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
CHAP TER 7 Methods of Tertiary Prevention Table 17-2 Evaluation of Blood Pressure(BP)and Staging of Hypertension, Based on Average Systolic BP and Diastolic BP in Persons Not Acutely Ill and Not Taking Antihypertensive Medications' Systolic BP(mm Hg) Diastolic BP(mm Hg) nterpretation Initiate Drug Treatment? Normal BP 20-139 8C-89 Prehypertension some cases 140-159 Stage I hypertension Yes: thiazides for most tage 2 hypertension hypertension. Not 一标 alifies is taken as the stage of hypertension. For example, if systolic is 165 and diastolic 95 mm Hg, this is stage monitored at 2-year intervals. Individuals with prehyper- and vasodilators. Although many antihypertensive medica- ension should be counseled about lifestyle changes and tions cause significant side effects, the wide range of choices should be used to develop a treatment plan that is satisfac tension should begin diet and lifestyle changes and should tory to the patient. diet and lifestyle changes and should be trea. should begin In controlled clinical trials, thiazide-type diuretics have other drugs. Thiazide diuretics should be used with caution cian should check for any evidence of target organ damage, in elderly patients because of possible orthostatic hypoten ecause any stage of hypertension is more severe if there is sion(lightheadedness or fainting), acute renal failure, and evidence of such damage electrolyte imbalances (particularly low potassium). Beta Most hypertension is classified as essential hypertension, blockers are a good choice for patients who have CAD, heart aning that the specific underlying cause is unknown. failure, or diabetes. Beta blockers are contraindicated Depending on the patient, however, hardening of the arter- however, in patients with conduction abnormalities, and car s,fluid retention, or changes in the renin-angiotensin- dioselective beta blockers are often used in patients with aldosterone system may be involved. Nonessential asthma or COPD. Beta blockers seem to be less effective as secondary)hypertension is caused by other, often treatable first-time treatment of high BP in patients without heart auses, such as renal artery disease, chronic kidney disease, disease; meta-analyses suggest an association with increased r obstructive sleep apnea. risk of cardiovascular events and death. 2 Symptomatic stage prevention and therapy are aimed at In the heart Outcomes Prevention Evaluation(HOPE) reducing systolic BP to less than 140 mm Hg, reducing dia trials, investigators found clear evidence that ACE inhibitors tolic BP to less than 90 mm Hg, and monitoring patients to can prevent deaths caused by MI and stroke and can reduce nsure that these levels are maintained. The goal is to prevent the mortality in many groups of high-risk cardiac patients damage to the organs at risk from hypertension to prevent However, ACE inhibitors should not be used in patients who disability, organ failure, and death. For patients with any might become pregnant( due to the risk of birth defects)or of hypertension, the following lifestyle modifications in patients who have bilateral renal artery stenosis dicated: weight reduction, increased physical activity, and institution of a healthy diet. In the Dietary Approaches D. Diabetes Mellitus to Stop Hypertension(DASH)trials, investigators found that instituting a diet that was rich in fruits, vegetables, grains, More than 26 million people in the United States have dia- and nonfat dairy products was associated with a reduction betes, and this number is rising. If current trends continue, in systolic BP, and even greater BP reductions were seen if one in three adults will have diabetes by 2050. About 5% sodium intake was restricted to no more than 1200 mg/day. of diabetic patients have type 1 diabetes mellitus, a disease Other dietary measures to reduce BP include the moderation that requires lifelong treatment with insulin and places them of alcohol intake and an increase in the intake of potassiun at higher risk for a variety of cardiovascular, renal, and other lcium, and magnesium Smokers should be encouraged serious complications. The remaining 95% of patients have stop smoking, because smoking cessation reduces the risk type 2 diabetes mellitus, usually associated with obesity and damage to many of the sam hat hypertension insulin resistance Much can be done to prevent ta For patients whose BP levels remain elevated despite these diabetes, as shown