Cardiovascular Medicine Book

Coronary Artery Disease

Hyperlipidemia

Hypertension

http://www.fpnotebook.com/

Cardiac RiskAka: Cardiac Risk Factor, Coronary Risk Factor

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  1. See Also
    1. Cardiac Risk Management
  2. Background
    1. Cardiac risks are multiplied by one another (not additive)
    2. Example of multplied risks (odds ratio)
      1. Relative risk of Tobacco abuse, diabetes, Hypertension: 13 fold increased risk
      2. Add Hyperlipidemia (4 risks): 42 fold increased risk
      3. Add Obesity (5 risks): 68 fold increased risk
      4. Add Stress (6 risks): 182 fold increased risk
    3. References
      1. Yusuf (2004) Lancet 364:937
  3. Grading: Cardiac Risk
    1. Framingham risk score
      1. http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof
    2. Diabetes-Related Cardiovascular Risk Calculator
      1. http://www.dtu.ox.ac.uk/index.php?maindoc=/ukpds/
    3. Interpretation of Cardiac Risk
      1. Low: <10% CAD 10 year risk (<0.6% per year)
      2. Moderate: 10-20% CAD 10 year risk (0.6-2.0% per year)
      3. High:>20% CAD 10 year risk (>2% per year)
  4. Risk Factors: Age
    1. Men over age 45
    2. Women
      1. Over 55: Normal onset Menopause
      2. Over 45: Early Menopause (no Estrogen Replacement)
  5. Risk Factors: Tobacco Abuse
    1. Current Tobacco use or within the last 5 years
    2. Especially more than 40 pack years
  6. Risk Factors: Hypertension
    1. Blood Pressure exceeding 140/90 mmHg
    2. Antihypertensive medication use
  7. Risk Factors: Hyperlipidemia
    1. LDL Cholesterol over 130 mg/dl
    2. HDL Cholesterol less than 40 mg/dl (ATP III guideline)
  8. Risk Factors: Diabetes Mellitus
    1. More than doubles risks of Coronary Artery Disease
    2. Considered Coronary Artery Disease equivalent
      1. Used in determining Hyperlipidemia Management
  9. Risk Factors: Family History premature CAD
    1. Definite Myocardial Infarction or sudden death
    2. Father or first-degree male relative under age 55
    3. Mother or first-degree female relative under age 65
    4. Sibling CAD history confers higher risk than parent
      1. Nasir (2004) Circulation 110:2150
  10. Risk Factors: Other (not used in Hyperlipidemia protocol)
    1. Obesity
    2. Sedentary lifestyle
    3. Type A Personality (especially hostility prone)
    4. Lack of supportive primary relationship
  11. Risk Factors: Emerging and those not used in calculation
    1. EKG abnormalities at rest
      1. See EKG Markers of Underlying Coronary Artery Disease
    2. Coronary Calcium Score
      1. Baseline coronary calcifications predict CAD events
      2. Can raise relative risk of CAD event for men to 10.5
        1. Contrast with diabetes CAD relative risk of 1.98
        2. Contrast with Tobacco relative risk of 1.4
      3. Kondos (2003) Circulation 107:2571
    3. Increased apolipoprotein B (LDL core)
      1. Better measure of coronary risk than LDL Cholesterol
      2. Associated with risk of fatal acute MI
      3. Sniderman (2002) Am J Cardiol 90:48i
    4. Decreased apolipoprotein A-1 (HDL core)
      1. Apo B to A1 ratio may be better than TC to HDL ratio
    5. Increased Homocysteine levels or low Serum Folate
    6. Increased C-Reactive Protein
      1. See C-Reactive Protein as Cardiac Risk Factor
      2. Not recommended for routine screening currently
      3. High-Sensitivity CRP may be used in high-risk patient
        1. hs-CRP >3 mg/L predicts more ischemic episodes
      4. Comparatively weak predictor of heart disease
        1. Odds ratio C-RP: 1.45
    7. ACE DD genotype
    8. Infections (e.g. Coxsackie Virus)
    9. Increased Fibrinogen
    10. Low birth weight
    11. Triglycerides
    12. Insulin Resistance Syndrome (Metabolic Syndrome)
  12. References
    1. (2001) JAMA 285:2486
    2. (1988) Arch Intern Med 148:36
    3. Grundy (1997) Circulation 95:2329

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