Established Coronary Heart Disease Research Articles

Blood Pressure Reactivity to Psychological Stress

The report by Matthews et al1 in this issue of Hypertension that increased systolic blood pressure reactivity while playing a video game predicts increased incidence of having some coronary calcification 13 years later is consistent with prior research they cite showing associations between cardiovascular reactivity to acute stress and various indices of atherosclerotic disease in human and animal studies. What sets this report apart from the prior research, however, is (1) the prediction of increased coronary artery calcification by blood pressure (BP) reactivity in a large, diverse sample of healthy young adults; (2) the demonstration that this prediction is independent of resting blood pressure and other established coronary heart disease (CHD) risk factors measured at the same time; and (3) the demonstration that the prediction is not mediated by interim development of hypertension or the metabolic syndrome. The authors are appropriately cautious in noting that final appraisal of the full implications of their findings will depend on results obtained when “BP reactivity protocols are added to future epidemiological protocols.” As one who has previously joined with other behavioral and social science advocates in what seemed, in many cases, to be an uphill battle to convince those in charge of designing large-scale …

Clinical Depression and Risk of Out-of-Hospital Cardiac Arrest

The association of depression with coronary heart disease-related mortality has been widely recognized. This finding may partly reflect an association between depression and sudden death, in part because the imbalance between sympathetic and parasympathetic tone is altered in depressed subjects. We, thus, investigated whether the presence and severity of clinical depression was associated with a higher risk of sudden cardiac death. We used data from a population-based case-control study of risk factors for incident out-of-hospital cardiac arrest (CA) conducted among enrollees of a health maintenance organization in western Washington State. Cases (n = 2228) were aged 40 to 79 years and experienced CA between January 1, 1980, and December 31, 1994. Controls (n = 4164) were a stratified random sample of enrollees defined by calendar year, age, sex, and prior heart disease. Clinical depression was defined as physician diagnosis of depression or use of antidepressant treatment within the year before the event. Referral to mental health clinics or hospitalization for depression defined severe depression. Clinically depressed patients had a higher odds ratio (OR) of CA (1.88; 95% confidence interval [CI], 1.59-2.23), which persisted after adjustment for confounders (OR, 1.43; 95% CI, 1.18-1.73). The association was observed in both sexes, in various age groups, and in subjects with prior physician-diagnosed heart disease (OR, 1.27; 95% CI, 1.01-1.60) and without prior physician-diagnosed heart disease (OR, 1.71; 95% CI, 1.22-2.41) (P = .13 for the interaction). Compared with nondepressed subjects, the risk of CA was increased in less severely depressed subjects (OR, 1.30; 95% CI, 1.04-1.63) and further increased in severely depressed subjects (OR, 1.77; 95% CI, 1.28-2.45) (P<.001 for trend). Clinical depression may be associated with a higher risk of CA independently of established coronary heart disease risk factors.

Association of Apolipoprotein E Genotype with Early Onset of Coronary Heart Disease in Greek Men

Apolipoprotein (apo) E polymorphism has been associated with coronary heart disease (CHD) although its relation to the age of CHD onset is still not defined. The age of onset of established CHD was obtained from 502 Greek men and compared to 103 healthy men. The age grouping was based on the age of CHD onset (earlier < or =44 years, n = 73, intermediate 45-64 years, n = 321, and later > or =65 years, n = 108). Apo E genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and the lipid profile was assessed. No differences in genotype and allele frequencies were found within the CHD groups. The apo epsilon3/4 genotype and the apo epsilon4 allele were less frequent in the earlier-onset group than in healthy men (11.0 % vs 22.3%, Pearson Chi-Square p = 0.028 and 6.8% vs 13.6%, Pearson Chi-Square p = 0.023, respectively). The lipid profile was similar in all genotypes of all groups except for high-density lipoprotein cholesterol levels, which were higher in epsilon2 carriers compared to non-epsilon2 carriers (in mg/dL [+/-SD]; 44 [9] vs 39 [10], in mmol/L [+/-SD]; 1.1 [0.2] vs 1.0 [0.3] p = 0.005). There is an association between apo E genotype and early onset of CHD in Greek men. In the earlier CHD onset group, the apo epsilon3/4 genotype was less frequent compared to healthy men. This supports that the apo epsilon3/4 genotype is associated with decreased risk of premature CHD. Because the results of similar studies are not consistent, it may be that the relationship between apo E genotype and CHD is related to ethnicity rather than a universal phenomenon.

