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A practical approach to risk assessment to prevent coronary artery disease and its complications
MacRae F Linton1, Sergio Fazio,
1Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232-6300, USA. mcrae.linton@vanderbilt.edu
Insights
New guidelines classify many individuals, including those with diabetes or atherosclerotic disease, as high risk for cardiovascular events. Emerging factors aid risk stratification for intermediate-risk patients.
Area of Science:
- Cardiology
- Preventive Medicine
- Risk Factor Assessment
Background:
- Emerging cardiovascular risk factors like C-reactive protein and homocysteine are noted.
- Current risk assessment may seem insufficient for identifying high-risk populations.
- New National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines redefine high-risk categories.
Framework:
- NCEP ATP III guidelines classify individuals with atherosclerotic disease, diabetes, or multiple risk factors as high risk (>20% 10-year coronary event/stroke risk).
- Metabolic syndrome (mild hypertension, dyslipidemia, hyperglycemia, visceral obesity) is a prevalent high-risk condition.
- Aggressive risk reduction therapies may be needed for up to 30% of the US adult population.
Implementation:
- Follow NCEP guidelines for patients with diabetes and atherosclerotic complications.
- Utilize Framingham calculation for common risk factors.
- Initiate early intervention for familial hypercholesterolemia (LDL cholesterol >200 mg/dL) or family history of early cardiovascular disease.
Implications:
- Emerging risk factors can refine risk stratification in intermediate-risk individuals.
- A significant portion of the adult population may require intensive cardiovascular risk management.
- Practical application of guidelines ensures comprehensive risk assessment and intervention.
Abstract:
The recent focus on emerging cardiovascular risk factors, such as C-reactive protein, homocysteine, and small, dense low-density lipoprotein (LDL), may give the false impression that the current approach to the assessment of cardiovascular disease risk fails to identify a large section of the high-risk population. On the contrary, the new guidelines of the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) propose classifying an enormous number of individuals, including people with any form of atherosclerotic disease, diabetes, and a combination of major risk factors, into the category of high risk (>20% likelihood of a major coronary event or stroke in 10 years). Considering the widespread prevalence of the metabolic syndrome-a high-risk condition characterized by mild hypertension, mild dyslipidemia, hyperglycemia, and visceral obesity-we may be faced with the challenge of implementing aggressive risk reduction therapies in as much as 30% of the adult US population. From the point of view of risk assessment, a practical approach is to follow the NCEP guidelines (ie, place patients with diabetes and those with atherosclerotic complications in the highest risk category), apply the Framingham calculation to determine risk in people with common risk factors, and initiate early intervention in people who have familial hypercholesterolemia (LDL cholesterol >200 mg/dL) or a family history of early cardiovascular disease. The emerging risk factors may be useful for further stratifying risk in individuals with intermediate risk and the presence of risk factors not included in the Framingham calculation.