What is Preventive Cardiology?

Article contributed by Mr Tay Hung Yong, Principal Physiotherapist at SHF’s Heart Wellness Centre.

Excerpt of article that first appeared in heartline, June 2018 issue.

Cardiovascular disease (CVD) is the leading non-communicable disease (NCD) in the world, and it was one of the top two causes of death in Singapore in 2016.

While CVD can mostly be prevented and controlled through a comprehensive and integrated action plan, it is very expensive to treat. Hence, regular health screenings are important to identify the early signs of CVD. In addition, modifiable behavioural risk factors namely a sedentary lifestyle, unhealthy diet, tobacco smoking and harmful consumption of alcohol are known to be associated with CVD.

This is where preventive cardiology is applicable – to help reduce the risk of developing CVD and prevent future heart events from recurring.

Primordial: Efforts taken to minimise the development of cardiovascular risk factors in a society or community

Primary: Treatment of risk factors to prevent heart diseases or a heart attack from occurring

Secondary: Treatment of existing conditions, thereby reducing recurrent heart events

Case Study

In order to understand the concept of preventive cardiology better, we will use a case study to illustrate how it works. Mr A is an overweight 60 year-old Singaporean Indian man. He is a heavy smoker, has high blood pressure, high cholesterol levels and a positive family history of heart disease (refer to Tables 1 & 2). Mr A is a full-time school attendant who walks about 6,000 steps per day.

Table 1 - Mr A’s ‘non-modifiable risk factors’ interpretation

Non-modifiable risk factors

Mr A

What does it mean?

Age

60 years old

The risk is higher for those aged over 60 years old

Gender

Male

Relative cardiac risk is higher than a woman of the same age

Origin

Indian

Very high/high adult morbidity

Family History

Family history of premature atherosclerotic cardiovascular disease (his father died of a stroke at 57 years old)

First degree relative having a CVD event means a higher cardiac risk for Mr A

 

 

Table 2 - Mr A’s ‘modifiable risk factors’ interpretation and targets

Modifiable Risk Factors

Mr A

Targets1

Interpretation1,

Body Mass Index

29.8 kg/m2

<23kg/m2

Obese and at an increased risk of co-morbidities

Waist Circumference

102cm

90cm

Substantially increased risk of metabolic complications

Diet

Fats

Mutton 3 portions/week (total 300g)

 

 

Total daily energy from fat  25 – 35%

SFA < 7%

MUFA ≥ 13%

PUFA ~ 10%

Opt for healthier cooking methods: steamed, grilled, baked; 1 portion of oily fish to replace red meat

Poor dietary habits = Increased CVD risk

Vegetables and Fruits

Average of 263g/day

400g/day (at least 4 portions per day)

Fish

Less than 1 portion per week

2+ portions per week (one of which should be oily)

Salt

>6g/day

<6g/day

Snacks

8 sweet + 10 savoury portions/week

Avoid snacks

Alcohol

None

<21 units/week

Legumes and Pulses

4 -5 times per week

Maintain

Nuts

None

1 serving/week

Protein

Red meat (300g/week)

Milk (1,400ml/week)

0.75-0.83g/kg of body weight/day = 65-72g/day

Total daily energy from protein: 15%

Excessive intake of protein means excessive caloric intake leading to weight gain

Carbohydrates

Daily rice at all meals, potatoes (fried) in curries, flat bread

Total daily energy from carbohydrates = 50%

Choose unpolished rice and other wholegrain products

Excessive intake of carbohydrates means excessive caloric intake leading to weight gain

Smoking Status

Current xx smoker

Quit smoking

Substantial increased risk of CVD

Lipids

TC

6.7 mmol/l

< 4.1 mmol/l

Dyslipidaemia; Singapore cardiac risk score ≥ 20% (high risk)1

 

LDL-C

4 mmol/l

< 2.6 mmol/l

 

HDL-C

1.1mmol/l

> 1 mmol/l

 

TG

1.3 mmol/l

< 1.7 mmol/l

 

TC:HDL-C

6.1

< 6

Blood Pressure

160/90mmHg

<140/90 mmHg

Grade 2 hypertension

Glucose

6.0 mmol/l

≤6.0mmol/l

Requires regular monitoring

1SCRS: Singapore Cardiac Risk Score, 2011

           

 

 

According to the Singapore Cardiac Risk Score (SCRS) assessment, Mr A is at a high risk of contracting coronary artery disease within the next 10 years. Since Mr A is a South Asian by origin, by World Health Organisation mortality stratum, he comes from a region of high/very high adult mortality. Thus, active management is justified, namely professional lifestyle management and medical management to reduce his risk, prolong his lifespan and enhance his quality of life (MOH, 2011). In an ideal situation, he would be referred to a family-based multi-disciplinary vascular health programme.