Patterns and Effectiveness of Lipid-Lowering Therapies in a Managed Care Environment

Objective To investigate the effectiveness of statin therapy and to compare the effectiveness results of this study with the reported efficacy of the corresponding data from randomized clinical trials in a moderate-to-high risk coronary heart disease (CHD) managed care population. Methods Subjects, ≥18 years old, with a new hyperlipidemia diagnosis or a new prescription claim for a lipid-lowering medication (LLM) between January 1, 1999 and March 31, 2001 were followed for 12 months. Subjects were classified into six medication categories of LLM use based partly on efficacy levels on package inserts. CHD risk factors were measured in the 24-month period prior, and subjects were required to have an established CHD or a CHD-related condition, or have two or more CHD risk factors. Results The study population consisted of 39,124 hyperlipidemic subjects with moderate-to-high CHD risk; 22,048 (56.4%) were untreated with LLMs. Absolute mean low-density lipoprotein cholesterol (LDL-C) reductions ranged from a 32 mg/dL decrease in the low-efficacy groups to a 57 mg/dL decrease in the high efficacy statin group; percent reductions ranged from a 19% reduction from baseline to a 32% reduction from baseline, respectively. Less than half of subjects (47%) reached LDL goals set forth by NCEP Adult Treatment Panel (ATP III) guidelines, however, the rate of reaching goal increased as statin efficacy increased. Conclusions While a dose–response relationship was observed, the effectiveness of statin therapy was less than stated in package labeling and only 72% of the users of the highest efficacy statins reached their ATP III goal. LLM use was inconsistent with that recommended by the NCEP ATP III CHD risk assessment. Hyperlipidemia treatment in the managed care setting remains in need of improvement.

The apolipoprotein CI content of triglyceride-rich lipoproteins independently predicts early atherosclerosis in healthy middle-aged men

In this study, we examined the apolipoprotein (apo) CI content of triglyceride-rich lipoproteins (TRLs) in relation to established coronary heart disease (CHD) risk factors and early atherosclerosis. In Western society, the postprandial state constitutes a nearly constant stress on the vasculature and the metabolism of lipoproteins. Delayed clearance of postprandial TRL remnants has repeatedly been associated with premature CHD and may include the enrichment of these remnants with apoCI. We examined 72 healthy 50-year-old men with an apoE3/E3 genotype who had undergone an oral fat load test and B-mode ultrasound examination of the intima-media thickness (IMT) of the common carotid artery. In the fasting state, plasma, very-low-density lipoprotein (VLDL), and low-density lipoprotein cholesterol, proinsulin, and apoB100-containing intermediate density lipoprotein levels were related to IMT (p < 0.05). In the postprandial state, IMT was related to triglycerides at 2 h (p < 0.01), large VLDL concentration at 3 h (p < 0.05), the apoCI plasma and TRL concentrations at 6 h (p < 0.05, p < 0.05), and the apoCI content of TRLs at 6 h (p < 0.002). Multivariate analysis revealed that the apoCI content of TRLs at 6 h (p < 0.0001), plasma triglyceride concentrations at 2 h (p < 0.006), and fasting plasma cholesterol concentration (p < 0.05) independently predicted IMT. In addition, the apoCI content of postprandial TRLs correlated strongly with the cholesterol content (r = 0.64, p < 0.0001). Our results indicate that the apoCI content of postprandial TRLs is a novel independent risk factor for early atherosclerosis in normolipidemic healthy middle-aged men with possible implication for the enrichment of TRL remnant lipoproteins with cholesterol.

