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How should chronic heart diseases be managed? Here’s what the American Heart Association’s revised guidelines say


The American Heart Association (AHA) and the American College of Cardiology (ACC) revised its almost decade-old guidelines for treating chronic heart conditions such as chronic chest pain, those who have had heart attacks or surgeries to open blockages in the heart vessels, or those who are living with narrowing vessels in the heart because of fatty depositions.

The guidelines suggest fewer tests and surgeries and wider use of some of the newer diabetes medicines. Importantly, it strongly suggests a healthy diet, regular exercise, and other lifestyle changes as the cornerstone of heart health.

The guidelines say that there is no need for tests such as treadmill tests or CT Angiography in those people who have not seen a recent change in symptoms or capacity. Even then, it suggests first attempting to correct it with the usual lifestyle changes and therapies.

“It reiterates what most cardiologists already believe. There is no need for these tests routinely in everyone. However, many get it done as part of healthcare packages,” said Dr Justin Paul, director of the Institute of Cardiology at Madras Medical College.

He added, “People should focus on adopting a healthy lifestyle and modifying risk factors rather than going fishing for blockages to fix.”

Agreeing, Dr VK Bahl, principal director of cardiac sciences at Max Hospitals and former head of the department of cardiology at AIIMS-New Delhi, said: “The major problem is that this recommendation is not easily accepted by the people. These days many healthcare packages include treadmill tests. I recently had a person come to me with the report when they did not need it in the first place.”

He said that doctors will look at the age, gender, family history of heart conditions, risk factors such as diabetes and hypertension, and lifestyle factors like smoking to calculate the probability of heart attack or death due to such cardiovascular events. Based on this, they will determine whether a test is needed, and which one.

Surgery is not for all

The guidelines focus on the medical management of chronic heart diseases; experts say procedures like angioplasty, to open vessels in the heart, are needed and absolutely necessary only in very few cases.

Dr Paul said, “In the most common form of heart attack, an angioplasty performed within hours of it is beneficial. After 24 hours the risk is almost the same as the benefit.” Explaining the rationale behind the process, he said that during a heart attack, the blood supply to a part of the heart is cut off due to the blockage, and the muscles in that part start dying. An immediate angioplasty to open the blockage in time saves the muscles. “Doing a procedure later on is like watering a paddy field after the crop has already died,” he said.

The Tamil Nadu government, with Dr Paul as the nodal officer, is trying to promote immediate angioplasty across 18 healthcare centres. His team is also studying the impact of an angioplasty done between 24 to 72 hours.

Dr Bahl said in an acute condition such as a heart attack, angioplasty can be life-saving. Medical management is as effective as surgeries or procedures to re-establish blood flow in chronic conditions, except for a few for whom the medicines have stopped working, or are at a high risk of death due to cardiovascular events.

What does the guideline say about medicines to be used?

The guidelines say that statins remain the first line of treatment for high levels of bad cholesterol. “There are a lot of messages on social media against the use of statins or long-term use of the medicine. However, it continues to be the number one therapy not only for lowering the cholesterol level but also for reducing the risk of cardiovascular events. When prescribed, people should continue to take the medicine,” said Dr Paul.

Dr Bahl added: “Other medicines such as ezetimibe or bempedoic acid may be prescribed in addition to statins in case the targets for LDL (low-density lipoprotein or bad cholesterol) are not achieved. These drugs are also recommended for people who cannot take statins because of adverse effects”. He said that for people who have already had a heart attack the target LDL has been lowered to 55mg/dL, which is very low and may not be achieved through statins alone.

Doctors usually prescribe medicines, such as aspirin, which prevent clotting of the blood after a heart attack or surgery in order to open blockages. The guidelines say, “Shorter durations of dual antiplatelet therapy are safe and effective in many circumstances, particularly when the risk of bleeding is high and the ischemic risk is low to moderate.”

Dr Paul said that two anti-platelet therapies may be given for a short duration after acute symptoms, but they should not be continued for long as they may lead to bleeding. He added that long-term use is not as prevalent in Western countries where the insurance regulates how long it can be prescribed, but in India, it is sometimes prescribed for longer durations as patients pay for the medicines themselves and it is not very expensive.

Dr Bahl added: “Earlier, aspirin was prescribed to all heart patients. But the benefits of the medicine are offset by the risk of excessive bleeding. Aspirin is not recommended anymore; statins or other anti-platelet therapy may be used to prevent clots.”

Beta-blockers are a class of medicines that reduce the stress on the heart and prevent abnormal rhythms. These medicines are usually prescribed after a heart attack. “There are studies to show that there is no benefit of using the medicine beyond a year or two after the heart attack,” said Dr Bahl.

Why does it recommend wider usage of diabetes medicines?

The guidelines recommend the use of newer generations of diabetic medicines such as semaglutide and mounjaro which are also known to reduce weight even for people without diabetes. And, this is not just because it reduces the risk factor for heart disease obesity.

“Around 20 years ago, a new class of diabetes drugs called glitazones was introduced. While it effectively lowered blood sugar levels, it also increased the risk of heart failure. Since the end game is not just to reduce blood glucose levels but to prevent deaths, it was decided anti-diabetes drugs would not be approved unless they were beneficial for the heart as well,” said Dr Bahl. He said this led to the search for new molecules and the eventual discovery of SGLT-2 inhibitors and GLP-1 receptor antagonist.

“These drugs have been shown to reduce the progression of coronary artery disease and heart failure,” said Dr Bahl.

Cost of treatment

The guidelines also recommend a team-based approach where the patient makes an informed decision about their health considering social determinants such as the costs of therapies. They say:

“Some new chronic coronary disease therapies are only available as branded formulations, and their high out-of-pocket costs can impede adoption or increase the risk of cost-related non-adherence… Therefore, clinicians have a key role in ensuring access and adherence to effective therapies by regularly discussing out-of-pocket costs.”

No need for supplements, e-cigarettes

One of the key takeaways of the guidelines also states that people do not use non-prescription supplements such as fish oil, omega-3 fatty acids, or vitamins as they have shown no benefit in reducing the risk of cardiovascular events.

The guidelines also specifically mention that e-cigarettes are not recommended as a tool for smoking cessation. Although e-cigarettes increase the odds of people quitting smoking, it says, it is not recommended because of a lack of long-term safety data and the risk of sustained use of e-cigarettes.

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