Examination of the incidence, prevalence, mortality, natural history, and risk factors of cardiovascular disease suggests the greatest benefits will be from a preventive approach. Further innovations in diagnosis and treatment for cardiovascular disease undoubtedly will improve the outlook of patients surviving the initial attack, but this can have only a limited impact because of the high initial mortality. When the heart or brain is infarcted, no therapy can be expected to restore full function. If the initial presentation is sudden death, therapy is unavailing. A preventive approach involving correction of predisposing factors in advance of the overt clinical expression of the disease can be expected to have a greater impact. To date, application of preventive measures of proven efficacy has been suboptimal.48 Their application in the next century, even for the growing elderly population, has immense potential for primary and secondary prevention. Evidence is accumulating that medical therapy (vigorous risk-factor control) may be at least as effective as surgical or invasive revascularization in preventing recurrence of MI, progression of angina to MI, and premature CHD mortality. The potential benefits for primary prevention of MI by modification of risk factors has been demonstrated by a meta-analysis and reviews of the larger and more rigorous epidemiologic studies.49 A multifactorial approach to risk reduction offers the best opportunity for saving patients at high risk and preventing the development of high-risk status in the first place.50
CHD often strikes without warning: One in five coronary attacks presents as sudden death, and two-thirds of the deaths occur in the community too precipitously to be brought under medical attention. While some strokes may give warning by transient ischemic attacks, most do not. Even when they do, intervention at that stage does not necessarily avoid a permanently damaging stroke or prolong life. Heart valves damaged by degenerative and rheumatic heart disease and infective endocarditis can be repaired surgically or replaced by prosthetic appliances; this approach often requires potentially dangerous anticoagulants to prevent emboli, and valve failure and hemolysis are distressingly common. Although such patients live longer, more comfortable lives than formerly, their survival does not approach that of patients with rheumatic fever who have been kept from progressing to severe valve damage by antibiotic prophylaxis against recurrent disease. Hypertension that pro-gresses to target-organ involvement is less manageable than if vigorously treated prior to such manifestations. The first sign of target-organ involvement is often a stroke, MI, or sudden death. Half of such events occur before evidence of organ involvement is discovered on routine biennial examination. In some respects, the occurrence of symptoms more properly may be regarded as a medical failure rather than as the initial indication for treatment (see Chap. 58).
A major impact on cardiovascular morbidity and mortality in the 21st century should derive from the practice of preventive medicine, from public health measures to alter lifestyle to one more favorable to cardiovascular health, and from health education to inform people of what they must do to protect their cardiovascular health. Recent expansion and improvements in these measures have occurred, conceivably contributing significantly to the 36 percent decline in cardiovascular mortality during the past two decades, which is responsible for most of the decline in overall mortality.2
The epidemiologic and clinical trial evidence of the cardiovascular diseases in the 20th century has set the stage for opportunities in the next century to direct research and public health activities that can substantially reduce the risk and impact of cardiovascular disease. Foremost among those opportunities is implementation of comprehensive preventive programs of government regulation, health education, and preventive medicine designed to control the major identified cardiovascular risk factors. This includes exploring further the underlying basis for clustering of atherogenic risk factors and the prevalence and impact of insulin resistance, promoting cardiovascular risk profiles to more efficiently target high-risk cardiovascular disease candidates for preventive measures, and finding better ways to implement preventive measures against obesity, insulin resistance, and cigarette smoking. The potential is large if physicians can be induced to more aggressively implement the proven measures recommended to prevent cardiovascular disease.
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