Multiple Risk Factor Intervention to Prevent Cardiovascular Disease. A High Powered and Evidence Based Approach

Abstract

On a worldwide scale cardiovascular disease is estimated to be the leading cause of death and loss of disability-adjusted life expectancy in the next decade. The INTERHEART study has demonstrated that classic risk factors such as abnormal lipids, smoking, hypertension, lack of regular physical activity, diabetes, abdominal obesity, psychosocial factors, excessive alcohol consumption, and inadequate intake of fruits and vegetables, account for most of the risk of myocardial infarction worldwide in both sexes and at all ages in all regions. In total, risk factors accounted for 90% of the observed risk in men and 94% in women in this large case-control study of acute myocardial infarction in 52 countries, suggesting that approaches to prevention have the potential to prevent most premature cases of myocardial infarction. In secondary prevention of cardiovascular disease, numerous clinical trials have tested the effects of single risk factor intervention in both myocardial infarction and stroke, leading to several sets of guidelines on both national and international levels. With this abundance of knowledge, the obvious question is: why does cardiovascular disease still account for around half of deaths in subjects below the age of 70 years? Much of the gap between recommended and actual levels of chronic disease care is attributable to medication nonadherence. The importance of this factor has been clearly demonstrated in a recent United States trial in myocardial infarction. In a prospective registry of 1521 patients admitted with a myocardial infarction and discharged with treatment with acetylsalicylic acid, beta-blockers and statins, 184 discontinued use of all 3 medications, 56 discontinued use of 2 medications, 272 discontinued use of 1 medication, and 1009 continued taking all 3 medications at 1 month. The consequences of discontinuing treatment were devastating. Patients who discontinued use of all medications at 1 month had lower 1-year survival (88.5% vs. 97.7%, P < .001) compared with patients who continued to take 1 or more of the medications.