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Managing multiple cardiovascular risk factors

Journal of Family Practice, March, 2008 by Roy C. Blank, Stephen Brunton

This article focuses on modifiable risk factors for which strong evidence supports the link to cardiovascular disease (CVD) and which can be addressed in a primary care practice. For best patient outcomes in such patients, clinicians should provide aggressive treatment for all modifiable risk factors--tobacco smoke, high blood cholesterol, high blood pressure, physical inactivity, obesity and overweight, and diabetes mellitus. Although controversy exists about which risk factors are most important, patients with diabetes should be treated as if they have known coronary heart disease. They should also receive aggressive and concurrent treatment for blood glucose, blood pressure, and lipids.

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The Comparative Risk Assessment Collaborating Group module of the global burden of disease 2000 study (a World Health Organization initiative) systematically assessed the changes in population health that would result from modifying the population distribution of exposure to a risk factor or a group of risk factors. The group identified tobacco, high blood pressure (BP), and high cholesterol as being among the most significant contributors to lost years of healthy life. (1) Disease management strategies should consider simultaneous treatment of all of these risk factors to reduce the risk of CVD. (2)

Multiple risk factors and escalating CVD risk

Multiple risk factors compound a patient's overall CVD risk; the effects of the major risk factors for CVD are multiplicative (ie, if one factor doubles risk and another triples it, their joint effects increase risk 6-fold). For example, diabetes alone is a coronary heart disease (CHD) risk equivalent and is, therefore, an important risk factor for intervention; however, the likelihood of cardiovascular events increases substantially in patients with concomitant diabetes and hypertension. The most common clustering of risk factors includes hypertension, dyslipidemia, and impaired glucose tolerance or type 2 diabetes. (2)

Diabetes as a CHD risk equivalent was originally demonstrated in a 1998 study (7 year follow-up) in which patients with diabetes but no history of myocardial infarction (MI) were found to have the same risk of CHD death as did nondiabetic patients with a prior MI history. (3) After 18 years of follow-up, the investigators stated that if the definition of CHD is expanded from MI alone to include ischemic electrocardiogram changes or angina pectoris, patients with type 2 diabetes (especially women) have an even higher risk of CHD death than do nondiabetic patients with prior CHD. (4)

It is beyond the scope of this article to discuss the current controversy of metabolic syndrome as a discrete diagnosis. What we must keep in mind, however, is that each risk factor is important, risk factors have synergistic detrimental effects, and modifiable risk factors should, in fact, be modified.

Cardiovascular risk assessment

The Framingham risk score is a commonly used tool to predict cardiovascular risk. (5) The algorithm assigns points according to risk factor exposure and severity, starting with age and including total cholesterol, high-density lipoprotein cholesterol (HDL-C), BP, and whether or not the patient smokes tobacco (available at http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof#moreinfo).

Because diabetes is considered a CHD risk equivalent, it is not included in the Framingham scoring algorithm. The resulting score provides a 10-year absolute risk assessment of CHD. A 10-year absolute risk of [greater than or equal to] 20% defines patients for whom intensified risk reduction should be implemented; these patients are considered to have a cardiovascular event risk equivalent to that of individuals who have CHD. (6)

The Framingham scoring algorithm was developed for people without known heart disease and is based on a primarily white, middle-class, male population. Still, the risk factor exposure has been shown to be reasonably accurate when measured in other populations. (7) The INTERHEART study identified 9 risk factors for acute MI:Dyslipidemia, smoking, diabetes, hypertension, and abdominal obesity, in that order, were the top 5 strongest modifiable risk factors for CHD, accounting for approximately 80% of the risk for an acute MI. (8) These risk factors are easily identifiable in patients seen in the primary care setting. Newer methods of detection (eg, carotid intima-media thickness, coronary calcium scoring) are not necessarily advocated but are being increasingly used by some physicians as a component of risk assessment.

Assessing risk

Because family physicians need to identify patients at risk, some method of risk assessment is necessary. There are many ways to assess risk; however, the key is to find a method that is practical in your clinical setting and apply it in a consistent fashion. Avoid choosing an overly complex approach that you will not use consistently. As stated, the modifiable risk factors in most patients--dyslipidemia, smoking, diabetes, hypertension, and abdominal obesity--will be readily identifiable. Once the assessment is completed and risks are identified, it is important to move on to modifying risk and providing ongoing monitoring of patients' progress. The importance of addressing all identified risks concomitantly cannot be overstated.

Health Care Industry

Managing multiple cardiovascular risk factors

Journal of Family Practice, March, 2008 by Roy C. Blank, Stephen Brunton

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