Heart Disease, Living Well with (cont.)

There are some strategies for which the amount of evidence is enormous, evidence which indicates that people can benefit themselves tremendously, and for which there is little controversy. There are other treatments and strategies for which the evidence is much less strong, and for which there is some controversy.

Someone may choose to pursue a strategy that is not yet well established, but they need to know that decision is a bit of a gamble. It may turn out when all is known and more studies are performed that the decision was a good one. Someone who, for example, decided to take aspirin before the evidence was definitive would have been fortunate to have made that decision. But someone who makes a decision before the evidence is firm, may also pay a penalty. For example, a woman who decided to take estrogen therapy before the trials were completed would have actually put herself at greater risk.

So what I tried to do in the book was distill the most important information in cardiology, express it to patients in a way they would understand and sort out what we know for sure and what knowledge is still evolving. I tried to give these patients some information about how to interpret new information that might be appearing on the news. The book also includes information about how patients should prepare for their visits with their physicians and the kinds of questions they should ask and tools to help them monitor their care.

How did the seven strategies evolve?

The seven strategies that are highlighted in the book derive from national guidelines that have been written by a large number of experts in cardiology. I have had the pleasure of participating on such a panel. We get many experts together and spend time going through the entire medical literature and identifying the strategies for which there is the most evidence and translating that evidence into recommendations to physicians for the care of patients with heart disease. Time and time again, these seven strategies are highlighted as the most important approaches to reducing risk for patients with heart disease. By the way, these strategies are also excellent for helping avoid heart disease in the first place.

What is remarkable is that despite the importance of these strategies, and the strength of evidence that exists regarding their benefit, there remain vast numbers of people who are not taking advantage of them. One of my goals in writing the book was to highlight these strategies -- make sure that people understand their importance and answer many frequent questions that people have about them. These strategies, in my mind, should be a checklist for each person who can go down the list and assess where they stand with respect to each one. People who pay attention to these seven strategies have done a remarkable service for themselves in reducing their risk of heart disease.

One thing to note in the book is that each of the strategies is framed in the book by the words "Take Charge." This is a call to the reader to get engaged and take control.

"Of the people with high blood pressure, only about 1 in 3 have a blood pressure that is at the target that has been identified by national experts. That is, only 1 in 3 is truly under control with respect to their blood pressure."

Let's go through the seven strategies, one by one.

The first strategy is take charge of your blood pressure.

It's remarkable that even though we have known about the potential hazards of high blood pressure, for many, many years, there remain a large number of people whose blood pressure puts them at substantial risk; that is, it is too high. Overall, about 1 in 3 adults have high blood pressure. Of those with high blood pressure, only about two-thirds have been told that their blood pressure is high. Among those with high blood pressure only about half have been treated with a medication to lower their blood pressure.

This is the amazing fact: Of the people with high blood pressure, only about 1 in 3 have a blood pressure that is at the target that has been identified by national experts. That is, only 1 in 3 is truly under control with respect to their blood pressure.

When I say take care of your blood pressure, I'm telling patients they need to know what their numbers are, they need to know whether their blood pressure is under control, and if it's not, they need to be talking to their doctor about what it takes to get their blood pressure to the target level that has been recommended.

The second strategy takes a similar approach with cholesterol levels. There are a third of people in this country who have never had their cholesterol tested. Just like blood pressure, there are only about 1 in 3 people who have high cholesterol who know it, a small percentage of them are on treatment, and a considerable proportion are not at the recommended target levels. Again, the thing that is important here is that patients know their cholesterol numbers and that they work with their physicians to reach the proper target.

Didn't the target numbers change within the last year for both cholesterol and blood pressure?

For both cholesterol and blood pressure, there is an increasing appreciation that the lower the levels, the lower the risk.

For blood pressure, at some point a low level can cause symptoms. People may feel light-headed, or dizzy or unsteady. For an older person, a fall can be catastrophic. So we try to be careful in treating blood pressure. Recently what is being called normal blood pressure was redefined a bit. But the numbers I have mentioned, that is, the large numbers of people who are not at target levels does not even take into account these lower targets. So even with the more traditional target, of a blood pressure of 140/90, many people are not reaching it.

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