Effect Of Risk Factor Modification Research Articles

The effect of lifestyle and risk factor modification on occlusive peripheral arterial disease outcomes: standard healthcare vs structured programme\u2014for a randomised controlled trial protocol

BackgroundPeripheral arterial disease (PAD) affects more than 200 million of the global population. PAD represents a marker for premature cardiovascular events. Patients with PAD, even in the absence of a history of myocardial infarction or ischemic stroke, have approximately the same relative risk of death from cardiovascular causes as patients with a history of coronary or cerebrovascular disease. Despite the high prevalence of PAD and the strong association with cardiovascular morbidity and mortality, patients with PAD are less likely to receive appropriate treatment for their atherosclerotic risk factors than those who are being treated for coronary artery disease.Atherosclerotic risk factor identification and modification play an important role in reducing the number of adverse outcomes among patients with atherosclerosis. Risk reduction therapy decreases the risk of cardiovascular mortality and morbidity in patients with PAD. In this study, we aim to evaluate the effectiveness of a lifestyle and risk factor modification intervention programme in achieving treatment goals for PAD risk factors.MethodsThis is a randomised, parallel group, active-control trial to compare the effectiveness of the risk factor modification intervention programme to standard healthcare in a tertiary vascular care centre, in the reduction of modified risk factors in PAD patients. The primary outcome of this study is to evaluate the effectiveness of a lifestyle and risk factor modification intervention programme in achieving treatment goals for PAD risk factors at 3 and 12 months. The secondary outcomes are to compare the impact of the programme on clinical outcomes in PAD patients at 12 months. Secondary outcomes include amputation-free survival, clinical improvement, haemodynamic improvement, need for revascularisation procedures, outcomes of revascularisation procedures, changes in quality of life and the incidence of adverse events.DiscussionThis study will provide clear evidence on the effectiveness of a lifestyle and risk factor modification intervention programme in achieving treatment goals for PAD risk factors, through a high-quality, well-powered clinical trial.Trial registrationThis trial was registered (11/07/2017) on the European Clinical Trials Database (EudraCT number 2017-002964-41) and ClinicalTrials.gov (NCT03935776) which was registered on 02 May 2019.

Cerebral Small Vessel Disease Burden and All-Cause Mortality: Mayo Clinic Florida Familial Cerebrovascular Diseases Registry

Goal: Cerebral small vessel disease (CSVD) leads to cognitive decline, gait disturbances, mood changes, and an increased risk of stroke. The goal of this study is to describe the relationship between a composite radiographic CSVD score and all-cause mortality. Materials and Methods: Data were collected from a prospective registry of patients with and without cerebrovascular disease from November 2010 through April 2018. The radiographic Total CSVD Score (tSVD) ranges from 0 (minimal disease) to 4 (severe disease), based on detection of lacunar infarcts, cerebral microbleeds, perivascular spaces, and subcortical or periventricular white matter hyperintensities. All-cause mortality served as the primary endpoint. The independent relationship between CSVD burden and all-cause mortality was assessed using Cox regression models with significance being P < .05. Findings: Four hundred and forty-nine patients were included (mean age, 63 years; 50.1% [225 of 449] women). The hazard ratio for mortality significantly increased with advancing score (1.92, P = .014 score 1; 2.92, P < .001 score 2; 4.23, P < .001 combined scores 3 and 4). Significance remained despite adjustment for coexistent cerebrovascular risk factors aside from age. Conclusions: The clinically practical tSVD score may serve as a predictor for all-cause mortality in populations with high disease prevalence. Continued investigations are needed to better understand the effects of risk factor modification on mortality and pathogenesis with the goal of developing disease modifying therapies.

Predicting, preventing, and managing cardiovascular and chronic kidney disease progression in people with type 2 diabetes: How to improve on traditional strategies.

Predicting, preventing, and managing cardiovascular and chronic kidney disease progression in people with type 2 diabetes: How to improve on traditional strategies.

