Lown Forum

T HE

2009

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LOWN CARDIOVASCULAR RESEARCH FOUNDATION

Addressing stress to promote cardiovascular health

Joe G., a Lown Center patient, recently visited the Lown Center concerned about periods of breathlessness. A 60 yearold computer programmer, for the past several years Joe had successfully managed his cardiovascular risk factorshypertension, diabetes, and high cholesterolwith medication and lifestyle. "This time, he was ten pounds heavier than six months earlier," Dr. Brian Bilchik recalls. "Afraid of being laid o, he was working 1012 hours a day, not exercising, and not thinking about what he was eating. He fell o his healthy program because of the perception that he didn't have the time." Ironically, the times when we most need to protect our health are often when we neglect it. People may feel they don't have the time to exercise or shop and cook; they may seek relief with alcohol, tobacco, or sweets; or they try to save money by cutting back on health care. In fact, these are the times when we need to invest in taking care of ourselves more than ever, because it's when we're most vulnerable to cardiovascular and other health problems. alive whose head is separated from his or her body?' Whether the cause is the current economy, a sick relative, or a near miss while driving, the physical eects of stress are very real." As humans, we are programmed for survival with a ight or ght response to stress. "Some challenges are stressful in ways that are positive and stimulating," notes Dr. Bilchik. "But ongoing stress, without a light at the end of the tunnel, lowers immunity, increases inammation, and decreases energy levels, which may lead to unhealthy behaviors. It's a perfect storm of psychological and physical factors that can accelerate coronary artery disease or increase an individual's risk of an acute event."

The Lown Center's approach to stress

Addressing stress along with other cardiovascular risk factors is a cornerstone of the Lown Center's approach to cardiac care. "We began researching stress and the heart in the 1960s because it was largely ignored," recalls Dr. Bernard Lown. "Our commitment to practicing medicine with a human face centers around the fundamental act of being perceptive to the psychologic dimensions of our patients. Probing and listening to the stories of their lives became a major element of our approach." Stress is a normal part of life; without some stress, life would be dull. But chronic stress can negatively aect quality of life and health. "There's no way to avoid it," Dr. Vinch notes, "and unfortunately there's no dial to turn it up or down. But there are very positive things that we can do to help ourselves handle it better and ameliorate its eects. At the Lown Center, we work with our patients to assess how stress is aecting them and help them develop healthy responses. Read the Lown Center's guide to addressing stress on page 5.

Stress and the heart

"People often think that stress is just in their heads," notes Dr. Craig Vinch. "So I ask them, 'Is there anyone

Addressing stress together with other cardiovascular risk factors is a cornerstone of the Lown Center's approach to cardiac care.

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President's message Lown Center vascular lab Time with patients and the US health care crisis Question from a patient

4 Lown Center N e w s B e a t 5 Guide to addressing stress 67 Training the next generation 8 National Forum Annual Meeting

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Presidents message
Vikas Saini, MD
I wish to extend a great "thank you" to everyone who responded to our annual appeal. In this time of nancial diculty, a donation to the Lown Cardiovascular Research Foundation indicates a special regard for our eorts, and this motivates us to keep forging ahead. During this period of scal pressures and changing roles, the LCRF Board has decided to restructure the Foundation's operations. I am sad to announce the departure of Carole Nathan from the Lown Foundation. Carole originally worked for the Lown Group as Appointment Coordinator and brought warmth and cheer to countless patients. She later brought those same traits to her role as Foundation Assistant. After becoming Executive Director, she worked tirelessly to keep our supporters, donors, and admirers feeling welcomed and part of the extended Lown family. We will miss her contributions immensely, and wish her great success in her future endeavors. Claudia Kenney has assumed the role of Foundation Administrator. For many years, Claudia was Executive Secretary to Dr. Bernard Lown at his Harvard School of Public Health research laboratories. After the Lown Center consolidated operations into its present Brookline location, Claudia worked as assistant to Dr. Tom Graboys. Those of you who already know Claudia are aware that she is a dedicated, extraordinarily organized, and competent person. We are fortunate to have her back in a new role. When you want to communicate with the Foundation, feel free to contact Claudia at 6177321318 ext. 3355. We are moving forward with the review of data on our management of coronary patients, the vast majority of whom came to us for a second opinion regarding bypass surgery or angioplasty. We have completed data collection for follow up of nearly 15 yearsthe longest period of follow up of any study of patients managed medically with our style of care. We expect to publish our results to provide further support to our patientfocused approach. This research will then inform our next round of investigations, which need to focus on primary and secondary prevention. We are exploring a system of detailed data capture and realtime analysis that would allow us to create a continuous qualityimprovement cycle for optimizing prevention. Such a system has the potential to be a valuable model for others in the new era of seeking highest quality at the lowest cost.

