1. Cardiovascular Disease: Risk Factors and Risk Assessment

2. Lifetime risk of CVD
Lifetime risk of overall CVD approaches 50 percent for persons aged 30 years without known CVD
Coronary heart disease (CHD) accounts for approximately one-third to one-half of the total cases of CVD

3. Framingham Heart Study
The lifetime risk of CHD was illustrated in a study of 7733 participants, age 40 to 94, in the Framingham Heart Study who were initially free of CHD
The lifetime risk for individuals at age 40 was 49% in men and 32% in women.
Even those who were free from CHD at age 70 had a non-trivial lifetime risk of developing CHD (35 and 24% in men and women, respectively)
Similar findings have been reported in a meta-analysis of 18 cohorts involving over 250,000 men and women

4. CVD Risk
Despite increases in longevity and decreases in age-specific death rates from CVD, CHD, and stroke since 1975, CVD and its related complications remain highly prevalent and expensive to treat

5. CVD Risk
While CVD remains the leading cause of death in most developed countries, mortality from acute MI appears to have decreased by as much as 50 percent in the 1990s and 2000s
Many individuals in the general population have one or more risk factors for CHD, and over 90 percent of CHD events occur in individuals with at least one risk factor

6. CVD Risk
The five leading modifiable risk factors are estimated to be responsible for more than half of cardiovascular mortality
Hypercholesterolemia
Diabetes
Hypertension
Obesity
Smoking

7. Atherosclerosis is responsible for almost all cases of CHD
Fatty streaks in adolescence
Plaques in early adulthood
Thrombotic occlusions and coronary events in middle age and later life

8. CVD Risk Factors
Based upon the absolute, relative, and attributable risks imposed by the various risk factors, concepts of "normal" have evolved from usual or average to more optimal values associated with long-term freedom from disease.
As a result, optimal blood pressure, blood glucose, and lipid values have been revised downward in the past 20 years

9. CVD Risk Factors
a number of other major cardiovascular risk factors declined substantially between 1960 and 2000
Serum total cholesterol ≥240 mg/dL (6.2 mmol/L) – 34 to 17 percent
Hypertension (blood pressure ≥140/≥90 mmHg) – 31 to 15 percent
Smoking – 39 to 26 percent

10. CVD Risk Factors: Age and Gender
 Cardiovascular risk factors promote CVD in either gender at all ages but with different relative importance
Diabetes and a low high-density lipoprotein (HDL)-cholesterol/total cholesterol ratio operate with greater power in women
The incidence of a myocardial infarction is increased six-fold in women and three-fold in men who smoke at least 20 cigarettes per day compared to subjects who never smoked

11. CVD Risk Factors: Age and Gender
Systolic blood pressure and isolated systolic hypertension are major CHD risk factors at all ages and in both genders
In patients <50 years of age, diastolic blood pressure was the strongest predictor of CHD risk
in those 50 to 59 years of age, all three blood pressure indices were comparable predictors of CHD risk
in those ≥60 years of age, pulse pressure was the strongest predictor

12. CVD Risk Factors: Age and Gender
Obesity or weight gain promotes or aggravates all the atherogenic risk factors and physical inactivity worsens some of them, predisposing subjects of all ages to CHD events
Age alone also appears to contribute to the development of CVD.

13. CVD Risk Factors: Family History
Family history is an independent risk factor for CHD, particularly among younger individuals with a family history of premature disease
there is general agreement that development of atherosclerotic CVD or death from CVD in a first degree relative (ie, parent or sibling) prior to age 55 (males) or 65 (females) denotes a significant family history
The risk of developing CHD in the presence of a positive family history has ranged from 15 to 100 percent in various cohorts, with most cohorts showing a 40 to 60 percent increase.

14. CVD Risk Factors: Hypertension
The lifetime risk of developing CVD is significantly higher among patients with hypertension
The determination of what blood pressure constitutes hypertension has long been the subject of debate…..
A separate issue is the goal blood pressure in patients who already have or are at high risk for cardiovascular disease.

