Number 36, 2007
Improving prognosis in ischemic heart disease: time to maximize benefit
 Back to the Summary
Graham Jackson
Guy's and St Thomas’ Hospital, Cardiothoracic Centre, London, UK
Correspondence: Dr Graham Jackson, Guy's and St Thomas’ Hospital, Cardiothoracic Centre, 6th Floor East Wing, London SE1 7EH, UK.
E-mail: graham@jacksonmd.fsnet.co.uk
Focusing purely on mortality as a quantity of life issue is obviously the most precise measurement of prognosis, but for many people it is the quality of life along the journey that is as, if not more, important. In the stable angina population the estimated annual mortality is 0.9–1.4%, with an annual non-fatal myocardial infarction incidence of 0.5–2.6% [1]. Within this clinical condition the conventional risk factors of hypertension, hyperlipidemia, diabetes and cigarette smoking adversely affect prognosis. These are, however, modifiable and there is good evidence for risk intervention leading to clinical endpoint benefit so we have time to maximize benefit medically.
In Europe each year 947 420 deaths are caused by coronary heart disease in women and 943 085 in men [2]. The myth that it is predominantly a man's disease has been dispelled by the facts; but women do develop the disease at an older age. In general, however, the same risk factors predispose to cardiovascular disease in men and women (even allowing for a degree of female hormonal protection), so management is the same with no room for sex bias.
Addressing prognosis must take into account the person's lifestyle and perception of the problem, their personal interpretation of life's quality and quantity, their social environment and family circumstances. An approach that leads to an active life of good quality without necessarily lengthening life must not be dismissed as scientifically invalid; living the same length of life with a preventable stroke is not a justifiable argument for avoiding risk reduction advice and therapy.
In this issue of Heart and Metabolism we start at the beginning; this sounds obvious, but often the basics are overlooked or taken for granted. From the dynamic nature of plaque progression it is logical to look at the prevention of plaque rupture; stabilizing the plaque being the primary objective. The UK National Institute for Health and Clinical Excellence has issued an excellent quick reference guide, which should be consulted in addition to our more comprehensive reviews [3]. Diabetes is a particular challenge needing comprehensive lifestyle and therapeutic intervention, not just glucose control. We look into the future with stem cells and enlarge on the growing recognition of the importance of metabolic therapy in improving prognosis as well as symptoms.
As we all get older, we may “feel our age” but age should not be a barrier to all the options available, although a more aggressive interventional approach should take into account the higher complication rate. Being old does not mean being denied a good quality of life.
Improving the prognosis for ischemic heart disease involves maximizing the evidence base we have accumulated; no risk factor should be managed in isolation, but we must not lose sight of quality of life and must tailor our approach accordingly.
REFERENCES
1. Fox K, Garcia MAA, Ardissino D, et al.
Guidelines on the management of stable angina pectoris. Executive Summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology.
Eur Heart J. 2006;27:1341–1381.
PMID: 16735367 [PubMed - indexed for MEDLINE]
2. Rayner M, Petersen S.
European cardiovascular disease statistics.
Oxford: British Heart Foundation; 2000.
3. National Institute for Health and Clinical Excellence.
MI: Secondary prevention. May 2007. Available at: http://guidance.nice.org.uk/CG48.
Accessed: June 2007.
|