CLINICAL UPDATE

Lown Center opens new vascular lab

To many people, "cardiovascular disease" is synonymous with "heart disease" but in fact the heart is only one component. The spectrum of cardiovascular diseases also includes conditions that aect the vascular system and other important organs such as the brain and kidneys. About 50% of people with coronary disease also have vascular disease, which is caused by the same build up of plaque. Depending on where the buildup occursfor example, in the neck, leg, or abdomenit can cause a range of problems, including pain, hypertension, or stroke. The Lown Center opened a new vascular lab in March 2009 under the direction of Dr. Fred Mamuya. "We can now provide our cardiac patients with stateoftheart vascular testing in a convenient, comfortable setting," he explains. "From the patient's perspective, it's an easy, simple test. Most of the testing is done with ultrasound it's like looking at a baby in its mother's womb and is extremely safe. Because testing is performed onsite, results are available quickly and are rapidly integrated into the diagnosis and treatment of our patients." Vascular testing may be used to diagnose DVT (deep venous thrombosis), assess the health of arteries that feed the brain or kidney, or look at the arteries in the leg. It has proved to be so useful in the early identication of some problems that it is now recommended for screening men over 50 who are smokers or who have a family history of aortic aneurysms. "With early identication of vascular problems and the use of the best, most appropriate medical therapies, we're further extending the Lown Center's philosophy of avoiding or postponing interventional procedures, "Dr. Mamuya arms.

Dr. Fred Mamuya, Vascular Lab Director, views images of a patient's carotid artery with Marcy Scaduto, Registered Vascular Technologist. The Lown Center's new lab provides patients with stateoftheart vascular testing in a convenient setting where test results are rapidly integrated into diagnosis and treatment.

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Time spent with patients a critical factor in the US health crisis

Bernard Lown, MD
That we have a dysfunctional health care system is widely acknowledged. No longer does one hear that Americans receive the best medical care in the world. The number of uninsured people in the US has reached 47 million, with an additional 30 million covered merely for catastrophic illness. No other industrial nation comes close to the approximately $7000 spent by each American annually for medical care. Mounting health expenditures preoccupy economists and politicians. The escalation is ascribed to an everaging population with greater health demands as well as to costly scientic and technological advances. What is largely ignored is the commodication of illness that America's marketoriented health care system fosters. The underlying intent is to maximize protability rather than promote wellbeing. Unnecessary tests and procedures are encouraged. Market values are the invisible elephant in the doctor's oce. They quench the human dimension in health care and corrupt the doctor patient relationship. The rst casualty is listening. Since listening to a patient consumes much time and is minimally reimbursed, it is most often done in a cursory, hasty manner, leaving the patient frustrated and the doctor uninformed.

The importance of history taking

History taking is by far the critical part of any encounter between doctor and patient. However, careful history taking is no longer the norm. It takes time for even an experienced doctor to sort out serious from trivial symptoms. Many patients complain that "doctors don't listen" and indeed they are frequently interrupted after a few sentences. Without listening, how do doctors reach a diagnosis justifying a course of treatment? Current technologies provide an intimate view of internal body organs. None of these imaging techniques, however, can expose the basis for an aching heart. Far worse, they open a Pandora's box of unsuspected abnormalities. Every healthy person is laden with diverse anomalies that may persist over a lifetime without causing mischief. So common are these that they have earned the name "incidentaloma." Once a potential pathology is identied, doctors feel compelled to explore further, refer patients to medical specialists, and advise invasive biopsies, thereby adding discomfort, potential complications, and mounting costs.

