New Heart Guidelines: Q&A with Richard Becker, MD

Richard Becker, MD, director and physician-in-chief of the newly named UC Heart, Lung and Vascular Institute, is also Mabel Stearns Stonehill Endowed Chair and Professor in the UC Division of Cardiovascular Health and Disease. Becker, also a spokesman for the American Heart Association (AHA), offered his thoughts on new cardiovascular disease prevention guidelines issued in November by the AHA and the American College of Cardiology.

Why are the new guidelines for prevention of cardiovascular disease significant?

“It’s a very unique document when you read it. Its beginnings date back to 2008 when the National Heart, Lung and Blood Institute (NHLBI) posed what they call, “critical questions” about health.

“From that original meeting in 2008 they identified four different perspectives on cardiovascular risk and its management. Initially, what is the best way to identify people who are at risk? Secondly, how do you manage through lifestyle changes some of that risk? Thirdly, how should one approach the topic of cholesterol? The fourth risk is to acknowledge that obesity is a disease.

“This is the first time that obesity and overweight are viewed not solely  as conditions  or risk factors because of their recognized association with high blood pressure and elevated cholesterol and blood sugar, but rather a disease that requires intervention.

“This is an important moment in public health because it changes not just how people think about it, but the necessary resources put into understanding it in more detail and defining optimal management. That is really, in my opinion, a milestone.

“The second important point about this collective of four separate documents is that the focus is very much on prevention. One can argue that is what we have been doing for the last 40 years, trying to prevent disease; however, global epidemics of overweight, obesity, hypertension and diabetes, coupled with frequent first-, second- and third-hand smoke exposure has reversed positive trends.

“This document underscores a direction for the United States and global health communities and reiterates that cardiovascular disease remains the leading cause of death despite our best efforts. This powerful message is directed squarely at the public, the scientific community, the medical community and also the health care payers, including the Centers for Medicare and Medicaid (CMS).

“I believe that we are seeing the beginnings of  a transformation emerge, wherein coverage for prevention of disease, including first cardiovascular events and recurring events will be the bedrock of health care at the population level, guided by physicians, nurses and other informed and highly committed providers.

“The fact that the planning for these documents originated at the NHLBI and was subsequently disseminated throughout the community by highly respected and connected organizations like the American Heart Association and the American College of Cardiology Foundation speaks loudly and clearly to the burden that cardiovascular disease represents.

“The third piece of the four-document series is dedicated to cholesterol and the intent is to identify individuals at greatest risk for having a first cardiovascular event—heart attack, stroke or death. Accordingly, it doesn’t focus solely on a cholesterol level. It focuses on people and conditions that carry with them potential risks.

“It also for the first time provides very clear guidance for the identification of risk, management and impact of intervention among African-Americans. One might ask, ‘Why it has taken so long to recognize, calculate and intervene on behalf of the large African-American population living in the United States?’

“I am very pleased to see the direction that the medical community is going.”

What are your views about LDL target changes?

“Some have said the guidance document is potentially at odds with prior guidelines in which “numbers or levels” were the primary focus. I don’t fully believe that to be the case.

“This document still includes an LDL (low-density lipoprotein) value of greater than 190 mg/dL as being an important risk factor for a first cardiovascular event. It also, when one reads the document carefully acknowledges that LDL cholesterol of 190 mg/dL or above carries risk even for individuals below 50 years of age and therefor requires attention.

“Management strategies, including those outlined in the second document highlight the important role of lifestyle modification, exercise and the appropriate diet. The message integrates healthy lifestyles and medication when needed.

“When one reads the document very closely it becomes clear that risk identification, disease detection and management are the goals. Rather than focusing on a particular number or level, it emphasizes degrees or intensity of treatment, which I believe is a pragmatic approach with a high likelihood of being translated to patient care.”

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