HMG-CoA Reductase Inhibitor Pharmacogenomics: Overview and Implications for Practice

HMG-CoA reductase inhibitors (statins) are widely prescribed and recommended as first-line therapy for most patients with hypercholesterolemia or established coronary heart disease. However, there is interpatient variability in lipid-lowering response to statins that is not explained by initial cholesterol levels and inadequate dosing alone. Genetic polymorphisms may contribute. This review discusses the potential contribution of polymorphisms in genes encoding proteins involved in drug metabolism and transport, cholesterol biosynthesis, lipid metabolism and others to lipid responses to statins.

Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart disease

Background Coronary heart disease is the major cause of illness and death in Western countries and this is likely to increase as the average age of the population rises. Consumers with established coronary heart disease are at the highest risk of experiencing further coronary events. Lifestyle measures can contribute significantly to a reduction in cardiovascular mortality in established coronary heart disease. Improved management of cardiac risk factors by providing education and referrals as required has been suggested as one way of maintaining quality care in patients with established coronary heart disease. There is a need to ascertain whether or not nurse-led clinics would be an effective adjunct for patients with coronary heart disease to supplement general practitioner advice and care. Objectives The objective of this review was to present the best available evidence related to nurse-led cardiac clinics. Inclusion criteria This review considered any randomised controlled trials that evaluated cardiac nurse-led clinics. In the absence of randomised controlled trials, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Participants were adults (18 years and older) with new or existing coronary heart disease. The interventions of interest to the review included education, assessment, consultation, referral and administrative structures. Outcomes measured included adverse event rates, readmissions, admissions, clinical and cost effectiveness, consumer satisfaction and compliance with therapy. Results Based on the search terms used, 80 papers were initially identified and reviewed for inclusion; full reports of 24 of these papers were retrieved. There were no papers included that addressed cost effectiveness or adverse events; and none addressed the outcome of referrals. A critical appraisal of the 24 remaining papers identified a total of six randomised controlled trials that met the inclusion criteria. Two studies addressed nurse-led clinics for patients diagnosed with angina, one looked at medication administration and the other looked at educational plans. A further four studies compared secondary preventative care with a nurse-led clinic and general practitioner clinic. One specifically compared usual care versus shared care introduced by nurses for patients awaiting coronary artery bypass grafting. Of the remaining three studies, two have been combined in the results section, as they are an interim report and a final report of the same study. Because of inconsistencies in reporting styles and outcome measurements, meta-analysis could not be performed on all outcomes. However, a narrative summary of each study and comparisons of specific outcomes assessed from within each study has been developed. Although not all outcomes obtained statistical significance, nurse-led clinics were at least as effective as general practitioner clinics for most outcomes. Recommendations The following recommendations are made: • The use of nurse-led clinics is recommended for patients with coronary heart disease (Level II). • Utilise nurse-led clinics to increase clinic attendance and follow-up rates (Level II). • Nurse-led clinics are recommended for patients who require lifestyle changes to decrease their risk of adverse outcomes associated with coronary heart disease (Level II).

Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart disease.

