Avoid smoke, all smoke, new health guidelines advise
Physicians have an obligation to tell every smoker to quit in a "clear, strong and personalized manner," and they should also warn non-smokers to avoid all exposure to secondhand smoke, according to the American Heart Association.
In a tough new set of guidelines for preventing heart disease and stroke, the Heart Association said the goal of every person who wants to avoid cardiovascular disease should be "complete cessation" and "no exposure to environmental tobacco smoke."
The influential group says that more has to be done to tackle obesity, another leading cause of heart disease. The new guidelines recommend at least 30 minutes of exercise every day, a greater effort to cut saturated fats and trans-fatty acids from diets and boosting consumption of fruits and vegetables.
The American Heart Association is also urging every physician to add a measuring tape to the armamentarium, declaring that waistlines that measure more than 40 inches (101 centimetres) for men and 35 inches (89 centimetres) for women pose a danger to the heart.
The U.S. recommendations would shift the focus to primary prevention, urging physicians to try to nip cardiovascular disease in the bud.
In Canada, the focus has always been on preventing recurrences among people who already have heart problems.
Canada does not have a single set of heart and stroke prevention guidelines like the United States.
But a spokesman for the Heart and Stroke Foundation of Canada praised the U.S. approach as bold and overdue.
"The focus on primary prevention is new and newsworthy and we're entirely in concert with these approaches," Andreas Wielgosz, the head of cardiology at Ottawa Hospital, said in an interview.
He said the tough new language on smoking and obesity, in particular, was entirely appropriate and should serve as a guide to physicians to not pull punches when counselling patients.
"The evidence on the dangers of secondhand smoke has been accumulating to the point where we should be saying that all exposure should be avoided," Dr. Wielgosz said. "And obesity is an out of control epidemic that we really have to tackle in an urgent manner."
About 23 per cent of Canadians smoke. More than 48 per cent of the adult population are overweight.
Cardiovascular disease is the leading cause of death in Canada, killing almost 80,000 people annually. It is also the leading cause of hospitalization, aside from childbirth, and a leading cause of disability. It is estimated that as many as eight million Canadians have some form of heart disease.
The shift in the United States to primary prevention means doctors will test patients much sooner.
"The challenge for health-care professionals is to begin comprehensive risk reduction for more patients at an earlier stage of their disease," said Thomas Pearson, a professor of cardiology at the University of Rochester. He was also chairman of the panel that drafted the new guidelines, which were published in today's issue of Circulation: Journal of the American Heart Association.
To this end, the new guidelines recommend that physicians start assessing patients' risk of cardiovascular disease at age 20. This "risk factor screening" should include having blood pressure, body mass index, waist circumference and pulse recorded every two years and cholesterol and blood glucose testing every five years, beginning at age 20.
In Canada, unless there is a family history of heart disease, thorough tests do not usually begin until age 40.
The American Heart Association says that by age 40 every person should receive a "global risk estimation" during an annual physical examination that clearly lays out their risk of developing cardiovascular disease during the next 10 years.
Dr. Wielgosz said routine screening at age 20 would be an expensive proposition. However, by 40, patients should expect a detailed risk assessment from their physician.
"We now have the tools to assess risk in a quantitative fashion and we advocate that every [general practitioner] should be doing this," he said.
The risk estimate includes an analysis of several factors, including exposure to tobacco smoke, waist circumference, blood pressure and lipid readings such as low-density lipoproteins, high-density lipoproteins and triglycerides.
Dr. Wielgosz said physicians must discuss these numbers with their patients, who in turn should know their readings and what they mean.
"I am constantly amazed at how patients can have their lipids taken and go away with nothing more than this gestalt impression that they're doing okay. Everybody should know their numbers, and what can be done to improve the numbers," he said.
The Heart Association's new guidelines also recommend far more aggressive treatment, with lifestyle changes and medication, even for people with borderline numbers. For example, the group recommends that high triglycerides be treated even if LDL and HDL are in the normal range.
The association also recommends, for the first time, that people at high risk of heart disease (defined as having a greater than 10 per cent chance of having a heart attack or stroke in the next decade) take low-dose Aspirin daily as a preventive measure.
Until now, Aspirin has been used almost exclusively to reduce the risk of recurrence in people who have had heart attacks previously. But the American Heart Association now says that, for most people, the benefits of Aspirin (which prevents the formation of clots that trigger many heart attacks and strokes) outweigh the risks, which include gastrointestinal bleeding and hemorrhagic stroke.
The Heart Association also recommends that people with atrial fibrillation, (an abnormal heart rhythm) be routinely treated with blood-thinning drugs.
Recommendations for avoiding heart attack and stroke:
No exposure to tobacco smoke.
Eat a healthy diet, rich in fruits and vegetables, fish and low-fat meats and dairy. Reduce saturated fats, trans-fatty acids (found in processed foods) and cholesterol.
Limit alcohol intake to two drinks daily for men and one drink for women.
At least 30 minutes of moderate-intensity exercise daily. A mixture of aerobic, resistance and flexibility training recommended.
Blood pressure maintained below 140/90 mm Hg (130/80 for people with diabetes).
Cholesterol levels maintained at below 3.367 mmol/L (millimoles per litre) low-density lipoproteins (LDL); above 1.036 mmol/L high-density lipoproteins (HDL); and below 1.695 mmol/L triglycerides.
Achieve and maintain desirable body weight: BMI (body mass index) less than 25.
Maintain waist circumference of less than 101 centimetres for men, less than 89 centimetres for women.
Normal fasting blood glucose below 6.105 mmol/L.
Daily low-dose ASA for those at high risk of heart disease.