II. Background

  1. Majority of patients with coronary events have a low Framingham risk
    1. High Framingham risk does predict more events
    2. However, low Framingham risk does not eliminate coronary risk
    3. Ajani (2006) JACC 48:1177-82 [PubMed]
  2. Cardiac Risks are multiplied by one another (not additive)
  3. 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
  4. References
    1. Yusuf (2004) Lancet 364: 937-52 [PubMed]

III. 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. Reynold's Risk Score
    1. http://www.reynoldsriskscore.org/
  4. Interpretation of Framingham 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)

IV. Risk Factors: Age

  1. Men over age 45
  2. Women
    1. Over 55: Normal onset Menopause
    2. Over 45: Early Menopause (no Estrogen Replacement)

V. Risk Factors: Tobacco Abuse

  1. Current Tobacco use or within the last 5 years
  2. Especially more than 40 pack years

VI. Risk Factors: Hypertension

  1. Blood Pressure exceeding 140/90 mmHg
  2. Antihypertensive medication use

VII. Risk Factors: Hyperlipidemia

  1. LDL Cholesterol over 130 mg/dl
  2. HDL Cholesterol less than 40 mg/dl (ATP III guideline)

VIII. 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

IX. 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. Premature Coronary Artery DiseaseFamily History confers 2 fold increased risk
    1. Lloyd-Jones (2004) JAMA 291(18):2204-11 [PubMed]
  5. Sibling CAD history confers up to a 5 fold increased risk (higher than parent)
    1. Nasir (2004) Circulation 110:2150-6 [PubMed]
    2. Murabito (2005) JAMA 294: 3117-23 [PubMed]

X. Risk Factors: Other substantial risks (not used in Hyperlipidemia protocol)

  1. HIV Positive status (especially if CD4 Count has ever been <500)
  2. Systemic Lupus Erythematosus
  3. Chronic Kidney Disease
  4. Chemotherapy
  5. Chronic Alcohol Abuse
    1. Whitman (2017) J Am Coll Cardiol 69(1):13-24 [PubMed]
  6. Systemic inflammatory states

XI. Risk Factors: Other Lifestyle Risk Factors

  1. Obesity
  2. Sedentary lifestyle
  3. Type A Personality (especially hostility prone)
  4. Lack of supportive primary relationship

XII. Risk Factors: Workplace chemical exposures

  1. Carbon Monoxide
  2. Lead Exposure
  3. Methylene Chloride (paint removers)
  4. Nitrate esters (explosives)
  5. Carbon Disulfide (Viscose rayon fibers)
  6. Tobacco smoke (passive exposure)

XIII. Risk Factors: Emerging and those not used in calculation

  1. EKG abnormalities at rest
    1. See EKG Markers of Underlying Coronary Artery Disease
  2. 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 RatioC-RP: 1.45
    5. References
      1. Ridker (2004) Circulation 109:1955-9 [PubMed]
  3. Coronary Calcium Score
    1. Baseline coronary calcifications predict CAD events
    2. Can raise Relative Risk of CAD event for men to 10.5 (in coronary calcium >1000)
      1. Contrast with diabetes CAD Relative Risk of 1.98
      2. Contrast with tobacco Relative Risk of 1.4
    3. Kondos (2003) Circulation 107:2571-6 [PubMed]
  4. 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-54i [PubMed]
  5. Decreased apolipoprotein A-1 (HDL core)
    1. Apo B to A1 ratio may be better than TC to HDL ratio
  6. ACE DD Genotype
  7. Infections (e.g. Coxsackie Virus)
  8. Increased Fibrinogen
  9. Low birth weight
  10. Triglycerides
  11. Insulin Resistance Syndrome (Metabolic Syndrome)

XIV. Management: Disproven preventive factors (not beneficial after evaluation)

  1. Vitamin E (increases cardiovascular risk )
  2. Beta Carotene (increases cardiovacular risk)
  3. Increased Homocysteine levels or low Serum Folate
    1. Folate supplementation does not appear to lower arterial cardiovascular risk

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