The projected effect of risk factor reduction on major depression incidence: A 16-year longitudinal Canadian cohort of the National Population Health Survey

BackgroundFew studies have examined the effect of risk factor modification on depression incidence. This study estimated the effect of risk factor modification on depression incidence. MethodsData analyzed were from the Canadian National Population Health Survey (NPHS) – a longitudinal population-based cohort study. The study followed-up a national cohort sample over a 16-year period from 1994 to 2010. Multivariate modified Poisson regression was used to estimate relative risk. ResultsThe cumulative incidence rate of depression during the 16-year follow-up was 12.07%. Being younger adult, female, Caucasian, poor, occasional/abstainer/former drinker, regular smoker, and having chronic disease were significantly associated with an increased risk of developing depression. About 40% of depression incidence (850,000 cases) was potentially attributable to modifiable risk factors (poor income, smoking, and having a chronic disease). A 10% reduction in the prevalence of these modifiable risk factors could potentially prevent about 165,000 cases of depression. LimitationsThe calculation of PAFs assumes that there is a causal relationship between a risk factor and depression. However, major depression has multiple causes. The potential effect of risk factor modification on depression incidence may vary by the profile of risk factors assessed in a particular study. Several potentially important risk factors were not included in this study. ConclusionPublic health campaigns targeted at significant modifiable risk factors could have a profound effect on future depression incidence. Prevention trials are needed to directly evaluate the effect of single and/or multiple risk factors modification on depression incidence.

Lifetime cardiovascular risk of childhood obesity

An increase in the incidence and an earlier onset of coronary artery disease is expected because of the increased prevalence of childhood obesity. Comorbidities of obesity, such as dyslipidemia, insulin resistance syndrome, hypertension, associated nutritional deficiencies, and a sedentary lifestyle or associated lifestyle factors such as tobacco smoke exposure, are likely to account for this increase because these are all independent risk factors for accelerated atherosclerosis. Because clinical atherosclerotic cardiovascular disease does not manifest in obese children, assessment of the subclinical markers of atherosclerosis may help in the evaluation of the progression of atherosclerosis, in further stratification of risk, and in monitoring the effects of intervention. Furthermore, because multiple risk factors with poorly understood interplay might be present in obese children, assessment of the vasculature directly, and perhaps the assignment of a "vascular age," may be a useful method to quantify the "end organ" effect of exposure to these various risks. Obese children may show favorable changes in their behaviors that result in an improvement in clinically measurable risk factors with various clinic-based and behavior modification therapies, but the vascular benefits of such interventions need to be studied further. Broad social, cultural, legislative, and policy changes that support healthy lifestyles within families and communities need to be implemented to decrease the prevalence of childhood obesity and its cardiovascular consequences in communities. The effect of risk factor modification on the vasculature will continue to be a resource for the direction of evidence-based therapy in obese children.

Assessment of atherosclerotic cardiovascular risk and management of dyslipidemia in obese children

As the prevalence of childhood obesity increases there is potential for an increase in prevalence and an earlier onset of coronary artery disease. Comorbidities of obesity such as dyslipidemia, insulin resistance syndrome, hypertension, sedentary lifestyle or associated lifestyle factors, like tobacco smoke exposure may result in premature onset of atherosclerosis. Obese children may have other diseases, which can also accelerate the development of atherosclerosis. As clinical atherosclerotic cardiovascular disease does not manifest in obese children, assessment of non-invasive markers of vessel function and structure may be helpful in further stratifying risk and in monitoring effects of intervention. Broad social and cultural changes outside the scope of the health sector are probably most effective in curtailing the epidemic of obesity and thus minimizing its cardiovascular manifestations. Pediatric health care providers should be diligent in screening and providing counseling regarding potential cardiovascular risk factors. Lifestyle alterations resulting in optimal weight management are of foremost importance in preventing the cardiovascular effects of obesity. A select group of children may be at high risk of premature cardiovascular disease despite rigorous implementation of these measures. These children may benefit from pharmacological therapy of dyslipidemia, insulin resistance syndrome or hypertension. Statins have been proven to be effective in decreasing blood low-density lipoprotein cholesterol levels in children and appear safe in the short-term, but their effect in eventually altering the timeline of atherosclerotic cardiovascular disease manifestations in adult life or its associated mortality and morbidity is unclear. The effect of risk factor modification on vascular functional and structural end points will continue to be a resource for evidence-based therapy in these children in the absence of hard clinical outcomes data. This article addresses an overview of assessment of atherosclerotic cardiovascular risk in obese children, but is restricted to an overview of the management of one risk factor - dyslipidemia.

