Case Study: While looking through your clinic schedule on Wednesday morning, you see that one of your favorite patients has scheduled his yearly physical with you. Frank is a 68-year-old man with a history of diabetes, hypertension and hypercholesterolemia. You have been managing his care for the past five years. You walk into the examination room and greet him warmly. However, Frank is not his usual happy, joking self this morning. Instead, he tells you, “Doc, I feel pretty good, in general. But one of my oldest friends from when we were kids died over the weekend. Heart attack. Is that something that could happen to me?”
Now serious, you realize that you have never discussed heart disease risk and prevention with Frank. Given that he has three of the major co-morbidities for cardiovascular disease – diabetes, hypertension, and hypercholesterolemia, he is at a higher risk for cardiovascular events than the general population. Furthermore, studies suggest that 25% of men and 16% of women ages 60-78 years old have cardiovascular disease (diagnosed or undiagnosed) or the equivalent (for example, stroke or peripheral vascular disease).
What do you want to do now?
You ask Frank what he knows about decreasing his risk of heart disease. He tells you that it will involve staying on his beta-blocker and statin, as well as taking an aspirin a day. You ask him how his glucose levels have been doing lately, and he tells you that his diabetes has been better managed since you changed his metformin dose three months ago. You congratulate him on managing his chronic medical problems well at home. However, you also want to emphasize that diet and exercise are important for preventing heart disease. Frank asks, “What do you suggest for diet and exercise? I already watch what I eat because of my diabetes. Is that the same diet you want me to keep to decrease my risk of heart disease?”
Actually, the same diet that would help him manage his hypertension is also a good diet for preventing heart disease. One of the diets you have recommended to him in the past, and which you continue to recommend, is the DASH (Dietary Approaches to Stopping Hypertension) diet. This diet recommends eating two servings of fish weekly, keeping sodium intake to less than 1500 mg per day, increasing fruit and vegetables to more than 4.5 cups a day, limiting sugar-sweetened beverages, and increasing fiber-rich foods.
How can you raise awareness in your clinic for heart disease prevention?
February is Heart Disease Prevention month. Take a proactive approach to preventing heart disease in your clinic by screening patients at-risk for heart disease using the ACC/AHA (American College of Cardiology/American Heart Association) ASCVD risk calculator. Make a note to yourself to ask about smoking, diet and exercise plans and recommend to patients that they follow one of the heart-healthy diets, such as DASH and the Mediterranean Diet. Follow up by suggesting that your patients work towards at least 150 minutes of moderate aerobic exercise per week or 75 minutes of vigorous aerobic exercise per week.
Braun MM, Stevens WA, and CH Barstow. Stable Coronary Artery Disease: Treatment. Am Fam Physician. 2018;97(6):376-384.
Lanier JB, Bury DC, and SW Richardson. Diet and Physical Activity for Cardiovascular Disease Prevention. Am Fam Physician. 2016;93(11):919-924.
Dr. V. Silverstein
Published on 2/6/19