in the landmark Diabetes Control and estyle modifications, use of one or more antihypertensive Complications Trial (DCCT)and the United Kingdom Pro medications is indicated, Because most hypertension is spective Diabetes Study(UKPDS) In patients with type 1 asymptomatic, providers must counsel patients about the diabetes, DCCT showed that improved control of blood importance of taking medications and the risks of stopping glucose levels significantly reduced the incidence of micro- treatment. The major classes of effective antihypertensive vascular disease(retinopathy, nephropathy, neuropathy) agents include diuretics, beta blockers, angiotensin- and reduced the incidence of macrovascular disease(ath converti g enzyme(ACE) inhibitors, angiotensin receptor erosclerosis of large blood vessels, MI, angina pectoris, blockers(ARBs), calcium channel blockers, alpha blockers, stroke, aneurysm, amputations of distal lower extremity). 32
12 SECTION 3 Preventive medicine and public health Similarly, in patients with type 2 diabetes, UKPDS found progress back from an illness, but the initiation of rehabilita- that in general the lower the average glycemic level in tion should be incorporated into the patient's care from th patients, the fewer the complications Patients in the DCCT intervention group had to self monitor their blood glucose level, keep detailed records of sulin dosage and glucose level, regulate dietary intake and A. General Approach level of insulin based on self-monitoring results, and be Rehabilitation must begin in the early phases of treatment if actively involved in other aspects of their care. Although the it is to be maximally effective. In patients who have had a risk of hypoglycemic episodes was three times as high in the stroke, head injury, hip fracture, or other problem that tem intervention group as in the control group, no serious porarily immobilizes them, it is important to keep joints sequelae of hypoglycemia occurred in the intervention flexible from the beginning of the illness or injury, so that group. One death from hypoglycemia occurred in the control weakened but recovering muscles do not have to overcome betia p. Weight gain was a common side effect of tight dia stiffened joints. Beginning rehabilitation efforts early also tends to increase the cooperation of patients and family Based on the results of DCCT,"tight control"(defined as members by conveying to them that improvement is expected control as good as that obtained in DCCT) may benefit The most effective rehabilitation program is tailored to patients who are willing to participate actively in their own meet the physical, emotional, psychological, and occupa are. Currently, the most used definition of tight control is tional needs of the individual. As stated earlier, these pro hemoglobin Alc(glycohemoglobin, or sugar linked to Hb) grams also need to address pa values less than 7% of total hemoglobin. Many U.S. patients Often. a rehabilitation counselor coordinates the efforts of with diabetes may have glycohemoglobin above the recom- a team of specialists. Physical therapists work to strength mended level(57% with Hb Alc <7% in 2004). Tight weakened muscles, increase joint movement and flexibility, control should be supplemented with frequent examination and teach patients ways of accomplishing routine tasks of the retina and with laser treatment of microvascular despite their disabilities. These tasks, or activities of daily lesions when indicated. The use of ACE inhibitors has proved living(see Chapter 14), include feeding oneself, transferring valuable not only in controlling hypertension but also in from bed to chair and back, grooming, controlling reducing the incidence of microalbuminuria (albumin bladder and bowels, bathing, dressing, walking on a level protein in the urine)a sign of diabetic kidney damage, and surface, and going up and down stairs, Speech therapists seek delaying the onset of diabetes-induced renal failure. to improve the ability of patients to articulate their thoughts All patients with type I or type 2 diabetes should be after a stroke or head injury that produces aphasia, and they dvised of the need for moderate to high levels of physical may help to evaluate whether or not stroke patients can activity and should receive individual counseling about swallow food safely. Occupational therapists evaluate the nutrition. They should be informed of the common compli- occupational abilities of patients, counsel them