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