Review: Imaging to assess effect of medical therapy in patients with diabetes mellitus

The incidence of type 2 diabetes is rapidly increasing throughout the world. As an independent risk factor for cardiovascular disease both at the microvascular and macrovascular level, diabetes is a condition that deserves the most aggressive medical management. The effectiveness of risk factor modification and glycaemic control on retarding atherosclerosis progression has been assessed by several invasive and non-invasive imaging methods that will be reviewed in this article.

Metabolic syndrome in severe chronic kidney disease: Prevalence, predictors, prognostic significance and effects of risk factor modification

Metabolic syndrome (MS) is a significant risk factor for cardiovascular disease, mortality and chronic kidney disease (CKD) in the general population. However, the prevalence, predictors, prognostic value and treatment of MS in the CKD population have not been rigorously studied. The study involved 200 stages 4 and 5 CKD patients enrolled in a randomized controlled trial of intensive multiple risk factor modification (targeting hypercholesterolaemia, hyperhomocysteinaemia, anaemia and disordered bone mineral metabolism) versus usual care. Participants were followed for a median period of 22 months. The overall prevalence of MS was 30.5%. MS was independently predicted by older age, peritoneal dialysis and Maori/Pacific Islander origin. When laboratory parameters were included as covariates, the only significant predictors of MS were higher serum malondialdehyde and lower serum adiponectin concentrations. MS was an independent predictor of time to composite end-point of cardiovascular death, acute coronary syndrome, revascularization, non-fatal stroke and amputation (adjusted hazard ratio 2.46, 95% CI 1.17-5.18). No significant difference in cardiovascular event-free survival was observed in those allocated to intensive risk factor modification compared with usual care. Metabolic syndrome occurs in 30.5% of stages 4 and 5 CKD patients and is associated with older age, peritoneal dialysis, ethnicity, increased oxidative stress, lower serum adiponectin concentrations and a significantly increased risk of future cardiovascular events. Intervention strategies targeting hypercholesterolaemia, hyperhomocysteinaemia, anaemia and disordered bone mineral metabolism may not be effective in ameliorating the heightened cardiovascular risk of CKD patients with MS.

Epidemiological Features of CKD in Taiwan

The incidence of end-stage renal disease (ESRD) in Taiwan is the highest in the world. However, epidemiological features of earlier chronic kidney disease (CKD) have not been investigated. Since implementation of the National Health Insurance Program in 1995, more than 96% of the population in Taiwan has been enrolled. A nationally representative cohort of 200,000 individuals randomly sampled from the National Health Insurance enrollees was followed up from 1996 to 2003. Clinical conditions were defined by using diagnostic codes. The prevalence and incidence of clinically recognized CKD were assessed. We also identified risk factors associated with the development of CKD. The prevalence of clinically recognized CKD increased from 1.99% in 1996 to 9.83% in 2003. The overall incidence rate during 1997 to 2003 was 1.35/100 person-years. The multivariate model indicates that age is a key predictor of CKD, with an odds ratio of 13.95 for the group aged 75-plus years compared with the group younger than 20 years. Other factors associated with increased risk for the development of CKD include diabetes, hypertension, hyperlipidemia, and female sex. The prevalence and incidence of CKD in Taiwan are relatively high compared with other countries. Our finding provides a reasonable explanation for the subsequent epidemic of ESRD in Taiwan. Further study is needed to identify the entire burden of CKD and the effectiveness of risk-factor modification.

