Methods of Tertiary Prevention such as the type and stage of disease, the type of injury, and available methods of treatment. This chapter discusses DISEASE, ILLNESS, DISABILITY, AND DISEASE PERCEPTIONS 206 pportunities for tertiary prevention and provides specific clinical examples of disability limitation and rehabilitation IL. OPPORTUNITIES FOR TERTIARY PREVENTION 206 IlL. DISABILITY LIMITATION 207 207 . Risk Factor Modifie I. DISEASE, ILLNESS, DISABILITY, 2. Therapy 208 AND DISEASE PERCEPTIONS 3. Symptomatic Stage Prevention 208 B. Dyslipidemia 20 Although sometimes used interchangeably, there are impor- Assessment 209 tant distinctions among disease, disability, and illness. Typi 2. Therapy and Symptomatic Stage Prevention 210 cally, disease is defined as the medical condition or diagnosis C. Hypertension 210 itself (e. g, diabetes, heart disease, chronic obstructive lung 1. Assessment 210 disease). Disability is the adverse impact of the disease on 2. Therapy and Symptomatic Stage Prevention 210 objective physical, psychological, and social functioning. For D. Diabetes Mellitus 2lI example, although stroke and paralytic polio are different IV, REHABILITATION diseases, both can result in the same disability: weakness of one leg and inability to walk. Illness is the adverse impact of B. Coronary Heart Disease 212 a disease or disability on how the patient feels. One way te Rehabilitation for Other Diseases 214 distinguish these terms is to specify that disease refers to the Categories of Disability 214 medical diagnosis, disability to the objective impact on the patient, and illness to the subjective impact. V. SUMMARY 214 Disability and illness obviously derive from the medical REVIEW QUESTIONS, ANSWERS, AND EXPLANATIONS disease. However, illness is also powerfully influenced by atients' perceptions of their disease, its duration and sever ity, and their expectations for a recovery; together, these beliefs are called illness perceptions. Disease and illness In practice, tertiary prevention resembles treatment of estab- interact; a patient's illness perceptions strongly predict lished disease. The difference is in perspective. Whereas recovery, loss of work days, adherence, and health care utili treatment Is sly about"fixing what is wrong, tertiary zation. To be successful, tertiary prevention and rehabilita prevention looks ahead to potential progression and compl tion must not only improve patients' physical functioning, cations of disease and aims to forestall them. Thus, although but also influence their illness perceptions. Although there treatment and tertiary prevention often share methods, their is some evidence of effective psychological interventions on motives and goals diverge illness perceptions, a recent systematic review of interven Methods of tertiary prevention are designed to limit the tions of illness perceptions in cardiovascular health found physical and social consequences of disease or injury after it too much heterogeneity among studies to allow for general has occurred or become symptomatic. There are two basic conclusions. Despite the mixed quality of the data, the prac- categories of tertiary prevention. The first category, disabil- ticing clinician should consider the patients' illness percep ity limitation, has the goal of halting the progress of the tions, if only to understand which patients are at high risk disease or limiting the damage caused by an injury. Thi of poor outcomes. ategory of tertiary prevention can be described as the " pre ention of further impairment. The second categ rehabilitation, focuses on reducing the social disability pro duced by a given level of impairment. It aims to strengther l. OPPORTUNITIES FOR the patient's remaining functions and to help the patient TERTIARY PREVENTION learn to function in alternative ways. Disability limitation ind rehabilitation usually should be initiated at the same The first sign of an illness provides an excellent opportunity time (i.e, when the disease is detected or the injury occurs), to initiate methods of tertiary prevention. The sooner dis- but the emphasis on one or the other depends on factors ability limitation and rehabilitation are begun, the greater 206
CHAPTER Methods of tertiary prevention 207 the chance of preventing significant impairment In the case I. Risk Factor Modification f infectious diseases, such as tuberculosis and sexually transmitted diseases, early treatment of a disease in one When cardiovascular disease becomes symptomatic (e.g erson may prevent its transmission to others, making treat with a heart attack), the acute disease needs to be addressed ment of one person the primary prevention of that disease with interventions, such as thrombolysis, rhythm stabiliza- in others. Similarly, early treatment of alcoholism or drug tion, and perhaps stents or surgical bypass. When a patient diction in one family member may prevent social and is stabilized, the risk factors to be addressed to slow or reverse emotional problems, including codepende im de disease progression are generally similar to those for primary oping in other family members prevention, but the urgency for action is increased. The fol Symptomatic illness can identify individuals most