II. Background
- Majority of patients with coronary events have a low Framingham risk
- High Framingham risk does predict more events
- However, low Framingham risk does not eliminate coronary risk
- Ajani (2006) JACC 48:1177-82 [PubMed]
- Cardiac Risks are multiplied by one another (not additive)
- Example of multplied risks (Odds Ratio)
- Relative Risk of Tobacco Abuse, diabetes, Hypertension: 13 fold increased risk
- Add Hyperlipidemia (4 risks): 42 fold increased risk
- Add Obesity (5 risks): 68 fold increased risk
- Add Stress (6 risks): 182 fold increased risk
- References
III. Grading: Cardiac Risk
- Precautions
- Risk calculators (Framingham, Pooled cohort) overestimate Cardiovascular Risks by as much as double
- Ko (2020) CMAJ 192(17):E442-49 [PubMed]
- Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator
- https://www.mdcalc.com/calc/10491/predicting-risk-cardiovascular-disease-events-prevent
- https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
- Expanded Test Sensitivity to include younger patients with cardiovascular, renal or metabolic risk factors
- May replace ASCVD Risk Estimator (less over-estimation of Cardiac Risk)
- Framingham Risk Score
- ACC ASCVD Risk Estimator Plus
- ACC/AHA 2013 Cardiovascular Risk Calculator
- QRISK Calculator
- https://qrisk.org
- Expanded Test Sensitivity to include ethnicities (e.g. southeast asian) at higher risk of cardiovascular events
- Diabetes-Related Cardiovascular Risk Calculator
- Reynold's Risk Score
- Interpretation of Framingham Cardiac Risk
- Low: <10% CAD 10 year risk (<0.6% per year)
- Moderate: 10-20% CAD 10 year risk (0.6-2.0% per year)
- High:>20% CAD 10 year risk (>2% per year)
IV. Risk Factors: Common/Conventional Risks
- Age
- Men over age 45
- Women
- Over 55: Normal onset Menopause
- Over 45: Early Menopause (no Estrogen Replacement)
-
Family History premature CAD
- Definite Myocardial Infarction or sudden death
- Father or first-degree male relative under age 55
- Mother or first-degree female relative under age 65
- Premature Coronary Artery DiseaseFamily History confers 2 fold increased risk
- Sibling CAD history confers up to a 5 fold increased risk (higher than parent)
-
Tobacco Abuse
- Current Tobacco use or within the last 5 years
- Especially more than 40 pack years
-
Hypertension
- Blood Pressure exceeding 140/90 mmHg
- Antihypertensive medication use
-
Hyperlipidemia
- LDL Cholesterol over 130 mg/dl
- HDL Cholesterol less than 40 mg/dl (ATP III guideline)
-
Diabetes Mellitus
- More than doubles risks of Coronary Artery Disease
- Considered Coronary Artery Disease equivalent
- Used in determining Hyperlipidemia Management
- Ethnicity and Race associated with significantly increased Cardiovascular Risk
- Black adults
- Relative Risk 2 for CV mortality compared with white patients
- Higher risk for undertreated comorbidities (e.g. Hypertension, Obesity)
- American Indian
- Relative Risk 1.5 for Coronary Artery Disease than white patients
- South Asian (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Maldives, or Bhutan)
- Higher risk of premature cardiovascular disease with higher hospitalization and mortality rates
- Shajahan (2024) Am Fam Physician 110(1):16-17 [PubMed]
- Black adults
- Other Lifestyle Risk Factors (not typically included in calculators)
- Obesity
- Sedentary lifestyle
- Type A Personality (especially hostility prone)
- Lack of supportive primary relationship
- Comorbidity with Substantial Risks (but not typically included in calculators or Hyperlipidemia protocols)
- HIV Positive status (especially if CD4 Count has ever been <500)
- HIV alone increases risk (Atherosclerosis and Platelet activation)
- Increased risk with medication non-compliance
- Increased risk with comorbid Hepatitis C infection
- Antiretrovirals (esp. increased lipids)
- HIV alone increases risk (Atherosclerosis and Platelet activation)
- Systemic inflammatory states (e.g. Systemic Lupus Erythematosus)
- Chronic Kidney Disease
- Chemotherapy
- Chronic Alcohol Abuse
- HIV Positive status (especially if CD4 Count has ever been <500)
V. Risk Factors: Workplace Chemical Exposures
- Carbon Monoxide
- Lead Exposure
- Methylene Chloride (paint removers)
- Nitrate esters (explosives)
- Carbon Disulfide (Viscose rayon fibers)
- Tobacco smoke (passive exposure)
VI. Risk Factors: Emerging (and those not used in calculators)
- EKG abnormalities at rest
- Increased C-Reactive Protein
- See C-Reactive Protein as Cardiac Risk Factor
- Not recommended for routine screening currently
- High-Sensitivity CRP may be used in high-risk patient
- hs-CRP >3 mg/L predicts more ischemic episodes
- Comparatively weak predictor of heart disease
- Odds RatioC-RP: 1.45
- References
-
Coronary Calcium Score
- Baseline coronary calcifications predict CAD events
- Can raise Relative Risk of CAD event for men to 10.5 (in coronary Calcium >1000)
- Contrast with diabetes CAD Relative Risk of 1.98
- Contrast with tobacco Relative Risk of 1.4
- Kondos (2003) Circulation 107:2571-6 [PubMed]
- Increased apolipoprotein B (LDL core)
- Better measure of coronary risk than LDL Cholesterol
- Associated with risk of fatal acute MI
- Sniderman (2002) Am J Cardiol 90:48i-54i [PubMed]
- Decreased apolipoprotein A-1 (HDL core)
- Apo B to A1 ratio may be better than TC to HDL ratio
- ACE DD Genotype
- Infections (e.g. Coxsackie Virus)
- Increased Fibrinogen
- Low birth weight
- Triglycerides
- Insulin Resistance Syndrome (Metabolic Syndrome)
VII. Management: Disproven preventive factors (not beneficial after evaluation)
- Vitamin E (increases Cardiovascular Risk )
- Beta Carotene (increases cardiovacular risk)
- Increased Homocysteine levels or low Serum Folate
- Folate supplementation does not appear to lower arterial Cardiovascular Risk
VIII. References
- Orman and Mattu in Herbert (2017) EM:Rap 17(9): 8-9
- (2001) JAMA 285:2486-97 [PubMed]
- (1988) Arch Intern Med 148:36-69 [PubMed]
- Grundy (1997) Circulation 95:2329-31 [PubMed]