regarding cations of diabetes and the importance of contacting their suitable types of work, provide them with job training or y note early ly symptoms of any of these retraining, and help them find a suitable job. Usually, the complications most cost-effective efforts are those designed to help a Many other hypoglycemic agents are being used to redr patient return to the previous place of employment. Some insulin resistance before it develops into frank type 2 diabe- patients may be able to resume their job, whereas others may tes. Current interest centers particularly on biguanides obtain a new or modified job there. Psychiatric or emotional metformin) and thiazolidinediones (glitazones ), which ounseling may be important, as may be spiritual counseling are more effective when used in combination than used by a member of the clergy. There also are specialists in alone. Oral hypoglycemic agents that act by stimulating the cardiac and pulmonary rehabilitation pancreas to produce more insulin(sulfonylureas, short- acting secretagogues)also are being used, but over time these B. Coronary Heart Disease ay exhaust the beta cells ability to make insulin. Oral hypoglycemics also tend to foster weight gain, which com Coronary heart disease (or CAD)was the first disease for pounds the problem of insulin resistance. The role, safety, which rehabilitation programs were developed, and these and impact on outcomes of newer agents such as glucago programs still provide the template for most rehabilitation. like peptide-1 analogs, incretins, amylin analogs, and di Most cardiac rehabilitation programs follow defined compo tidy peptidase-4 (DPP-4) inhibitors are not yet fully nents and stages"(Table 17-3). Core components of reha- established. For most patients, metformin should be the bilitation for all cardiac conditions include a comprehensive first-line agent assessment of the patient's clinical and functional status. This information provides the basis for a rigorous program aimed at gradually improving physical functioning, risk N. REHABILITATION factor profile, and psychosocial status Occurring after disease already has caused damage, rehabili tation may seem to take place when there is nothing left to BLOOD PRESSURE MONITORING prevent. However, the goal of rehabilitation is to reduce the If resting systolic BP is 130 to 139 mm Hg or diastolic BP social disability produced by a given level of impairment, both 85 to 89 mm Hg, recommend lifestyle modifications, by strengthening the patients remaining functions and by management,sodium restriction, and helping the patient learn to function in alternative ways moderation of alcohol intake(<30 g/day in men; <15 g/ Often, rehabilitation specialists can contribute to a patient's lay in women), according to DASH diet
CH ER 7 Methods of tertiary pr 213 Table 17-3 Core Components of Cardiac RehabiLitation (post-ACS and post-PCI) Component Established/Agreed Issues Class(Level) Issues? Patient assessment Clinical history: review clinical courses of ACs I(A) Physical examination: inspect puncture site of PCI and emities for presence of arterial pulses. by bicycle ergometry or treadmill maxi stress test(cardiopulmonary exercise test if available)within 4 weeks after acute events, with maximal testing at 4-7 weeks Physical activity Exercise stress test guide: With exercise capacity more than 5 Should resistance METs without symptoms, Patients can resume routine physical activity 2 physical activity; otherwise, patients should resume physical days per week be activity at 50% of maximal exercise capacity and gradually Physical activity: Slow, gradual, progressive increase of moderate ass IIb [C))(21 intensity aerobic activity, such as walking, climbing stairs, and cycling, supplemented by an increase in daily activities (e.g. gardening, housework Exercise training Program should include supervised, medically prescribed, I(B Low risk patients: At least three sessions of 30-60 min/wk rcise at 55%0-70% of m workload (METs 二 HR at onset of symptoms; 21500 kcal/wk to be expend Resistance exercise: At least I hr/wk with intensity of 10-1 repetitions per set to moderate fatigue. I(C) (physical activity) to avoid weight gain Weight control Mediterranean diet with low levels of cholesterol and saturate I (B) anagement Statins for all patients, intensified to a lipid profile of cholesterol: <175 mg/dL, or <155 mg/dL in high-risk patients LDL-C: <100 mg/dL, or <80 mg/dL in high-risk patient Triglycerides: <150 mg/dL