in need lowing modifiable risk factors are important to address when of preventive efforts. In this sense, the symptoms function cardiovascular disease has already occurred: hypertension similar to screening, by defining individuals especially in smoking, dyslipidemia, diabetes, diet, and exercise. health promotion and disease prevention messages. When ne nt prad ice, which risk factor to address first should be they become ill, however, they may understand for the first tant risk factor to modify should be the one the patient is time the value of changing their diet, behavior, or environ- actually motivated and able to change Any change there will ment. Forexample, a person at risk for coronary artery disease improve risk, and successful behavior change in one area can who has experienced no symptoms will generally be less open provide motivation for further change later to changes in diet and exercise than someone who has expe rienced chest pain. The onset of symptoms may provide window of opportunity for health promotion aimed at pre CIGARETTE SMOKING venting progression of the disease ("teachable moment") Smoking accelerates blood clotting, increases blood carbon cular disease is used here to illustrate the approach monoxide levels, and causes a reduction in the delivery of to prevention after the disease has made its presence known. oxygen. In addition, nicotine is vasoconstrictive(causes blood However, almost any hospitalization or major life event(e.g, vessels to tighten). The age-related risk of myocardial infarc- pregnancy, birth of a grandchild can be a teachable moment tion(MI)in smokers is approximately twice that in non- for patients, and the prognosis for most diseases improves smokers. For individuals who stop smoking, the excess risk ith better diet exercise, and adherence. declines fairly quickly and seems to be minimal after 1 year of nonsmoking Smoking cessation is probably the most effective behavioral change a patient can make when cardio vascular disease is present. Smoking cessation also helps to I. DISABILITY LIMITATION slow related smoking-induced problems most likely to com plicate the cardiovascular disease, such as chronic obstruc Disability limitation includes therapy as well as attempts to tive pulmonary disease(COPD) halt or limit future progression of the disease, called symp- tomatic stage prevention. Most medical or surgical therapy f symptomatic disease is directed at preventing or minimiz- DIABETES MELLITUS ing impairment over the short-term and long-term. For Type 2 diabetes mellitus increases the risk of repeat MI example, both coronary angioplasty and coronary artery or restenosis (reblockage)of coronary arteries. Keeping pass are aimed at both improving function and extending the level of glycosylated hemoglobin(a measure of blood ife. These are attempts to undo the threat or damage from sugar control; e.g. Hb Ale)at less than 7% significantly an existing g disease, in this case, coronary artery disease reduces the effect of diabetes on the heart, kidneys, and (CAD). The strategies of symptomatic stage prevention eyes ties advocate treating diabetes as a lude the following coronary heart disease equivalent, based on a Finnish study 1. Modifying diet, behavior, and environment that showed that patients with diabetes(who had not had 2. Screening frequently for incipient complications attack)had a similar risk of Mi as patients wit 3. Treating any complication that is discovered lished CAD. Even though this study's methods and results are in dispute, the management of diabetes mellitus has n this section, CAD, hyperlipidemia, hyperten shifted. The approach no longer focuses only on suga nd diabetes mellitus are used to illustrate how methods control, but instead aims for multifactorial strategy to ider of disability limitation can be applied to patients with tify and target patients' broader cardiovascular risk factors. chronic diseases. The emphasis is on symptomatic stage This approach includes treating lipids and controlling blood pressure(BP) A. Cardiovascular Disease HYPERTENSION Cardiovascular disease encompasses coronary artery disea Any hypertension increases the risk of cardiovascular disease, erebrovascular accident(CVA, stroke), heart failure, and and severe hypertension(systolic BP 2195 mm Hg)approxi peripheral artery disease(PAD). If cardiovascular disease has mately quadruples the risk of cardiovascular disease in already occurred, the clinician's immediate goal is to prevent middle-aged men. Effects of hypertension are direct death and damage. Beyond that, the clinicians (damage to blood vessels)and indirect(increasing demand goal is to slow, stop, or even reverse the progression of the on heart). Control of hypertension is crucial at this stage disease process prevent progression of cardiovascular disease
