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Premium member Presentation Transcript Overview of the risk factors for cardiovascular disease : Overview of the risk factors for cardiovascular disease Amr Behiri M.D. American Board Certified in Internal Medicine Assistant Professor, The Ohio State University Internal Medicine Hospitalist, Reston Hospital Center, VA May 22, 2011Introduction: Introduction Cardiovascular disease (CVD) is common in the general population, affecting the majority of adults past the age of 60 years . The prevalence of coronary heart disease (CHD) is approximately 1/3 to 1/2 that of total CVD . 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 .Introduction (cont.): Introduction (cont.) The lifetime risk for individuals at age 40 was 49 % in men and 32 % in women. Even those who were free from disease at age 70 had a lifetime risk of 35 % and 24 % in men and women, respectively. No other life-threatening disease is as prevalent or expensive to society, and persons with CVD are likely to die from their disease.Introduction (cont.): Introduction (cont.) As a diagnostic category, CVD includes four major areas: Coronary heart disease (CHD) manifested by myocardial infarction (MI), angina pectoris, heart failure (HF), and coronary death Cerebrovascular disease manifested by stroke and transient ischemic attack Peripheral artery disease manifested by intermittent claudication Aortic atherosclerosis and thoracic or abdominal aortic aneurysmIntroduction (cont.): Introduction (cont.) The presence of vascular disease in one of these territories significantly increases the likelihood of disease in other vascular distributions. For example, patients with a low ankle-brachial index (a noninvasive test for peripheral artery disease) have a significantly increased risk of fatal MI, TIA, or stroke, and stroke patients have an increased incidence of CHD .Introduction (cont.): Introduction (cont.) Many of the important risk factors for cardiovascular disease are modifiable by specific preventive measures. In the worldwide INTERHEART study of patients from 52 countries, nine potentially modifiable factors accounted for over 90 % of the population-attributable risk of a first MI. These included smoking, dyslipidemia , hypertension, diabetes, abdominal obesity, psychosocial factors, daily consumption of fruits and vegetables, regular alcohol consumption, and regular physical activity.General principles: General principles Atherosclerosis is responsible for almost all cases of CHD . This insidious process begins with fatty streaks that are first seen in adolescence; these lesions progress into plaques in early adulthood, and culminate in thrombotic occlusions and coronary events in middle age and later life.General principles (cont.): General principles (cont.) Risk factor assessment is useful in adults to guide therapy for dyslipidemia , hypertension, and diabetes, and multivariate formulations can be used to help estimate risk for coronary disease events .General principles (cont.): General principles (cont.) It has been asserted that approximately one-half of all patients suffering a CHD event have no established risk factors other than age and gender, a claim that has contributed to efforts to identify other markers of cardiovascular risk.General principles (cont.): General principles (cont.) Based upon 14 randomized clinical trials of CHD, included more than 120,000 subjects with ST elevation MI, non-ST elevation acute coronary syndrome, or percutaneous coronary intervention . Risk factors were defined by information collected at the time of study enrollment, including smoking, diabetes, hypertension, and hyperlipidemia .General principles (cont.): General principles (cont.) At least one of these four risk factors was present in 85 percent of women and 81 percent of men. When stratified by age, the lowest prevalence of at least one risk factor was seen among subjects >75 years old (77 percent of women and 65 percent of men).PowerPoint Presentation: Major risk factors Target organ damage Hypertension Heart disease Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Cigarette smoking Obesity (BMI ≥30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Stroke or transient ischemic attack Microalbuminuria or estimated GFR <60 mL /min Chronic kidney disease Age >55 years for men, >65 years in women Peripheral arterial disease Family history of premature coronary disease Men - <55 years Women - <65 years RetinopathyGender and age: Gender and age Cardiovascular risk factors promote coronary disease in either gender at all ages but with different strengths. 