Medical Device Daily National Editor

TORONTO – "Don't take the escalators, don't eat lunch, don't breath."

Those were the instructions shouted to attendees by a session moderator as they filed out of a big hall of the Metro Toronto Convention Center, the session titled "Aerobiology, the Environment and Cardiovascular Health" and launching official activities of the annual scientific meeting of the Heart Failure Society of America (HFSA; Minneapolis).

This tongue-in-cheek clarion call for better health served as a pessimistic summary of message from the session – which probably should have been titled simply, "The Environment and Cardiovascular Health" – that heart disease is a product of the environment, not faulty human biology.

Asking, "What the hell is this session about?" first presenter Salim Yusuf, MD, director of both the division of cardiology and the Population Health Research Institute at McMaster University (Hamilton, Ontario), answered that it was to identify the "root cause" of heart disease. And cutting to the hypothetical chase, he said that it is found in "sociology," not biological processes, and the result of broad global movement of human populations from "rural" to "urban" environments inimical to a healthy heart.

He noted the development of two contradictory healthcare trends: on the one hand, medical science's victories against infectious diseases that used to take the most lives. On the other, increasing urbanization — from one-third of the world's populations living in cities in 1970 to an expected 60% in 2025, he said – as the major driver of heart disease.

Yusuf emphasized that the urbanizing factors that lead to heart disease aren't taking place only in the most developed "rich countries," or mostly among white people.

From 80% to 90% of this burden "is in lower- and middle-income countries," he said, so that targeting cardiovascular disease among "a minority of rich people will not solve the problem. We need a global perspective rather than a North American perspective." Focusing on "less than 2 billion white Caucasians ... is not the basis for action," Yusuf said.

The core issue is not "ethnicity," but "where you live and how you live — as people in India and China start to live like people in Europe and America, they will start to die like people in Europe and America."

Yusuf criticized the U.S. government for lobbying to put the maximum healthy body mass index at 25, two points higher than recommended, as a covert promotion of the food industry. "Who said governments will act in the best interests of [their] people?" he said.

Building on Yusuf's analysis, Richard Jackson, MD, of the School of Public Health at the University of California (Berkeley), described what he said was the typical pre-heart failure patient produced by the urban environment and seen by the cardiologist: a middle-aged man working at a sedentary job, complaining of being tired all the time and is advised to exercise — but can't find the time or opportunity. He tends to look and feel depressed, his tiredness and inaction lead to further complications.

"The environment," Jackson said, "is rigged against your patient and against you."

As examples:

• He showed a photo of a suburban home, its main feature being a three-car garage, a symbol of not much walking being done.

• He lambasted what he called "super-sized schools, way out of town, on cheap land," requiring "fossil fuel" transportation for its students. Thus, he said the number of America's children who walk or bike to school has dwindled to about 13%.

• He showed slides of walker-unfriendly subdivision layouts that encourage the request: "Mom, can you drive me?"

• And he criticized urban sprawl because "the less dense the environments, the more people drive; the more time spent in a car, the higher probability of obesity; the more walking, the less obesity." By contrast, dense development encourages walking and biking.

Thus, he argued that one of the major weapons against heart failure is urban planning. And he encouraged what is perhaps one of the more interesting (and, realistically, less workable) recommendations made at the conference: that a medical person be part of the planning team to encourage the development of walking paths and park systems.

While "aerobiology" got the first word in the title of the presentation, it was the last word in the actual presentation.

(And a reporter from the electronic media, who appeared apparently only for this part of the session, was likely disappointed that it failed to offer aggressive assault on air pollution as the cause of heart disease.)

While air pollution obviously impacts breathing, its role in heart disease is not well understood but currently being explored in depth, according to Dr. Joel Kaufman, MD, professor of medicine and director of the Occupational and Environmental Medicine Program at the University of Washington (Seattle).

He described a variety of dangerous pollutants but said a key issue remains: how to link these to impact on the heart and that it is too early to make specific recommendations concerning pollution and heart health improvement.

Most of the research in this area is looking at "particulate matter [PM], commonly referred to as soot," he said, and the possibility that this is related to "premature" death.

"Very fine soot particles may be causing cardiovascular disease," and "a lot of work is going on trying to understand this."

Kaufman said some studies indicate that people living close to major highways have higher risk for left ventricular myocardial infarction. And after adjustments for factors such as blood pressure, the use of medications and other factors, it is clear, he said, that "something is going on."

Micro-particles may result in inflammation, oxidative stress and basil construction, Kaufman said, but that the way in which these small particles move from the lungs to the cardiac epithelium is still "an open question."

"Lumped together, cardiopulmonary mortality and the mechanisms underlying these observations are obscured, not well worked out," he said. But he expressed certainty that short-term PM exposure is linked to hospitalizations for heart failure and represents a "substantial public health burden."