US expert says revolution needed in heart care

By Niall Hunter


A world expert on preventing and treating heart disease has said people should be encouraged by Governments and health insurers to take more control of their heart health.

Prof Barry Franklin of William Beaumont Hospital, Detroit, USA said a sea-change was coming worldwide in healthcare, in terms of health systems encouraging increased patient self-responsibility, not least in order to control unsustainable health costs arising from treating heart disease and stroke.

Prof Franklin was a keynote speaker at a recent major cardiovascular disease prevention conference in Galway run by the West of Ireland Cardiac Foundation, Croi.

Croi has recently launched the National Institute for Preventive Cardiology, aimed at driving research and education into heart disease prevention and rehabilitation and developing new models of preventive care and service delivery.

Prof Franklin, in an interview with, said people need more regular contact with their doctor than, say once a year, in order to check on their cardiovascular health.

"People as a matter of course usually take care of their cars - you get an oil change; you make sure your house has adequate insurance, etc. Increasingly, you've got to meet certain metrics. In other words, health systems and insurers in future will not let you walk around with a high cholesterol level. If you can't control cholesterol with diet and exercise, then you will need to be put on a statin because we know that the lower the cholesterol, the lower the risk for coronary disease."

Prof Franklin said, ultimately, health systems will save billions by being more pro-active in getting people to look after their health and taking responsibility for staying in good health, and governments should encourage people to get regular health checks. "It's in the best interests of their citizens."

However, he acknowledges that a problem for doctors is that they find it difficult to devote enough time to advise patients on maintaining a healthy lifestyle and diet.

"Doctors in the US typically spend 12-15 minutes with each patient. In that, they can cover at least six different topics - from aches and pains to other health issues. However, doctors often have a very limited amount of time to start talking to patients about smoking cessation, physical activity, what they should be eating etc. I think the answer is that the doctor should certainly mention diet, physical activity and smoking cessation.

"But I think in future we are going to see increasing reliance on allied health professionals in this area, such as nurses, exercise physiologists and other members of the healthcare team working in conjunction with doctors to implement heart disease preventive programmes, under the direction of the doctor."

As a major advocate of prevention measures in heart disease, does he think Governments should impose extra taxes on heavy fat foods and sugary drinks in spite of pressure from the food industry?

"It's a difficult call and we have the same kinds of concerns in the US. That said, I believe the evidence is overwhelming that high sugar and high fat foods and drinks over time lead to an increase in chronic diseases, disability, death and healthcare expenditure. So from that standpoint, although some people may be unhappy about it, if we can deter people by putting taxes on these kinds of things I think ultimately it will have a profound impact on public health, so I would be supportive of this. Some people might say ‘I'm losing my rights if you're going to tax me in this way', yet the evidence is really pretty overwhelming that these foods and drinks unequivocally contribute to chronic disease, as does cigarette smoking and indeed second hand smoke."

As regards encouraging more people to quit smoking, a key risk factor for heart disease, Dr Franklin said e-cigarettes have a role to play.

"I think certainly anything is worth a try, so I would support e-cigarettes in terms of smoking cessation. However, I would also say the jury is still out on them - we need to be shown data. In the US and throughout the world, cigarette smoking remains the number one preventable cause of death and disability. On average, the lifetime cigarette smoker has 10 or 11 fewer years lifespan than the non-smoker, which is huge. Research has also shown that it's never too late to quit smoking, with the biggest health benefits with quitting seen in people under the age of 40. So anything that can play a role in getting people to stop smoking should be used. The jury may be still out on e-cigarettes but I would support using them."

As far as heart disease is concerned, Prof Franklin believes ‘meat is murder'.

