Cite this article: Mastorci F, Vassalle C, Pingitore A (2017) The Words of the New Era of Cardiovascular Prevention: Awareness and Empowerment, Humanism and Esthetics in a Complex Network. J Cardiol Clin Res 5(3): 1104.
*Corresponding author
Pingitore A, Clinical Physiology Institute, CNR, Via Moruzzi, 1, 56124 Pisa, Italy, Tel: +39050312605; Email:
The Words of the New Era of Cardiovascular Prevention: Awareness and Empowerment, Humanism and Esthetics in a Complex NetworkFrancesca Mastorci1, Cristina Vassalle2, Alessandro Pingitore1*1Clinical Physiology Institute, Italy2Fondazione G. Monasterio, Regione Toscana, Italy
Abstract
Cardiovascular disease (CVD) currently represents the leading cause of death, accounting for over 15 million deaths worldwide each year. The protection from susceptibility to CVD can be considered as the final result of the fine-tuning cross talk among environmental factors, gene expression modulation by environment and endogenous homeostatic regulatory systems. In this view, the evaluation of risk factors in cardiovascular prevention field is associated to a parallel transformation of medicine’s clinical goals. This shifts the focus towards implementation and definition of multidisciplinary teams of clinicians and researchers to provide integrated care, early detection and prevention of cardiovascular disease, according a complex interplay of physical, social, economic, cultural and environmental factors, with which the patient is related. In this scenario, bioethical perspective has pointed to the importance of the patient’s point of view in health care decisions through its call to respect patient autonomy according to humanistic conceptions to emphasize ‘‘patient-centeredness’’ outcomes. This integrative, holistic, and personalized perspective offers the possibility for studying patient as a person and human body as a complex adaptive system in which health and disease could be viewed in an onlinear, dynamic, and inter-active network in order to develop multiple purpose preventive and therapeutic treatments.
ABBREVIATIONSCV: Cardiovascular
INTRODUCTION“Medicine is certainly very complex, and technology helps us
shed light into this abyss for better patient care, but the patient is even more complex. However, we should consider many more variables than we usually do”
Daniele Rovai, 2015
In the new era of Medicine, in particular in the cardiovascular prevention field, one element of debate is whether the traditional approach is sufficient or new strategies are needed. This novel possible dimension represents a perspective that explores the factors and relationships contributing to health and therefore
to the enhancement of health-related quality of life. According this view, the subject is reacquiring a central role in a context of an integrated and complex system of interconnections with the environment in which he/she lives. The environment has to be considered in the more general meaning of the term, including the different aspects of lifestyle (diet, exercise, stress), economic, social and working factors, and climate. The response to these multivariate interconnections induces continuous physiological and biological adaptation, i.e. allostasic response, in order to maintain homeostasis that is the equilibrium among organs and systems working within the human body [1]. The loss of this equilibrium may culminate in the so called allostatic load potentially favoring the appearance and the progression of the diseases such as cardiovascular (CV) and neurological diseases, and cancer. This is a crucial point when considering that the major causes of death and disability, in industrialized countries,
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and manage themselves without medical intervention. In this perspective, subject could use interactively technology, including portable/wearable devices, instruments for physiological vital signal monitoring, apps for checking lifestyle habits, and biohumoral point-of-care diagnostic tools, that offer the opportunity for self-monitoring living and environmental parameters, and also suggestions to reduce potentially dangerous behaviors and thus reducing the risk for diseases and improving quality of life in a personalized point of view.
Humanistic medicine: patients as persons
The patient-centered new medicine perspective revokes the humanistic epoch, in which the anthropocentrism has been strengthened in all the human fields, from that socioeconomic to artistic and to philosophic one. In the last years, new medical approaches, Humanistic Medicine, Systems Medicine and Biopsychological model, promoted an integrative, holistic, personalized and patient-centered approach. The need for patient-centered approach addresses issues of quality and holistic health care, and it meets these broader challenges by recognizing that before people become patients, they need to be informed and empowered in promoting and protecting their own health, highlighting that biological, psychological, and social factors may contribute to the appearance and progression of diseases [11,12]. The first sentence of Engel was “The dominant model of disease today is biomedical, and it leaves no room within this framework for the social, psychological, and behavioral dimensions of illness”.
In a letter recently published on JACC, Rovai and colleagues [13] concluded as follows: “physicians must rediscover the human dimension of patients, their fragility faced with the disease and their anxieties; they should spend more time communicating with their patients, resume the habit of performing a physical examination as complete as possible, better understand nonverbal body language, and, finally, consider themselves an integral part of the cure”.
Moreover, in a humanistic perspective, it is intriguing the concept of Esthesis, already used in neuroscience, hence the new term Neuroesthetic, to study beauty or bad, in particular in relation to an artistic production. Esthesis rises from the Greek word αίςθηςίς that means sensation and from the verb αίςθαυόµαί that means to percept through the senses. Therefore, the introduction of this word in the CV prevention framework, is associated, on one side, with the study of the subject’s perception of the environment through the senses, highlighting thus the importance of the environment on the subject’s health, and with the subject’s perception of his/her health status, i.e. awareness, on the other side.