Blood I(B) lifestyle modification and drugs if necessary to treat to cessation bout tobacco and intervene according to stage of change Psychosocial for distress and intervene if necessary I(B) Modified from Piepoli MF et al: Eur J Cardiovasc Prev Rehabil 17: 1-17, 2010. ACS, Acute coronary syndrome; HR, heart rate; LDI-C, low-density lipoprotein cholesterol; METS, metabolic equivalent tasks; PCI, Primary percutaneous coronary intervention If resting systolic BP is 140 mm Hg or greater or if dia a Assess for psychosocial factors that may impede success. stolid BP is 90 mm Hg or greater, initiate drug therapy. Intervention: provide structured follow-up Offer behav- Expected outcomes are BP less than 140/90 mm Hg(or ioral advice and group or individual counseling <130/80 mm Hg if patient has diabetes or heart or renal Offer nicotine replacement therapy, bupropion, varen- failure)and BP less than 120/80 mm Hg in patients with cline, or both. The expected outcome is long-term absti left ventricular dysfunction nence from smoking a Manage psychosocial issues SMOKING CESSATION Screen for psychological distress, as indicated by clinically All smokers should be professionally encouraged to stop usin ignificant levels of depression, anxiety, anger or hostility, all forms of tobacco permanently. Follow-up, referral to special socialisolation, marital/family distress, sexual dysfunction rograms,and pharmacotherapy(including nicotine replace adjustment, and substance abuse of alcohol and/or other nent)are recommended, as a stepwise strategy for smoking psychotropic agents cessation Structured approaches are to be used(e. g, five"As Use interview and/or other standardized measurement ask, advise, assess, assist, arrange; see Box 15-2) Offer individual and/or small group education and coun a Ask the patient about his/her smoking status and use seling on adjustment to heart disease, stress management, other tobacco products. Specify both amount of smoking and health-related lifestyle change(profession,motor (cigarettes per day) and du num ber of vehicle operation, sexual activity resumption) Whenever possible, include spouses and other family a Determine readiness to change; if ready, choose a date for members, domestic partners, and/or significant others in quitting. such sessions
SECTION 3 Preventive medicine and public health Teach and support self-help strategies and ability to by statute. If the disability is job-related, the person is par obtain effective social support. ially reimbursed for lost wages and fully reimbursed for the a Provide vocational counseling in case of work-related stress. costs of medical care from the state workers' compensation Expected outcome: Absence of clinically significant psy- fund(see Chapters 18 and 24) chosocial problems and acquisition of stress manage In the United States a person with a permanent disability ment skills ay be reimbursed at a fixed rate for the rest of life or for defined period. The rate varies from state to state(as stipu Cardiac rehabilitation has been shown to be one of the lated by law), but it is based on the type of disability and most cost-effective interventions in preventing progression degree of function lost( as determined by a clinician ing self-management by disadvantaged patients. Rehabili tation usually involves the following four stages V SUMMARY 1. Enrollment of patients while they are in the hospi 2. Reconvalescence at home The goal of tertiary prevention is to limit the physical and 3. Supervised group programs social consequences of an injury or disease after it has 4. Lifelong maintenance occurred or become symptomatic. The two major categories f tertiary prevention are disability limitation and rehabilita tion. Whereas disease and disability describe objective diag C. Rehabilitation for Other Diseases noses and impairments, illness also encompasses patients PULMONARY REHABILITATION perceptions,assumptions,and expectations about their disease. These illness perceptions strongly predict disease Evidence of the positive impact of pulmonary rehabilitation outcomes and patient first came from a landmark study on lung reduction surgery' ethods of disability limitation include therapy, which and was later confirmed in systematic reviews. Since then, seeks to undo or reduce the threat or damage from an exist- the indications for pulmonary rehabilitation have been ing disease, and symptomatic stage prevention, which broadened beyond COPD, and rehabilitation programs are