Endothelial progenitor cells: diagnostic and therapeutic considerations

Endothelial progenitor cells (EPCs) may be defined as adherent cells derived from peripheral blood- or bone marrow-derived mononuclear cells demonstrating acLDL uptake and isolectin-binding capacity. The number of circulating EPCs inversely correlates with the number of cardiovascular risk factors and is reduced in cardiovascular disease. This measurement may therefore serves as a surrogate marker for cardiovascular disease risk. EPC numbers can be modified by various means. However, the effectiveness of risk-factor modification on EPC number and function is currently unknown. Furthermore, EPCs may be used as a potential therapy for a variety of vascular disease states including ischaemia, restenosis and pulmonary hypertension. This review provides an update on multiple factors that affect EPC number as well as highlighting the potential use of EPCs as a novel marker of vascular dysfunction. Furthermore, potential gene- and/or EPC-based approaches to a number of vascular disease states are explored.

Flow-Mediated Dilation: Just a Marker of Local Shear Stress?

To the Editor: We read with interest the article by Mitchell et al1 and agree that flow-mediated dilation (FMD%) response may be partially explained by shear stress (diastolic shear stress [DSS]) or flow changes.2 However, this does not necessarily mean that risk factors do not influence the vascular response. Indeed, Megnien et al3 showed that shear stress reduction provokes different diameter changes in hypercholesterolemic compared with normal subjects. Moreover, experiments performed by our group (M. Laclaustra et al, unpublished data, 2003) on healthy male subjects showed that HDL-cholesterol level was the strongest predictor of FMD% among all lipid variables considered in the study. This finding was actually apparent after controlling by average flow velocity during the first minute of hyperemia (model’s R 2=0.173). Thus FMD% may have a greater sensitivity to detect the effects of risk factor modification than shear stress, as shown in previous articles, including the one incorporating the very first description of the flow-mediated dilation technique.4 Indeed, in those reports, significant differences among groups were found for FMD% values but not for hyperemic flow values. Mitchell et al1 rightly point out that the fact that brachial artery diameter was included in the equations used for calculations of FMD% …

Ineffective secondary prevention in survivors of cardiovascular events in the US population: report from the Third National Health and Nutrition Examination Survey.

Survivors of myocardial infarction (MI) or stroke are at high risk for subsequent cardiovascular events. There is limited assessment of the effectiveness of risk factor modification through current secondary preventive strategies in the US population. We determined the adequacy of risk factor modification in 1252 survivors of MI, stroke, or both in a nationally representative sample of US adults and identified factors related to inadequate control of risk factors. The adequacy of control for hypertension, diabetes mellitus, cigarette smoking, alcohol use, and hypercholesterolemia was assessed by personal interview, blood pressure measurements, and serum glycosylated hemoglobin and cholesterol levels in 17 752 US adults who participated in the Third National Health and Nutrition Examination Survey between 1988 and 1994. We also evaluated the role of potentially related factors, including age, sex, race/ethnicity, educational attainment, socioeconomic status, and medical insurance status using multivariate logistic regression analysis. Of 738 known hypertensive persons, hypertension was uncontrolled in 388 (53%). Previously undiagnosed hypertension was detected in 138 others (11%). Of 289 diabetic persons, serum glucose control was inadequate in 141. Of 1252 survivors, 225 (18%) were currently smoking, and heavy alcohol use was observed in 56 persons. Hypercholesterolemia was poorly controlled in 185 (46%) of 405 persons with known hypercholesterolemia. Undetected hypercholesterolemia was observed in 160 persons (13%). In the multivariate analysis, high-risk profiles were more likely to be observed in persons aged 46 to 65 years, women, and African Americans. High prevalence of inadequate secondary prevention was found in a subset of the US population at highest risk for stroke and MI. Considerable efforts are required to effectively implement risk factor modification strategies after MI or stroke, particularly in middle-aged persons, African Americans, and women.

Ineffective Secondary Prevention in Survivors of Cardiovascular Events in the US Population: A Report from the Third National Health and Nutrition Examination Survey.