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 sixfold in women and threefold in men who smoke at least 20 cigarettes per day compared to subjects who never smoked.Gender and age (cont.): Gender and age (cont.) Systolic blood pressure and isolated systolic hypertension are major risk factors at all ages in either sex. The Framingham study found that the relative importance of systolic, diastolic, and pulse pressure (the difference between the systolic and diastolic blood pressures) changes with age.Gender and age (cont.) : Gender and age (cont.) In patients <50 years of age, diastolic blood pressure was the strongest predictor; in those 50 to 59 years of age, all three blood pressure indices were comparable predictors while in those ≥60 years of age, pulse pressure was the strongest predictor 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 coronary events.Family history: Family history Family history is a significant independent risk factor for coronary heart disease, particularly among younger individuals with a family history of premature disease. Family history was evaluated in a prospective study from the Physician's Health Study of 22,071 men followed for 13 years and the Women's Health Study of 39,876 women followed for 6.2 years .Family history (cont.): Family history (cont.) Compared to no parental history of an MI, a maternal history, a paternal history, and both maternal and paternal history was associated with a relative risk of cardiovascular disease of 1.71, 1.40, and 1.85 in men and 1.46, 1.15, and 2.05 in women. A history of paternal MI at an age <60 years was associated with a greater risk of cardiovascular disease than infarction at a later age; in comparison, any maternal history of infarction was associated with a greater risk.An analysis from the Framingham Offspring Study : An analysis from the Framingham Offspring Study Patients with at least one parent with validated premature cardiovascular disease (before age 55 in a father or before age 65 in a mother) had a significantly greater risk for cardiovascular events (age-adjusted odds ratio [OR] 2.6 for men and 2.3 for women ). After adjustment for other risk factors, parental history was still significant (OR 2.0 for men and 1.7 for women).Lipids and lipoproteins: Lipids and lipoproteins Lipids, principally cholesterol and triglycerides, are the water insoluble compounds that require larger protein containing complexes called lipoproteins to transport them in blood . The protein components of the lipoprotein are known as apolipoproteins or apoproteins .Lipids and lipoproteins (cont.): Lipids and lipoproteins (cont.) Evidence for the pathogenic importance of serum cholesterol has largely come from randomized trials which showed that reductions in total and LDL-cholesterol levels (almost entirely with statins ) reduce coronary events and mortality when given for primary and secondary prevention .The following lipid and lipoprotein abnormalities are associated with increased coronary risk.: The following lipid and lipoprotein abnormalities are associated with increased coronary risk. Elevated total cholesterol and elevated LDL-cholesterol . Low HDL-cholesterol. Increased total-to-HDL-cholesterol ratio. Hypertriglyceridemia . Increased non-HDL-cholesterol. Increased Lp (a). Increased apolipoprotein B ( apo B; found primarily in LDL) and decreased apolipoprotein A-I ( apo A-1; found in HDL). Small, dense LDL particles. Different genotypes of apolipoprotein E ( apoE ) influence cholesterol and triglyceride levels as well as the risk of CHD.Lipids and lipoproteins (cont.): Lipids and lipoproteins (cont.) The prevalence of dyslipidemia is increased in patients with premature CHD: as high as 75 to 85% compared to approximately 40 to 48% in age-matched controls without CHD. In the worldwide INTERHEART study of patients from 52 countries, dyslipidemia (defined as a raised apo B to apo A-1 ratio) accounted for 49% of the population-attributable risk of a first MI.Pravastatin CARE trial: Pravastatin CARE trial Kaplan-Meier analysis of the incidence of coronary death or nonfatal myocardial infarction in post-MI patients who had average levels of cholesterol and were randomized to therapy with pravastatin or placebo. The incidence of these endpoints was significantly reduced by therapy with pravastatin (p = 0.003). A similar percent benefit was seen in the subgroup of patients with near normal levels of LDL-cholesterol (125 to 150 mg/ dL [3.2 to 3.9 mmol /L]). Redrawn from Sacks, FM, Pfeffer , MA, Move, LA, et al for the Cholesterol and Recurrent Events Trial Investigators, N Engl J Med 1996; 335:1001.Pravastatin prevents CHD: Pravastatin prevents CHD Kaplan-Meier analysis of the efficacy of pravastatin versus placebo in 6,595 middle-aged men with hypercholesterolemia (mean serum cholesterol concentration 272 mg/ dL [7.0 mmol /L]). At the end of the study, the men treated with pravastatin (dashed red line) had a 32 percent reduction in definite nonfatal myocardial infarction (MI) or death from coronary heart disease (CHD, top panel) and a 22 percent reduction in death from any cause (lower panel). Data from Shepherd, J, Cobbe , SM, Ford, I, et al, N Engl J Med 1995; 333:1301.Hypertension : Hypertension Hypertension is a