attempts to halt or limit progression of disease. The strate now used for many chronic respiratory diseases gies of symptomatic stage prevention are taken from primary prevention(modification of diet, behavior, and environ- CANCER REHABILITATION omplications, treatment for complications). The effective More and more patients experience cancer not as an acute management of chronic diseases, such as coronary artery lethal illness but rather as a chronic disease. This trend has disease, dyslipidemia, hypertension, and diabetes mellitus, engendered an increased interest in the role of cancer reha requires a combination of therapy and symptoma ilitation. In contrast to patients with most other diseases, prevention. This approach also can be used in the cancer patients often suffer as much from complications of ment of many other diseases, including stroke, therapy as from the disease itself. obstructive pulmonary disease, arthritis, and some cancers and infectious diseases D. Categories of Disability Rehabilitation should begin in the early stages of ment. Depending on the needs of the patient, the rel Disability is a socially defined concept but has tion team may include a rehabilitation counselor; ph implications for financia support. Most states therapist; speech therapist; occupational therapist; and psy- everal categories for reimbursement of workers chiatric, emotional, or spiritual counselor. Under most stat ob-related injuries or illnesses covered under a laws governing workers' compensation, several categories of job-related illnesses or injuries are recognized permanent a Permanent total disability (e. g, loss of two limbs or loss total disability of vis disability, temporary partial disability, and death. The goal a Permanent partial disability (e-g, loss of one limb or of rehabilitation for workers, whether their impairment is loss of vision in one eye) temporary or permanent, is to minimize the social and occu a Temporary total disability (e.g, fractured arm in truck pational consequences of the impairment Ithough it might seem that the opportunity for preven- Temporary partial disability (e. fractured arm in ele- tion is lost when a disease appears or an injury occurs,this is often not the case. The appearance of symptoms or the ■ DeatH threat of severe complications may lead patients to take an active interest in their health status, seek the health care that death) according to a fixed schedule. Less well-defined nesses and injuries, such as repetitive motion or back inju References ries, are usually compensated by a mixture of financial and 1. Petrie K), Jago LA, Devcich DA: The role of illness perceptions benefit training, and even job placement. 20:163-167,2007 A disability is considered"temporary"if it is expected that 2. Giri P, Poole I, Nightingale P, et al: Perceptions of illness and a person will return to his or her job within a time defined their impact on sickness absence. Occup Med 59: 550-555, 2009
CHAPTER 7 Methods of Tertiary Prevention 215 Keogh KM, Smith SM, White P, et al: Psychological family 25. Ong KL, Cheung BMY, Man YB, et al: Prevalence, awareness, 17:105-11 adults, 1999-2004. Hypertension 4 -75,2007 4. Goulding L, Furze G, Birks Y: Randomized controlled trials of 26. Svetkey LP, Sacks FM, Obarzanek E, et al; The DASH diet, with coronary heart disease: svetave illness beliefs in people sodium intake, and blood pressure trial( DASH-sodium): rationale and design. J Am Diet Assoc 99(suppl 8): 96-104, 1999 66:946-961,2010 27. Yusuf S, Sleight P, Pogue J, et al: Effects of 5. Haffner SM, Lehto S, Ronnemaa T, et al: Mortality from coro converting enzyme inhibitor, ramipril, on cardiovascular events nary heart disease in subjects with type 2 diabetes and in non high-risk patients. N Engl J Med 342: 145-153, 2000 it prior myocar 8. Bangalore S, Sawhney S, Messerli FH: Relation of beta-blocker- N Engl Med339:229234,1998 induced heart rate lowering 6. Bulugahapitiya U, Siyambalapitiya S, Sithole J, et al: Is sion. J Am Coll Cardio! 52: 1482-1489, 2008 a coronary risk equivalent? Systematic review and meta- 29. Carlberg B, Samuelsson O, Lindholm LH: Atenolol in hyper alysis, Diabet Med 26: 142-148, 2009 nsion: is it a wise choice? Lancet 364(9446): 1684-1689, 2004 7 Breslow L: Risk factor intervention for health maintenance. 