the room’. It is an important risk factor for heart disease but is being undertreated.
  5. Cardiac rehabilitation and prevention is the most powerful but under-funded service in UK cardiology.