Written by: Rob Philibert, MD PhD
There is an old folk tale from India about three blind men who attempt to describe an elephant based on one touch. Each man touches a different part of the elephant, such as a foot, a tusk, or a tail, and thereby comes to a different perspective on the elephant that fails to capture the entirety of the animal. The moral of the story is that a complete understanding of any complex subject requires a holistic perspective.
Modern medicine seems not to have learned this lesson. Increasingly, the practice of medicine is increasingly balkanized. These intellectual silos impede the implementation of best practices for the prevention and care of coronary heart disease (CHD). For example, after the third-year medical school, psychiatrists rarely, if ever, receive continuing medical education regarding the assessment and management of CHD. Similarly, internists rarely receive education on behavioral health techniques for preventing and managing CHD. Because of this, patients do not receive an integrated best practice treatment plan that is personalized for their unique risk profile. Instead, what they often receive is a fragmentary set of handouts and an oral recommendation to exercise and lose weight. As a result, patients and their families suffer otherwise preventable cardiac deaths and other life-changing events. Considering the fact that the United States spends $4.1 trillion per year for healthcare, this failure to provide a holistic, integrated approach is unacceptable.
Changing this dynamic requires the realization that patients are not categories, they are people. Over their lifetime, the vast majority of patients will develop CHD or one of the numerous other associated cardiovascular risk factors, such as hypertension, for CHD. Similarly, these same patients will also likely experience depression, anxiety, or substance use syndromes. Critically, the presence of CHD increases the risk of behavioral illness while the risk for behavioral illness increases the risk for CHD.
Intuitively, this pattern of comorbidities should be obvious. After all, one of the most common forms of substance use, smoking is one of the largest preventable risk factors for CHD. Conversely, the onset of symptomatic CHD increases apprehension and alters our ability to participate in normal socialization. As a result, those with CHD are at increased risk for anxiety and depressive syndromes. Conversely, because those with depression are less likely than others to exercise routinely and consume well-rounded diets, they also are more likely to develop CHD. Certain medications used in the treatment of behavioral or cardiovascular disease make the situation worse. For example, the use of beta-blockers for the control of hypertension elevates the risk of depression while the use of antipsychotics in those with behavioral illness increases the risk for CHD. These are but a small set of examples of the overlap between behavioral and cardiovascular health. But how do these details help us achieve better prevention and treatment of both sets of disorders?
I believe that the pathway forward requires clinicians to embrace the lesson from the biblical Solomon and consider the whole patient. Evaluation of patients for possible CHD should include a full biopsychosocial assessment of both risk and resilience factors for illness. Similarly, evaluations for patients for depression should include also include the impact of the illness on dietary and preventive exercise regimens critical to heart health.
Cardio Diagnostics is committed to helping clinicians provide holistic risk assessment and management tools for their patients. Recently, we introduced Epi+Gen CHD, and artificial intelligence guided integrated genetic epigenetic test for CHD risk. This test is the new standard for sensitivity. In direct head-to-head testing, Epi+Gen CHD predicted nearly twice as many CHD events as the ASCVD risk calculator. Better still, unlike the unidimensional output from these lipid-based risk calculators, Epi+Gen CHD three epigenetic assays provide a personalized, holistic assessment of the complex interplay of the environment with each individual’s unique genetic risk for CHD.
Learn the lesson from the folk tale. CHD risk prevention is more than just lipid reduction. Use the more holistic multidimensional assessment provided by Epi+Gen CHD™.
Resources:
- https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
- https://pubmed.ncbi.nlm.nih.gov/34148365/