Coronary heart disease is the major cause of illness and death in Western countries and this is likely to increase as the average age of the population rises. Consumers with established coronary heart disease are at the highest risk of experiencing further coronary events. Lifestyle measures can contribute significantly to a reduction in cardiovascular mortality in established coronary heart disease. Improved management of cardiac risk factors by providing education and referrals as required has been suggested as one way of maintaining quality care in patients with established coronary heart disease. There is a need to ascertain whether or not nurse-led clinics would be an effective adjunct for patients with coronary heart disease to supplement general practitioner advice and care. The objective of this review was to present the best available evidence related to nurse-led cardiac clinics. This review considered any randomised controlled trials that evaluated cardiac nurse-led clinics. In the absence of randomised controlled trials, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Participants were adults (18 years and older) with new or existing coronary heart disease. The interventions of interest to the review included education, assessment, consultation, referral and administrative structures. Outcomes measured included adverse event rates, readmissions, admissions, clinical and cost effectiveness, consumer satisfaction and compliance with therapy. Based on the search terms used, 80 papers were initially identified and reviewed for inclusion; full reports of 24 of these papers were retrieved. There were no papers included that addressed cost effectiveness or adverse events; and none addressed the outcome of referrals. A critical appraisal of the 24 remaining papers identified a total of six randomised controlled trials that met the inclusion criteria. Two studies addressed nurse-led clinics for patients diagnosed with angina, one looked at medication administration and the other looked at educational plans. A further four studies compared secondary preventative care with a nurse-led clinic and general practitioner clinic. One specifically compared usual care versus shared care introduced by nurses for patients awaiting coronary artery bypass grafting. Of the remaining three studies, two have been combined in the results section, as they are an interim report and a final report of the same study. Because of inconsistencies in reporting styles and outcome measurements, meta-analysis could not be performed on all outcomes. However, a narrative summary of each study and comparisons of specific outcomes assessed from within each study has been developed. Although not all outcomes obtained statistical significance, nurse-led clinics were at least as effective as general practitioner clinics for most outcomes.Recommendations The following recommendations are made.

Parental history of stroke and myocardial infarction predicts coronary artery calcification: The Coronary Artery Risk Development in Young Adults (CARDIA) study

Few studies have examined the relationship between parental history of stroke and myocardial infarction (MI) and subclinical atherosclerosis, especially among young, asymptomatic individuals. This study investigates the association between coronary artery calcification (CAC) and parental history of stroke and MI in African-Americans and Caucasians from the CARDIA study. Parental history of stroke and MI was determined by self-administered family history questionnaire at baseline and Year 5 examinations. Presence of coronary calcification was determined by computed tomography on 3041 individuals, age 32 to 47, including 1375 African-Americans and 1666 Caucasians. Analyses were restricted to individuals free of clinically manifest coronary heart disease (CHD) and stroke. Parental history of stroke is associated with a two-fold greater risk of CAC in African-Americans, and this relationship is independent from established CHD risk factors (95% CI=1.14-3.43). There is no relationship between parental history of stroke and CAC status in Caucasians. Parental history of MI is associated with a two-fold greater risk of CAC in Caucasians (95% CI=1.38-2.92). The impact of parental history of MI in African-Americans is lower (OR=1.65; 95% CI=1.01-2.69) and no longer statistically significant after adjusting for known CHD risk factors. The identification of individuals with a parental history of stroke and MI provides important information for clinicians by which to target primary prevention efforts. Further characterization of familial factors, especially genetic factors, contributing to increased risk of CAC will shed light on the basis of the observed associations.

High-density lipoprotein subpopulation profile and coronary heart disease prevalence in male participants of the Framingham Offspring Study.

High-density lipoprotein (HDL) is a heterogeneous lipoprotein class and there is no consensus on the value of HDL subspecies in coronary heart disease (CHD) risk assessment. We tested the hypothesis whether specific HDL subpopulations are significantly associated with CHD-prevalence. ApoA-I concentrations (mg/dL) in HDL subpopulations were quantitatively determined by native 2d gel electrophoresis, immunoblotting, and image analysis in male participants in the Framingham Offspring Study (FOS). CHD cases (n=169) had higher prebeta-1 and alpha-3 particle and lower alpha-1, prealpha-3, and prealpha-1 particle levels than either all (n=1277) or HDL cholesterol-matched (n=358) controls. alpha-1 and prealpha-3 levels had an inverse association, whereas alpha-3 and prealpha-1 particle levels had a positive association with CHD prevalence after adjusting the data for established CHD risk factors. Standardized logit coefficients indicated that alpha-1 HDL was most significantly associated with CHD prevalence. Moreover, each mg/dL increase in alpha-1 particle level decreased odds of CHD by 26% (P<0.0001), whereas each mg/dL increase in HDL cholesterol decreased odds of CHD by 2% in a model including all established CHD risk factors. Specific HDL subpopulations were positively correlated, whereas others were inversely correlated with CHD prevalence in male subject in the FOS, indicating that the various HDL particles might have different roles in the cause of CHD.