"Market values are the invisible elephant in the doctor's oce. They quench the human dimension in health care. The rst casualty is listening." Dr. Bernard Lown

When doctors give short shrift to listening and conversing, health costs mount. More than 80% of problems that bring someone to a doctor are minor. They derive from the stresses of living. In a majority, the symptoms do not augur a stroke, a lethal heart attack, or cancer. In a bygone age, when an extended family reigned, older relatives counseled simple, commonsense remedies that decompressed the agitation provoked by unexplained symptoms. Minor illnesses, real or imagined, were healed by the passage of time. This fact, which the ancient Greeks comprehended, accounted for the dominance of Hippocratic medicine over more than two millennia. Hippocrates promoted the notion that, given time and gentle intervention, the body is selfhealing.
Adapted from an article originally published by ProCor, the Lown Foundation's program promoting cardiovascular health in devel oping countries. Read more articles by Dr. Lown on ProCor's website: www.procor.org.

History taking fosters trust and thereby lays a foundation for the most quintessential aspect of doctoring. Without trust, instructions are more likely to be ignored, medications not taken, diets not followed. Instead the patient goes to the internet to search for alternative diagnoses and diering remedies, and to shop for specialists. Preventive medicine, though the most costeective approach, is largely neglected because it is time intensive. In the absence of meaningful discourse, the doctor is compelled to focus on the acute and emergent. Diligent prevention invariably plays second ddle to heroic cures. Of all the skills mastered by a physician, listening is by far the most dicult. One learns to be attentive to the uttering eyelid, the inaudible sigh, the unshed tear. Proper listening enables one to comprehend the unique narrative of another human being. Even at its scientic best, medicine is dependent on the intimate story. For doctors, this is an exhilarating act of discovery; for patients, it identies a healer. Medicine is ultimately a social discipline. It begins with a unique story from a fellow human being craving help.

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Question from a patient

Shmuel Ravid, MD, MPH
Is it true that lowering cholesterol with Zetia does not provide additional protection from heart disease but may increase my risk of developing cancer? Background: Ezetimibe (Zetia) is a lipidlowering drug that
inhibits intestinal absorption of cholesterol. It is also marketed in combination with Zocor (simvastatin) as Vytorin. Zetia was approved by the FDA based on its eectiveness in lowering total and LDL (bad) cholesterol. Zetia enhances the eect of statin drugs (Zocor, Lipitor, Crestor, etc.) that reduce incidence and progression of cardiovascular disease (CVD). Zetia has been heavily marketed by Merck since 2002 although data on patient outcomes and longterm safety were not available. In 2008, the ENHANCE study revealed that combined Zetia and simvastatin reduced cholesterol more than simvastatin alone, but did not reduce CVD events or plaque formation in the carotid arteries of patients with high cholesterol.1 A similar study, SEAS, which added Zetia to simvastatin, failed to show improved CVD outcomes in patients with aortic stenosis (narrowing of the aortic heart valve).2 The SEAS study also revealed higher incidence of cancer and cancer deaths in the group taking Zetia. Higher cancer risk was not corroborated in an analysis of the combined data from SEAS and two other studies of Zetia, however.2