26 Background and Purpose: Survivors of myocardial infarction (MI) or stroke are at high risk for subsequent cardiovascular events. There is limited assessment of the effectiveness of risk factor modification through current secondary preventive strategies in the US population. Methods: The adequacy of control for hypertension, diabetes mellitus, cigarette smoking, alcohol use and hypercholesterolemia was assessed by personal interview, blood pressure measurements, and serum glycosylated hemoglobin and cholesterol levels in a nationally representative sample of US adults. We also evaluated the role of potentially related factors including age, gender, race/ethnicity, educational attainment, socioeconomic and medical insurance status using multivariate logistic regression analysis. Results: A total of 1252 survivors of MI or stroke were evaluated in the Third National Health and Nutrition Examination Survey. Among the 738 known hypertensive persons, hypertension was uncontrolled (systemic blood pressure &gt;140/90 mm Hg) in 388 (53%) patients. Previously undiagnosed hypertension (systemic blood pressure &gt; 140/90 mm Hg) was detected in 138 (11%)other survivors. Of the 1252 survivors, 225 (18%) persons were currently smoking and heavy alcohol use was observed in 56 persons. Hypercholesterolemia was poorly controlled (serum cholesterol &gt;240mg/dl) in 185 (46%)of the 405 persons with known hypercholesterolemia. Undetected hypercholesterolemia was observed in 160 (13%) persons. In the multivariate analysis, high risk profiles (defined as presence of two or more poorly controlled risk factors) were more likely to be observed in persons aged 45–65 years (OR 2.5, 95% CI 1.3–4.8), women (OR 1.6, 95% CI 1.3–2.1) and African-Americans (OR 1.4, 95% CI 1.01–1.9). Conclusions: Our report points out the alarming magnitude of inadequate secondary prevention in the US population. Considerable efforts are required to effectively implement risk factor modification strategies after MI or stroke, particularly in middle aged persons, African-Americans and women.

Ineffective Secondary Prevention in Survivors of Cardiovascular Events in the US Population: A Report from the Third National Health and Nutrition Examination Survey.

26 Background and Purpose: Survivors of myocardial infarction (MI) or stroke are at high risk for subsequent cardiovascular events. There is limited assessment of the effectiveness of risk factor modification through current secondary preventive strategies in the US population. Methods: The adequacy of control for hypertension, diabetes mellitus, cigarette smoking, alcohol use and hypercholesterolemia was assessed by personal interview, blood pressure measurements, and serum glycosylated hemoglobin and cholesterol levels in a nationally representative sample of US adults. We also evaluated the role of potentially related factors including age, gender, race/ethnicity, educational attainment, socioeconomic and medical insurance status using multivariate logistic regression analysis. Results: A total of 1252 survivors of MI or stroke were evaluated in the Third National Health and Nutrition Examination Survey. Among the 738 known hypertensive persons, hypertension was uncontrolled (systemic blood pressure >140/90 mm Hg) in 388 (53%) patients. Previously undiagnosed hypertension (systemic blood pressure > 140/90 mm Hg) was detected in 138 (11%)other survivors. Of the 1252 survivors, 225 (18%) persons were currently smoking and heavy alcohol use was observed in 56 persons. Hypercholesterolemia was poorly controlled (serum cholesterol >240mg/dl) in 185 (46%)of the 405 persons with known hypercholesterolemia. Undetected hypercholesterolemia was observed in 160 (13%) persons. In the multivariate analysis, high risk profiles (defined as presence of two or more poorly controlled risk factors) were more likely to be observed in persons aged 45–65 years (OR 2.5, 95% CI 1.3–4.8), women (OR 1.6, 95% CI 1.3–2.1) and African-Americans (OR 1.4, 95% CI 1.01–1.9). Conclusions: Our report points out the alarming magnitude of inadequate secondary prevention in the US population. Considerable efforts are required to effectively implement risk factor modification strategies after MI or stroke, particularly in middle aged persons, African-Americans and women.