An index to measure the association between dietary patterns and coronary heart disease risk factors: findings from two Italian studies

Background. To examine the association between established coronary heart disease (CHD) risk factors and eating patterns by creating a dietary index utilizing a limited amount of food frequency questionnaire data on specified indicator foods. Methods. Selected data from the Italian Risk Factors and Life Expectancy (RIFLE) project collected between 1978–1979 and 1983–1984 on 7665 men and women, aged 20–59 years, were used to compute a dietary index summarizing the relative proportion of fatty to non-fatty foods. The association between this index and systolic and diastolic blood pressure (SBP, DBP), body mass index, total serum cholesterol (TC), and blood glucose, controlling for potential confounders was then tested using multiple linear regression. Results. Among men, a positive association was found between the index and all five CHD risk factors ( P < 0.01). Among women, the associations were weaker, becoming statistically significant only for TC and glucose. Conclusions. Our food index was able to detect relationships between diet and traditional CHD risk factors. A tool such as this, which requires only a limited number of key indicator food items, might enhance the use of existing food frequency questionnaires and also streamline the process of collecting new dietary information.

1310: Smoking Behaviour in European Patients with Established Coronary Heart Disease

Restricted accessAbstractFirst published April 20041310: Smoking Behaviour in European Patients with Established Coronary Heart DiseaseE. de Swart, W. Scholte op Reimer, […], J. Deckers, and E. Boersma+1-1View all authors and affiliationsVolume 3, Issue 1https://doi.org/10.1017/147451510400300112

1369: Quality of Life in Patients With Established Coronary Heart Disease: Results from the Euro Heart Survey on Coronary Revascularization (EHS-CR)

1369: Quality of Life in Patients With Established Coronary Heart Disease: Results from the Euro Heart Survey on Coronary Revascularization (EHS-CR)

Principles of prevention of cardiovascular disease

Dear Sir The International Atherosclerosis Society (IAS) recently released harmonized guidelines for prevention of atherosclerotic disease through clinical management.1 These guidelines integrate and harmonize existing guidelines for this purpose. Thanks to a large number of clinical trials, it is now possible to provide strong evidence-based guidelines for risk factor modification to prevent both recurrent atherosclerotic events (secondary prevention) and new onset events (primary prevention). Most guidelines in the cardiovascular field are in agreement that intensive risk-factor intervention is both efficacious and cost effective for secondary prevention. Moreover, recent guidelines have extended the concept of secondary prevention to include high-risk patients having several types of cardiovascular disease (CVD) including established coronary heart disease (CHD), peripheral arterial disease, …

Role of fibric acid derivatives in the management of risk factors for coronary heart disease.

Although elevated low-density lipoprotein (LDL)-cholesterol is a well established coronary heart disease (CHD) risk factor, the ability to adequately discriminate high-risk individuals by this risk factor alone is limited and other metabolic risk variables are known to modulate CHD risk. For instance, it has been reported that the cluster of metabolic disturbances observed among individuals with abdominal obesity, the so-called metabolic syndrome, is associated with a substantially increased risk of CHD. Among the features of the dyslipidaemic profile observed in these individuals, the high triglyceride-low high-density lipoprotein (HDL)-cholesterol dyslipidaemia is predictive of an elevated risk of CHD. Fibric acid derivatives (fibrates) have been used in clinical practice for more than 2 decades as a class of agents known to decrease triglyceride levels while substantially increasing HDL-cholesterol levels, with a limited but significant additional lowering effect on LDL-cholesterol levels. Although the clinical benefits of HMG-CoA reductase inhibitors (statins) have been well documented by primary and secondary prevention trials that justify their widespread use, it was not until the publication of the VA-HIT (Veterans Affairs High-Density Lipoprotein Intervention Trial) that the relevance of identifying HDL-cholesterol as a therapeutic target to reduce the risk of recurrent CHD events was finally confirmed. The clinical benefits of fibrate therapy are especially important in the subpopulation of patients with low HDL-cholesterol levels with the metabolic syndrome, particularly in patients with type 2 diabetes mellitus or in abdominally obese, hyperinsulinaemic patients. Evidence also suggests that there is a 'fibrate effect' that mediates the reduction in CHD risk beyond the favourable impact of these agents on HDL-cholesterol levels. This last notion is consistent with the pleiotropic effects of fibrates which are known to be related to their mechanisms of action. Through peroxisome proliferator-activated alpha-receptors, fibrates have a significant impact on the synthesis of several apolipoproteins (apo) and enzymes of lipoprotein metabolism as well as on the expression of several genes involved in fibrinolysis and inflammation. Fibrate therapy has been reported to decrease apo CIII levels (a powerful inhibitor of lipoprotein lipase) and increase apo AI levels, as well as to increase lipoprotein lipase activity. Such changes contribute to improve the catabolism of triglyceride-rich lipoproteins, leading to a substantial increase in HDL-cholesterol levels accompanied by a shift in the size and density of LDL particles (from small, dense LDL particles to larger, more buoyant cholesteryl ester-rich LDL). It is proposed that some of these pleiotropic effects could explain some of the clinical benefits of fibrate therapy beyond its HDL-raising properties, particularly among patients with abdominal obesity, hyperinsulinaemia or type 2 diabetes with both low HDL- and low/normal LDL-cholesterol levels.

