Treatment of Heart Disease

Cardiovascular disease (CVD), which includes coronary heart disease, cerebrovascular disease (strokes), and peripheral artery disease, is the single most common cause of death in the United States. Caused by atherosclerosis, the buildup of fatty plaques along the inner walls of arteries, CVD causes significant disability and is a large source of health care costs. Behavioral medicine specialists have developed a number of interventions to prevent and treat CVD.

One risk factor for CVD is high blood cholesterol, or hypercholesterolemia. The diagnostic criteria for hypercholesterolemia are presented in Table I. The most prominent intervention effort aimed at treating hypercholesterolemia, initiated by the National Heart, Lung, and Blood Institute, is known as the National Cholesterol Education Program (NCEP).

If atherosclerotic buildup increases, the arteries narrow and restrict blood flow. The formation of a clot can completely stop blood flow, causing an MI or cerebral vascular accident (CVA; or stroke). Atherosclerosis is a life-long process, partially controlled by inherited genetic factors such as metabolism. Although humans have no influence over their genes, our physiological factors affecting atherosclerosis include blood cholesterol, blood pressure, and obesity. These physiological factors and CVD risk are partially

Table I National Cholesterol Education Program Guidelines for the Treatment of Hypercholesterolemia

Recommended

level

200 mg/dl TC»

130 mg/dl LDL

Moderate risk

200 -240 mg/dl TC

130-160 mg/dl LDL

High risk

>240 mg/dl TC

>160 mg/dl LDL

a TC, total cholesterol; LDL, low-density lipoprotein (i.e., ''bad'' cholesterol).

a TC, total cholesterol; LDL, low-density lipoprotein (i.e., ''bad'' cholesterol).

Behavioral Medicine influenced by modifiable behaviors, for example, physical activity, diet, and tobacco use. Behavioral medicine practitioners are actively involved in developing effective interventions in these areas, at both the patient and caregiver level.

Regular physical activity may reduce blood pressure by reducing obesity, increasing aerobic fitness, and reducing the blood levels of certain stress-related chemicals such as adrenalin. In individuals who already have hypertension, exercise significantly reduced resting blood pressure in most studies. Other studies have examined the effect of activity interventions on individuals who do not yet have hypertension, but who are at high risk for developing it (e.g., people with "high normal'' blood pressure). One such study found that increased physical activity was one factor reducing the risk of future hypertension in this population. Many other studies have found cardiovascular benefits from dietary and smoking interventions.

The benefits from these interventions, although significant, are limited. Atherosclerosis has traditionally been viewed as a unidirectional process. Therefore, behavioral and medical interventions have been aimed at slowing, rather than reversing the sclerotic process. Recently, however, the Lifestyle Heart Trial attempted to reverse atherosclerosis through behavior change. This trial was notable for its comprehensiveness. Patients with severe heart disease were randomly assigned to either a standard-treatment control group or a radical lifestyle change intervention. In the intervention group, participants were introduced to the program through a weekend retreat with their spouses. Then, participants attended 4-hour, biweekly group meetings. They were placed on an extremely low-fat vegetarian diet (fat was limited to 10% of calories, compared with a national average of about 40%). Caffeine use was eliminated, and alcohol was limited to two drinks per day. The group sessions included relaxation and yoga exercises; participants were expected to practice relaxation and meditation for 1 hour each day. Sessions also included exercise and smoking cessation instruction for participants who smoked.

The results of this intensive behavior change program were striking. Participants reduced their fat intake from 31% to 7% of total calories. They increased daily exercise from 11 minutes to 38 minutes per day. They increased their relaxation and meditation time from an average of 5 minutes per day to 82 minutes per day. As a result, participants' total cholesterol lev els dropped markedly, often to below 150 mg/dl. Blood pressure also fell. They lost, on average, 22 pounds over the 1-year course of the study. Angina (chest pain) dropped by 91% in the experimental group, whereas it increased by 165% in the control group. Impressively, participants in the experimental group were almost twice as likely as control group members to show actual reductions in arterial blockage.

This study demonstrated that a behavioral intervention that includes daily exercise and relaxation, along with an extremely low-fat diet, can have an impressive impact on the clinical picture of individuals with severe heart disease. Related research focuses on the impact of behavioral interventions on individuals who do not yet have heart disease, but who may develop it in the future.

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