RISK FACTOR FOR CORONARY ARTERY DISEASE Dr.Animesh Mishra; MD (BHU), DM (Delhi University). Associate Professor, Department of cardiology NEIGRIHMS,Shillong-12

PURPOSE OF THIS VEDIO-CONFERENCING Dissemination of information relative to the prevention of atherosclerosis and its adverse consequences. Development of educational pro-grams specific to the role of the cardiovascular specialist with regard to prevention. Cooperative development of practice guidelines, for consultative as well as rehabilitation services, to deliver cost-effective preventive care. Policies of fair reim-bursement for effective services. Participation in the assessment of clinical outcomes of such programs.

Cont.... To promote preventive cardiac care by Endorsing anti-smoking policies & programs. Encouraging healthy dietary behavior. Promoting prudent physical activity. Ensuring adequate control of blood pressure. Managing patients with hyperlipidemia, metabolic, coagulative and other risk factors. Advising primary care physicians with regard to risk reduction. Developing a cardiovascular health promotion plan for cardiac patients and their families.

Definition of CHD Framingham definition: Angina pectoris, recognized and unrecognized MI,USA,& CHD deaths. Recent Framingham report :“Hard" CHD excludes angina pectoris.) (AFCAPS/Tex CAPS): Specified acute coronary events as USA, AMI & coronary death.

Major Independent Risk Factors AHA/ACC Scientific Statement: Cigarette smoking Elevated blood pressure Elevated serum total (and LDL) cholesterol Low serum HDL cholesterol Diabetes mellitus Advancing age

Other Risk Factors Predisposing risk factors    Obesity    Abdominal obesity    Physical inactivity    Family history of premature coronary heart disease    Ethnic characteristics    Psychosocial factors *These risk factors are defined as major risk factors by the AHA . Cont….

Conditional risk factors    Elevated serum triglycerides    Small LDL particles    Elevated serum homocysteine    Elevated serum lipoprotein (a)    Prothrombotic factors (eg, fibrinogen)    Inflammatory markers (eg, C-reactive protein)

MENTAL STRESS,DEPRESSION,AND CARDIOVASCULAR RISK From Clinician’s perspective-As a modifiable risk factor 1- Acute stress 2- Work related stress (a)-Job strain (b)-Effort-reward imbalance 3-Psychological metrics.

Cont…. In a meta-analysis of 11 studies of healthy individuals Depressive mood. (RR-1.7) Clinical depression.(RR-2.3) Whether therapy for post-infarction depression reduces recurrent event rates remains controversial

Body weights BMI Normal weight : 18.5–24.9 kg/m2 Overweight : 25–29 kg/m2; Obesity : >30.0 kg/m2 class I 30.0–34.9 class II 34.9–39.9, class III ≥40 kg/m2). Abdominal obesity is defined according waist circumference: men >102 cm (>40 in) &women >88 cm (35 in)

Clinical Importance of Global Estimates for CHD Risk Total (global) risk summation of all major risk factors can be clinically useful for 3 purposes: 1) Identification of high-risk patients who deserve immediate attention and intervention, 2) Motivation of patients to adhere to risk-reduction therapies. 3) Modification of intensity of risk-reduction efforts based on the total risk estimate.

Primary Versus Secondary Prevention This presentation focuses mainly on risk assessment for coronary disease and not on risk for cardiovascular outcomes. Framingham scores estimate risk for persons without clinical manifestations of CHD Therefore, the scores apply only to primary prevention. Once coronary atherosclerotic disease becomes clinically manifest, the risk for future coronary events is much higher than that for patients without CHD regardless of other risk factors, and in this case, Framingham scoring no longer applies.

Severity of Major Risk Factors The scoring does not adequately account for severe abnormalities of risk factors,e.g. severe hypertension, severe hypercholesterolemia, or heavy cigarette smoking. This underestimation is particularly evident when only 1 severe risk factor is present. Thus, heavy smoking or severe hypercholesterolemia can lead to premature CHD even when the summed score for absolute risk is not high. Likewise, the many dangers of prolonged, uncontrolled hypertension are well known.

Diabetes Mellitus as a Special Case in Risk Assessment Both type 1 and type 2 diabetes confer a heightened risk for CVD. When the risk factors of diabetic patients are summed, their risk often approaches that of patients with established CHD. Considerations about the very high risk of patients with diabetes apply to ethnic groups that have a relatively high population risk for CHD. Inclusion of patients with type 2 diabetes in the very-high-risk category may not be appropriate when they belong to ethnic groups with a low population risk.

Definition of a Low-Risk State Serum total cholesterol: 160 to 190 LDL-C :100 to 129 HDL-C: >45 in men and >55 in women Blood pressure: <120 mm Hg systolic and <80 mm Hg diastolic Non Smoker No diabetes mellitus

IDEAL GOAL FOR INDIVIDUALS Serum total cholesterol: 100 to 130 LDL-C :<80 HDL-C: > 80 Blood pressure: <115 mm Hg systolic and <75 mm Hg diastolic Non Smoker No diabetes mellitus