"It's not only the harmful additives that are often put into meat but there's a very high percentage of saturated fat, which has been linked unequivocally with the development of cardiovascular disease. The smartest guy I know is Bill Roberts, editor of the American Journal of Cardiology and he said: ‘we fatten our cows and pigs, we kill them...and then they kill us'. And he's right - a recent British study showed that vegetarians have a 32% lower risk for ischaemic heart disease than non-vegetarians, and that's not by chance. Study after study shows us that high meat consumption leads to cardiovascular disease. We need to cut our meat consumption."

Prof Franklin is a strong advocate of eating more fish, wholegrain, fruit and vegetables and drastically reducing our intake of food with excessive salt content.

He stresses,however, that excessive amounts of exercise can be bad for you, and you can overdose on exercise just as you can on medication. However, he also says the least fit people can often gain the most benefit from exercise and they can start with just a small amount of walking.

Prof Franklin says an often overlooked risk factor for developing heart disease and dying from heart conditions if you already have them is stress.

"With this, it's not the stress per se, what's more important is how people respond to that stress. I have some patients whose heart rates and blood pressure in reaction to stressful events don't change at all and I have other patients who are called ‘hot reactors', who show big increases in heart rate and blood pressure etc. under the same conditions. If you're in a heated argument, the risk of a heart attack in the next hour can increase two to threefold compared to just sitting down reading a newspaper. So you need to avoid getting stressed."

"Some people over-respond to things. Like if you get angry because someone in front of you in the supermarket queue has more than 10 items and the limit is 10 items, that's not a good idea. Chronic stress over time can contribute to the development of cardiovascular disease as well as triggering acute coronary events."

Prof Franklin also believes pollution also has a role in people developing cardiovascular disease.

"There's an increasing amount of research on this. I just co-wrote a scientific paper where we reviewed the literature and there is no question that high particulate matter air pollution can actually contribute to a host of physiological changes which over time can exacerbate heart disease and can actually trigger acute coronary events. In the US we have got to tell coronary patients, pulmonary patients, pregnant patients, they shouldn't be exercising out in the middle of city smog or very heavy traffic. However, overall the benefits of exercising, even with a little bit of pollution, probably outweigh the risks. We know about 80% of the reasons why coronary disease exists - there is 20% that is so far unexplained and I believe some of that is due to air pollution."

Controversially, Dr Franklin believes that common high-tech interventions to treat heart disease, such as angioplasty, stents, open heart surgery, etc, despite being very expensive, are not as effective as they should be and are usually no better than conventional medical/drug treatment of heart conditions. Research has shown, he said, that patients who get these procedures often do not live longer than those who get more conventional treatment.

"In my opinion, this is because the body's coronary artery tree is very extensive. In other words, when you look at all the branches of those arteries - doctors are going in and fixing a little specific area. What about all those other areas they're not touching? I believe taking statin drugs, lowering cholesterol, stopping smoking etc have a global effect on the entire coronary tree, as opposed going into one little area that presumably we fix, although sometimes by putting a foreign object in, such as a stent, you may be screwing up that particular area. I don't believe the coronary tree is designed to have pieces of metal inside its elastic arteries. Often times, the lesions that rupture are the 20 or 30% that the doctors aren't even touching."

"It's a case of sometimes trying to do the heroic thing when in fact what we are doing is palliative-type procedures. We are trying to take care of the problem immediately but we are not getting at the root cause of heart disease, which to large extent is poor diet, inactivity and cigarette smoking. The cost of these procedures to the US health system is unsustainable. We need to do more prevention."

Rehabilitation programmes for people wjho have suffered cardiac events, Prof Franklin says, are typically associated with a 25% to 50% reduction in subsequent coronary events.

"Whether it is the exercise, whether it is the associated cardiovascular risk factor reduction, whether it is the psychosocial benefits or the ongoing medical surveillance in the rehab programme - they all contribute to the benefits. When we see these patients three days a week sometimes we pick up new heart problems- all these things contribute to better outcomes. Doctors today should increasingly be ensuring that patients can get to cardiac rehab and Governments and health insurers should ensure that there are no financial barriers to people getting access to these programmes."



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