Are National Cardiac Guidelines being Applied by Vascular Surgeons?

Introduction. National cardiac guidelines recommend that patients with intermittent claudication should be managed in the same way as those with established coronary heart disease. This survey aimed to determine the attitudes of vascular consultants to risk factor management in new patients attending their out-patient clinic. Methods. An anonymous postal questionnaire was sent to all 394 members of the Vascular Surgical Society in June 2002. Questions were asked about the following measures: serum cholesterol levels, the presence of diabetes, antiplatelet therapy, exercise regimens, blood pressure, thrombophilia, smoking and the availability of local guidelines and expertise. Results. A response rate of 65% was obtained. Most (85%) consultants would measure a random cholesterol, but 34% would only treat claudicants if the cholesterol was greater than 5.5 mmol/l. Furthermore, 23% would inappropriately use diet alone as initial cholesterol lowering therapy. Over a quarter of consultants would not screen for diabetes or measure blood pressure. Nearly all (99%) would recommend aspirin and 66% would recommend nicotine replacement therapy. Only 55% had access to a smoking cessation clinic, and 34% to a formal exercise program. The majority (56%) did not have local risk factor management guidelines, only 16% had access to a vascular physician, and 65% would prefer to have this expertise available for difficult cases. Discussion. Management of major risk factors was found to be sub-optimal. Thus guidelines for the prevention of coronary disease in clinical practice are not being applied to claudicants.

Patients' perspectives on statin therapy for treatment of hypercholesterolaemia: a qualitative study.

Health Care Practitioners' attempts to implement secondary prevention targets for coronary heart disease (CHD) may be restricted by low rates of persistence with statin therapy. There is a need to understand why some patients, despite having established CHD and elevated cholesterol, do not comply with their prescribed statin regimen. To explore patients' perspectives on compliance with statin therapy. Primary care, West of Scotland. The research approach was qualitative. Thirty-three patients prescribed statin therapy and identified as having different patterns of compliance (poor moderate and good) were interviewed. The in-depth interviews were conducted on a one to one basis. Patients prescribed statin therapy for less than three months were excluded. Data were analysed thematically with the assistance of QSR Nudist. From analysis of the narrative data, two broad categories, i.e. 'Patient-health care provider communication' and 'Health beliefs' were identified. These categories encompassed six main themes: 'Initiation of therapy'; 'Subsequent feedback'; 'Sources of misconceptions'; 'Unconditional acceptance'; 'Conditional acceptance'; 'Deferment and Rejection'. Acceptance of and compliance with statin therapy appeared to be associated with the provision, interpretation and feedback of information during patient-practitioner consultations, and patients' beliefs about personal health status, cholesterol, and recommended cholesterol-lowering strategies. Patients' beliefs and understanding about cholesterol, and the role of cholesterol modifying strategies should be determined prior to the initiation of therapy and at appropriate intervals thereafter.