LOWN CARDIOVASCULAR CENTER

NewsBeat
Dr. Charles Blatt was interviewed about the risks and benets of anti coagulation with warfarin (Coumadin) for Best of Times, a current events program on Newton Cable Television in March 2009. The segment aired in rotation on NewTV and other community access television stations. The Louise Lown Heart Hero Award was featured on the March 20, 2009 edition of 3FOUR50 TV Channel News, an online global showcase of videos about chronic disease. Watch it at http://www.3four50.com. Dr. Brian Bilchik received a Service Award from the National Forum to Prevent Heart Disease and Stroke on March 19, 2009 in recognition of his contributions as ViceChair of the Communications Implementation Group. Dr. Bilchik also recently completed a twoyear term as CoChair of the Brigham and Women's Hospital Physician Council. Dr. Vikas Saini writes a monthly column called "From the Heart Doc" for the Indian edition of Prevention Magazine (www.prevention.intoday.in). On March 4, 2009, Dr. Saini presented the Lown Group's approach to managing chronic angina at Ganga Ram Hospital in Delhi, India. Dr. Lown was keynote speaker at Miriam Hospital in Providence, RI on May 7. LCRF board member Dr. Barbara Roberts, head of the Women's Cardiac Center at Miriam Hospital, organized the event. An interview with Dr. Lown which was recorded by Peace Talks Radio in March is available online at www.goodradioshows.org. Dr. Fred Mamuya and Dr. Brian Bilchik addressed the Brookline Rotary Club in February in recognition of Heart Health Month. The topic of their presentation was "Preventive Strategies for Vascular Disease."
Dr.Bernard Lown addressed the Women's International Forum of the United Nations on April 23, 2009. Left to right: Dr Fatimah Gambari of Nigeria; Diana Hill, Co President of the Women's International Forum; and Dr. Lown.

What this means for our patients: Statins are the

pharmaceutical intervention of choice for lowering cholesterol in patients with, or at risk for, CVD. Only if the maximal tolerated dose of statins fails to achieve target goals should other proven drugs be considered (niacin, fenobrate [Tricor], or gembrozil). Zetia lowers cholesterol, but its longterm benet and safety are unproven. It should only be used as a last resort. I prescribe Zetia only to patients with signicant CVD and risk factors who cannot achieve optimal control with statins alone or with other proven drugs. New drugs should be promoted and prescribed only after they are proven safe and shown to improve patients real outcomes, not just indirect measures of ecacy such as cholesterol levels. Regardless of the medical regimen chosen, regular physical activity, optimal weight, and a low saturatedfat diet are eective and necessary steps for preventing CVD and protecting your health.
1 2

New England Journal of Medicine, April 3, 2008. New England Journal of Medicine, September 25, 2008

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The Lown Cardiovascular Center's guide to addressing stress

During trying times, it's more important than ever to protect your health. Here are some tips from the Lown Cardiovascular Center on how to reduce stress in easy, enjoyable ways that don't take much time or cost money. If you are concerned that stress may be aecting your health, talk with your Lown physician. You may benet from a referral to a therapist to help identify stressors and strengthen skills for handling them.

1 Physical activity
Physical activity is good for your heart and helps reduce stress. Everyone, especially people with heart disease, benets from regular physical activity: walking, swimming, even gardening or dancing. If you have trouble nding time to exercise, remind yourself that physical energy promotes mental energy, and that by taking care of yourself you'll be better able to meet the needs of those around you. Choose an activity you enjoy, start slow, and stay with it. Combining physical activity and social activities, or pairing with another person, can help you stay motivated. Discuss any concerns about increasing your activity with your cardiologist, who will help you determine what's right for you.

5 Social support
Being alone or lonely may exacerbate cardiac and other risk factors. A sense of companionship enhances not only longevity but also quality of life. Spend time with friends or participate in community activities. Providing support is as healthy as seeking it. Dr. Mamuya prescribes "random acts of kindness" as an antidote to stress.

