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
- Framingham Risk Score
- 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: Age
- Men over age 45
- Women
- Over 55: Normal onset Menopause
- Over 45: Early Menopause (no Estrogen Replacement)
V. Risk Factors: Tobacco Abuse
- Current Tobacco use or within the last 5 years
- Especially more than 40 pack years
VI. Risk Factors: Hypertension
- Blood Pressure exceeding 140/90 mmHg
- Antihypertensive medication use
VII. Risk Factors: Hyperlipidemia
- LDL Cholesterol over 130 mg/dl
- HDL Cholesterol less than 40 mg/dl (ATP III guideline)
VIII. Risk Factors: Diabetes Mellitus
- More than doubles risks of Coronary Artery Disease
- Considered Coronary Artery Disease equivalent
- Used in determining Hyperlipidemia Management
IX. Risk Factors: 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)
X. Risk Factors: Other substantial risks (not used in Hyperlipidemia protocol)
- 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 Lupus Erythematosus
- Chronic Kidney Disease
- Chemotherapy
- Chronic Alcohol Abuse
- Systemic inflammatory states
XI. Risk Factors: Other Lifestyle Risk Factors
- Obesity
- Sedentary lifestyle
- Type A Personality (especially hostility prone)
- Lack of supportive primary relationship
XII. 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)
XIII. Risk Factors: Emerging and those not used in calculation
- 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)
XIV. 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
XV. 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]
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