Self-Care: An Ounce of Prevention to Promote or a Pound of Cure to Manage Cardiovascular Health

Time is growing short to achieve the American Heart Association’s 2020 target "to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%" set in 2010.1 This target expanded the focus of the American Heart Association beyond treatment of cardiovascular disease (CVD) with a new and important emphasis on prevention and reducing risk. In this instance, cardiovascular health includes ideal health behaviors (e.g. maintaining normal weight, not smoking, adequate exercise) as well as ideal health factors (e.g. normal blood pressure, cholesterol and glucose). For many Americans with a predisposition for chronic conditions that increase CVD risk (e.g. diabetes, high cholesterol, hypertension), a focus on maintaining cardiovascular health is paramount. Self-care, one tactic within our power to support this goal, is the focus of an American Heart Association Scientific Statement.2 The authors wrote a compelling statement with abundant evidence regarding the importance of self-care across the life span. The authors also asked readers to imagine that CVD is no longer the number one cause of death because interventions promoting self-care were at the hierarchy of best practice.2 However, given the current healthcare climate favoring treatment of disease over prevention,3 a monumental paradigm shift is needed at all levels involved in cardiovascular health care (e.g. individuals, health providers, payers). Several factors warrant consideration regarding the importance of self-care across the lifespan.

First, absence of symptoms does not equate with lack of disease or risk. CVD is silent for years with indicators of atherosclerosis occurring across the lifespan.4,5 For example, adolescents can have clinically significant atherosclerotic lesions.6 There also is an increased risk of CVD among women who have pre-eclampsia during pregnancy.7 Among these women, the relative risk of hypertension after approximately 14 years is 3.70 (95% CI 2.70-5.05). For stroke, the relative risk is 1.81 (95% CI 1.45-2.27) after approximately 10 years. Given the possibility of the early onset of latent CVD, self-care becomes an attractive investment option in terms of quality of life as well as medical costs. Setting the stage for preventive cardiovascular health with self-care early in life has potential to extend ones healthy lifespan. Otherwise, the potential is great for requiring many years of self-care management of chronic conditions.

Second, although Americans are gaining years in life expectancy, aging is a major risk factor for CVD.3 This translates into an increase in years accompanied by the need to manage chronic conditions such as diabetes, hypertension, and heart disease. Benjamin Franklin noted, "In this world, nothing can be certain except for death and taxes"; however, it would certainly be preferable to age in the best possible health. Fortunately, there is a self-care strategy to increase health and longevity also known as regular exercise.3 Exercise improves outcomes in terms of prevention as well as outcomes among those already diagnosed with CVD. In the case of individuals who experience a major cardiovascular event, cardiac rehabilitation is beneficial offering exercise and self-care coaching. Unfortunately, less than a third of eligible patients participate.8 The authors of the self-care statement report non-traditional models of cardiac rehabilitation can be considered (e.g. structured home and community-based programs) as they are effective. Certainly, initiating and maintaining a regular exercise routine can be challenging for a variety of reasons (e.g. environmental restraints, sedentary habits). However, when considering the indisputable benefits, health care providers need to coach and patients need to commit to lifestyles that incorporate exercise as a routine self-care strategy.

Finally, several challenges to initiating and maintaining lifestyle changes exist in terms of knowledge, time and financial implications. Health providers as lifestyle coaches potentially lack training in behavior change interventions. Time to counsel also may be limited within the context of an office visit. Sadly, it seems counterintuitive that reimbursement by payers for lifestyle counseling often is less than for treatment of a disease.9 Thus, the aforementioned highlights the need for the paradigm shift for supporting lifestyle counseling on self-care. The authors of the self-care scientific statement cite a large body of evidence supporting several strategies for improving self-care using a life course approach. The Benjamin Franklin quote "An ounce of prevention is worth a pound of cure" is apropos to this premise.10 The quote was actually about creating a fire department and does not refer to healthcare; however, it is congruent with the 2020 goal of the American Heart Association. Accordingly, it is time to take action and make concerted efforts to move self-care to the forefront in the hierarchy of healthcare delivery.