well-established risk factor for adverse cardiovascular outcomes, including CHD mortality and stroke. In the worldwide INTERHEART study of patients from 52 countries, hypertension accounted for 18 percent of the population-attributable risk of a first MI.Hypertension (cont.): Hypertension (cont.) Systolic blood pressure is at least as powerful a coronary risk factor as the diastolic blood pressure, particularly in older patients, and isolated systolic hypertension is now established as a major hazard for coronary heart disease and stroke . There is also evidence that the pulse pressure, which is determined primarily by large artery stiffness, is a predictor of riskHypertension (cont.): Hypertension (cont.) Although blood pressure at the time of risk assessment (current blood pressure) is typically used in most prediction algorithms, this does not accurately reflect an individual's past blood pressure experience. Two analyses demonstrate the importance of inclusion past blood pressure into risk prediction models, since the duration as well as the degree of hypertension are both risk factors.Hypertension (cont.): Hypertension (cont.) Ambulatory blood pressure measurements may be more predictive in patients with office or white coat hypertension . A separate issue is the goal blood pressure in patients who already have or are at high-risk for cardiovascular disease. Epidemiologic studies in the general population have shown that the risk of cardiovascular disease increases progressively at blood pressures above 110/75 mmHg .Hypertension (cont.): Hypertension (cont.) Data from clinical trials suggest that patients with cardiovascular disease may benefit from a lower than that in the general hypertensive population.CHD mortality v BP and age: CHD mortality v BP and age Coronary heart disease (CHD) mortality rate, pictured on a log scale with 95 percent confidence intervals, in each decade of age in relation to the estimated usual systolic and diastolic blood pressure at the start of that decade. CHD mortality increases with both higher pressures and older ages. For diastolic pressure, each age-specific regression line ignores the left- hand point ( ie , at slightly less than 75 mmHg), for which the risk lies significantly above the fitted regression line (as indicated by the broken line below 75 mmHg). Data from Prospective Studies Collaboration, Lancet 2002; 360:1903.Benefit of Rx of mild HTN: Benefit of Rx of mild HTN Reduced incidence of fatal and total coronary heart disease (CHD) events and strokes following antihypertensive therapy in 17 controlled studies involving almost 48,000 patients with mild to moderate hypertension. The number of patients having each of these events is depicted, with active treatment lowering the incidence of coronary events by 16 percent and stroke by 40 percent. However, the absolute benefit - as shown, in percent, by the numbers at the top of the graph - was much less. Treatment for approximately 4 to 5 years prevented a coronary event or a stroke in two percent of patients (0.7 + 1.3), including prevention of death in 0.8 percent. Data from Hebert, PR, Moser, M, Mayer, J, et al, Arch Intern Med 1993; 153:578.Diabetes mellitus: Diabetes mellitus Insulin resistance, hyperinsulinemia , and elevated blood glucose are associated with atherosclerotic cardiovascular disease. In an analysis of over 13,000 participants in the Copenhagen Heart Study, the relative risk of incident of MI or stroke was increased two to three fold in those with type 2 diabetes, and the risk of death was increased two fold, independent of other CHD risk factors.Diabetes mellitus (cont.): Diabetes mellitus (cont.) A significant number of patients with an acute MI have previously undiagnosed diabetes. In the worldwide INTERHEART study of patients from 52 countries, diabetes accounted for 10 percent of the population-attributable risk of a first MI .Diabetes mellitus (cont.): Diabetes mellitus (cont.) The all-cause mortality risk associated with diabetes is comparable to the all-cause mortality risk associated with a prior MI. While the causes of death are not equally frequent in these groups (CVD death is more frequent after MI, while non-CVD death is more frequent in patients with diabetes), the 2002 National Cholesterol Education Program report designated diabetes a CHD risk equivalent, thereby elevating it to the highest risk category.Diabetes mellitus (cont.): Diabetes mellitus (cont.) Guidelines published by the National Cholesterol Education Program and the sixth Joint National Committee have provided a framework to treat coronary risk factors aggressively in diabetics. There is compelling evidence of the value of aggressive therapy of serum cholesterol (goal LDL-cholesterol <100 mg/ dL [2.6 mmol /L]) and hypertension in patients with diabetes (goal systolic pressure less than 130 mmHg ).Obesity: Obesity In an analysis of data from 4780 adults in the Framingham Offspring Study, obesity as measured by body mass index (BMI) significantly predicted the occurrence of coronary heart disease and cerebrovascular disease after adjusting for traditional risk factors.Obesity and mortality: Obesity and mortality In a prospective study of over one million men and women who never smoked and had no history of disease at enrollment and were followed for 14 years, all cause and cardiovascular mortality progressively increased at high body mass indices (BMI) and were highest in those who were heaviest (BMI ? 