GLOBAL RISK ASSESSMENT

The following factors should be taken into account in assessing the patient's level of cardiovascular risk:

Plasma lipids and lipoproteins

High plasma cholesterol due to elevation of LDL cholesterol level is a causal risk factor for coronary disease.
Elevated lipid levels should also be assessed in the light of levela of HDL cholesterol:

• Hyperlipidaemia requires more active therapy ic:\www
  
  • HDL cholesterol <0.9 mmol/l (35 mg/dl) in men
    
  • HDL cholesterol <1.1 mmol/l (42 mg/dl) in women
    
• High risk is conferred by:
  
  • plasma cholesterol: HDL cholesterol ratio >5
    
  • especially by LDL cholesterol: HDL cholesterol ratio >5
    
  • elevated plasma triglyceride in the presence of low HDL cholesterol
    
• Genetic hyperlipidaemias require early diagnosis since coronary disease may develop before the age of 40.

Family history of coronary disease

The following should be noted:

• number of affected relatives (in context of family size)
• age of onset of coronary disease
• closeness of relationship to the patient

Hypertension

• Hypertension is a risk factor for:
  
  • stroke
    
  • coronary heart disease
    
  • other cardiovascular diseases
    
• Treatment reduces the incidence of stroke and also coronary disease.
  
• Treatment is of benefit in mild and severe hypertension, at all ages up to 75.
  
• The goal for blood pressure reduction is:
  
  • systolic pressure 140 mmHg or less
    
  • diastolic pressure 85 - 90 mmHg or less; but after the age of 75 the goal should be less ambitious
• Isolated systolic hypertension is a cardiovascular risk factor, especially in the elderly, and its treatment reduces risk.
  
• Hypertension tends to coexist with lipid and thrombogenic risk factors; this clustering is due in part to truncal obesity and inheritance.
  
• Because of the high risk conferred by multiple risk factors, comprehensive treatment of all risk factors is essential

Cigarette smoking

Smoking is the cause of about 30% of cardiovascular deaths, affecting first events and recurrences.

• Smoking cessation reduces risk and is highly cost effective.
  
• Doctors can contribute to public health teaching on smoking by making educational materials available in waiting rooms and advising on the risks of smoking and techniques for stopping.
  

Diabetes

• Coronary and peripheral atherosclerosis are major causes of morbidity and mortality in diabetics.
• The increased risk in diabetics may result from many factors including:
  • plasma lipid abnormalities (high triglyceride, low HDL cholesterol, sometimes high cholesterol)
  • hypertension
  • nephropathy
  • obesity
  • insulin resistance
  • hyperglycaemia itself
• Lipid disorders are usually more pronounced in non-insulin-dependent diabetes and glucose intolerance than in treated insulin-dependent diabetes.
• Lipid abnormalities are improved by glycaemic control, especially if body weight is normalised, but may persist.

Obesity

• Life expectancy is greatest when the body mass index (BMI) (i.e. weight in kg: height in metres2) is 20 - 25. See the table of desirable weight for height.
• Reduction of overweight is important in preventing and treating:
  • hypertension
  • hyperlipidaemia and low HDL cholesterol levels
  • non-insulin-dependent diabetes
• In addition to its effects on coronary risk factors, obesity is also directly a risk factor for coronary heart disease.
• Correction or reduction of overweight is therefore centrally important to lessening the risk of heart disease.
• The distribution of obesity, as well as its extent, is significant. Excess of truncal and intra-abdominal fat, specifically, is a risk factor for coronary disease and is an important adverse influence on lipid levels, HDL cholesterol, blood pressure and glucose tolerance.

Thrombogenic risk factors

• High serum fibrinogen is a risk factor for CHD. The place of fibrinogen measurements in clinical practice is under investigation, as is the status of levels of Lp(a), a further risk factor.
• Antiplatelet drugs reduce recurrence oc:\www
  • myocardial infarction
  • cardiac death
  • unstable angina
  • thrombosis in aortocoronary bypass grafts
• Antiplatelet drugs should be considered in patients with:
  • transient ischaemic attacks
  • completed thrombotic stroke and cerebral embolism
  • acute or chronic occlusion of a peripheral artery

Age

• Risk factors operate at all ages; coronary disease is most common after the age of 60, and risk factor reduction is appropriate and necessary at all ages except when life expectancy is severely limited.
• Genetic hyperlipidaemias require early diagnosis since coronary disease may develop before the age of 40.

Sex

• Coronary disease is rare in premenopausal women except when multiple risk factors are present.
• After the menopause, risk increases progressively, hence risk factors in this group require the same management as in men.
• A healthy lifestyle should be adopted by both sexes at all ages.

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