SCREENING FOR CARDIOVASCULAR DISEASE: Concepts, Conflicts, and Consensus

CVD in the United States is prevalent, costly, and disabling. Wherever in the arterial tree atherosclerosis occurs, the process appears to begin in youth, to develop under the influence of the same risk factors, and to be amenable to the same interventions. The relationship between CVD and its associated risk factors is continuous, is graded, and extends below thresholds previously defined as normal. This observation, in turn, is based on an appreciation that in our society, the gap between normal and optimal can be considerable. CVD is a multifactorial process, often related to modifiable lifestyle choices; we focus on any single risk factor to the exclusion of others puts patients in danger. Because risk factors rarely occur in isolation, risk assessment must be as multifactorial as the underlying disease process. By understanding differences between risk factors in terms of the impact of their modification on the underlying disease, targeted interventions become possible that are tailored to the likelihood of an individual patient acquiring CVD. To change the overall prevalence of an epidemic disease such as CVD, however, such a high-risk approach must be applied in concert with a population strategy that seeks to effect smaller degrees of change in the large segment of society that may be at only moderate risk but--because of their great numbers--bears most of the morbidity and mortality of CVD. Finally, despite the remarkable progress that has been made in our understanding of the pathophysiology of CVD and the effectiveness of risk factor modification, significant gaps remain between knowledge and behavior. Fewer than 50% of diabetics are even aware that they have the disease. Only a third of those whose lipid levels qualify them for treatment receive intervention of any kind, including dietary advice. Only 27% of hypertensives have their blood pressure adequately controlled. The potential impact of more vigorous screening practices in the primary care setting on the health of individuals and communities cannot be overstated.

Modeling all-cause mortality: projections of the impact of smoking cessation based on the NHEFS. NHANES I Epidemiologic Follow-up Study.

A model that relates clinical risk factors to subsequent mortality was used to simulate the impact of smoking cessation. Survivor functions derived from multivariate hazard regressions fitted to data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Followup Study, a longitudinal survey of a representative sample of US adults, were used to project deaths from all causes. Validation tests showed that the hazard regressions agreed with the risk relationships reported by others, that projected deaths for baseline risk factors closely matched observed mortality, and that the projections attributed deaths to the appropriate levels of important risk factors. Projections of the impact of smoking cessation showed that the number of cumulative deaths would be 15% lower after 5 years and 11% lower after 20 years. The model produced realistic projections of the effects of risk factor modification on subsequent mortality in adults, Comparison of the projections for smoking cessation with estimates of the risk attributable to smoking published by the Centers for Disease Control and Prevention suggests that cessation could capture most of the benefit possible from eliminating smoking.

786-5 Risk Factor Modification Improves Flow-Mediated Brachial Artery Vasoactivity but not Cold Pressor Vasoactivity in Men with Coronary Artery Disease

Coronary risk factors are associated with impaired endothelium-mediated vasoactivity in the peripheral and coronary circulation. To determine the effect of risk factor modification (RFM) on brachial artery vasoactivity, we studied 23 men with coronary artery disease (CAD). Using 7.5 MHz ultrasound, brachial artery diameter changes (%Δ Diam) in response to flow mediated (FM) and cold pressor (CP) stimuli were measured in 13 men 1 week after the initial presentation of ischemic heart disease and in another 10 men 1 year after aggressive risk factor modification, (smoking cessation, lipid lowering). Chronically managed patients had significantly lower total cholesterol and smoking frequency. Acute vs. Chronic CAD Age (yrs): 46 46 Chol (mg/dl): 219 171 * HDL (mg/dl): 36 32 Smoking: 63% 6% * BP (mmHg): 123/71 130/80 FM (% Δ Diam): 4.8% 10.9 * CP (% Δ Diam): -2.4% -2.3% * p &lt; 0.01 FM vasoactivity normalized with risk factor modification and was similar to our controls 11.5 ± 7.0%. CP response remained abnormal despite chronic RFM. This suggests that FM vasoactivity is dependent on risk factor status, but CP vasoactivity may be dependent on the presence of CAD.

A comparison of populations self-selected and randomly selected for coronary risk factor screening

Levels of coronary risk factors in 3,090 adults who sought screening over a 2-year period in Perth, Western Australia, were compared with those in 722 subjects who were selected at random to attend the screening center. Self-referred (SR) subjects were less likely than random-sample (RS) subjects to have suffered from, or be on treatment for, heart disease, hypertension, gout, or diabetes but were more likely to have a family history of premature heart disease. They were less likely to be current smokers and overweight (women only) but more likely to be sedentary at work and have higher mean serum cholesterol levels. SR also had more knowledge about coronary heart disease (CHD) and its causes and were more likely to believe that this knowledge had influenced their behavior, but were less likely than RS to be satisfied with their knowledge level. Smokers among SR were more likely to express a wish to give up smoking than smokers in the RS. These findings are consistent with previous observations. The differences, although statistically significant, were generally small and did not clearly favor one group with respect to total risk of CHD. Therefore the effectiveness of risk factor modification following screening should not be greatly affected by self-selection for screening. Effectiveness may be greater in self-selected subjects because of their apparently greater motivation toward risk factor change.