35). Data from Calle EE, Thun , MJ, Petrelli JM, et al, N Engl J Med 1999; 341:1097Metabolic syndrome : Metabolic syndrome Patients with the constellation of abdominal obesity, hypertension, diabetes, and dyslipidemia are considered to have the metabolic syndrome (also called the insulin resistance syndrome or syndrome X). Individuals with the metabolic syndrome have a markedly increased risk of coronary artery disease .Nonalcoholic fatty liver disease: Nonalcoholic fatty liver disease Nonalcoholic fatty liver disease is a clinico-histopathological entity with features that resemble alcohol-induced liver injury that occurs in patients with little or no history of alcohol consumption. Although its etiology is unknown, it is frequently associated with obesity, type 2 diabetes mellitus, and hyperlipidemiaChronic kidney disease : Chronic kidney disease The increased coronary risk in patients with ESRD has been well described, but there is now clear evidence that mild to moderate renal dysfunction is also associated with a substantial increase in CHD risk. Practice guidelines from the National Kidney Foundation in 2002 and the American College of Cardiology/American Heart Association task force in 2004 recommended that chronic kidney disease be considered a CHD risk equivalent.Chronic kidney disease (cont.): Chronic kidney disease (cont.) The magnitude of the risk associated with renal disease was evaluated in an analysis of data from over 1 million patients in a single, large integrated health care system who had not undergone dialysis or kidney transplantation . Approximately 18 % of patients had an estimated GFR <60 . At a median follow-up of 2.8 years, there were over 51,000 deaths, 138,000 cardiovascular events, and 554,000 hospitalizations.Chronic kidney disease (cont.): Chronic kidney disease (cont.) Compared with an estimated GFR > 60 , estimated hazard ratios for any cardiovascular event for those with GFRs between 45 to 59, 30 to 44, 15 to 29 mL /min per 1.73 m2, or less than 15 mL /min per 1.73 m2 were 1.4, 2.0, 2.8, and 3.4, respectively .GFR CV outcomes: GFR CV outcomes In an analysis of data on over one million ambulatory adults, a lower estimated glomerular filtration rate (GFR) was associated with a higher incidence of various cardiovascular outcomes. In panel A, GFR is correlated with all-cause mortality. In panel B, GFR is correlated with cardiovascular events (defined as hospitalization for coronary heart disease, heart failure, ischemic stroke, and peripheral arterial disease). In panel C, GFR is correlated with hospitalization. The rate of events in each panel is standardized for age. Reproduced with permission from: Go, AS, Chertow , GM, Fan, D, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351:1296.Lifestyle factors: Lifestyle factors A diet rich in calories, saturated fat, and cholesterol contributes to other risk factors that predispose to coronary heart disease . Weight gain promotes the major cardiovascular risk factors and weight loss improves them.Exercise: Exercise Exercise of even moderate degree has a protective effect against coronary heart disease and all-cause mortality. In a retrospective study, for example, men who engaged in moderately vigorous sports activity had a 23 % lower risk of death than those who were less active. In the worldwide INTERHEART study of patients from 52 countries, lack of regular physical activity accounted for 12 % of the population-attributable risk of a first MI.Exercise (cont.) : Exercise (cont.) In addition to the amount of exercise, 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 and cardiovascular mortality.Exercise (cont.) : Exercise (cont.) The importance of fitness was illustrated in a prospective study of 6213 men referred for exercise testing who were followed for a mean of 6.2 years . After adjustment for age, peak exercise capacity, measured in metabolic equivalents (METs), was a stronger predictor of mortality than other established cardiovascular risk factors among men with and without cardiovascular disease. For each one MET increase in exercise capacity, there was a 12 %improvement in survival .Cigarette smoking: Cigarette smoking The risk of MI increases with tobacco consumption in both men and women and is higher in inhalers compared to noninhalers . On the other hand, the risk of recurrent infarction in a study of smokers who had an MI fell by 50 % 