Risk Factors for CAD in Objective-C

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Risk Factors for CAD
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Epidemiologic studies have identified a number of important risk factors for CAD Most patients with coronary heart disease have some identifiable risk factor These include a positive family history (the younger the onset in a first-degree relative, the greater the risk), male gender, blood lipid abnormalities, diabetes mellitus, hypertension, physical inactivity and obesity, and cigarette smoking A large international epidemiologic study of myocardial infarction shows that most of the population-attributable risk is explained by eight factors: abnormal lipids, smoking, hypertension, diabetes mellitus, abdominal obesity, psychosocial factors, consumption of too few fruits and vegetables and too much alcohol, and lack of regular physical activity Smoking remains the number one preventable cause of cardiovascular disease worldwide Although smoking rates have declined in the United States in recent decades, 19% of women and 23% of men smoke According to the World Health Organization, 1 year after quitting, the risk of coronary heart disease decreases by 50% Various interventions have been shown to increase the likelihood of successful smoking cessation (see 1)
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Centers for Disease Control and Prevention Overweight and Obesity: Home (wwwcdcgov/ncdphp/dnpa/obesity; accessed March 2007) Gardner CD et al Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial JAMA 2007 Mar 7;297(9):969 77 [PMID: 17341711] Howard BV et al Low-fat dietary pattern and risk of cardiovascular disease: the Women s Health Initiative Randomized Dietary Modification Trial JAMA 2006 Feb 8;295(6):655 66 [PMID: 16467234] Pearson TA et al; Centers for Disease Control and Prevention; American Heart Association Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association Circulation 2003 Jan 28;107(3): 499 511 [PMID: 12551878] Rosamond W et al Heart Disease and Stroke Statistics 2007 Update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2007;115:e69 71 [PMID: 17194875] Yusuf S et al; INTERHEART Study Investigators Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study Lancet 2004 Sep 11 17;364(9438):937 52 [PMID: 15364185]
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Primary & Secondary Prevention of Coronary Heart Disease
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Although many risk factors for CAD are not modifiable, it is now clear that interventions such as smoking cessation, treatment of dyslipidemia, and lowering of BP can both prevent coronary disease and delay its progression and complications after it is manifest Treatment of lipid abnormalities delays the progression of atherosclerosis and in some cases may produce regression Even in the absence of regression, fewer new lesions develop, endothelial function may be restored, and coronary event rates are markedly reduced in patients with clinical evidence of vascular disease A series of clinical trials has demonstrated the efficacy of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) in preventing death, coronary events, and strokes Beneficial results have been found in patients who have already experienced coronary events (secondary prevention), in those at particularly high risk for events (diabetics and patients with peripheral artery disease), and those with elevated LDL cholesterol without multiple risk factors Benefits occurred regardless of age, race, or the presence of hypertension There is clear evidence that treatment with statins can prevent coronary events and stroke in patients without clinically manifest atherosclerosis (primary prevention) and LDL levels as low as 130 mg/dL It is also clear that for patients with vascular disease, statins provide benefit for those with normal cholesterol levels, and that more aggressive LDL lowering is associated with greater benefits The Heart Protection Study demonstrated that simvastatin 40 mg a day reduces vascular events by more than 20% in patients with prior myocardial infarction, stroke, peripheral vascular disease, or diabetes with total cholesterol levels as low as 135 mg/dL The treatment benefit was similar regardless of baseline LDL cholesterol, with equal benefit above or below 100 mg/dL This result
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suggests that all patients at significant risk for vascular events should receive a statin regardless of their cholesterol levels The PROVE-IT trial showed that vascular events were reduced with more aggressive lipid lowering (atorvastatin 80 mg/d compared to pravastatin 40 mg/d following an acute coronary syndrome), providing more evidence of lower is better for patients with vascular disease The TNT (Treating to New Targets) trial likewise found greater benefit with more aggressive LDL lowering (atorvastatin 80 mg versus 10 mg) in a population of patients with coronary heart disease and LDL cholesterol < 130 mg/dL The IDEAL (Incremental Decrease in End Points Through Aggressive Lipid Lowering) trial provided only modest support for very aggressive lipid lowering, showing a nonstatistically significant reduction in major coronary events with 80 mg/d of atorvastatin compared with 20 mg/d of simvastatin in patients with prior myocardial infarction Although true regression of plaque is uncommon even with intensive lipid therapy (as in the REVERSAL and ASTEROID trials), progression can be prevented at least in the short run in many patients Treatment of abnormally low HDL levels or elevations of lipoprotein(a) and small, dense LDL particles is more difficult, but oral niacin in high dosages (2 3 g/d or more) may be effective A trial in postinfarction patients has demonstrated that an increase in HDL levels with gemfibrozil (600 mg twice daily) in patients with relatively low LDL levels prolongs reinfarction-free survival, although the larger FIELD trial failed to show prevention of nonfatal myocardial infarction or coronary heart disease death with fenofibrate for patients with type 2 diabetes mellitus The value of reducing elevated triglyceride levels is less clear, but since elevated triglycerides are often associated with other lipid abnormalities, treatment of high-risk patients with niacin, gemfibrozil, or fenofibrate for levels above 400 mg/dL is appropriate Antioxidant therapy has been advocated as a preventive measure However, many large, well-controlled studies have failed to demonstrate a benefit with vitamin E therapy In fact, the Heart Protection Study and the Heart Outcomes Prevention Evaluation (HOPE) trial found that vitamin E may even be harmful by increasing the likelihood of heart failure and other trials have suggested that vitamin E may hinder the effectiveness of statin therapy Elevated plasma homocysteine levels are associated with an increased risk of vascular events Although homocysteine levels can be reduced with dietary supplements of folic acid (1 mg/d) in combination with vitamin B6 and vitamin B12, two randomized clinical trials have shown that they are of little or no value in preventing vascular events Antiplatelet therapy is another very effective preventive measure Aspirin (325 mg every other day) in males over the age of 50 years reduces the incidence of myocardial infarction A similar approach (100 mg every other day), however, did not prevent myocardial infarction in women age 45 years or older, although stroke did appear to be reduced Thus, the role of aspirin in primary prevention, including the dose, remains controversial A prudent approach would be to administer 81 325 mg daily to men with multiple coronary risk factors or concomitant diabetes starting at age 45 50 years if no contraindication is
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