Diagnosis and management of new cardiovascular risk factors

Independent risk factors for coronary heart disease (CHD) can best be identified by means of long-term prospective epidemiological studies. These factors should not be viewed in isolation, but as part of a complex governing a person's global risk of CHD. In the Münster Heart Study (PROCAM), 8-year follow up of a cohort of middle-aged men has led to the identification of nine variables which independently contribute to CHD risk: age, smoking history, personal history of angina pectoris, family history of myocardial infarction (MI), presence of diabetes mellitus, systolic blood pressure and the levels of low density lipoprotein (LDL) cholesterol, high density lipoprotein cholesterol and triglyceride. An algorithm based on these risk factors may be used to calculate an individual's risk of fatal or non-fatal MI and is available in interactive fashion on the website of the International Task Force for Prevention of Coronary Heart Disease at www.chd-taskforce.com. Treatment goals for LDL cholesterol depend on a person's level of risk: for persons with a small increase in risk 160 mg x dl(-1), for those with a moderate increase in risk 135 mg x dl(-1) and for those at high risk, including those with a history of CHD (secondary prevention) 100 mg x dl(-1). Intervention trials indicate that lowering of LDL cholesterol for 5 years produces much of the benefit predicted from the epidemiological data. The place of newer risk markers such as Lp(a), homocysteine, and parameters of clotting and inflammation in risk prediction and management remains to be determined.