University of Virginia Health System

Heart Care Important Both Before and After Problems Occur

People need to take care of their hearts both before and after heart trouble starts, according to two new studies.

"We tested the hypothesis that higher levels of blood pressure and body mass index (BMI) in midlife would be powerful determinants of heart failure risk in later life," says lead researcher Dr. Ramachandran S. Vasan.

"This is exactly what we found," adds Vasan, a senior investigator with the Framingham Heart Study and a professor of medicine at Boston University School of Medicine.

Body Weight, Blood Pressure Are Key

In the first study, an increase of about 20 points of systolic blood pressure at age 50 was associated with a 36 percent higher risk of heart failure up to 20 years later. Every one-point increase in BMI (a ratio of weight to height) at age 50 was associated with a 6 percent increase in the risk of heart failure, explains Vasan.

"The study highlights the importance of maintaining an ideal BMI and blood pressure over the life course of individuals," he says.

For the study, Vasan's team collected data on 3,362 people who were part of the Framingham Heart Study who had routine examinations between 1969 and 1994. During follow-up, 518 people developed heart failure.

"The prevention of heart failure should begin early in life and should include screening for elevated blood pressure and BMI," says Vasan. "Failure to identify or treat such modifiable risk factors in early and mid-adulthood may result in the loss of opportunities to reduce the incidence of heart failure in later life."

Dr. Gregg C. Fonarow, a professor of cardiology at the University of California at Los Angeles, says he agrees that keeping both your weight and blood pressure down will help you avoid the ravages of heart failure.

"The lifetime risk for developing heart failure in both men and women is one in five," says Fonarow. "However, heart failure can be prevented, and there are a number of modifiable risk factors for heart failure, including hypertension, obesity and diabetes.

"Maintaining a healthy blood pressure and body weight is essential to reduce the risk of heart failure," he adds.

The second study found that fewer than 20 percent of patients seek cardiac rehabilitation after a heart attack or coronary bypass surgery. The study results are published in the journal Circulation.

"It has been shown by many trials that cardiac rehabilitation reduced the risk for new coronary events, re-hospitalization, and mortality," says study leader Dr. Jose A. Suaya of Brandeis University.

"The main advantage of cardiac rehabilitation is to reduce mortality. Cardiac rehabilitation also improves functional capacity," says Suaya. "Patients can walk more without pain and improve their quality of life," he says.

For the study, Suaya's group collected data on 267,427 men and women, ages 65 and older, who had survived a heart attack or bypass surgery.

In the year after hospital discharge, only 18.7 percent of the patients had at least one cardiac rehabilitation session. Patients who underwent bypass surgery were more likely to seek rehabilitation - 31 percent - compared with 13.9 percent of heart attack patients.

More men had cardiac rehabilitation (22.1 percent) than women (14.3 percent). Age also played a role - patients between the ages of 75 to 85 were less likely to go for rehabilitation, the researchers found.

In addition, Suaya's group found that patients with other medical conditions - such as diabetes, a previous stroke, congestive heart failure or cancer - were significantly less likely to seek cardiac rehabilitation.

There are many reasons why patients don't seek rehabilitation, the researchers say.

"Many doctors may be reluctant to refer patients to cardiac rehabilitation," says study co-author Donald S. Shepard, Ph.D., of Brandeis University. "In addition, patients may not know or ask about it."

Whether patients are recommended for cardiac rehabilitation may depend who treats them, says George A. Beller, M.D., Ruth C. Heede Professor of Cardiology and Professor of Internal Medicine at the University of Virginia Health System.

"Often, cardiologists who take care of heart attack patients in the hospital focus primarily on performing procedures such as placing of stents in blocked coronary arteries and starting patients on drugs to reduce risk of death or another heart attack," he says. "Unfortunately, they don't discuss lifestyle modification changes or recommend supervised cardiac rehabilitation as adjuncts to drugs and procedures."

More Rehabilitation Services Needed

Shepard also notes that many medical institutions do not promote the service, which typically includes exercise and advice on diet.

"It's not glamorous and, from the data we have, it is not very profitable," he says.

It may also be difficult for people to get to rehabilitation centers, notes Shepard.

"One of the findings in the study was that the closer you are, the more likely you are to use the service," he says. "Travel time and travel expense are things that reduce the use of the service."

"More needs to be done to ensure that eligible patients are effectively enrolled in supervised cardiac rehabilitation," Fonarow adds. "The American Heart Association's 'Get With The Guidelines Program' is one example of a highly successful initiative to improve referral to cardiac rehabilitation after hospitalization for cardiovascular event or surgery."

UVA's Beller says doctors need to do a better job communicating the value of cardiac rehabilitation to patients.

"The value of the multidisciplinary approach needs to be convincing to get patients to sacrifice the time to travel [to a rehabilitation center]," he says.

In addition to a supervised exercise program, cardiac rehabilitation includes a comprehensive risk reduction program, including nutritional counseling, evaluation of a patient's blood pressure and lipid levels and related issues such as depression that may affect a patient's heart health.

Undergoing a supervised rehabilitation program - where a patient is monitored for heart rhythm disorders during exercise - will also build a patient's confidence, Beller says.

Patients exercising at home following heart surgery or a heart attack are often afraid to push themselves for fear of further damaging their hearts, he says.  

Learn more about preventing heart disease, UVA's Heart & Vascular Center and heart health at www.uvahealth.com.   

Women can learn more about their unique risks for heart disease - and how to better manage those risks - through Live Red, UVA's new heart-health initiative. You'll learn how heart-attack symptoms can be different for women than for men, and you can take an online risk assessment to learn your personal heart disease risk factors.

There, you can sign up for Club Red, our free heart-healthy club for women. Benefits include tips from UVA healthcare providers and a gift package to help you live red in style.

Always consult your physician for more information.