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Boosting patient adherence can enhance outcomes
Cardiovascular disease remains the leading cause of death and morbidity worldwide, including in the United States.
Randolph P. Martin, M.D., FACC, FASE, FESC, emeritus professor of cardiology at Emory University Healthcare and chief medical officer for Caption Health, notes we live in an obesogenic, salty and sedentary environment, so thinking about preventative cardiology has never been more important than it is today.
“We’re in an environment now where obesity is rampant and becoming an issue for the young and old alike; our diet tends not to be conducive to healthy living, and we’re increasingly sedentary,” he says. “I try to encourage patients, family and friends to live both a heart-healthy and active life, as that will not only decrease their chances of heart attacks and strokes but help them simply feel better and more able to enjoy life.”
Following a healthy lifestyle can help prevent heart disease and the causes of heart disease, such as diabetes and hypertension. Additionally, healthy living helps prevent some significant cancers and may, in fact, help prevent other diseases like dementia and Alzheimer’s.
Internist Vicken Zeitjian, M.D., a cardiovascular fellow at The University of Texas Health Science Center at San Antonio, notes that self-care and making adjustments are a huge part of heart health.
“I recommend all my patients ... adhere to a heart-healthy diet, exercise daily or at least five times per week, aim to reach ideal body weight, ... quit bad habits like smoking and help minimize their comorbidities like treating obstructive sleep apnea, hypertension, hypercholesterolemia and diabetes,” he says.
Promoting heart health
Arash Bereliani, M.D., FACC, a clinical associate professor of medicine and cardiology at UCLA’s David Geffen School of Medicine and an attending cardiologist at Cedars-Sinai Medical Center in Los Angeles, notes the first step in promoting heart health for patients is to motivate them.
“For some patients, positive reinforcement, such as feeling better and having more energy or living long enough to see their grandchild get married, is effective,” he says. “For others, a negative reinforcement such as ‘If you don’t change your life habits or if you don’t watch your diet, you might need heart surgery soon or you might end up having a stroke’ can do the job.”
Bereliani always gives patients hope that they have a chance to prevent those conditions, adding that it’s vital you don’t cause fear or anxiety.
“I emphasize to them that they should not get scared but, rather, get motivated to take care of themselves,” he says. “The challenge as a physician is to know which tactic to use to make them understand and to motivate them the right way to take steps to take care of their heart health. Using the wrong technique could backfire and either cause more anxiety and fear, which (are) harmful, or might not do anything to change their behavior.”
He recommends that everyone older than 40 have a baseline checkup for underlying heart disease by a cardiologist who is well trained and knowledgeable in the field of prevention and who knows what tests to order.
Then there are the basics, Bereliani explains, like regular exercise, the right diet, stress reduction and a good night’s sleep. Additionally, mild to moderate alcohol consumption for patients who do not have high blood pressure or diabetes or liver disease could be beneficial.
Martin has a three-step blueprint for fostering heart health.
“My first three actions are always to listen, talk and then encourage patients to lead a heart-healthy lifestyle,” he says. “I try to be encouraging (and) sympathetic for how hard it is to do all this and give them ways to go after one thing at a time. I also try to emphasize that these steps aren’t just good for them — (they’re) good for their families, children, loved ones and friends.”
He also points patients to an August 2009 article from the Archives of Internal Medicine titled “Healthy Living is the Best Revenge,” which highlights that there are no magic pills and that the future of health care really begins with each one of us.
Explaining this to patients is one thing, but getting them to actually make the changes is quite another.
Martin finds that being a motivational listener is effective.
“Just telling a patient what to do often doesn’t help, but listening and showing empathy for how hard all of these things can be to tackle at once can help,” he says. “It’s easier to point out the gaps between where they should be and where they are — and then encourage them to make some lifestyle changes. I also make sure to keep up with my patients a lot and compliment them when they’re making progress.”
One of the key things he encourages his patients to do is know their numbers: blood pressure, weight, waist-hip measurement, cholesterol and blood sugar.
“I keep encouraging my patients. I tell them it’s tough, and we tackle one thing at a time,” Martin says. “If they’re having problems with smoking cessation, then I get them help and resources, like those from the (Centers for Disease Control and Prevention). If they’re having trouble getting active, I tell them to just start walking and give them a regime for that. I also encourage them to check out apps like those recommended by sites like the Mayo Clinic — there are blood pressure apps, stress management apps, heart rate monitor apps and so on.”
A diet rich in fruits, vegetables, high fiber, low cholesterol, monounsaturated fats instead of
saturated fats, and omega-3 fatty acids is ideal for heart health, according to Zeitjian. A Mediterranean diet also reduces the risk of cardiovascular disease.
In Bereliani’s practice, they have a program that enables the team of nurses and assistants to continuously engage with patients via phone calls, Zoom meetings and emails to make sure the patients follow his recommendations.
“Our newsletters and social media also constantly remind our patients the importance of taking care of their heart health by implementing my recommendations,” he says.
And when he realizes a patient is not following his advice, Bereliani sets up an office meeting with them to try to understand the psychology behind their nonadherence.
“Many of these patients have underlying psychological issues such as anxiety, depression or trauma,” he says. “Once I discover their psychological barrier, I either discuss the case with their family, with the permission of the patient of course, and using a team approach, we come up with a plan to address the underlying issue. Once the underlying issue has been addressed, the patient is very likely to start taking care of himself or herself.”
Preventative cardiology is one of the most important aspects of the field. Many cardiovascular
diseases such as coronary artery disease, heart failure and arrhythmias are a result of multifactorial components — principally, lifestyle habits, comorbidities and genetics.
“We can only focus on the first two,” Zeitjian says. “In terms of what you can do, think of the acronym COSHED (cholesterol, overweight, smoking, hypertension and exercise), which literally means ‘hit on the head’ (and) is figuratively what would happen if we do not focus on prevention.”
The new advancements in preventive cardiology have enabled physicians to not only determine one’s current risk of heart disease but to accurately predict one’s future risk of a heart attack or heart disease.
“If the right testing is performed and if the right treatments and prevention are implemented, no one should die of heart disease at least until at a very old age,” Bereliani says. “Unfortunately, many physicians and cardiologists either do not perform the right tests or do not implement the right preventive strategies for their patients. Most cardiologists are very good at treating heart disease when it has already occurred but not very good at preventing heart disease.”
Zeitjian notes that despite the tremendous advancements in the field, primary prevention nearly always results in longevity as opposed to secondary prevention.
“Most of my patients are referred for established cardiovascular disease, and we have medications and procedures (that) can treat them. However, they have increased morbidity and mortality despite our interventions,” he says. “No matter where you stand on the health spectrum, it is never too late to invest in yourself. Prevention can not only prolong life, but improve the quality of your life.”