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INTRODUCTION

Cardiovascular disease is the leading cause of death in developed nations; prevention is targeted at modifiable atherosclerosis risk factors (Table 215-1). Identification and control of these attributes reduce subsequent cardiovascular event rates.

TABLE 215-1ESTABLISHED ATHEROSCLEROTIC RISK FACTORS

ESTABLISHED RISK FACTORS

Cigarette Smoking

Cigarette smoking increases the incidence of, and mortality associated with, coronary heart disease (CHD). Observational studies show that smoking cessation reduces excess risk of coronary events within months; after 3–5 years, the risk falls to that of individuals who never smoked. Pts should be asked regularly about tobacco use, followed by counseling and, as needed, antismoking pharmacologic therapy to assist cessation.

Lipid Disorders

(See Chap. 189) Both elevated LDL and low HDL cholesterol are associated with cardiovascular events. Each 1-mg/dL increase in serum LDL correlates with a 2–3% rise in CHD risk; each 1-mg/dL decrease in HDL heightens risk by 3–4%. ATP III guidelines advise a fasting lipid profile [total cholesterol, triglycerides, HDL, LDL (calculated or directly measured)] in all adults, repeated every 5 years. Recommended dietary and/or pharmacologic approach depends on presence or risk of coronary artery disease (CAD) and the LDL level (Table 215-2); treatment should be most aggressive in pts with established CAD and in those with "equivalent risk" (e.g., presence of peripheral arterial disease or diabetes mellitus). Drug therapy is indicated when LDL level exceeds goal in Table 215-2 by 30 mg/dL (0.8 mmol/L). If elevated triglyceride level [≥200 mg/dL (≥ 2.6 mmol/L)] persists after control of LDL, secondary goal is to achieve non-HDL level (calculated as total cholesterol minus HDL) ≤30 mg/dL (0.8 mmol/L) above the target values listed in Table 215-2. In pts with isolated low HDL, encourage beneficial lifestyle measures: smoking cessation, weight loss, and increased physical activity. Consider addition of fibric acid derivative or niacin to raise HDL in pts with established CAD (see Chap. 189).

TABLE 215-2LDL CHOLESTEROL GOALS AND CUTPOINTS FOR THERAPEUTIC LIFESTYLE CHANGES (TLC) AND DRUG THERAPY IN DIFFERENT RISK CATEGORIES

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