Prevention of heart disease in infants and children

Summary In this monograph, measures are discussed that should be undertaken during childhood to prevent heart disease. Known causes of congenital heart disease include maternal rubella, ingestion of thalidomide during pregnancy, chromosomal anomalies and somatic syndrome complexes. Appropriate preventive measures are immunization with live-attenuated rubella vaccine and avoidance of unnecessary medications during pregnancy. Analysis of chromosomes and genetic counseling in families with an infant with Down's syndrome may be a preventive measure. Prenatal diagnosis of hereditary defects associated with CHD seems to be a promising area of prevention. The outlined etiologic factors account for less than 6% of CHD. Multifactorial inheritance (genetic-environmental interaction) may be responsible for the majority of the CHD. Appropriate genetic counseling and quoting the risk of recurrence is all that one usually can do. Acute rheumatic fever (ARF) is causally related to streptococcal throat infection. Prevention of first attacks of ARF by prompt identification and adequate treatment of streptococcal pharyngitis and prevention of recurrences of ARF with monthly doses of long-acting penicillin seem appropriate. Orodental or other surgical procedures produce transitory bacteremia and these bacteria may lodge on the diseased or deformed heart valves or endocardium and cause endocarditis. Antibiotics are recommended for preventing endocarditis in any patient with a congenital or acquired heart defect 1–2 hours prior to and for 2 days following any potentially bacteremia-producing procedure. The etiology of atherosclerosis is not clearly established. In longitudinal epidemiologic studies, the concept of “risk factors” was developed, which indicates any personal characteristic(s) that is associated with a higher than average incidence of atherosclerosis. Risk factor modification for the adult population to reduce the incidence of atherosclerosis appears to be generally accepted. Despite lack of concrete evidence for effectiveness of risk factor modification in the pediatric age group, many groups of workers recommend such a modification. These include a lowfat and low-cholesterol diet for all children (beyond infancy), screening for hyperlipidemia and prompt treatment if detected, routine blood pressure recording in the pediatrician's office, lowering of dietary salt intake, discouraging cigarette smoking, prevention (or early treatment) of obesity, encouraging moderate exercise and monitoring carbohydrate tolerance of progeny of diabetic patients. Identification of children at risk by a family history of premature onset of an atherosclerotic event may be more practical because of a higher yield. These and the progeny of persons with hypertension, diabetes mellitus and hyperlipidemia should be screened for hyperlipidemia, hypertension (and treated appropriately if present) and counseled as to proper nutrition, exercise and avoidance of smoking. Health education of children and the population at large with regard to current knowledge of risk factors of coronary heart disease and possible methods of prevention is necessary if programs for prevention of atherosclerosis are to be effective. When dealing with children with functional (innocent) heart murmurs and mild organic heart disease, the pediatrician and the pediatric cardiologist should ensure by appropriate counseling that “cardiac nondisease” is not produced. Finally, the miscellaneous group includes prevention of irreversible damage to cardiovascular structures or complications in patients with congenital or acquired heart disease by timely and appropriate medical and/or surgical intervention.

The Estimation and Interpretation of Attributable Risk in Health Research

Various measures of attributable risk are discussed together with a rationale for their use as an alternative to relative risk in health research. Methods of estimation are presented for use with three important kinds of epidemiological study design with one dichotomous risk factor for a dichotomous disease outcome; the study designs are then compared with respect to efficiency. Procedures to analyse confounded, polytomous and interacting risk factors are proposed and it shown that there is a simple relationship between two distinct estimators previously suggested for use with deleterious and beneficial (or preventive) factors. Finally the relevance of attributable risk to an assessment of the potential effects of risk factor modification is discussed in the preventive medicine framework.