Cardiovascular disease is now the leading cause of death worldwide; prevention is targeted at modifiable atherosclerosis risk factors (Table 202-1). Identification and control of these attributes reduce subsequent cardiovascular event rates.
TABLE 202-1ESTABLISHED ATHEROSCLEROTIC RISK FACTORS ||Download (.pdf) TABLE 202-1ESTABLISHED ATHEROSCLEROTIC RISK FACTORS
|Modifiable Risk Factors |
| Cigarette smoking |
| Dyslipidemias (↑LDL or ↓HDL) |
| Hypertension |
| Diabetes mellitus |
| Obesity |
| Sedentary lifestyle |
|Unmodifiable Risk Factors |
| Premature coronary heart disease in first-degree relatives (age <55 in men, <65 in women) |
| Age (men ≥45 years; women ≥55 years) |
| Male sex |
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.
(See Chap. 178) 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%. Fasting screening lipid profile in adults should include total cholesterol, triglycerides, HDL, and LDL (calculated or directly measured). Recommended dietary and/or pharmacologic approach depends on presence or risk of coronary artery disease (CAD); treatment should be most aggressive in pts with established CAD and in those with “equivalent risk” (e.g., presence of diabetes mellitus). Current guidelines by American Heart Association/American College of Cardiology recommend statin therapy for four specific groups of pts at highest risk (Table 202-2). In pts with isolated low HDL, encourage beneficial lifestyle measures: smoking cessation, weight loss, and increased physical activity (see Chap. 178).
TABLE 202-2GROUPS RECOMMENDED FOR STATIN THERAPY ||Download (.pdf) TABLE 202-2GROUPS RECOMMENDED FOR STATIN THERAPY
|Group ||Recommendation |
|Clinical atherosclerotic disease (ASCVD) ||High-intensity statina |
|LDL cholesterol ≥190 mg/dL ||High-intensity statina |
|Diabetics (age 40–75, LDL 70–189 mg/dL) with || |
| 10 year cardiac riskc ≥7.5% ||High-intensity statina |
| 10 year cardiac riskc <7.5% without established ASCVD ||Moderate-intensity statinb |
|Nondiabetics (age 40–75, LDL 70–189 mg/dL) with || |
| 10 year cardiac riskc ≥7.5% ||Moderate-to-high intensity statina,b |
(See Chap. 117) Systolic or diastolic bp > “optimal” level of 115/75 mmHg is associated ...