6 Find what's right for you

Incorporate stress reduction into every day. Be creative! Here are some ideas from Lown Center physicians: Take ve: "I encourage my patients to take just ve minutes a day and do something they enjoy," counsels Dr. Fred Mamuya. Meditation: "Research has shown that simple meditation techniques can change how people respond to stress," notes Dr. Vinch. How to start? Close your eyes and focus on your breath as you inhale and exhale, or visualize yourself in a peaceful setting for a few minutes. Dance: "I tell some patients to pull down the shades, turn up the music, and dance," reports Dr. Bilchik. Down time: "Take a vacation! It's obvious, but sometimes people overlook it," recommends Dr. Saini. We surveyed Lown Center sta about their personal strategies for reducing stress. Here's a sampling: Joanne LaptewiczRyan, Lown Center administrator: "Read a good book then discuss it with friends." Claudia Kenney, Foundation administrator: "Cardio kickboxing and playing the piano." Fred Mamuya, MD: "Listen to my 12yearold son practice the cello." Helene Glaser, head nurse: "Ride my motorcycle." Lisa Foote, administrative assistant: "Crochet." Craig Vinch, MD: "Regular exercise and sleep." Sheila Harrington, exercise physiologist: "Go out with my camera and take photographsanywhere." Sal Cravotta, administrative assistant: "Cook."
Share your personal destressing strategy. We'll post suggestions in the Lown Center waiting area to inspire others. Email it to info@lownfoundation.org or mail it to us at 21 Longwood Avenue, Brookline, MA 02446.

2 Nutrition
Pay attention to what you're eating when you're stressed. Curb any cravings for salt, sweets, caeine, or fast food, which simply increase feelings of fatigue or guilt. Instead, choose fruits, vegetables, and whole grains. Talk to your cardiologist about how to cut down on salt. Start your day with a simple, nutritious breakfast. Take time to prepare and enjoy a healthy meal of foods that are local and fresh. Eating at home saves money too!

3 Sleep
Stress can adversely aect sleep. Being well rested helps people cope better and promotes healing. Instead of staying up until you feel tired, establish a sleeping schedule based on when you typically wake up. Working backwards, plan 7 hours to sleep plus 30 minutes to fall asleep. Consider reducing your caeine intake and keep in mind that alcohol impairs sleep quality.

4 Don't neglect your health

More than half of American families report postponing physician visits or not lling prescriptions to save on health care costs. Consider your health your most valuable investment. Instead of postponing medical appointments, make the most of them by writing down questions beforehand, and ask whether less expensive drugs are available.

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Training the next generation of physicians: A hallowed tradition

For medical students, who receive most of their training in hospitals, the trend toward shorter inpatient stays for cardiac patients has dramatically altered their learning experience. "Patients are admitted sicker, stay a shorter amount of time, and after being discharged are managed on an outpatient basis. Medical students only see acutely sick patientsthey no longer have the opportunity to gure out what is wrong or observe someone getting better," explains Dr. Charles Blatt.
At the beginning of the course, students receive a thick syllabus of readings and a stack of about 200 electrocardiograms to interpret, with the expectation they will review ten each night for discussion with Dr. Blatt the next day. But the most important item in their training package is a 3"x5" index card, he says. "I tell them to note everything in the course of the day that they don't know or understand. Later we discuss it, and I steer them to relevant reading or lend them my favorite textbooks."

To address this gap in Students begin by observing Dr. medical education, Dr. Blatt or another Lown physician for Blatt developed a several days. They examine patients Harvard Medical School on their own and then observe the (HMS) course titled senior physician taking medical "Clinical Cardiology in the histories, performing clinical exams, Outpatient Setting" and interpreting EKGs for the same more than a decade patients. After each patient visit and ago. The course at the end of the day, Dr. Blatt sits "Perhaps most valuable was observing the relationship between provides HMS students with them to discuss what they Lown Center patients and their physicians, " says Deborah with the experience of observed. Patients are always Vinton, who took a monthlong Harvard Medical School course working sidebyside consulted on whether or not they directed by Dr. Blatt. Left to right: Dr. Shmuel Ravid, Dr. Charles with cardiologists at want a student to participate in Blatt, Deborah Vinton, Dr. Brian Bilchik. the Lown Center. The their care. Dr. Blatt reports that course trains one student each month throughout the most patients enjoy contributing to the education of a year except in the summer. medical student and appreciate the extra attention. According to Deborah Vinton (HMS '09), who took the course in March 2009, it oers medical students the opportunity to learn "what we don't learn in medical school and don't see in other physician practices." (Read more about her experience on page 7). Training the next generation of physicians has long been part of Lown Center activities. "From the very inception, we felt that the process of teaching provided the most extreme form of learning, " recalls Dr. Bernard Lown. "Students liked to be with us because we gave them a clinical view from the trenches, not from the books. This began a tradition which hallowed the importance of teaching." The Lown Center oers medical students a unique setting in which to learn the art and science of medicine. "We have the capacity to perform onsite all of the necessary noninvasive diagnostic studies. Students observe how each test is performed, participate in interpreting test results, and under my supervision begin to develop the skill of distilling the results for patients, referring physicians, and the permanent medical record," Dr Blatt explains.
In addition to spending each day seeing patients with Lown physicians, students attend weekly Lown Center clinical conferences; develop and present a seminar; and accompany Lown Center physicians to Grand Rounds and medical conferences at Brigham and Women's Hospital. "Teaching is part of being a physician." Dr. Blatt arms. "And it's a privilege to have such a high caliber of students."