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.Diet: Diet There is growing evidence suggesting that fruit and vegetable consumption is inversely related to the risk of coronary heart disease (CHD) and stroke. In a meta-analysis of seven prospective cohort that included over 230,000 men and women, the risk of stroke was reduced by 11 percent for each additional daily portion of fruit; there was no such effect with vegetable intake .Diet (cont.): Diet (cont.) On the other hand, the worldwide INTERHEART study of patients from 52 countries found that lack of daily consumption of fruits and vegetables accounted for 14 percent of the population-attributable risk of a first MI.Diet (cont.): Diet (cont.) High fiber intake is also associated with a reduction in the risk of CHD and stroke compared to low intake. In two studies of male and female health professionals, a 10 g increase in total daily dietary fiber intake was associated with a relative risk for MI of 0.81Psychosocial factors : 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.Estrogen deficiency: Estrogen deficiency The incidence of CHD increases in women after menopause, an effect that was thought to be secondary to hypoestrogenemia . A number of observational studies suggested that hormone replacement therapy (also called menopausal hormone therapy) may have a cardioprotective effect. However, these findings were not confirmed in the Women's Health Initiative, mostly of primary prevention, and the HERS trials of secondary prevention . Estrogen-progestin replacement had no cardioprotective effect and may have produced harm .HRT and CHD HERS II: HRT and CHD HERS II Data from the HERS-II trial on the incidence of coronary heart disease events (death or nonfatal myocardial infarction) in 2763 postmenopausal women with a prior history of myocardial infarction or interventional procedure who were treated with combined hormone replacement therapy of placebo. There was no difference between the two groups. The curves are truncated at year seven when less than half of the cohort remained in follow-up. Data from Grady, D, Herrington, D, Bittner, V, et al, JAMA 2002; 288:49.C-reactive protein : C-reactive protein The baseline level of inflammation, as assessed by the plasma concentration of C-reactive protein (CRP), predicts the long-term risk of a first MI , ischemic stroke, or peripheral artery disease . Measurement of CRP levels improves risk stratification. A statement from the Centers for Disease Control and Prevention and the American Heart Association published in 2003 concluded that, in patients at intermediate risk for CHD, serum hs -CRP may, at the discretion of the physician, help direct further evaluation and therapy for primary prevention .CRP risk future MI: CRP risk future MI In apparently healthy men (left panel) and women (right panel), the adjusted relative risk of future myocardial infarction is associated with increasing quintiles of high sensitivity C-reactive protein ( hs -CRP). Risk estimates are adjusted for age, smoking status, body mass index (kg/m2), diabetes, history of hyperlipidemia , history of hypertension, exercise level, and family history of coronary disease. Data from Ridker , PM, Circulation 2001; 103:1813.Microalbuminuria: Microalbuminuria Microalbuminuria reflects vascular damage and appears to be a marker of early arterial disease. A number of studies have shown that microalbuminuria is an important risk factor for cardiovascular disease and early cardiovascular mortality.Mediastinal radiation : Mediastinal radiation Exposure to mediastinal radiation during treatment for malignancy has been linked to subsequent development of cardiac disease, including pericardial disease, valvular disease, cardiomyopathy , and coronary heart disease (CHD) manifesting as either angina or MI. CHD following mediastinal radiation tends to involve the ostia of the left main and right coronary arteries.POSSIBLE RISK FACTORS FOR CHD: POSSIBLE RISK FACTORS FOR CHDLeft ventricular hypertrophy : Left ventricular hypertrophy LVH which is associated with HTN as well as with age and obesity, is a risk factor for CHD. Electrocardiographic and anatomic LVH, based upon the finding of an enlarged cardiac silhouette on a chest x-ray, each independently increased the risk of cardiovascular disease in the Framingham study. Manifestations of atherosclerosis occurred at two to three times the general population rate in persons with LVH. Echocardiographic evidence of LVH , which is more sensitive than the ECG, also is predictive of cardiovascular risk.Electrocardiographic findings : Electrocardiographic findings EKG abnormalities at rest and during exercise in asymptomatic persons often indicate ischemic myocardium resulting from a compromised coronary circulation. However, these findings alone are not sufficiently predictive in individual patients.Heart rate: Heart rate Resting and peak exercise heart rate may be predictive of cardiovascular and