30. US Centers for Disease Control and prevention: chror lence200:908912,1978 disease prevention and health prevention: diabetes successes 8. Dawber TR, Meadors GE, Moore FE Jr: Epidemiologie d opportunities for population-based prevention and control pproaches to heart disease: the Framingham Study. Am J at a glai Public Health 41: 279-286, 1951 9. Healy GN, Matthews CE, Dunstan Dw, et al: Sedentary time 31. Diabetes Control and Complications Trial. DCCT Research and cardio-metabolic biomarkers in U.S. adults: NhaneS Group. N Engl/ Med 329: 683-689, 1993 2003-06. Eur heart32:590597,2011 32. Santiago JV: Lessons from the Diabetes Control and Complica 10. Lissner L, Odell PM, D' Agostino RB, et al: Variability of body tions Trial. Diabetes 42: 1549-1554, 1993 reight and health outcomes in the Framingham population 33, Stratton IM, Adler AL, Neil HA, et al: Association of glycaemia N Engl med32418391844,1991 with macrovascular and microvascular complications of typ 11. Wing RR, Jeffery RW, Hellerstedt WL: A prospective study of diabetes: prospective observational study. BM/321: 405-412 effects of weight cycling on cardiovascular risk factors. Arch stern Med155:1416-1422,1995 34.H W, et al: Is glycem 12. Gotto AM, Pownall H]: Manual of lipid disorders, ed 3, Balti in U.S. adults? diabetes Care 31: 81-86, 2007 more, 2002, williams& wilkins. 35. Bennett WL, Maruthur NM, Singh S, et al: Comparative effec- 3. Sumithran P, Prendergast LA, Delbrid et tiveness and safety of medications for type 2 diabetes: an ersistence of hormonal adaptations to weight loss. N EnglJ pdate inch Med365:1597-1604,201l. Intern med154:602-613,2011 14. Cereda E, Malavazos AE, Caccialanza R, et al: Weight cycling is 36. Piepoli MF, Corra U, Benzer W, et al: Secondary prevention associated with body weight excess and abdominal fat accum through cardiac rehabilitation: from knowledge to implemen- lation: a cross-sectional study. Clin Nutr 30: 718-723, 2011 tation. Cardiac Rehabi of E Association 15. Taing KY, Ardern CI, Kuk JL: Effect of the timing of weight for Cardiovascular Prevention and Rehabilitation. Eur J Car- cycling during adulthood on mortality risk in overweight diovasc Prey rehabil 17: 1-17. 2010 menopausal women. Obesity( Silver S 37. Mead H, Andres e, Ramos C, et al: Barriers to effecti 413,2012 rdiac patients: the patients'ex ive self- 16. Strohacker K, McFarlin BK: Influence of obesity, physical inac Patient Educ Counsel 79: 69-76, 2010 tivity, and weight cycling on chronic inflammation. Front biosci ez F, Naunheim K, et al: A ra comparing olume-reduction su 7. Field AE, Malspeis S, willett WC: Weight cycling and mortality emphysema. N Engl J Med among middle-aged or older women. Arch Intern Med 169: 881- 2003 39. Puhan MA, Gimeno-Santos E tzm, et al: Pulmona 18. National Cholesterol Education Program: Executive summary rehabilitation following exace of the third report of the NCEP Expert Panel on Detection, Syst Rev(10): CD005305 Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 285: 2486-2497, 2001 40. Spence RR, Heesch KC, WJ: Exercise and cancer 19.http://www.nhlbi.nihgov/guidelines/cvd_adult/background Cancer Treat rey 36: 185 20. Frick MH, Elo O, Haapa K, et al: Helsinki Heart Study: primary 41. LaDou J: Occupational and environmental medicine, ed 3, Stam revention trial with gemfibrozil in middle-aged men with ord, Conn, 2004, Appleton Lange lipidemia. N Engl Med 317: 1237-1245, 1987. 21. Arntzenius AC, Kromhout D, Barth JD, et al: Diet, lipoproteins, Intervention Trial. N Engl)Med, atherosclerosis: the Leiden Select Readings and the progression of corona 5-811,1985 22. Smulders YV, Blom HJ: The homocysteine controversy. J Inh Diabetes Control and Complications Trial, DCCT Research Group Metab Dis 34: 93-99. 2011 N Engl J Med329:683689,1993 L, et al: Effect of homocysteine int Franklin D]: Cancer rehabilitation: challenges, approaches, and new entions on the risk of cardiocerebrovascular events: a meta directions. Phys Med rehabil Clin North Am 18: 899-924, 2007. nalysis of randomised controlled trials. Int J Clin Pract Gordon DL, Katz DL: Stealth health: how to sneak age-defying, 64:208-215,2010. disease-fighting habits into your life without really trying. Pleas 24. National Institutes of Health, National Heart, Lung, and Blood antville, NY, Readers'Digest 2005 [Information for patients. J Institute: The Seventh Report of the Joint National Committee Gotto AM, Pownall H]: Manual of lipid disorders, ed 3, Baltimore on Prevention, Detection, Evaluation, and Treatment of High 2002, Williams wilkins BloodPressure2003;http://www.nhlbi.nih.gov/guideline Hypertensiontreatmentguidelineswww.nhlbi.nih.gow/guidelines/