 

Behavioural and Psychosocial Management  

As part of the preventive cardiology programme, a comprehensive assessment of Mr A’s health will be done. It involves a multi-disciplinary team to look into the different aspects of his lifestyle - smoking, diet, physical activity level, psychological status, socioeconomic environment and family history. Based on the initial assessment results (refer to Tables 1 & 2), there is an urgent need to manage his risk level.

Before embarking on any programme, it is important to assess Mr A’s motivation level, as it can affect the outcome of his programme. Information should be shared beforehand on the various conditions and interventions, to correct any misconceptions and doubts that he might have. Secondly, Mr A should be guided to set goals for different issues, using the SMART approach - Specific, Measurable, Achievable, Realistic and Time-frame. Once the goals are set, reviews are to be done regularly to ensure due diligence.

Family involvement such as support from one’s spouse is equally important, as they are likely to share the same lifestyle. Mr A’s lifestyle and behavioural change might be more successful with his wife’s support. Do also check if any financial assistance is required.

People like Mr A should be screened for signs of depression and anxiety. A quick screening tool such as the Hospital Anxiety and Depression Score (HADS) might be useful. 

 

Smoking cessation (refer table 3)

Smoking is a major risk factor of most NCDs. Globally, 10% of all CVD deaths can be attributed to tobacco smoking in adults above 30 years of age. Smokers face a 2.4 times risk of CVD compared to non-smokers. The good news is the risk would start to halve after 2 years post quitting. Getting Mr A to quit would reduce his risk of CVD drastically. In a preventive cardiology team, the smoking cessation counsellor could be any personnel trained in smoking cessation.

Mr A is considered to be a heavy smoker with a long smoking history. Smoking addiction revolves around physical, emotional and behavioural dependence. The smoking cessation counsellor would assess his nicotine dependence using questionnaires. If he had expressed a willingness to quit, we can help him by getting him to set a quit date first. Quitting can be done abrupt or gradually. We also need to find out the reasons for quitting. Reinforcing these internal motivating factors would increase the chances of success. In addition, Mr A could use a variety of drugs such as varenicline, buproprion and nicotine to help quit smoking.

Mr A has a high chance to lapse in his first quit attempt as 50% of first-time quitters lapse within the first week. It is important to arrange intense follow-up right after the first counselling session to reinforce the cessation. 

In Singapore, there are a number of clinics which offer smoking cessation counselling. They are listed on our health promotion board website: https://www.hpb.gov.sg/workplace/workplace-programmes/smoking-cessation-programmes

 

Diet/Meal Plan modification (refer table 3)

Another important component of preventive cardiology programme is diet counselling. It could be done with a nurse, nutritionist or dietitian. Atherogenic diet had been identified as one of nine major CVD risk factors.

From the initial assessment, we can notice that Mr A’s diet has the following problems: excess caloric intake, excess salt, insufficient fruits and vegetables, excess intake of saturated fat. A cardioprotective diet is recommended for Mr A. lf the cooking is done by his spouse, it is important to involve her during diet counselling and set SMART goals together.  

From his diet history, he is consuming excess salt at more than 6 grams a day, above the recommendation of 6g/day. There should not be additional table salt added to cooking or at the dinner table.

Mr A is eating a high level of saturated fats from fried food, red meat and full fat milk. The cooking method needs to change to steam, bake or grill. There is a need for him to switch from full fat milk to low fat and cut down the milk consumption. In order to meet the SCRS recommendation, he should switch from red meat to one serving of oily fish/week.

Looking at his fruits and vegetable intake, it does not meet the recommended requirement of 400g/day. (FSA, 2006) He can also increase his fruits and vegetables intake which is a source of fibre and will help decrease his LDL and TC. (Trichopoulou et al., 2003) Increase dietary fibre intake has also been shown to decrease CVD risk. (Threapleton et al., 2013)

A complete switch to fresh produce and other healthier food choices might be straining financially for this family. It is important to teach his wife how to read food labels so that she could select the healthiest choice of food within budget constraint. 

Lastly, the dietitian needs to work on his snacking habits. We can introduce nuts and fruits to him as an alternative. The long term goal is to stop his snacking habit.