208 SECTION 3 Preventive medicine and public Health SEDENTARY LIFESTYLE has progressed when the patient comes under medical care. Even in the presence of severe CAD, there may be little or no It seems that at least 30 minutes of moderate exercise (. g, warning before MI occurs. After acute medical and surgical fast walking )at least three times per week reduces the risk therapy (tertiary prevention) is provided, the provider of cardiovascular disease. There is increasing evidence that should initiate efforts directed at symptomatic stage preven- sittingitself, independent of the amount of exer sa it is tion(also tertiary prevention in this case) the risk of MI. The uncertainty occurs partly because difficult to design observational studies that completely 3. Symptomatic Stage Prevention avoid the potential bias of self-selection ncipient heart disease may have cues that tell them to avoid Every patient with symptomatic cardiac disease needs evalu potential benefits of even modest. easing emphasis on the ation for risk factors and a plan to reduce the risk of adverse exercise). Nevertheless, there is ine direct effects on lipids and also helps to keep weight down, gone revascularization(opening up blocked arteries)through which itself improves the blood lipid profile. Conversely, percutaneous transluminal coronary angioplasty(cardiac there is a growing appreciation for adverse health effects of catheterization) or coronary artery bypass surgery, the goals sedentariness nclude preventing restenosis and slowing the progression of atherosclerosis elsewhere EXCESS WEIGHT In people who are overweight, the risk for cardiovascular BEHAVIOR MODIFICATION disease partly depends on how the body fat is distributed. Fat Patients should be questioned about smoking, exercise, and an be distributed in the hips and legs (peripheral adiposity eating habits, all of which affect the risks of cardiovascular giving the body a pear shape) or predominantly in the disease. Smokers should be encouraged to stop smoking(see bdominal cavity(central adiposity, giving the body an apple Chapter 15 and Box 15-2), and all patients should receive shape, more common in men than women. Fat in the hips nutrition counseling and information about the types and and legs does not seem to increase the risk of cardiovascular appropriate levels of exercise to pursue Hospitalized patients sease. In contrast, fat in the abdominal cavity seems to be with elevated blood lipids should be placed on a"heart more metabolically active, and the risk of cardiovascular healthy diet(see Chapter 19)and encouraged to continu disease is increased. This is not surprising, because fat mobi this type of diet when they return home. This change in diet lized from the omentum goes directly to the liver, which is the requires considerable coaching, often provided by a special center of the body s lipid metabolism. Centrally located body ized cardiac rehabilitation nurse, dietitian, or both fat is implicated in the insulin resistance syndrome and is asso- ciated with increased sympathetic tone and hypertension Weight loss ameliorates some important cardiac risk OTHER MEASURES The assessment and appropriate management of known risk studies question this conclusion. The most recent findings events in patients with symptomatic CAD in this area suggest that weight gain and loss may result in lasting hormonal and cytokine alt erations that facilitate B. Dyslipidemia regaining weight. Although weight cycling may have spe cific associated risks, whether any such risks are truly inde pendent of obesity itself remains unclear. 3-l6At tion in one or more of the lipids or lipid particles found emia, is a general term used to ibe an abnormal elev expert opinion generally supports a benefit from ape ve/ght on the following with greater benefit clearly attached to sustain the blood. The complete lipid profile provides information loss(http://www.nwcr.ws/).acHievingsustain loss remains a considerable challenge(see Chapter 19) Total cholesterol (TC) High-density lipoprotein(HDL) cholesterol DYSLIPIDEMIA a Low-density lipoprotein(LDL) cholest The risk of progression of cardiovascular disease is increased a Very-low-density lipoprotein(VLDLcholesterol, which in patients with dyslipidemia(abnormal levels of lipids and is associated with triglycerides(TGs) the particles that carry them), which can act synergistically The TC level is equal to the sum of the HDL, LDL, and with other risk factors(see later and also Chapter 5, espe VLDL levels cially Table 5-2, and Chapter 19). Disease progression can be slowed by improving blood lipid levels or by address TC=HDL+LDL+ VLDL other modifiable risk factors(e.g, hypertension, diabete (HDL)+(LDL)+(TGs, that benefit from diet and exercise The"good cholesterol, "HDL, is actually not only cholesterol 2. Therapy but rather a particle(known as apoprotein) that contains cholesterol and acts as a scavenger to remove excess choles- The immediate care and long-term care of patients with terol in the body(also known as reverse cholesterol transport) symptomatic CAD depend on the extent to which the disease HDl is predominantly protein, and elevated HDL levels have
