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Approximately 36% of all deaths that occurred in the United States in 2000, most of which were a result of heart disease, were attributable to behavioral or lifestyle factors, including tobacco use, poor diet, physical inactivity, and alcohol.1 In 2009, it was estimated that high blood pressure accounted for 45% of all cardiovascular deaths, followed by overweight-obesity, physical inactivity, high low-density lipoprotein (LDL) cholesterol, smoking, high dietary salt, high dietary trans-fatty acids, and low dietary omega-3 fatty acids.2 In persons under the age of 70, smoking was the single largest risk factor for cardiovascular death.


Although genetic factors undoubtedly contribute to individual susceptibility to these risk factors, a prime ingredient of this risk is the person's behavior. The costs of treating heart disease are escalating at an increasingly rapid pace due to the widespread use of sophisticated and increasingly expensive treatments such as drug-eluting coronary artery stents, implantable cardioverter-defibrillators, and gene therapy. Most efforts to contain the increase in health care costs have focused on limiting supply (a largely unfulfilled promise of managed care) and imposing some sort of rationing. However, as long ago as 1993, Fries et al3 pointed out that restricting demand could achieve the same objective. They identified six factors, four of which are directly relevant to this chapter. They include the following facts:


  1. Much disease is preventable.

  2. Risky behavior costs money. Lifetime medical costs, which averaged $225,000 per person, have been clearly related to health behavior. For example, costs are approximately one-third higher in smokers compared with nonsmokers.

  3. Self-management can result in savings. Several studies have shown that providing medical consumers with information and guidelines about self-management can lower the use of medical services by 10% or more.

  4. The promotion of healthy behavior at work successfully reduces costs. This has also been documented in numerous studies.


The resulting tasks for the field of behavioral cardiology in the care of patients with heart disease are as follows: (1) to better identify patients at risk by developing tools that reliably assess behavior that harms and behavior that protects; (2) to educate physicians in the risks associated with lifestyle factors and in managing these risks together with their patients; (3) to develop and test the efficacy and cost-effectiveness of interventions to promote lasting behavior change in patients; and (4) to identify barriers for the implementation of health behavior guidelines in cardiology practice and find ways to overcome these barriers.


This chapter focuses on the major lifestyle or behavioral factors that influence the incidence of coronary heart disease (CHD), as well as the progression of existing CHD, and how they can be modified. These factors are smoking, diet, exercise, and adherence to prescribed medication regimens. They all have an impact on a patient's prognosis, and they are linked to long-established biologic risk markers, such as blood pressure, cholesterol, triglycerides, and glucose-insulin homeostasis, and more recently identified risk markers, such as endothelial ...

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