The cholesterol level of approximately half the US population puts these individuals at significant risk. A fasting lipoprotein profile (measuring total cholesterol, LDL-C, HDL-C, and triglyceride levels) helps determine an individual’s risk status. The US Preventive Services Task Force recommends screening for lipid disorders in men 20–35 years of age and women aged 45 years and older when other risk factors exist, and all men aged 35 years and older regardless of other risk factors. Experimental studies directly support the central role of LDL in atherogenesis, and lowering LDL-C levels is associated with a reduction in CVD risk. Conversely, HDL-C appears protective against atherosclerosis because of its anti-inflammatory properties and its ability to transport cholesterol from vessel walls to the liver for disposal. In general, current guidelines recommend a high-HDL and low-LDL concentration to decrease CVD risk.
Other CHD risk factors, such as hypertension, smoking, diabetes mellitus, short sleep duration, obesity, and limited physical activity should be assessed and managed appropriately in all adults (Table 4-1). The INTERHEART study, which involved 15,000 patients with acute MI versus 15,000 controls in 52 countries, found that current smoking, hypertension, diabetes mellitus, abdominal obesity, psychosocial factors, and a raised apolipoprotein B/apolipoprotein A-I ratio increased the risk of acute MI, while moderate or strenuous exercise, daily consumption of fruits and vegetables, and daily consumption of small amounts of alcohol were protective.
Table 4-1 Risk Factor Modification Treatment Goals
A number of risk assessment tools are available to estimate the 10-year risk of a cardiovascular event, including the pooled cohort equations on the American Heart Association (AHA) website (United States); QRISK (United Kingdom); HeartScore (Europe); and MESA (Multi-Ethnic Study of Atherosclerosis; United States). Physicians are encouraged to use the risk tool best suited to the individual patient, because relative cardiac risk varies among national, ethnic, and racial groups. Use of these tools guides the clinician in identifying patients requiring aggressive treatment and those most likely to benefit from such treatment.
2013 prevention guidelines tools: CV risk calculator (pooled cohort equations). AHA website. http://professional.heart.org/professional/GuidelinesStatements/PreventionGuidelines /UCM_457698_Prevention-Guidelines.jsp. Accessed February 21, 2019.
Goff DC Jr, Lloyd-Jones DM, Bennet G, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 129(25 Suppl 2):S49–73.
Graham I, Atar D, Borch-Johnsen K, et al; European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG). European guidelines on cardiovascular disease prevention in clinical practice: executive summary: Fourth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2007; 28(19):2375–2414.
HeartScore. European Association of Preventive Cardiology website. www.heartscore.org/en_GB. Accessed February 21, 2019.
MESA risk calculator. https://mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx. Accessed February 21, 2019.
QRISK3-2018 risk calculator. ClinRisk website. http://qrisk.org/three. Accessed February 21, 2019.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.