 

Physical Activity (refer table 3)

A physical activity specialist is a very important member of the preventive cardiology team. He would assess the patient’s physical activity level as well as his level of fitness using tools such as activity diary, pedometer, accelerometer, and various fitness tests. His pedometer readings also put him at low active level. His estimated caloric expenditure from light walk is 917 kcal. He is just below the 1,000 kcal needed to effect a 35% reduction in CVD risk.

In exercise science, we term fitness level as functional capacity. There are various walk, cycle or step tests which can be used to determine his functional capacity. Our target for Mr A is to increase his functional capacity by 1 MET as that would help to reduce his CVD risk by 12%. The long term goal is to bring his functional capacity to above 11 METs so that his relative risk of premature mortality remains low.  

If Mr A likes walking, a SMART goal for home physical activity would be 7,500 steps/day and 30 min of usual-pace walking by mid-programme reassessment and 10,000 steps/day and 30-min of briskwalking by end of programme.

 

Losing weight and reducing abdominal circumference (refer table 3)

Mr A is already close to being classified as being obese class I and with central obesity. The dietitian and exercise specialist would need to help him reduce his caloric intake and increase his caloric expenditure. Losing weight would also help him control his lipids level and blood pressure. The food type and proportion still follows that of a cardio-protective diet. We also need to moderate his expectation of weight loss as he is quitting smoking concurrently and weight gain is common among quitters, so a more realistic goal is to maintain his weight as the benefits of quitting smoking far outweighs the disadvantages from gaining some weight.

 

Medical Management (refer table 3)

The doctor would be the person-in-charge of Mr A’s medical management. His BP and LDL levels are considered as elevated risk factors and need to be treated with medical and lifestyle intervention so that further complications could be prevented. For BP, there is a possibility that we are seeing an artificially high reading, thus there may be a need for him to continue monitoring at home. Medications would be given to manage his blood pressure and cholesterol, in addition to his lifestyle therapy.

Conclusion

Mr A has a high risk of developing CHD according to risk estimation. Hence, he is referred to a family-based multidisciplinary cardiovascular health programme to assess and manage his risk factors. His wife has also been roped in to assist and provide support to him to change his behaviour and lifestyle. Both have been involved in the whole process of setting SMART goals for the various risk factors. The programme looks comprehensively into his diet, physical activity level, weight loss, smoking, psycho-social aspect, hypertension and dyslipidaemia.

The management plan includes behavioural and pharmacological support to his smoking cessation, diet modification and increase in physical activity to support his weight loss, lower his blood pressure and improve his lipid profile as well as medications to manage his blood pressure and lipids. The benefits of such a plan will only been seen if he adopts the changes lifelong. He will lower his risk of CVD and experience a better quality of life and longer lifespan.

 

Table 3 A sample of Mr A’s 24-week management plan

Modifiable Risk Factors

Action Plan1,2

Body Mass Index

Initial Assessment and Counselling:

Advise to lose weight/maintain weight in view that he needs to quit smoking as well

Education on importance of losing weight in relation to CVD risk. Provide pamphlets for further reading.

Assess how confident and important is losing weight/maintaining weight to the patient

Uncover any barriers that might be unknown till now.

Provide consultation with the dietician and physical activity specialist

Determine SMART goals

Encourage wife to attend the consultations together

Draw up a meal plan

Devise an exercise regime

Plan for follow-up and monitoring

Mid-programme review

Re-assessment of anthropometric measurements

Review of SMART goals

Encourage couple to attend health promotion talks and workshops

Increase intensity of exercise

End-programme review and future plans

Re-assessment of anthropometric measurements

Review of SMART goals

Maintain weight loss/Prevent weight gain

Reinforce the importance of physical activity/exercise and balanced diet

Waist Circumference

Physical Activity

Initial Assessment and Counselling:

Advise to increase physical activity and take up a form of regular exercise.

Education on importance of being physically active in relation to CVD risk. Provide pamphlets for further reading.

Assess the confidence and importance patient has towards increasing physical activity/exercise.

Devise an physical activity regime:

Frequency: to walk every day

Intensity: increase from low to moderate, i.e. from slow to brisk walk (teach “talk” test)

Time: increase from 20 min to at least 30 min

Type: Mainly aerobic exercise, i.e. walking

The change should be in a bottom up manner, i.e. Time, Intensity and then Frequency

Continue to use a pedometer. A SMART goal is at least 7500 steps/day.

Get him to attend a structured exercise programme with his wife.

Plan for follow-up and monitoring

Mid-programme review:

Re-assessment of cardiovascular fitness level

Review of SMART goals

Increase intensity of exercise

Introduce him to conditioning exercise, covering all major muscle groups to done at least 2x/week.