CHAP TER 7 Methods of Tertiary Prevention 209 been associated with decreased cardiovascular risk. LDL, the for example, TC tends to be normal, but there is an adverse bad cholesterol, is likewise not just cholesterol bi pattern of lipoproteins-high triglycerides and low HDL. ticle that contains it. Elevated LDL levels have been associ- This pattern originally was discerned in the Framingham ated with increased cardiovascular risk. A high level of Heart Study and is sometimes referred to as syndrome X In chegenesis(development of fatty arterial plaques ). Much of as the presence of a non-HDL cholesterol level 200 mg/dL damage may be caused by oxidative modification of the or greater on two successive measurements, Many clini LDL, making it more atherogenic. 2 VLDL, another "bad cians find this index useful because it uses the total contribu cholesterol, " is actually a precursor of LDL. The particle is tion of cholesterol fractions currently considered harmful predominantly triglyceride. Some specialists pay attention to the ratio of the tc level to he previous formulas clarify why total cholesterol alone the HDL level, as discussed later is not the best measure for cardiovascular risk, cholesterol is cholesterol, but the risk for heart disease comes from how is packaged in different VLDL, LDL, and HDL particles HIGH-DENSITY LIPOPROTEIN LEVEL Additional measures of potential interest in risk stratifica- In general, the higher the HDL level is, the better. The tion are related to lipids not routinely included in the lipid minimum recommended HDl level is 50 mg/dL in women panel. These include HDL subfractions, the size and density and 40 mg/dL in men. An HDL level less than 40 mg/dL is of LDl particles, and lipoprotein(a), or Lp(a) lipoprotein. of special concern if the LDL level or the triglyceride level is high(see later). An HDL level greater than 60 mg/dL is L. Assessment considered a negative risk factor, or a protective factor, reducing an individuals risk of cardiovascular disease A variety of index measures have been proposed to assess the need for intervention and to monitor the success of preven- tive measures. The most frequently used guidelines are those LOW-DENSITY LIPOPROTEIN LEVEI of the Third National Cholesterol Education Program In an adult without known atherosclerotic disease or major NCEP),as modified based on more recent research. This risk factors for cardiovascular disease, an LDL level of less discussion and Table 17-1 indicate the levels of blood lipids than 130 mg/dL is considered acceptable, and another lipid suggested by the widely accepted NCEP recommendations profile is recommended within 5 years. If the LDL is border for deciding on treatment and follow-up. New NCEP recom- line elevated(130-159 mg/dL), and the patient has no more mendations are expected in 2012 than one cardiovascular risk factor, the lipid profile should be repeated within I year. If two or more risk factors are resent, however, dietary and lifestyle changes should be TOTAL CHOLESTEROL LEVE recommended. If the LDL level is 160 mg/dL or greater, Some screening programs measure only the total cholesterol dietary and lifestyle changes should be recommended, and (TC)level. In adults without known atherosclerotic disease, lipid-lowering therapy should be considered. A LDL greater a TC level less than 200 mg/dl does not require the need for than 190 mg/dL usually calls for pharmacotherapy action, although the level should be checked every 5 years. A In the presence of demonstrated atherosclerotic disease level between 200 and 239 mg/dL is considered borderline or multiple major risk factors, the criteria have been tight high, and a fasting lipid profile is recommended, with action ened. LDL was the primary focus of the revisions to the determined on the basis of the findings. If TC level is 240 NCEP-Ill recommendations. For high-risk patients,an in addition, lipid-lowering drugs should be considered lts mg/dL or greater, d enosiS based on a fasting lipid prof LDL level of 100 mg/dL or more should lead to the institu- eded, and dietary and lifestyle changes should be initia ion of dietary and lifestyle changes and to treatment with lipid-lowering medications. The NCEP-lIl recommenda The TC level may be misleading and is a poor summary tions state that the Ldl target should be less than 70 mg/dL measure of the complicated lipoprotein-particle distribu- in very-high-risk patients, such as patients with CAD or tions that more accurately define risk In insulin resistance, CAD equivalents, such as peripheral vascular disease, carotid Table 17-l Evaluation of Blood Lipid Levels in Persons without and with Coronary Risk Factors or Coronary Artery Disease(CAD) Lipid Fraction Optimal mg/dL Acceptable mg/dL Borderline mg/dL Abnormal mg/dL For Persons with No CAd and No more than One Risk Factor* Total cholesterol 200 200-239 100-129 130-159 40-59 Triglycerides For Persons with Major CHD Risk Factors or Existing CHD LDL isk factors are cigarette smoking, diabetes, hypertension, and family history of early CAD CHD, Coronary heart disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; mg/dL, milligrams per deciliter
