00:00
infarction increases.
So, evidence based medicine does work. A number
of the evidence based medicines, and I’m
going to show you some data briefly that supports
the idea, I’m going to show you, in other
words, the evidence that patients can do well
if they take the medicines. Number one of
the evidence based medicines of the Statins,
I’m going to show you data, that you can
decrease recurrent myocardial infarction that
is another heart attack or death by 30% to
40% if you take your Statins. I’m going
to show you about platelet... Anti-platelet
agents to prevent blood clots from forming.
00:33
I’m going to show you about Beta Blockers
and ACE inhibitors. I’m going to show you
about a whole variety of different chemicals
that will help to prevent another heart attack.
00:44
The former surgeon general in the United States
Everett Koop said, “Drugs don’t work that
patients don’t take.” Obviously, it’s
important to try and talk the patient into
taking their medicines as prescribed and regularly
and follow up with their doctor. When they
do that, the outcome is usually good. When
they don’t do it, sometimes the outcome
is good, but more frequently, the outcome
is not good, there's further injury to the
heart. So, let’s look at some of this evidence
base. First of all, here you see a composite
from a number of Statin trials in which the
lighter color is recurrent myocardial infarction
and the darker color is death. And you can
see these are reduction in each of these events
in a variety of different subgroups. On individuals,
who've had angioplasty - PTCA, individuals
who had a previous MI, individuals who had
coronary bypass and so forth, in every subgroup,
there's a reduction, you can see 30%, 40%,
even 50% reduction in recurrent MI and a smaller,
but very large reduction in death. So, Statins
are sort of number one on the list of evidence
based medicine that is really important for
patients to take after a myocardial infarct.
02:00
Here are Beta Blockers, there's also significant
improvement, not as dramatic as with Statins,
but again, across all subgroups a remarkable
decrease in further events, further events
being another heart attack, MI or the worst
outcome, death. Here we see for the taking of
Aspirin. Again, this is an older article from
the Lancet because we've had Aspirin for a very
long time as an evidence based medicine and
you can see here again, reduction… significant
reductions in events with the use of Aspirin
versus placebo - a control.
02:38
So, evidence based medicine does work. I’m
now going to show you six areas where there's
a consensus among cardiologists about how
to manage these patients. I'm then going
to show you four controversial areas where
there's still work going on and where there's
some debate among the experts. The first
consensus I've already shown you, evidence
based medicines really work, they really do
reduce recurrent myocardial infarction and
they reduce death, including sudden death.
And you see listed here what I just showed
you in earlier slides, Statins, the Beta Blockers
and the platelet agents. I didn’t show you
the data for ACE inhibitors, but I’m going
to show that to you in just a moment in the
next slide. But also, secondary prevention
measures in lifestyle have been shown to reduce
events. Here's exercise, diet, appropriate
smoking cessation, so forth, cardiac rehab
intervention such as lifestyle have also been
shown to decrease the death rate. Here, is
the slide showing you the ACE inhibitor reductions
just like in the same sub-groups that we had
before with the Beta Blockers and with the
Statins. You can see again marked reductions
in events when patients are placed on ACE
inhibitors and inhibit the rennin-angiotensin
system that we’ve talked about in the past.
So, again, what are the evidence based medicines?
Statins, Beta Blockers, Anti-platelet agents,
ACE inhibitors or in the newer version, angiotensin
receptor blockers that do the same thing,
that inhibit the rennin-angiotensin system.
04:23
All of them work in patients who've had
an acute ischemic event to prevent a second
ischemic event and to prevent death.
So, what’s the second consensus agreement?
Cigarette smoking, public enemy number one.
Cigarette smoking is the cause of a huge number
of deaths, not just from coronary heart disease,
but from a variety of cancers and end-stage
lung disease. I take care of a number of these
patients when I'm on the internal medicine
service. I think the worst way you can die
is from respiratory that is lung failure,
where you’re drowning all the time, you’re
constantly short of breath even with the most
minimal activity. Commonest cause of severe
end-stage lung disease - cigarette smoking,
public enemy number one. If you continue to
smoke after you've had a heart attack, you
have a six times increased risk of dying in
the next 10 years. And there's a variety
of techniques for smoking cessation, usually
one works on a com-, in particularly in severely
addicted smokers, a combination of behavioral
modification techniques and there are some
drugs that also help patients to stop smoking.