III. Detection and Evaluation

ATP III recognizes that detection of cholesterol disorders and other coronary heart disease (CHD) risk factors occurs primarily through clinical case finding. Risk factors can be detected and evaluated as part of a person's work-up for any medical problem. Alternatively, public screening programs can identify risk factors, provided that affected individuals are appropriately referred for physician attention. The identification of cholesterol disorders in the setting of a medical examination has the advantage that other cardiovascular risk factors—including prior CHD, PVD, stroke, age, gender, family history, cigarette smoking, high blood pressure, diabetes mellitus, obesity, physical inactivity—co-morbidities, and other factors can be assessed and considered prior to treatment. At the time of physician evaluation, the person's overall risk status is assessed. Thus, detection and evaluation of cholesterol and lipoprotein problems should proceed in parallel with risk assessment for CHD. The approach to both is described below. The guiding principle of ATP III is that the intensity of LDL-lowering therapy should be adjusted to the individual's absolute risk for CHD. In applying this principle, ATP III maintains that both short-term (≤10-year) and long-term (> 10-year) risk must be taken into consideration. Thus, treatment guidelines are designed to incorporate risk reduction for both short-term and long-term risk (composite risk). ATP III identifies three categories of risk for CHD that modify goals and modalities of LDL-lowering therapy: established CHD and CHD risk equivalents, multiple (2+) risk factors, and 0-1 risk factor (Table III.1-1). View this table: Table III.1-1. Categories of Risk for Coronary Heart Disease (CHD) ### a. Identification of persons with CHD and CHD risk equivalents Coronary heart disease . Persons with CHD are at very high risk for future CHD events (10-year risk >20 percent). Several clinical patterns constitute a diagnosis of CHD; these include history of acute myocardial infarction, evidence of silent myocardial infarction or myocardial ischemia, history of unstable angina and stable angina pectoris, and history …

Prevalence of chronic infections in subjects with hypoalphalipoproteinemia

Dyslipidemias in patients with coronary heart disease confer a greater risk of ischemic cardiac events than comparable dyslipidemias in people free of disease. A major dyslipidemia can be diagnosed in more than 80% of patients with established premature coronary heart disease. These dyslipidemias constitute not only elevations of low-density lipoprotein cholesterol (hypercholesterolemia) but also indicate abnormalities in the metabolism of triglyceride-rich lipoproteins, high-density lipoproteins, and lipoprotein(a). Clinical trials have demonstrated that therapy to lower low-density lipoprotein levels can delay angiographic progression of coronary stenoses and reduce recurrent cardiac event rates. These clinical benefits from low-density lipoprotein cholesterol lowering may occur as early as 6 to 12 months after initiation of therapy. Intervention strategies for dyslipidemias are directed toward lowering the low-density lipoprotein cholesterol fraction to 90 to 100 mg/dl. This approach begins with dietary modification, weight loss, smoking cessation, and aerobic exercise. Patients with hypercholesterolemia refractory to nonpharmacologic intervention require lipid-lowering agents. The choice of lipid-lowering medications is influenced by concomitant abnormalities of lipoprotein metabolism, such as hypertriglyceridemia or hypoalphalipoproteinemia. Treatment of primary dyslipidemias other than hypercholesterolemia may be warranted in the presence of other cardiac risk factors; however, a broader spectrum of clinical trial data is needed to support or refute this contention.

