The "house of prevention" has no walls. It begins at birth and ends at death. The responsibility of prevention rests upon the shoulders of the health care professional, the individual or patient, his or her support network, and society.
As guest editors of Volume 18, Issue 2, "Emerging Issues in Prevention," we elected to include 11 relatively short manuscripts, rather than the usual 7 or 8. As such, the authors were constrained to fewer pages and challenged to "abstract" their presentations. In addition, the contributors were encouraged to include complementary tables and/or figures, if appropriate. This resulted in a uniquely focused issue with pertinent preventive care data that, we hope, will be clinically relevant and useful to your practice, whether it is in the acute or chronic care setting.
Drs Oken and Fletcher present an in-depth discussion of 2 of the safest and most effective medications for the primary and secondary prevention of cardiovascular disease (CVD), HMG-CoA reductase inhibitors (statins) and antiplatelet agents. The rationale for these medications is strongly supported with relevant data, as are their underlying mechanisms of action.
Berra and Klieman address the new "National Cholesterol Education Program" and Adult Treatment Panel (III) guidelines for identification and treatment of persons with and without known coronary heart disease, with specific reference to lipid lowering drug classes. These new definitions move millions of people into more intensive total- and LDL-cholesterol treatment categories as compared with ATP II. The authors review the compelling role of diet and exercise in combating dyslipidemia and the metabolic syndrome. The accompanying tables serve as a handy reference when managing patients with abnormal blood lipids/lipoproteins.
The proportion of US adults who are classified as obese rose 49% between 1991 and 1998. The skyrocketing prevalence of obesity has created a major public health concern, because it is strongly associated with several chronic diseases, including type 2 diabetes, coronary heart disease, and metabolic syndrome. Recent evidence suggests that the most likely explanation for the current obesity epidemic is a continued decline in energy expenditure that has not been matched by an equivalent reduction in energy intake. McInnis reviews these issues, as well as the components of a successful weight reduction program, including a multifactorial approach integrating nutrition, physical activity, and behavior modification strategies and interventions.
In "Early and More Vigorous Detection of Diabetes," Lamendola discusses the benefits of early detection and treatment of type 2 diabetes. Escalating scientific evidence suggests that the prevention or delay of type 2 diabetes, even in persons at greatest risk, is attainable through modest lifestyle changes, especially weight loss and regular physical activity. The impact of the cost of screening is also emphasized. Appropriate tables again serve as a useful reference.
Houston Miller makes the case for aggressively managing blood pressure, even in older adults. In the 90s blood pressure control was overshadowed by interventions designed to favorably modify cholesterol and its subfractions. Currently, increasing emphasis is being placed on aggressively managing systolic and/or diastolic hypertension. Framingham data and the "Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI)" as well as other clinical trials provide the basis for her provocative discussion.
Franklin, Swain, and Shephard provide new insights in the prescription of exercise/physical activity for coronary patients, with specific reference to the concept of oxygen consumption reserve for prescribing training intensities, the amount of physical activity (kcal/week) required to halt and potentially reverse the progression of coronary atherosclerotic lesions, the value of upper body/resistance training, and the relationship between aerobic fitness and mortality in patients with documented coronary disease. Additionally, strategies for enhancing long-term exercise compliance, and the emerging role of complementary lifestyle activity are discussed.
Convertino reviews the negative influence of bed rest and physical inactivity on cardiovascular function after an acute coronary event, independent of cardiac damage. He emphasizes that simple exposure to orthostatic stress, such as intermittent sitting or standing during the bed rest stage of hospital convalescence and recovery phase at home, may obviate much of the deterioration in exercise performance that normally follows an acute myocardial infarction or coronary artery bypass graft surgery. These recommendations have particular relevance to health care professionals who manage patients in acute care and early outpatient settings.
New research has disproved the theory that cholesterol-laden plaque gradually builds up on passive artery walls and, when it occludes an affected "pipe," a heart attack occurs. Indeed, over the last 2 decades scientists have shown that coronary arteries bear little resemblance to inanimate pipes. Acute myocardial infarction frequently occurs with less obtrusive plaques that rupture suddenly, triggering the formation of blood clots. Moreover, it appears that inflammatory processes play a key role in this cascade of events. "Emerging Issues in Prevention" would not be complete without a discussion of novel cardiovascular risk factors that may influence or trigger this sequelae. To this end, Hughes presents pertinent data and important clinical revelations regarding managing lipoprotein (a), hyperhomocysteinemia, C-reactive protein, infection, fibrinogen, and microalbuminuria.
"Primary Prevention in Patients with a Strong Family History of CHD" reviews the components of risk determination and the critical role (and potential impact) of primary prevention in individuals with a strong family history of CHD. The interplay of genetics and environment are discussed. Burke emphasizes that addressing primary prevention in this population begins with a comprehensive risk factor assessment and family history, including validated screening tools such as the 10-year Framingham Risk Score.
Harrell, Pearce, and Hayman present pertinent clinical trial data documenting the prevalence and tracking of coronary risk factors in children. Innovative strategies for promoting primary prevention in children and adolescents in health care and community-based settings are discussed.
Last but not least, Allen and Scott discuss alternative models for the cost-effective delivery of prevention programs, with the goal of enhancing accessibility and effectiveness. Evidence is presented supporting advanced practice nurses and community health workers providing care as members of multidisciplinary teams as successful strategies for enhanced outcomes.
Unfortunately, the treatment of coronary artery disease has evolved to include an array of costly and palliative coronary revascularization procedures (that are not without risk) that fail to address the underlying causes of the disease-high-fat and high-cholesterol diets, cigarette smoking, hypertension, obesity, and physical inactivity. The challenge for all health care professionals is to enroll increasing numbers of patients, at an earlier stage of their disease, in medically directed home-based or group interventions that are designed to circumvent or attenuate barriers to participation and adherence, using a variety of techniques to facilitate monitoring and/or communication, so that many more individuals may realize the benefits that primary and secondary prevention can provide.
This issue is the first of 2 issues addressing prevention of CVD. Joan Fair, ANP, PhD, will join us as guest editor for Part 2, Issue 18:4. Issue 18:4 will address skill sets for prevention. We trust both prevention issues will offer information and tools to assist you in your practice of managing primary and secondary prevention of CVD.