Put Disease Prevention First

Worldwide, noncommunicable diseases are the dominant cause of death, with atherosclerotic cardiovascular disease a major contributor.1 These deaths are spread across high- to low-income countries, with ≈1 in 3 of all cardiovascular disease deaths occurring in individuals aged <70 years, amounting to an estimated 6 million cases annually.1 Analyses in many countries have shown that both an improvement in risk factors and advances in medical therapies have contributed to the fall in age-standardized mortality from coronary heart disease (CHD).2 Importantly, leading a healthy lifestyle has broader implications for the prevention and management of other noncommunicable diseases including cancer, diabetes mellitus, and chronic respiratory diseases.Article see p 590After decades of major advances in the treatment of acute CHD events it is being appreciated increasingly that evidence-based long-term management of CHD is critical to achieve optimal reductions in mortality and morbidity. Each year, ≈50% of major coronary events occur in those with a hospital discharge diagnosis of CHD.3 Half of these recurrent events are fatal.3 A significant number of such CHD events will occur within the first year after hospitalization for nonfatal acute coronary syndromes.4Older trials of comprehensive cardiac rehabilitation inclusive of exercise, other aspects of a healthy lifestyle, and adherence to pharmacological therapies can improve the course of CHD and reduce all-cause and cardiovascular mortality by up to 25%.5 However, concerns have emerged as to whether the benefits of cardiac rehabilitation continue to apply in an era where acute reperfusion therapy (eg, fibrinolysis/primary percutaneous coronary intervention) and a suite of preventive pharmacotherapies (aspirin and other antiplatelet agents, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and β-blockers) are very widely available. Indeed, much of the highest level trial evidence for cardiac rehabilitation6 in survivors of acute …