MedicalResearch.com Interview with:
Dr. Jean Philippe Empana, MD, PhD
Research Director, INSERM U970
Paris Cardiovascular Research Center (PARCC) Team 4 Cardiovascular Epidemiology & Sudden Death Paris Descartes University
MedicalResearch.com: What is the background for this study?
Response: In 2010, the American Heart Association (AHA) has emphasized the primary importance of the Primordial prevention concept, i.e. preventing the development of risk factors before they emerge, as a complementary prevention strategy for cardiovascular disease (CVD).
Accordingly, the AHA has developed a simple 7-item tool, including 4 behavioral (nonsmoking, and ideal levels of body weight, physical activity and diet) and 3 biological metrics (ideal levels of untreated blood pressure, fasting blood glucose and total cholesterol) for promoting an optimal cardiovascular health (CVH). The relevance of the concept and of the tool has been several times reported by individual studies and meta-analyses (combining the results of several studies) showing substantial and graded benefit for cardiovascular disease but also mortality, quality of life and even cancer risk with higher level of CVH. However, most studies relied on one measure of cardiovascular health.
In the present work, using serial examinations from the well-known Whitehall Study II, we described change in CVH over time and then quantified the association of change in cardiovascular health over 10 years with subsequent incident cardiovascular disease and mortality. This analysis is based on 9256 UK men and women aged 30 to 55 in 1985-88, and thereafter examined every 5 years on average during 30 years.
MedicalResearch.com: What are the main findings?
Response: The main findings are the following.
- Firstly, less than 10% of the participants had an optimal cardiovascular health, and this was (unfortunately) consistent across examinations.
- Secondly, when examining change over 10 years in CVH, only 13% improved their CVH, mostly from low to moderate (6.8%) and from moderate to high status (5.8%); and only 0.3% (n=19) improved from low to high. In 58% with stable CVH, 13.5% had low, 39% moderate, and 5.5% high CVH. There were 29% who worsened their CVH, including 18.0% from moderate to low, 9% from high to moderate and 2% from high to low CVH (i.e. 11% were initially high CVH). Interestingly, stable moderate CVH, and initially high CVH were more likely in younger participants, in women and in white participants.
- Thirdly, we observed associations between change in cardiovascular health over 10 years and CVD and mortality. In particular, this analysis shows that compared to those with stable low CVH, those with stable moderate CVH, but also those who improved their CVH and those with initially high CVH were at substantial lower risk of CVD and mortality. For instance, there was a 81% (non significant) and a 61% (significant) relative risk reduction of CVD for those who improved from low to high CVH and from moderate to high CVH respectively; a significant 38% relative risk reduction of CVD for those with stable moderate CVH; even those with initially high CVH but who worsened their CVH to either moderate or low after 10 years had a significant lower risk of CVD (risk reduction ranging from 34 to 51%) compared to those with stable low CVH. All these results were obtained after adjusting for a number of covariates.
MedicalResearch.com: What should readers take away from your report?
Response: Firstly, the proportion of people with optimal cardiovascular health (5 ideal metrics or more) is too few, less than 10%. Policy makers and physicians should motivate citizens and patients to adopt optimal lifestyle to increase this proportion. But importantly as well, this and other studies emphasize that citizens should be actors of their (cardiovascular) health.
Secondly, while 13% of the participants improved their CVH, this improvement was mainly from moderate to high CVH. While challenging, people with poor cardiovascular health should be encouraged to increase their CVH and should be a priority target for prevention. This is important as the paper shows that although not statistically significant, such improvement is associated with lower risk of CVD.
Thirdly, there was some age, gender and socioeconomical (i.e. difference in ethnicity) differences in the change in cardiovascular health, whereby improvements in CVH were mostly observed in the younger, women and white people.
Fourthly, that people with initially high cardiovascular health but who subsequently worsened their CVH were still at significant lower risk of CVD and death, may suggest that achieving as early as possible an optimal CVH is of value.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Being conducted in UK participants aged 30 to 55 at study recruitment, the results of this study should be confirmed in more ethnically diverse population and in other age groups.
In addition, the association between change in cardiovascular health and non cardiovascular disease outcomes should be explored. In the case of positive findings, it would suggest that the promotion of change/improvement in CVH would have benefit beyond CVD.
MedicalResearch.com: Is there anything else you would like to add?
Response: One value of primordial prevention is the promotion of positive health : the adoption of optimal lifestyle is encouraged and the risk reduction of CVD emphasized. This is a paradigm shift with the classical approach whereby the number of risk factor is calculated and the risk of having the disease communicated to the patient. Positive health may be a better source of motivation for the population.
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