More Lown Center training news...

Ghideon Ezaz, a Harvard Medical School student from Eritrea, completed a oneyear preceptorship with Dr. Brian Bilchik in April 2009 . Ghideon is the ninth HMS student to complete this intensive oneon one training program at the Lown Center.

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Lessons I will carry with me

Deborah Vinton, HMS '09
Deborah Vinton trained at the Lown Cardiovascular Center in March 2009. In this article, she shares her thoughts about her experience. At the end of my fourth year of medical school, I chose to enroll in an outpatient cardiology rotation at the Lown Center. As a future emergency medicine physician, I knew that I would see large numbers of patients with cardiac related illness. I wanted a strong background in cardiology and hoped to gain perspective on how cardiologists manage their patients in an outpatient setting, so when these patients came to the emergency room I would be better prepared to deliver the best treatment possible. During my month at the Lown Center I practiced valuable skills, such as reading EKGs and echocardiograms, and dictating notesskills which I hadn't had the chance to focus on during my previous months on the wards. During patient exams, Dr. Blatt patiently taught me how to identify subtle heart sounds through a substantial amount of repetition and guidance. Only in a setting like the Lown Center, in which I was able to work oneonone with a senior cardiologist and see many patients, was it possible to acquire these skills. However, the most valuable aspect of my experience was observing Dr. Blatt's relationship with his patients. He relayed a realistic sense of optimism, helping patients focus on bringing joy to their everyday lives and pursuing activities that would promote both cardiac and psychological health. Even when running short on time, Dr. Blatt discussed a patient's broader concerns and stressors at home. Patients inevitably revealed information relevant to their clinical wellbeing which otherwise would have never surfaced. I began to appreciate the importance of being fully present in the room with a patient. Whether it is in a crowded emergency room or outpatient clinic, the world stops for that moment. What I witnessed at the Lown Center was that by letting people open up, even if it only takes 30 seconds longer, I will be able to provide innitely better care of my patients, even during very brief rsttime interactions. I am extremely grateful for my experience at the Lown Center and hope to carry with me its approach toward patient care for the duration of my medical career.

A mentor of mine...
Reprinted from Letters to the Editor, New York Times, March 11, 2009. Dr. Cohen was a Lown Fellow from 19871988. The "mentor" to whom Dr. Cohen refers is Dr. Bernard Lown. A mentor of mine once told a story of a patient whose son admired a certain Russian poet. He made a notation of this in his oce note. Several years later, upon seeing this woman again, he inquired as to whether her son "still read Pushkin." The patient nearly fell o her chair, so taken was she by her doctors recalling this seemingly trivial but meaningful fact. I have used this anecdote repeatedly in my own career, jotting down reminders as to my own patients reading proclivities and other personal miscellany. Bringing up these tidbits at future visits is useful in creating trust between patient and doctor. Unfortunately, I have yet to encounter an electronic medical record system that allows one to document the reading habits of the patient or his family members. Ronald B. Cohen, Woodbury, N.Y., March 6, 2009

