Each paper in the series will focus on a different behavioral consideration that impacts cardiovascular health: nutrition and diet; healthy weight; exercise and physical activity; tobacco-free lifestyle; blood pressure; cholesterol; blood sugar; and psychological health.

In the first review paper, the authors state that diet modification can be a vital step to prevent cardiovascular disease. While various biological, economical, physical, social and psychological factors influence food choices, interventions targeting these factors can lead to meaningful improvements in long-term eating habits.

Edward Yu, ScD, et al., explain that research has consistently shown that a healthy diet – particularly one high in fruits, vegetables, whole grains, fish, nuts and legumes and low in processed meats, refined grains, sodium and sugary beverages – is associated with the prevention of heart disease.

However, many people face roadblocks in achieving an ideal diet. Higher prices, lack of nutritional knowledge and a limited availability of healthy food – or “food deserts” – can all contribute to a poor diet in low income and minority populations.

Large amounts of sugar and sodium are added to processed food products to help make them more palatable. Social determinants such as culture, community, friends, family and social media can also have an influence over food choices.

To help improve diets, the authors recommend policy strategies across multiple levels, including nutrition labeling, taxing sugar-sweetened beverages, providing economic incentives for the production of healthy foods, regulating food marketing, promoting healthy school and work environments, and funding educational campaigns.

“Given the magnitude of the cardiovascular disease burden in the U.S. and globally and the complexity of dietary risk factor modification, simultaneous prevention strategies and policies across multiple societal levels are needed to make a measurable impact on reducing prevalence rates,” says senior author Frank B. Hu, MD, PhD. “Health professionals and community leaders have a great responsibility to promote cardiovascular health and disease prevention but require a basic nutrition knowledge base. A concerted effort from all levels of society will be needed to fundamentally change the current food environment and global food system.”

On the tobacco front, both prevention of smoking initiation among youth and smoking cessation among established smokers may be crucial for reducing smoking prevalence and its associated negative health consequences.

Sara Kalkhoran, MD, MAS, et al., examined policies to achieve complete cigarette abstinence as part of efforts to reduce the risk of heart disease. They found that tobacco use can be characterized as a chronic disease beginning in childhood because nearly all cigarette smokers report they smoked their first cigarette during adolescence and then continue to use tobacco for decades.

The authors note that multiple factors influence the initiation and maintenance of tobacco use and are categorized into levels of influence: intra-individual, interpersonal, community and organizational, and societal and policy.

They explain that since tobacco use causes more than six million annual deaths and is the leading preventable cause of death worldwide, clinicians who care for patients with cardiovascular disease should give as high a priority to treating tobacco use as to managing other cardiovascular disease risk factors.

Furthermore, the authors describe the importance of broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass media campaigns and restrict tobacco marketing. They also suggest that clinicians should routinely screen for tobacco use and secondhand smoke exposure with patients, provide smoking cessation intervention in the hospital and post discharge, and offer evidence-based smoking cessation treatments to all current smokers at every visit.

“Increasing adoption and effective implementation of tobacco control policies is a key worldwide public health priority,” they write. “Given the importance of tobacco abstinence for cardiovascular health, cardiologists can act as tobacco control advocates to help reduce smoking initiation among youth and young adults and promote smoking cessation among adults at-risk for or already affected by cardiovascular disease.”

Yu E, Malik VS, Hu FB. J Am Coll Cardiol 2018;72:914-26. Kalkhoran S, Benowitz NL, Rigotti NA. J Am Coll Cardiol 2018;72:1030-45.

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In the final analysis, there were 16,244 patients, of whom 4,061 were taking edoxaban and 12,183 taking warfarin. Their median age was 72 years and median CHA2DS2-VASc score was 3.

During follow-up, the incidence of ischemic stroke was 3.22 per 100 person-years and 3.89 per 100 person-years for edoxaban and warfarin, respectively. The risk of ischemic stroke was significantly lower with edoxaban than with warfarin (hazard ratio, 0.693; p=0.033).

Edoxaban, compared with warfarin, was associated also with a lower risk for all the other studied endpoints: ICH reduced by 60 percent, hospitalization for GI bleeding by 40 percent, hospitalization for major bleeding by 47 percent and all-cause death by 28 percent. Patients receiving edoxaban 60 mg and 30 mg showed trends toward better outcomes for most clinical events compared with warfarin.

According to the authors, this is the first study to examine the effectiveness and safety of edoxaban compared with those of warfarin in a population-based cohort.

Lee S-R, Choi E-K, Han K-D, et al. J Am Coll Cardiol 2018;72:838-53.

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Results showed that 8.3 percent of the trastuzumab-treated patients developed heart failure vs. 2.7 percent of patients who did not receive trastuzumab. As age increased, there was a consistent increase in the risk of heart failure.

Among patients treated with trastuzumab, 46.2 percent received guideline-adherent cardiac monitoring, which according to the National Comprehensive Cancer Network begins before initiating treatment and occurs every three months while on treatment. Therapies using anthracyclines, taxanes and radiation were associated with guideline-adherent monitoring.

Researchers said there could be many explanations for the low rates of cardiac monitoring seen in the trastuzumab-treated patients, including a low perceived need on the part of physicians rather than lack of awareness of guidelines.

“We must remember that while cardiac monitoring is recommended in different guidelines, such recommendations are not based on category 1 data, and the timing recommended, and the intervals of testing are rather arbitrary,” says Henry. “In examining the rate of both cardiac monitoring and cardiotoxicity we could begin to address the controversial issue of whether cardiac monitoring is warranted in young breast cancer patients.”

Henry ML, Niu J, Zhang N, et al. JACC Cardiovasc Imaging 2018;11:1084-93.

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“There is no perfect, one size fits all dietary pattern for preventing heart disease,” says lead author Andrew M. Freeman, MD, FACC. “But, most of the evidence continues to reinforce that a predominantly plant-based diet lower in fat, added sugars, added salt, processed foods, and with limited if any animal products seem to be where the data are pointing us. It is important for clinicians to stay on top of rising food trends and current scientific evidence to provide meaningful and accurate nutritional advice for patients.”

This the second JACC perspective from ACC’s Prevention of Cardiovascular Disease Council discussing food trends. The first review found that current evidence strongly supports eating plenty of fruits, vegetables, whole grains, legumes and nuts in moderation. It also covered eggs and cholesterol, vegetable oils, berries and antioxidant supplementation, nuts, juicing and gluten.

Freeman AM, Morris PB, Aspry K, et al. J Am Coll Cardiol 2018;72:553-68.

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