Kones Richard, Rumana Umme
Cardiometabolic Research Institute, Houston, TX.
Hosp Pract (1995). 2014 Aug;42(3):84-95. doi: 10.3810/hp.2014.08.1121.
This article presents core epidemiological studies that establish the basis for cardiovascular prevention strategies. The results of the classic INTERHEART and INTERSTROKE studies that delineated population-attributed risk for myocardial infarction and stroke are described. Differences in the levels or types of prevention-primordial, primary, and secondary-lead to the concept that risk occurs on a continuum throughout life with great variability, beginning in infancy. Any meaningful and sustained reduction in cardiovascular risk must begin in childhood, as habits formed early in life have an impact for decades. Although it is never too late to improve unhealthy habits, interventions early in life are more likely to be effective in preventing disease from developing, in delaying manifestations, or in reversing pathology through evidence-based therapies that are applied later. There is compelling evidence that coronary atherosclerosis, heart disease related to diabetes, and hypertension begin with endothelial activation. Oxidative stress and reduced nitric oxide availability are also among the earliest of events, from which a self-amplifying web of events proceed. The American Heart Association, even prior to its now-validated and classic definition of risk metrics, developed a strategic plan to improve health habits in the population and at the community level for promoting and monitoring behavior change and patients' self-reported health status. Other initiatives for improving cardiovascular health are in place as well. Despite improvements in treatment of risk factors, there has been minimal, if any, success in reversing the dual epidemics of obesity and diabetes. These 2 factors continue to drive the high burden of cardiovascular risk, and now lead current public health issues. Because treatment alone cannot fully address this tsunami of risk, it has been suggested that all physicians assume an unprecedented and aggressive role as advocates for behavior change to prevail against the foes of obesity and diabetes.
本文介绍了核心流行病学研究，这些研究为心血管疾病预防策略奠定了基础。文中描述了经典的INTERHEART和INTERSTROKE研究结果，这些研究明确了心肌梗死和中风的人群归因风险。预防水平或类型（即原级预防、一级预防和二级预防）的差异引出了这样一个概念：风险在一生中呈连续状态出现，具有很大的变异性，从婴儿期就开始了。心血管风险的任何有意义且持续的降低都必须始于儿童期，因为早年形成的习惯会影响数十年。尽管改善不健康习惯永远不会太晚，但早年进行干预更有可能有效预防疾病发展、延缓症状出现或通过后期应用的循证疗法逆转病理状况。有令人信服的证据表明，冠状动脉粥样硬化、与糖尿病相关的心脏病以及高血压始于内皮激活。氧化应激和一氧化氮可用性降低也是最早出现的事件之一，由此引发一系列自我放大的事件。美国心脏协会甚至在其现在已得到验证的经典风险指标定义之前，就制定了一项战略计划，以改善人群和社区层面的健康习惯，促进和监测行为改变以及患者自我报告的健康状况。其他改善心血管健康的举措也已实施。尽管在危险因素治疗方面有所改善，但在扭转肥胖和糖尿病这双重流行趋势方面，即便有成效也微乎其微。这两个因素继续推动着心血管疾病的高风险负担，并且现在导致了当前的公共卫生问题。由于仅靠治疗无法完全应对这一风险海啸，有人建议所有医生应承担起前所未有的积极角色，倡导行为改变，以战胜肥胖和糖尿病的威胁。