Usefulness of lipid-lowering therapy in elderly patients

O of all acute myocardial infarcts and 60% of all acute myocardial infarction deaths occur in individuals aged 75 years. Forty-five percent of octogenarians have clinical evidence of cardiovascular disease. Coronary heart disease (CHD) is the most common problem; 58% of mortalities at 85 years of age are due to cardiovascular disease. Concomitantly, men and women aged 60 years have the highest prevalence of hypercholesterolemia. Based on Framingham Study data, although total cholesterol level loses its predictive value for CHD in men after age 70, it predicts CHD in women into the ninth decade. The total: high-density lipoprotein cholesterol ratio predicts CHD even at ages 80 years.2 Survey data demonstrate marked undertreatment of hypercholesterolemia in elderly subjects. Some of this reflects less aggressive screening in elderly populations, some is caused by the lower priority given to dyslipidemia by physicians and patients, some involves concerns about drug safety, and some is predicated by concerns about drug costs. Time trends in cholesterol-lowering therapy among 5,000 community-dwelling individuals aged 65 years in the Cardiovascular Health Study identified that 4.5% of eligible men and 5.9% of eligible women were treated with lipid-lowering agents in 1989 to 1990, increasing only to 8.1% of men and 10.0% of women in 1995 to 1996.3 In contrast, clinical trials of statin therapy show that the effectiveness of lipid lowering is similar in elderly and nonelderly populations, and that the incidence of adverse drug events and laboratory abnormalities is also similarly low in the elderly and nonelderly. Importantly, the statin-related decrease in low-density lipoprotein cholesterol levels in primary and secondary coronary prevention trials decreased the risk of CHD and of all-cause mortality. The risk reduction, about 30%, was similar in middle-aged and elderly patients treated for about 5 years (with data available to age 75 years). In patients of the Scandinavian Simvastatin Survival Study (4S), simvastatin-treated patients had a 34% decrease in all-cause mortality, due predominantly to a 43% decrease in CHD mortality. Although there was similar decrease in the relative risk for major CHD events in those older and younger than age 65, the absolute reduction was twice as great in older patients because mortality rates increase substantially with older age. Patients with myocardial infarction aged 65 to 75 years in the Cholesterol And Recurrent Events (CARE) trial showed a 32% decrease in major coronary events in the pravastatintreated group, including a 45% decrease in coronary death and a 40% decrease in stroke. Treatment of 1,000 older patients prevented 225 cardiovascular hospitalizations, in contrast to 121 hospitalizations prevented in 1,000 younger patients. Patients 65 years in the Long-term Intervention with Pravastatin and Ischemic Disease (LIPID) study, all of whom had average or below average cholesterol levels after myocardial infarction or unstable angina, had a 25% risk reduction in major coronary events when receiving pravastatin 40 mg/day, identical to the benefit of patients 65 years old.6 In the Primary Prevention AirForce/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS), there was a 32% decrease in first acute coronary event beyond age 65, compared with a 38% decrease at age 65 years. Patients 65 years of age were not included in the West Of Scotland COronary Prevention Study (WOSCOPS) primary prevention trial.8 Fewer than 20% of patients eligible for therapy based on National Cholesterol Education Program II guidelines in the Cardiovascular Health Study were untreated at baseline initiated therapy in the 6 years of follow-up, even those with a history of CHD.3 In the recently presented British Heart Protection Study (HPS), which enrolled patients 80 years of age, there was comparable benefit in the population below age 65, age 65 to 69, 70 to 74, and 75 years of age. In elderly, as in younger patients, simvastatin 40 mg/day reduced the risk of myocardial infarction, stroke, and myocardial revascularization by 1/3. There was no excess of adverse events, including abnormal blood enzyme levels, in older compared with younger patients. Current information is limited regarding patients 75 years of age. Given the comparable pathobiology of atherosclerosis at middle and elderly ages, the high attributable risk of hypercholesterolemia and high prevalence of established CHD at elderly ages, and the substantial and comparable CHD risk reduction associated with lipid-lowering at middle and elderly ages, a more aggressive screening of older individuals for lipid abnormalities is recommended, along with the institution of lipid-lowering therapy based on National Cholesterol Education Program III guidelines. From the Department of Cardiology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia. Manuscript received May 14, 2002; revised manuscript received and accepted June 4, 2002. Address for reprints: Nanette K. Wenger, MD, Emory University School of Medicine, 69 Jesse Hill Jr. Drive, SE, Atlanta, Georgia 30303. E-mail: nwenger@emory.edu.