Ft. Lauderdale—The process leading to the first coronary or cerebrovascular event is a continuum that can be interrupted, but risk factors must be treated earlier and more aggressively. That was the message given to neurologists by J. Donald Easton, MD, in his no-nonsense, plain-spoken style. Rather than thinking about “primary” and “secondary” prevention, the process should be considered a spectrum, he said. “You don’t just all of a sudden go from primary to secondary. You’re working your way towards secondary right at this moment.”

Dr. Easton, who is the Co-Chairman of the Department of Clinical Neurosciences at Brown University, Providence, Rhode Island, made his remarks during the 26th International Stroke Conference.

Dr. Easton relates his new awareness of the need for earlier and more aggressive prevention strategies to a dinner conversation he had with a well-known lipidologist. “I reached over and took two salted cashews and ate them,” he recounted. The lipidologist asked, “Which statin are you on?” Dr. Easton replied that he did not, in fact, take a statin.

The lipidologist then asked about his blood cholesterol level. “I told him it was 220 [mg/dL], but the HDL is 105 [mg/dL].” The lipidologist said that 180 mg/dL is better.

Pointing to the salted cashews, the lipidologist next asked about Dr. Easton’s blood pressure. “I told him 140/85 mm Hg.” The lipidologist said 135/75 is better and then asked whether or not he was taking an ACE (angiotensin-converting enzyme) inhibitor. Dr. Easton had to admit that no, he was not taking an ACE inhibitor or aspirin.

Referencing to Dr. Easton’s age, the lipidologist commented, “Did you know that one out of five 60-year-old American males has had his first coronary event? What the hell are you waiting for, your first myocardial infarction?”

Dr. Easton admitted that “since then, I’ve thought a little differently about the prevention of strokes and myocardial infarctions … I think we often recommend too little treatment, too late.”

Dr. Easton traced a timeline for cardiovascular events among those with an average atherosclerosis risk-factor profile. Myocardial infarctions begin occurring among individuals in their 50s. About eight years later, transient ischemic attacks (TIAs) occur, followed by strokes, and finally, vascular death. “TIA and stroke occur late in the atherosclerotic process,” he pointed out.

Most neurologists get involved when the first symptomatic brain event occurs, Dr. Easton said, but noted that “you have to have a major [atherosclerotic] burden before you have your first symptom, and that’s too late.” Clinical risk-factor profiles can identify those at risk long before an initial TIA occurs, he said.

It is estimated that 85% of excess risk for premature coronary artery disease can be explained by major risk factors such as blood pressure, cholesterol, smoking, and diabetes. Research by Scott Grundy, MD, PhD, for example, suggested that when none of these risk factors is present, patients may not have an event until they are 80 years old. If all of these risk factors are present, a myocardial infarction might be expected in their 40s.

An individual’s stroke risk, however, depends on the number and severity of risk factors present. For instance, the average elderly American male by 65 or 70 years of age, without any information about risk factors, has a risk of stroke of about 0.6% within the next year, Dr. Easton said. An episode of amaurosis fugax raises that risk to 2.2%, a TIA, to about 4%, and so on. In a patient with a 90% symptomatic carotid stenosis and a number of medical risk factors, the risk of stroke gets as high as 40% per year, he said.

Major risk factors for stroke have been identified, and preventive therapies are readily available. The crucial question is when to start treatment. Recent guidelines from the sixth Joint National Committee on Hypertension describe optimal blood pressure for adults as 120/80 mm Hg; 140/90 is considered high normal, and above 140/90 is hypertension. Although cutoff points are valuable, it’s important to realize that “you are on a spectrum that is one of progressing severity,” Dr. Easton said. While it’s clear that even small reductions in blood pressure can be potent in reducing clinical events, more than half of those with demonstrated hypertension are not being treated and still fewer are actually controlled. That is without even addressing the large number of patients who do not know they are hypertensive. ACE inhibitors, just one of the range of antihypertensive agents available, promise in recent trials to have other positive benefits beyond lowering blood pressure.

The same is the case when cholesterol is considered, Dr. Easton said. According to National Cholesterol Education Program guidelines, in the absence of coronary disease, an LDL level below 130 mg/dL is “desirable” but, in the presence of coronary disease, LDL greater than 100 mg/dL calls for aggressive treatment. “With coronary disease and an LDL greater than 100 [mg/dL], we’re supposed to be aggressive, but if your LDL is 129 [mg/dL] and ... you haven’t had any coronary events, then you don’t have to do anything about it,” he said. “I would again suggest that’s nonsense; it seems to me that the horse is out of the barn.”

Statins have been shown in a number of large reliable trials to reduce heart disease events and, in some, stroke as well—not to mention osteoporosis and dementia. A variety of statin drug effects in addition to cholesterol lowering are likely contributing to these reductions, he added.

“Why shouldn’t we jump in and be aggressive?” Dr. Easton asked. He acknowledged that preventive therapies—such as antiplatelet treatment, statins, and ACE inhibitors—are not without risk.

With regard to cost, evaluations and treatments become bigger and costlier once a coronary or cerebrovascular event occurs, Dr. Easton pointed out. “The biggest cost of them all is your time in the nursing home from here on out after your major stroke.” According to Dr. Easton, it is not a question of whether too much money is spent on treatment or evaluation, but that not enough money is spent before the first event occurs.

“When I’m asked the question ‘Can we afford it?’, I put it to you that we live in an affluent society that spends hundreds of millions of dollars on beautifying conditioners and pet grooming,” he said. “So you can decide for yourself whether we can afford more aggressive prevention of disability and premature death.”

NR