Further increase steps taken per day: 10000/day

End-programme review and future plan:

Re-assessment of physical fitness level

Review of SMART goals

Reinforcement of what he has learnt from the programme

Maintain 10000 steps/day.

 

Diet

Initial Assessment and Counselling:

Education on importance of diet in relation to CVD risk. Provide pamphlets for further reading.

Assess his diet in greater detail (3-day food record)

Assess his motivation level to change dietary habits.

Get him to think positively about the changes.

Identify any unknown barriers.

Refer to dietician for intense counselling

Involve wife for the consultation

Determine SMART goals, i.e. start with small changes (cut off salt at the table, snack on fruits, reduce red meat to once a week and increase vegetables intake)

Draw up a meal plan using the Eat Well Plate as a guide. ( ½  plate of vegetables, ¼ plate of protein, ¼ of carbohydrates and 1 piece of fruit)

Plan for follow-up and monitoring

Mid-programme review

Review of SMART goals and progress.

Discuss about lapses and possible solutions

Encourage couple to attend nutrition workshops and healthy cooking class

Teach wife how to read food labels

Introduce more dietary changes:

Use cooking methods like bake, steam instead of fry

Reduce fried food to at most once a week.

Replace red meat with oily fish

Create a 500-caloric intake for weight loss

End-programme review and future plans

Re-assessment of SMART goals

Positive reinforcement for achieving the goals

Maintain diet change.

Smoking

Initial Assessment and Counselling:

Advise him to quit smoking

Education on the health dangers of smoking in relation to CVD risk. Provide pamphlets for further reading.

Assess his breath CO level

Assess how motivated he is to quit smoking.

Assess his nicotine dependence level using Fagerstrom Test for Nicotine Dependence

Assess his emotional and behavioural/habitual dependence level.

Set a quit date with him.

Determine if he wants to do it gradually or abruptly.

Check for cues to smoking/barriers to quitting.

Assist with behavioural modification (CBT and MI) and pharmacological aids (varenicline and nicotine replacement gum)

Inform him about possible medication side effects and withdrawal symptoms.

Arrange for follow-up and monitoring of breath CO level

Mid-programme review

Re-assessment of breath CO level.

Discuss about side effects and withdrawal symptoms he has experienced.

Discuss about possible lapses that occurred.

Determine if he needs another round of varenicline treatment.

End-programme review and future plans

Maintain quit status, if successful.

Join support group.

Reinforce positive behaviour

Equip him with skills to cope with lapses.

Lipids

TC

Initial Assessment and Counselling:

Review of lipid profile

Education on lipids in relation to CVD. Provide pamphlets for further reading.

Explain how lifestyle changes (smoking cessation, diet change and increase physical activity) can help his lipid profile. Successful lifestyle change can improve LDL level by 15%.

Since he needs to decrease his LDL by 50%, a statin can be given. Simvastatin at a dosage 20mg can reduce TC, LDL and TG by 38%.

Discuss about possible side-effects and symptoms. Reassure him so as to encourage adherence to medication.

Plan for follow-up and review

Mid-programme review

Reassessment of lipid and renal panel blood test.

Positive reinforcement should be given if the results are going in the right direction.

If results are not satisfactory, check with Mr A if he had been adhering to medication regime and lifestyle changes.

If he is complaining of severe somatic symptoms such as muscle aches and lethargy, consider switching to another statin.

End-programme review and future plans

Re-assessment of lipid profile.

If targets are met,

Reinforcement of lifestyle changes.

Maintain medication regime.

Reassess lipid profile annually.

If targets are not met,

Check for possible lapses in lifestyle changes

Adjust medication

More intense follow-up.

HDL

LDL

TG

TC : HDL

Blood glucose

Initial Counselling and Assessment

Although blood glucose is within normal limits (≤6.0mmol/l) in terms of SCRS guidelines, it is considered to be in impaired fasting glucose zone under ADA’s guidelines.

Encourage adherence to lifestyle changes as advised earlier

Repeat fasting glucose at end-programme review.

End-programme review and future plans

Reassess FBG again.

If FBG≤6.0mmol/l, repeat test annually.

If FBG≥6.1mmol/l and <7.0mmol/l, repeat test on another day.

1SCRS: Singapore Cardiac Risk Score, 2011

2Jennings et al., 2009. Preventive Cardiology: a practical manual. New York: Oxford University Press

TC: total cholesterol; HDL: high density lipoprotein; LDL: low density lipoprotein; TG: triglycerides; MET: metabolic equivalent