A Controversy That Care Managers Should Know About

PART I

This is the first of a two-part series about cardiovascular risk, identifying people with those risks, and helping them lower it — and importantly, what role care managers can play in that effort. In part one, we present the statistics on cardiovascular risk and define an actor — metabolic syndrome — that started an ongoing controversy in the medical community. In part two, we will describe how different areas of the medical community have disagreed with the definition and focus of the condition, and how this lack of consensus may be affecting a concerted effort to decrease cardiovascular risk. We also focus on how care managers can respond to the needs of the patient in the face of the controversy — helping them identify and decrease their cardiovascular risks and improve quality of life while, at the same time, the medical community clarifies the evidence.

Look around. In malls, on bleachers at ball games, in offices, at family dinners. Every place you go, you will find us. We are young and old, male and female, from every ethnic group, and we look like a cross-section of America. We are busy living our lives, going to work, taking care of our families. We feel well, and many of us consider ourselves healthy. But the truth is there are those among us who are “walking cardiovascular time-bombs.” And in many cases, we don’t even know it — until it’s too late.

The statistics on cardiovascular disease in America aren’t pretty. Coronary heart disease (CHD) is the largest major killer of both American males and females, causing one in five deaths in the U.S. Every 25 seconds an American suffers a coronary event, and every minute one of us dies from it, according to statistics from the American Heart Association (AHA). This year, approximately 785,000 Americans will experience a new coronary attack, 470,000 will have a recurrent one, and an additional 195,000 will have a silent event. 

Age, gender and ethnicity will play a strong predictive role in who lives, who dies, and who goes on to acquire co-morbid chronic illness associated with CHD. The AHA reports that approximately 37 percent of people who experience a coronary attack in a given year will die from it. For those who survive a first cardiac event, the morbidity expected to occur within five years is significant, and depending on age and ethnicity, some of us can expect to face co-morbid states that could include heart failure, stroke or sudden death. Men die at higher rates than women, and blacks at higher rates than whites (with some age differences). And let’s not forget the projected price tag of CHD for 2009 — $165.4 billion for direct and indirect costs, says that AHA.

And those are just coronary events. What about stroke? In 2005, stroke accounted for roughly one out of every 17 deaths in the U.S. Mortality one year after stroke is significant. Depending on age it stands at 21 percent for men and 24 percent for women age 40 and above. Stroke leaves us with terrible morbidities. For survivors of stroke age 65 and above, patients experience the following just six months after the event:

• 50 percent have some hemiparesis, or weakness on one side of the body.
• 30 percent are unable to walk without some assistance.
• 26 percent are dependent in activities of daily living.
• 35 percent have symptoms of depression.
• 19 percent have aphasia, a form of language impairment.
• 26 percent are institutionalized in a nursing home.

As we see from the data, stroke leaves a significant number of us with life challenges — difficulty with daily tasks and communication that we take for granted, loss of independence, and high rates of depression — all adding to a lower quality of life. These stroke statistics, added to the CHD statistics, point out the need to identify and target those of us at risk and to intervene on those risks early — before the time-bomb explodes.

THIS YEAR, APPROXIMATELY 785,000 AMERICANS WILL EXPERIENCE A NEW CORONARY ATTACK, 470,000 WILL HAVE A RECURRENT ONE AND AN ADDITIONAL 195,000 WILL HAVE A SILENT EVENT.

Given this frightening information on cardiovascular risk, one would hope the entire medical community would be firmly amassed behind a well-defined effort to identify and decrease risks in this population. That is not so. Instead, there is a significant disconnect between various sectors of the medical community that do not agree on how to find the right people, nor what to do about them. Before delving into the controversy, we have to understand what metabolic syndrome is, and what is known about it. There is no time to waste, and care managers can play a role in helping all of us stay well.