The role of unknown risk factors in coronary heart disease Dr . A.A. Rafighoust ,MD

The importance of traditional risk factors in predicting risk of cardiovascular disease (CVD) is well known.

Cholesterol screening, the most common test used to screen for CVD risk, is unable to identify approximately half of who will develop acute myocardial infarction

Not all individuals with coronary heart disease have traditional risk factors Khot et al. JAMA 2003

Analysis of more than 120/000 pts with CAD shows: 15% of men,19% of women had no evidence of: Hyperlipidemia Hypertension Diabetes Smoking And more than half had: Only one of the general risk factor

Despite the importance of blood lipids: 50% of all Mis occur among individuals without overt hyperlipidemia

77% of all future CVE occur among pts with LDL- C less than 160mg/dc; 46% in LDL-C less than 130mg

More precise risk assessment is essential to reduce risk for CVD

Uncommon Risk factors For atherosclerosis .

Novel Risk Factors Hyperhomocysteinemia Infection and inflammation Hemostatic and coagulation disorders inactivity and obesity Fast food restaurant abuse Second hand smoke

Novel risk factors include inflammation

inflammation Inflammation has been firmly established as pivotal for development of future cardiovascular events

inflammation play a central role, in not only the: Development Progression Of atherosclerosis

But also in the subsequent plaque: Instability Thrombosis That result in the clinical manifestation of an: ACS

Marker of Inflammation

C-reactive protein (CRP) High-sensitive c-reactive protein (hsCRP) is the most widely studied inflammatory biomarker

it is a strong predictor of short and long term C it is a strong predictor of short and long term C.V risk among: Healthy men and women Pts with prior coronary events

HOMOCYSTEIN

Mechanisme: Remain uncertain but include Endothelial dysfunction acceleration of LDL-C oxidation

Pro-atherogenic pro- thrombotic

Infection and Inflammation Chlamydia pneumoniae Helicobacter pylori Cytomegalovirus Herpes virus Periodontal disease

Helicobacter pylori Thought to be a potential factor in causing pathophysiology of atherosclerosis

A mechanism for chronic systemic inflammation from Gm (-) organisms Periodontal Disease A mechanism for chronic systemic inflammation from Gm (-) organisms After adjustment for other SRF in one study, there is a significant increased ischemic stroke risk (RR 2.1) among those with periodontitis.

Advanced disease estimated prevalence: 15% -60-64 yo >45% in >65 y.o. One study showed a significant ischemic stroke risk (RR 2.1) among those with periodontitis

Psoriasis and Risk of Coronary Artery Disease: Detection of Early Atherosclerosis Eric H. Yang, MD, FACC Assistant Professor of Medicine Director of the Coronary Care Unit Interventional Cardiology University of North Carolina at Chapel Hill

Severe psoriasis is associated with an increased risk of CAD. The risk is highest in younger patients. Future studies are needed to determine if systemic therapy reduces this risk.

Other novel risk factors with the risk of recurrent CVD: Lower serum albumin Higher serum createnin

Serum albumin: Albumin is a negative acute-phase reactant,so it may reflect the role of inflammation in recurrent CVD

Serum createnin: Was a strong prediction of all-cause mortality among Mi survivors In our studies: Those with createnin greater than or equal to 1.4 were at 66% higher risk for recurrent CVD than those with less than 1.4mg/d

Earthquake And Coronary Heart Disease