It’s really important that this be told
to patients. I tell them the first thing in
the hospital that cigarette smoking is absolutely
the best way that they can have another heart
attack, they really have to stop. We'll
help them in any way we can, but smoking cessation
is absolutely critical and has been shown
to make a big difference when patients who've
had myocardial infarct stop smoking.
05:59
Well, let’s look at the next consensus.
One can predict in a statistical manner, patients
who are high risk for developing coronary
disease. There are a number of different indices
that can be calculated. The European Society of
Cardiology has one, the Framingham study
form is used often in the United States and
basically, what we're doing is we're looking
at risk factors and for each risk factor the
patient has, you get a certain number of points.
06:28
The higher number of points you score, the
greater your likelihood of developing coronary
disease. Now, these statistics don’t predict
the future, they can’t tell you for sure
you’re going to have a heart attack or not,
they just tell you the risk. I always tell
my patients, it’s like going out to the
horse races. You can bet on the favorite or
you can bet on the hundred-to-one long shot.
The hundred-to-one long shot almost never
wins, once in a hundred, but the 2-to-1 favorite
usually wins. I want you to follow the evidence
based medicine rules so you can be the favorite,
the to 2-to-1 shot to survive. I can’t tell
the future, but I can tell you the odds of
you being here from ten years… ten years
from now, if you follow with our program or
if you don’t follow with our program. And
again, here are the factors. Again, you've
heard them again and again. Of course, age,
there's nothing we can do about yet, but
there's all the other things, hyperlipidemia,
hypertension, cigarette smoking and so forth.
When patients eliminate these factors, the
chances of another heart attack or death are
markedly reduced and when we eliminate them
even before a heart attack, we can help to
decrease the chance that a patient will eventually
even develop a heart attack or need angioplasty.
So, let’s talk about consensus number four,
that is patients with chronic coronary disease
are surviving longer than they did in the
past. There's a variety of reasons, people
are taking to heart the lifestyle changes,
they're on evidence based medicines, they're
seeing their doctors and theyre following
through. And what we see from that is, in
fact, the public health statistics show in
the United States and also now in Western
Europe, a decline in the death rate from coronary
heart disease. It’s a combination of lifestyle
changes and also, evidence based medicine.
08:24
Here you see some statistics that show between
50 years ago and now, the marked decrease
in the number of patients who have coronary
heart disease and all heart disease mortality,
they are markedly down. Let me show you a
diagram that demonstrates the same thing.
08:45
Here you see the curve going up to right around
a little after year 2000, you can see a marked
decrease in all forms of heart disease, in
coronary heart disease and in stroke deaths
in the United States. Similar statistics are
now being seen in many Western European countries
and again, it’s a result of two things - lifestyle
changes on the part of the patient that accounts
for approximately 50% and evidence based drugs
that accounts for the other 50%.
09:18
To continue the argument that atherosclerosis
and coronary artery disease deaths are decreasing,
there are, as I mentioned, a number of factors.
There's both lifestyle changes on the part
of the patients and also evidence based medicine.
One thing we've seen in the United States
is that over recent decades, the mean serum
cholesterol for a large number of patients’
sample has actually decreased. This implies
both drug therapy with Statins and also lifestyle
changes. But, maybe it isn’t all that, there
may be a selection factor. The same thing
was noticed with tuberculosis in the early
years of the 20th century well before there were
effective antibiotics, there was a decline
in tuberculosis deaths. Again, probably because
of better living conditions, better nutrition,
in other words public health measures. It
can be seen from autopsy studies in servicemen
killed in action over recent American wars
that actually, atherosclerosis is decreasing.