15. What is normal blood pressure?
Normal blood pressure: systolic <120 mmHg and diastolic <80 mmHg
Prehypertension: systolic 120 to 139 mmHg or diastolic 80 to 89 mmHg
Hypertension:
Stage 1: systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg
Stage 2: systolic ≥160 mmHg or diastolic ≥100 mmHg

16. CVD Risk Factors: Lipids and Lipoproteins
The following lipid and lipoprotein abnormalities are associated with increased CHD risk
Elevated total cholesterol and elevated LDL-cholesterol
Low HDL-cholesterol
Hypertriglyceridemia
Increased non-HDL-cholesterol
Increased Lipoprotein (a)
Increased apolipoprotein C-III
Small, dense LDL particles
Different genotypes of apolipoprotein E (apoE) influence cholesterol and triglyceride levels as well as the risk of CHD

17. CVD Risk Factors: Diabetes
 Insulin resistance, hyperinsulinemia, and elevated blood glucose are associated with atherosclerotic cardiovascular disease
In addition to the importance of diabetes as a risk factor, diabetics have a greater burden of other atherogenic risk factors than nondiabetics, including 
hypertension, obesity, increased total-to-HDL-cholesterol ratio, hypertriglyceridemia, and elevated plasma fibrinogen. The CHD risk in diabetics varies widely with the intensity of these risk factors

18. CVD Risk Factors: Lifestyle Factors
Cigarette smoking is an important and reversible risk factor for CHD
Smoking is an independent major risk factor for total atherosclerotic CVD, CHD, cerebrovascular disease, and all-cause mortality, with an apparent dose-dependent relationship
In the worldwide INTERHEART study of patients from 52 countries, smoking accounted for 36 percent of the population-attributable risk of a first MI
Conversely, the risk of recurrent infarction in a study of smokers who had an MI fell by 50 percent within one year of smoking cessation and normalized to that of nonsmokers within two years
The benefits of smoking cessation are seen regardless of how long or how much the patient has previously smoked

19. CVD Risk Factors: Lifestyle Factors
Exercise — Exercise of even moderate degree has a protective effect against coronary heart disease and all-cause mortality
Exercise may have a variety of beneficial effects including an elevation in serum HDL-cholesterol, a reduction in blood pressure, less insulin resistance, and weight loss.
In addition to the amount of exercise performed, the degree of cardiovascular fitness (a measure of physical activity), as determined by duration of exercise and maximal oxygen uptake on a treadmill, is also associated with a reduction in coronary heart disease risk and overall cardiovascular mortality

20. CVD Risk Factors: Diet

21. CVD Risk Factors: Other considerations
Psychosocial factors — Psychosocial factors may contribute to the early development of atherosclerosis as well as to the acute precipitation of myocardial infarction and sudden cardiac death.
The link between psychologic stress and atherosclerosis may be both direct, via damage of the endothelium, and indirect, via aggravation of traditional risk factors such as smoking, hypertension, and lipid metabolism.
Depression, anger, stress, and other factors have been correlated with cardiovascular outcomes

22. CVD Risk Factors: Other considerations
Inflammatory markers — Numerous inflammatory markers have been reported to be associated with increased risk of CVD
C-reactive protein (CRP) is both the most extensively studied marker of inflammation and the marker most widely used in clinical practice.
Its precise role in the assessment of cardiovascular risk continues to evolve.
While the precise role of CRP remains uncertain, epidemiologic studies have suggested that interleukin-6 (IL-6) has a direct causal role in the development of CHD

23. Risk Assessment of CVD
Estimation of cardiovascular risk in an individual patient without known cardiovascular disease use of multivariate risk models
Framingham risk score (1998) — The original Framingham risk score, published in 1998, was derived from a largely Caucasian population of European descent
Subsequent studies have suggested that the Framingham risk score performs well for prediction of CHD events in black and white women and men

24. Framingham risk score (1998)
Prediction variables used
Endpoints assessed
Age
CHD death
Gender
Nonfatal MI
Total or LDL cholesterol (mg/dL)
Unstable angina
HDL cholesterol (mg/dL)
Stable angina
Systolic blood pressure (mmHg)
Diabetes mellitus (yes or no)
Current smoking (yes or no)

25. Framingham risk score (2008)
The original 1998 and revised 2002 Framingham risk scores do not include all of the potential manifestations and adverse consequences of atherosclerosis such as vascular complications

26. Framingham Risk Score 2008 Prediction variables used
Endpoints assessed
Age
CHD death
Gender
Nonfatal MI
Total cholesterol (mg/dL)
Coronary insufficiency or angina
HDL cholesterol (mg/dL)
Fatal or nonfatal ischemic or hemorrhagic stroke
Systolic blood pressure (mmHg)
Transient ischemic attack
Blood pressure treatment (yes or no)
Intermittent claudication
Diabetes mellitus (yes or no) HF
Current smoking (yes or no)

27. ATP III hard CHD risk score (2002)
Prediction variables used in ATP III hard CHD risk score (2002)
Age
Gender
Total cholesterol (mg/dL)
HDL cholesterol (mg/dL)
Systolic blood pressure (mmHg)
Blood pressure treatment (yes or no)
Current smoking (yes or no)