SECTION 3 Preventive medicine and public health or diabetes mellitus. Achieving this target exercise, and smoking cessation) before prescribing a lipid Isually requires aggressive statin therapy along with good lowering medication, such as an HMG-CoA reductase diet and ise(see Table 17-1). inhibitor(statin drug). When CAD becomes symptomatic, lifestyle modifications and drug treatment(usually statins) TRIGLYCERIDE AND VERY-LOW-DENSITY LIPOPROTEIN LEVEL should be started as soon as possible. When statins are not well tolerated or do not achieve targeted lipid reductions on The VLDL level can be determined for most patients by their own, newer drugs, such as ezetimibe, are available dividing the triglyceride(TG) level by 5. The desired TG level Although newer drugs may improve lipid numbers, however, is less than 150 mg/dL. Although levels greater than 200 mg/ as yet there is no good evidence that these improve patient dL were previously considered reasons for concern and treat outcomes, such as preventing heart attacks and strokes or ment,the clinical perspective on TG levels is evolving. Some delaying death experts believe that treating high tG levels may not be helpful in mitigating the risk of cardiovascular disease, and C. Hypertension >500 mg/dL)to reduce the risk of pancreatitis In the United States, 43 million to 50 million people are estimated to have hypertension, and approximately half have TOTAL CHOLESTEROL-TO-HIGH-DENSITY LIPOPROTEIN RATIO not yet been diagnosed. Groups at increased risk include pregnant women, women taking estrogens or oral contra Some investigators monitor the TC/HDL ratio. Using this ceptives, elderly persons, and African Americans. Children approach, one group reported that angiograms in patients also are at risk for hypertension ith a TC/HDL ratio greater than 6.9 showed progression of The Joint National Committee on Prevention, Detection coronary atherosclerosis during the study, whereas those in ivaluation, and Treatment of High Blood Pressure (NC) patients with a lower TC/HDL ratio did not show progres- convened by the National Heart, Lung, and Blood Institute n.Currently, a TC/HDL ratio of less than 4.5 is recom- It publishes period reports addressing the diagnosis, treat mended if atherosclerotic disease is absent, and a ratio of less ment, and prevention of hypertension. According to the than 3.5 is recommended if atherosclerotic disease is present. Seventh Joint National Committee Report (NC 7), hyper- tension is defined as an average systolic BP of 140 mm Hg or TRIGLYCERIDE-HIGH-DENSITY LIPOPROTEIN RELATIONSHIP greater, or an average diastolic BP of 90 mm Hg or greater, when blood pressure is properly measured on two or more Research suggests that the combination of an HDL level less occasions in a person who is not acutely ill and not taking than 30 mg/dL and a TG level greater than 200 mg/dL places antihypertensive medications. These levels are high enough an individual at high risk for CAD, and the possibility of for treatment to bring proven benefits. New recommenda- genetic hyperlipidemia should be considered. This pattern is tions from JNC 8 are expected in 2012 often associated with insulin resistance and hypertensi sometimes referred to as the metabolic syndrome. This adverse pattern, as noted earlier, may be concealed by a normal"total cholesterol level. This is one reason why lipid Hypertension may be detected by community or occupa screening should generally include the standard panel rather tional screening, by individual case finding (e.g., when a than total cholesterol alone person seeks care for dental problems or for medical prob ems unrelated to hypertension), or when a person develops HOMOCYSTEINE LEVEL one or more common complications of hypertension, such as visual problems, early renal failure, congestive heart Elevated homocysteine levels are associated with an increased failure, stroke, or MI. Over the last 20 years, the risk of mor risk of atherogenesis. Thus far, however, interventions tality from CAD and stroke in hypertensive individuals has through dietary supplements of folic acid, pyridoxine, or decreased, in part because of the early detection and vitamin B,2 have not shown improved outcomes. Some improved management of high blood pressure. However, believe that homocysteine is merely a marker for the true" much still remains to be done Only slightly more than one culprit. Likewise, all the lipid fractions, lipoprotein particles, third of patients with hypertension are"well controlled and indices previously discussed may actually be markers of (up from 29% in 2000). This fact underscores how the true culprits; none is consistently explanatory, and lives could be saved and how much disability could be improving the patient's numbers, even for the most explan vented if we were better at delivering consistent car patien mponents, does not consistently lead to improved Chapter 28) Table 17-2 provides information regarding the evaluation and staging of hypertension, based on average systolic BP 2. Therapy and Symptomatic Stage Prevention and diastolic BP. In addition to listing the ranges for normal BP and prehypertension, Table 17-2 shows the ranges for two Any primary care clinician should be able to treat patients stages of hypertension with a moderately elevated total cholesterol level or abnor ma! lipid levels and should be aware of the therapeutic 2. Therapy and Symptomatic Stage Prevention probably should be treated by specialists, however. In the After the stage of nyp following actions(see also Table pertension has been determined primary prevention of CAD, clinicians should recommend a JNC 7 recommends trial of lifestyle modifications(dietary changes, increased 17-2). Individuals with normal blood pressure should be