So, it is automatic that anyone killed in
action in the military has an autopsy and
of course, one of the things that are looked
at is the coronary arteries. You can see that
there is a decline in the incidence of mild
and severe coronary artery disease from individual
study at the time of the Korean War 50 - 60
years ago, at the time of the Vietnam War
30 years ago and more recent experience in
Iraq and Afghanistan. There is a definite
decline in individuals of the same age in
atherosclerotic findings.
So, I think the public health statistics of
a declining serum cholesterol, the public
health statistics of a declining mortality
are being reflected here as well, that there
is declining coronary atherosclerosis. This
should not be cause for contentment. There's
still a lot of people, as I gave you the
statistics earlier, who are having heart attacks
and who are needing coronary bypasses and
angioplasties and drugs. So, this disease
has not gone away. Nevertheless, there is
reason for some optimism and hope except for
what’s in the next slide. This slide shows
the incidence of diabetes mellitus in the
United States. I don’t have to tell you
what it shows. It shows a remarkable
increase in the incidence of diabetes in Americans.
11:43
Part of this is due to increasing obesity
and unfortunately, in Western Europe, the
same pattern is being seen and by the way,
in China and India, the same pattern is being
seen. Increasing gross national product, increasing
well being and income, results in better diets,
more cigarette smoking, more rich foods, less
activity as people drive cars around and what’s
the result? You can see marked increase in
diabetes. Diabetes is a major risk factor
for coronary disease and we worry that maybe
we’re going to see a reversal of the
trend that we’ve seen for the last 50 years.
Maybe, we’re going to start to see coronary
artery disease go up again with the increasing
incidence of diabetes. At the moment, in the
United States, there are major programs that
are seeking to try and stem this remarkable
increase in diabetes in the US.
Let me show it to you in another way. I’m
going to show you three maps of the United States.
The darker the color means the more diabetes
as you can see. So, here we are in 1990, some
whites and some greys, a few darkened areas.
12:51
Uh-oh, here's 1995, a lot more dark and look,
here’s 2001, even more dark and I can tell
you having seen recent statistics, it’s
even worse. So, diabetes is a major issue
to worry about.
Now, let’s talk about another consensus
and that is a good physician can make a big
difference in the life of a coronary disease
patient. Since a lot of the improvement in
the risk for coronary disease relates to taking
evidence based medicine, it’s really the
good physician that can convince the patient
why they need to continue to take these medicines.
It’s a frightening statistic in the US that
50% of people who have had an ST-elevation
myocardial infarct have stopped their Statin
drug within a year. When they interview
patients "Oh," they said, “Well, I thought
I didn’t need to keep taking it or I don’t
like to take chemicals, I would rather treat
myself with natural product,” and so forth.
Obviously, when these people stopped their
Statins, their increased risk for having another
myocardial infarction or dying goes up. So,
evidence based medicine is an important component
and having a physician who can make a difference
in your life and convince you to take your
medicines is very, very important. Not only
will this physician convince you to take your
medicines, but will also work with you to
increase the likelihood that you’re gonna
adhere to a healthy lifestyle, which will
also decrease your likelihood of having a
myocardial infarct.
14:22
And the final consensus then relates to
the physician, it’s the cardiac rehab program.
14:27
By the way, often run by nurses and exercise
physiologists, there have been a variety of
studies that show statistically significant
decrease in recurrent myocardial infarction
and death in patients who go to cardiac rehab
programs. Cardiac rehab programs do work and
of course, what do they do? They consist of
exercise, encouragement of the patient take
their medicines and they’re indicated for
all forms of coronary artery disease - myocardial
infarction, patients with stable angina pectoris,
patients who are at high risk, patients who
had angioplasty or bypass. Any manifestation
of coronary disease, patient’s benefit by
going to cardiac rehab, by learning about exercise
and diet and smoking cessation and taking
their evidence based medicines and being encouraged
to continue to follow that. This is a definite…
definite positive and a good physician will
encourage the patient to follow through on
cardiac rehab interventions.
Well, let’s look at controversies now. I've