Lown Cardiovascular Research Foundation

For more than 30 years, the Lown Cardiovascular Research Foundation has promoted a humane and costeffective model of cardiac care that advocates prevention over costly, invasive treatments and restores the relationship between doctor and patient.
Board of Directors Nassib Chamoun Chairman of the Board Vikas Saini, MD President Bernard Lown, MD Chairman Emeritus Thomas B. Graboys, MD President Emeritus Patricia Aslanis Charles M. Blatt, MD Joseph Brain, SD Janet Johnson Bullard Carole Anne McLeod C. Bruce Metzler Barbara H. Roberts, MD Ronald Shaich Robert F. Weis Advisory Board Martha Crowninshield Herbert Engelhardt Edward Finkelstein William E. Ford Renee Gelman, MD George Graboys Barbara Greenberg Milton Lown John R. Monsky Jeffrey I. Sussman David L. Weltman CONTACT US

Lown Cardiovascular Research Foundation

21 Longwood Avenue Brookline MA 02446 (617) 7321318 info@lownfoundation.org www.lownfoundation.org Lown Cardiovascular Center Brian Z. Bilchik, MD Charles M. Blatt, MD Wilfred Mamuya, MD, PhD Shmuel Ravid, MD, MPH Vikas Saini, MD Craig S. Vinch, MD Lown Forum Editor Catherine Coleman Editorial support Claudia Kenney
c2009 Lown Foundation Printed on recycled paper with soy based ink.

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National Forum Annual Meeting tackles health reform

Brian Bilchik, MD, Director, ProCor
Heart disease and stroke are the rst and third leading causes of death in the United States respectively. One in three US adults has cardiovascular disease and yet one in ve adults is uninsured. Last year, the cost to treat these diseases was estimated at close to $450 billion, and CVDrelated costs are expected to increase signicantly over the next two decades as baby boomers age. The National Forum for Heart Disease and Stroke Prevention, which is made up of more than 80 organizations, provides leadership in implementing the Public Health Action Plan to Prevention Heart Disease and Stroke developed by the Centers for Disease Control. productivity and health care costs in 20232. Unfortunately, at present the US spends only pennies of its health care dollars on prevention. Special sessions at the Forum meeting were dedicated to strategies for reducing salt consumptionthe single most costeective, ecient, and practical strategy for decreasing risk factors of heart disease and stroke. About 80% of the salt we consume comes from processed food and prepared meals. Only 15% is added during cooking or at the table, and a mere 5% occurs naturally in foods. The UK has made tremendous progress with policies reducing salt intake in the population and an exciting pilot program

I have been involved with the National Forum for the last four years, initially as ViceChair of the Communication Implementation Group, which was charged with developing key messages for the Forum, and more recently as ViceChair of the Regional and Global Collaboration Implementation Group. Over the past several months, ProCor has helped develop a digital library for the Forum. We also recently distributed a survey on global CVD training needs to our email network, ensuring that the ideas and experiences of people in low and middleincome countries are represented among its ndings.

About 80% of the salt we consume comes from processed food and prepared meals. Only 15% is added during cooking or at the table, and a mere 5% occurs naturally.
in New York City is now underway. Hopefully the rest of the US will learn from these successes. Sir William Osler once said, The way to live a long life is to get a chronic disease and take care of it. The hope and aim of the Lown Cardiovascular Center is not only to take care of patients with chronic disease, but to be one step ahead of it.
References 1 Trust for Americas Health, 2008 2 Milken Institute, 2007 ProCor is the Lown Foundation's program promoting cardiovascular health in developing countries. To learn more, visit www.procor.org or email info@procor.org.

The annual meeting of the National Forum in Washington DC on March 1820, 2009 focused on health reform. Spending $10 per person per year on prevention strategies outlined in the Action Plan would save $16 billion annually after 5 years1, and an additional $1.1 trillion in lost

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