Fat Fighters

Apparently a little knowledge really is a dangerous thing – if, that is, neither doctors nor their patients are taking a simple message to heart, which is what appears to be happening.

According to two studies released in November at the annual American Heart Association meeting, in Orlando, Fla., Canada is suffering from a “treatment gap” between the best possible medical care and actual clinical practice – despite all that’s known about cholesterol lowering programs designed to reduce the risk of heart attack and cardiovascular death. In short, many Canadians still aren’t receiving the preventive care they should be getting. Dr. J. George Fodor is head of research at the University of Ottawa Heart Institute’s Prevention and Rehabilitation Centre and founding president of the Canadian Hypertension Society. Fodor was a primary investigator in one of the two studies initiated by the Heart Institute to assess treatment patterns in Canadian primary care. Monumentally titled Investigation and Treatment of Hypercholesterolemia and Other Dyslipidemias in Canadian Primary Care Practice [THDCPCP], the study revealed that, “despite definitive studies which demonstrate that cholesterolowering treatment reduces heart attacks, hospitalization and mortality, only 60 per cent of the highest risk patients are receiving treatment.”

Heart disease claims 80,000 Canadians a year, Fodor noted, “but we are making very good progress: Lifestyle changes and medical advances in treatments [have been] reducing the impact of heart disease by approximately two per cent a year in the past 20 years, and there is a decline of about 40 per cent in coronary heart disease [CHD], so definitely things are going right. The question is, can we do more? And definitely there is a large potential to improve this trend and reduce further the burden of heart disease.”

The second study, Gauging (Cholesterol Treatment) Awareness Among Physicians – GAAP for short – surveyed 250 Canadian primary care physicians “to compare attitudes and awareness with actual… treatment practice.” It found “a high level of discrepancy between what physicians perceive as optimal practice and what is actually practised.”

In fact, while 90 per cent of the doctors surveyed said they’re familiar with treatment guidelines with respect to cholesterol and practise according to those guidelines, GAAP found that a significant proportion of those doctors (54 per cent) don’t actually initiate treatment until patients have cholesterol levels above the recommended initiation of treatment level.

There was a similar finding with respect to patients with a history of heart disease: 34 per cent of the doctors in the study waited until patients were beyond recommended levels. There was an even greater gap in fundamental understanding: While 86 per cent of the physicians had heard about the Scandinavian Simvastatin Survival Study (4S) – the first major cholesterol treatment study to demonstrate the relationship between cholesterol reduction and improved patient outcome – more than 25 per cent of the doctors couldn’t name even one of the study’s conclusions.

“These findings are both alarming and disappointing,” says Dr. Jacques Genest Jr., director of the Cardiovascular Genetics Laboratory at the Clinical Research Institute of Montreal. Of course, it takes time for physicians to integrate new findings into their clinical practice, and high cholesterol, very much like hypertension, is a silent disorder – there’s a lesser sense of urgency. That’s reflected in patient attitudes, too: “In many cases,” Genest notes, “the patients we’re trying to reach simply do not see their physician until they have a problem that justifies a visit. So, as physicians, we are guilty of not applying the guidelines, which are well established, but the [patient] population should also realize that cardiac disease can be changed in its natural course.”

To close the gap, Genest suggests reinforcing the idea that, “in highly selected individuals – especially those at very high risk, those who already have heart disease and elderly patients – cholesterol lowering can reduce coronary mortality by about 40 per cent. Many Canadians are not receiving the treatment that they need, and, in terms of healthcare, closing that treatment gap should be a high priority.”

For patients, the message is clear: If you’re in a high risk group – if you have a family history of heart disease, if you’re obese, if you have diabetes or hypertension or you’re a smoker – it’s essential that you discuss with your physician whether you should have a lipids profile done. “All coronary heart disease patients should have a yearly assessment of their lipids profile,” Fodor says, “and our study verified that… only 32 per cent of these patients had a full investigation to an extent that we require to institute proper therapy.”

Therapy may consist of a number of elements, including medication.

According to the 4S Study, the lipid lowering medication simvastatin (Zocor), for example, reduced overall mortality by 30 per cent and saved substantial healthcare costs as well, reducing hospitalization, revascularization (bypass surgery), angioplasty, and other such factors by some 42 per cent. In another three year study, 201 patients who received 10 to 40 mg of simvastatin daily enjoyed a 28 per cent reduction in total cholesterol, a 32 per cent reduction in LDL (“bad”) cholesterol, a 12 per cent reduction in triglycerides, and a 14 per cent increase in HDL (“good”) cholesterol.

Genest: “These medications are extremely well tolerated. The side effects that would cause withdrawal are occurring in less than one per cent of cases, and long term follow up shows that effects on the liver or kidneys are very rare. These medications taken daily are well tolerated.”

Beyond medication, what else can you do? Watch your diet: Most of us could stand to eat less fat, particularly saturated fat. If you’re overweight, ask your doctor or a registered dietitian for advice about safe and effective weight loss plans. If you have hypertension (high blood pressure), pay particular attention to keeping it under control. If you’re sedentary, try to increase the amount of physical activity you get: Any increase will boost your level of “good” cholesterol. Do you smoke? Stop – it’s a killer.