RISK OF CORONARY HEART DISEASE

prepared by

European Society of Cardiology
European Atherosclerosis Society
European Society of Hypertension

Prevention of Coronary Heart Disease in Clinical Practice
Recommendations published in October 1994 in the European Heart Journal and Atherosclerosis

PRIORITIES OF CORONARY HEART DISEASE PREVENTION IN CLINICAL PRACTICE

1. Patients with established CHD or other atherosclerotic vascular disease
2. Asymptomatic subjects with particularly high risk (subjects with severe hypercholesterolemia or other form of dyslipidaemia, diabetes, or hypertension; subjects with a cluster of several risk factors)
3. Close relatives of
   • patients with early-onset CHD or other atherosclerotic vascular disease
   • asymptomatic subjects with particularly high risk
4. Other individuals met in connection with ordinary clinical practice

LIFESTYLES AND CHARACTERISTICS ASSOCIATED WITH INCREASED RISK OF FUTURE CORONARY HEART DISEASE

• Lifestyles
  • Diet high in saturated fat, cholesterol, and calories
  • Tobacco smoking
  • Excess alcohol consumption
  • Physical inactivity
• Biochemical or physiological characteristics (modifiable)
  • Elevated plasma total cholesterol (LDL cholesterol)
  • Elevated blood pressure
  • Low plasma HDL cholesterol
  • Elevated plasma triglycerides
  • Hyperglycaemia / Diabetes
  • Obesity
  • Thrombogenic factors
• Personal characteristics (nonmodifiable)
  • Age
  • Sex
  • Family history of CHD or other atherosclerotic vascular disease at early age (in men <55 years, in women <65 years)
  • Personal history of CHD or other atherosclerotic vascular disease

RISK TABLES

HOW TO USE THE RISK TABLES

1. To determine a person’s absolute 10-year risk of a coronary event (heart attack), identify the table relating to the person’s sex, smoking status, and age.
2. Within the table, find the cell nearest to the person’s systolic blood pressure (mmHg) and cholesterol.
3. Compare cell colour with key and read the risk level.
4. The effect of lifetime exposure to risk factor can be assessed by following the table upwards with increasing age.
5. Notice - For patients with coronary heart disease, the level of risk should be increased by at least one category. People with family history of coronary event at an early age, diabetes, or a family history of hyperlipidaemia are also at increased risk.

RISK LEVEL

Percent chance of coronary event in 10 years

Based on a risk function derived from the Framingham Study, Anderson KM et al: An updated coronary risk profile. A statement for health professionals. Circulation 83:356-362,1991

The table assumes the HDL cholesterol to be 1.0 mmol/1 (39 mg/dl) in men and 1.1 mmol/l (43 mg/dl) in women. People with lower levels and/or with triglycerides above 2.3 mmol/l (200 mg/dl) are at higher risk.

GUIDE TO LIPID MANAGEMENT

Total cardiovascular risk should be assessed first and the major components of risk identified. If 10-years CHD risk exceeds 20% or will exceed 20% if projected to age 60, more intensive advice for all risk factors will be required. Clinical vascular disease will increase the risk to more than 20% for most and to more than 40% for many.

Cholesterol level	General risk factor advice	Intensive physician & dietician-directed risk advice	Drug treatment considered if diet fails	Comment
350 mg/dl 9 mmol/l	YES	YES	YES	Check fasting lipids Exclude secondary hyperlipidaemia Check family members
300 mg/dl 8 mmol/l	YES	YES	YES if CHD risk >20%	Check fasting lipids Exclude secondary hyperlipidaemia
250 mg/dl 7 mmol/l	YES	YES if CHD risk >20%	Occasionally if very high risk
200 mg/dl 5 mmol/l	YES	YES if CHD risk >20%

• Diet is the cornerstone of management.
• General risk-factor advice implies avoidance of tobacco, weight control, less than 30 percent of dietary calories as fat (of which less than a third are from saturated fat), control of hypertension, and frequent leisure exercise.
• Management decisions should not be based on a single cholesterol measurement. Laboratory variation may be 0.5 mmol/l (20 mg/dl) or more.
• Raised triglycerides signal the need for fasting lipid estimation (HDL cholesterol may be low). Hypertriglyceridaemia often responds to weight and alcohol control.
• The benefits or otherwise of drug treatment in women and in the elderly are unknown.

GUIDE TO BLOOD PRESSURE MANAGEMENT

Total cardiovascular risk should be assessed first and the major components of risk identified. If 10-year CHD risk exceeds 20% or will exceed 20% if projected to age 60, more intensive advice for all risk factors will be required. Clinical vascular disease will increase the risk to more than 20% for most and to more than 40% for many.

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