Complexity perspective to cardiovascular prevention
The perspective to study subject/patient in an integrated framework cannot disregard the concept of complexity, understood as “a phenomena shown in systems characterized by nonlinear interactive components, emergent phenomena, continuous and discontinuous changes, and unpredictable outcomes”. [14]. This view offers the possibility for studying complex adaptive systems, focusing on the patterns and
have shifted from a predominance of nutritional deficiencies and infectious diseases, to the chronic degenerative diseases. This shift, termed “the epidemiologic transition” [2,3], is highly correlated with changes in personal and collective wealth (the economic transition), social structure (the social transition), and demographics (the demographic transition), and actually driving the need for investment in the discovery and development of public health and preventative medicine policies. CV disease is a model of chronic degenerative disease, and currently represents the leading cause of death, accounting for over 15 million deaths worldwide each year. According to 2020 World Health Organization projections, due to aging population and an increasing prevalence of risk factors, CV diseases and their complications, in particular post-ischemic heart failure, will be the most important cause of death and morbidity, with high costs to worldwide healthcare systems [4]. Most available models for CV risk calculation, including Framingham Score, EuroScore, and Procoram, use a traditional risk factors (such as age, gender, body mass index, lipid profile, smoking, diabetes, hypertension). However, it is widely acknowledged that also various psychosocial factors are closely related with CV, so that new noncommunicable risk factors, part of the lifestyle and psychosocial sphere (such as depression, locus of control, perceived stress, and life events) has been included in the Interheart Score [5], opening to the psychocardiology concept as a bridge between psychological factors and CV disease [6].
Patient empowerment and awareness
A growing body of evidence suggests that underlying of improved health outcomes, better care, and lower costs is built upon engaged patients who are active participants in their care. Therefore, the ambition of the CV prevention policy should be to increase the awareness and the empowerment of the subjects toward her/his health with the result to reduce CV risk profile. Encouraging patient engagement with healthcare beyond the clinical setting can help patients to know the intricate inter-relationship of lifestyle choices and disease, increasing awareness. For example, in hypertensive patients, self-monitoring of blood pressures is a simple and fast intervention that has been shown to enable behavioural changes and bridge gaps in the patient-clinician relationship, as well as a daily self-monitoring improves medication adherence and healthier lifestyle choices [7]. The increasing relevance of the subject’s point of view is linked to the switch from saving lives to improving lives. This change is due to the high life expectancy reached in industrialized countries, and the increasing relevance of quality of life and prevention [8]. This is a fundamental point considering that the higher the perception of risks, the higher the engagement in risk-reducing behavior [9,10].
Self-management education represents another strategy to support patient engagement, empowerment, and awareness improving health outcomes. Self-management education is different from traditional patient education, because it teaches patients problem solving skills, so that the future of patient empowerment may lie in technological advancements and better access of patients to these technologies. The current technology, the age of WebMD and e-health, can help subjects to monitor
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relationships among the parts, where systems are viewed as nonlinear and able to adapt to a changing environment. Thus, health and disease could be viewed as topics having an onlinear, dynamic, and inter-active network in which small changes can result in large effects and large changes may result in no or in small effects [15]. In this nonlinear system, in which the results of changing one factor are unpredictable yet may still be replicable, the physiological parameters and systems (e.g., biomarkers, sympathetic and parasympathetic transmitters, cytokines, metabolic hormones) interact reciprocally, varying in their functionality in response to external and internal demands in order to maintain homeostatic balance, and freely responding to stimuli in unpredictable ways.
The pathophysiological evidences of this complex and dynamic network are that several biomarkers have properties going beyond their original identified function (e.g. vitamin D, osteocalcin, natriuretic peptides), as well as different drugs are effective in multiple disease (as the case of statins also effective in osteoporosis) [16, 17]. Furthermore, oxidative stress and inflammation are two of the major triggers driving the alterations occurring in chronic diseases, including cellular senescence (telomere shortening), mitochondrial dysfunction, epigenetic changes, abnormal microRNA profiles [18]. Also, cardio protection should be regarded as a complex dynamic network in which metabolic, molecular and hormonal mechanisms are strictly integrated to each other and act at distinct time periods, with different times of action and with potential different effects, from protective to maladaptive or toxic, depending on the context in which they work, the time of activation and the interaction among them [19].
Furthermore, healthy human systems are characterized by variability and elasticity, whereas regularity, or fixed response, indicates illness and pathology. Less complex signals from the system represent the loss of vitality preceding manifest disease. In the complex human system, injury and loss of variability at any connection can lead to organ isolation and to subsequent failure of the organ’s ability to stabilize itself. The complexity of systems is pivotal to the survival and maintenance of allostasis. In fact, allostasis allows ongoing evaluation of the match between internal resources and external demands and provides the organism to produce physiological adjustments in advance of need through anticipatory arousal.
DISCUSSION & CONCLUSIONThe protection from susceptibility to cardiovascular disease
can be considered as the final result of the fine-tuning cross talk among environmental factors, gene expression modulation by environment and endogenous homeostatic regulatory systems. This shifts the focus towards implementation and definition of multidisciplinary teams of clinicians and researchers to provide integrated care, early detection and prevention of cardiovascular disease, according a complex interplay of genetic and epigenetic factors, psychosocial and environmental influences, and lifestyle choices, with which the patient is related. In recognition of the multifactorial complexity underlying cardiovascular disease and associated patient needs for management, the patient-
center cure is further strengthened by improving awareness and empowerment of patients toward own health. All these findings suggest that in the future new approaches, based on holistic, personalized or patient-centered point of view, may focus on the multiple and integrated pathophysiological pathways involved in CV prevention and diseases in order to develop multiple purpose preventive and therapeutic treatments, in a humanistic medical sense.
ACKNOWLEDGEMENTSThis work is dedicated to the memory of Dr. Daniele Rovai.
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Mastorci F, Vassalle C, Pingitore A (2017) The Words of the New Era of Cardiovascular Prevention: Awareness and Empowerment, Humanism and Esthetics in a Complex Network. J Cardiol Clin Res 5(3): 1104.
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