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Expanding the Primary Prevention Role of Lifestyle and Statins to Reduce First Cardiac Event Risk

In This Article

  • Two recent studies expand practitioners’ tool kits during a consult by providing patients with two action steps to help manage risk of premature death from heart disease
  • The first study demonstrates that among patients who are genetically predisposed to coronary artery disease, a healthy lifestyle reduces risk by 50%
  • The second study demonstrates that for individuals at high genetic risk for heart attack, statins can reduce the risk by 44%

Two recent high-profile studies from Massachusetts General Hospital’s Preventive Cardiology group expand practitioners’ tool kits during a consult by providing patients with two action steps to help manage risk of premature death from heart disease (HD).

Amit V. Khera, MD, MSc, cardiologist at Mass General evaluated whether positive lifestyle behaviors lower heart attack risk. The research is based on a new analysis of 55,000 people over 20 years that reveals the power of a healthy lifestyle—no smoking; moderate, regular exercise; eating plenty of vegetables, fruits and grains— can overcome genetic predisposition and risk of HD. This work was published in The New England Journal of Medicine.

Pradeep Natarajan, MD, MMSc, director of Preventive Cardiology at Mass General, examined the effects of prescribing statins in the primary prevention setting, identifying a new subgroup of patients prone to a higher burden of atherosclerosis—as well as greater relative benefit from statin therapy in the primary prevention setting. The study, published in Circulation, relates to the clinical utility of using genetic data from 57 genes associated with HD to derive a new polygenic HD risk score.

Actionable Results Through Lifestyle Changes

In the study led by Dr. Khera and Sekar Kathiresan, MD, Mass General investigators demonstrate that among patients who are genetically predisposed to coronary artery disease (CAD), a healthy lifestyle reduces CAD risk by 50%. Healthy behaviors include abstaining from smoking, eating a healthful diet, exercising regularly and avoiding obesity. Through these lifestyle changes, the risk for CAD becomes the same as that handled by the rest of the population.

“Your DNA is not your destiny,” says Dr. Khera. “Even if your genetic risk score for a heart attack is high, you can significantly offset genetic misfortune and risk by adopting a healthy lifestyle. This finding has been quite impactful in my discussion with patients, as they have the power to change their risk.”

Risk Reduction for Statins

Dr. Natarajan explains that there is some controversy related to whether patients should be on statins to prevent the first heart attack. But even so, he says, “we know statins will reduce risk by about 25%, regardless of risk components. The surprise of our study is that for individuals at high genetic risk for heart attack (as measured by a blood test), you can reduce the risk by 44% with statins.”

It was not previously known whether this subgroup would respond to statin therapy. A 44% risk reduction that was observed, is approximately twice what is expected, as compared to the normal lowering of risk for first cardiac event in existing subgroups, such as those with elevated cholesterol. These results are very impressive and will be useful in managing patients in the clinic. If validated in further research, the identification of this new subgroup and its response to statin therapy could improve preventive cardiology’s lifesaving impact by expanding statin eligibility guidelines, giving practitioners a new and powerful clinical tool.

Next Steps

Both studies’ findings are highly actionable, strengthening preventive care of cardiology patients by improving prediction, mitigation and control of risk to prevent the first heart attack event.

In terms of lifestyle, physicians now have new and compelling evidence they can use in the consult room to motivate patients to adopt healthy behaviors—while also giving patients considerable control on how these behaviors are implemented. As a care strategy, combining a physician’s data-driven advice with a patient’s prerogative about implementation often leads to highly effective partnering in health stewardship.

This partnering concept also pertains to the polygenic risk score determined by Dr. Natarajan’s group, because the test is easily obtained through a blood test during the first days of life.

“If patients are told early in life they are genetically at a higher risk of an (heart attack) event, ideally, we’d have a program in place that helps them evaluate lifestyle effects, statin treatments and other preventions, such as evidence-based follow-up plans, support and education,” says Dr. Natarajan.

“Actionable interventions can start at birth,” explains Dr. Khera. For example, parents of a genetically at-risk newborn can be educated on how to raise the child using a preventive cardiology lifestyle paradigm.

“Among the benefits of this type of score,” he says, “is that you can calculate it when a person is very young and based on high or low genetic risk factors, and advise patients about the importance of lifestyle choices.”

Both investigators are validating the application of their findings for precision medicine by testing performance of risk scores in other ethnicities and cultures.

“Ultimately we aim to answer: what are the risk components for each individual and how can they each be modified?” says Dr. Natarajan.

“The practical goal of both these studies is, if you are at increased genetic predisposition for a first cardiac event, what can you do: (a) in terms of healthy lifestyle and (b) by taking medication?” says Dr. Khera. “We now have much stronger clinical messages based on our new analyses that show adopting healthy behaviors can offset genetic risk, and statin therapy can potentially play a more powerful therapeutic role in a new subgroup of patients.”

CAD risk reduction when genetically predisposed patients maintain a healthy lifestyle

heart attack risk reduction for genetically high-risk heart disease patients when on statins

Refer a Patient to the Corrigan Minehan Heart Center

Learn more about Dr. Natarajan's research

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