CHD mortality . In one study of 3527 men followed for eight years, those with a resting heart rate >90 beats per minute had an adjusted relative risk of cardiovascular mortality of 2.02 compared to those with a heart rate <70 beats / minute. In another report, the relative risk of death from cardiovascular causes associated with an increment of 35 beats per minute in the peak heart rate was 2.7 (p = 0.003) for healthy men. A lower than expected peak heart rate during exercise, known as chronotropic incompetence, is also predictive of CHD and all-cause mortality.Vitamins, antioxidants and homocysteine: Vitamins, antioxidants and homocysteine Oxidation of LDL particles appears to be associated with increased risk of atherosclerosis, suggesting that antioxidant therapy may reduce the incidence of CVD. Despite this association, randomized prospective studies of vitamin E, vitamin C, and beta-carotene have shown no clear evidence of benefit. Both cross-sectional and prospective studies have linked elevated levels of homocysteine to increased risk for CHD.Vitamins, antioxidants and homocysteine (cont.): Vitamins, antioxidants and homocysteine (cont.) Higher serum homocysteine concentrations are frequently accompanied by reduced levels and intake of folate and vitamin B12. However, numerous prospective randomized trials of folate supplementation to lower serum homocysteine have demonstrated no reduction in major cardiovascular outcomes ( eg , death, myocardial infarction, stroke).Hyperuricemia: Hyperuricemia Large epidemiologic studies have shown that hyperuricemia is associated with an increased incidence of CHD and increased mortality in those with and without preexisting CHD . Proposed mechanisms for such an increase in risk include the development of hypertension and oxidative stress . It is unclear if hyperuricemia has a causal effect or, as has been more often suggested, is simply a marker for other risk factors, such as hypertension, dyslipidemia , and diabetes . Hyperuricemia has also been identified as a risk factor for mortality in patients with HF, where it may be a reflection of decreased tissue perfusion.Arterial stiffness: Arterial stiffness Measured as the aortic pulse wave velocity (PWV) between the carotid and femoral arteries, is a predictor of cardiovascular events. This was demonstrated in a meta-analysis of 17 studies that included over 15,000 patients in whom aortic PWV had been correlated to clinical outcome. The pooled relative risks for total cardiovascular events, cardiovascular mortality, and all-cause mortality were significantly increased comparing high versus low aortic PWV groups: 2.26 (95% CI 1.89-2.70), 2.02 (95% CI 1.68-2.42) and 1.90 (95% CI 1.61-2.24) respectively.Collagen vascular disease : Collagen vascular disease Patients with collagen vascular disease, especially those with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), have a significantly increased incidence of cardiovascular disease (CVD). In the Nurses' Health Study, those with RA for more than 10 years, compared to those without RA, had an increased risk of CVD (RR 3.1, CI 1.64-5.87). An even higher relative risk has been demonstrated for patients with SLE, especially among young women.PowerPoint Presentation: Aortic arch/abdominal aorta calcification Coronary artery calcification Serum phosphate Retinal vessel caliber Markers of inflammation Coagulation factors BNP and N-terminal pro-BNPPowerPoint Presentation: Iron overload Mercury Small for gestational age Obstructive sleep apnea Genetic markersRisk factors coronary disease: Risk factors coronary disease Positive risk factors Age: male ≥45, female ≥55 or premature menopause without estrogen replacement therapy Family history of premature coronary heart disease: definite myocardial infarction or sudden death before age 55 years in male first-degree relative and before age 65 in female first-degree relative Current cigarette smoking Hypertension: blood pressure >140/90 mmHg, or an antihypertensive medication HDL cholesterol <40 mg/ dL (1.03 mmol /L)* Negative risk factors• HDL cholesterol ≥ 60 mg/ dL (1.55 mmol /L) Status based on presence of risk ractors other than low-density lipoprotein cholesterol * Confirmed by measurements on several occasions. If the HDL cholesterol level is >60 mg/ dL , subtract one risk factor. Data from Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285:2486.POTENTIAL BENEFITS OF RISK FACTOR MODIFICATION: POTENTIAL BENEFITS OF RISK FACTOR MODIFICATION The importance of identifying people at risk is that many of the important risk factors for CVD are modifiable by specific preventive measures. In the worldwide INTERHEART study of patients from 52 countries, nine potentially modifiable factors accounted for over 90 percent of the population-attributable risk of a first MI . These included smoking, dyslipidemia , hypertension, diabetes, abdominal obesity, psychosocial factors, daily consumption of fruits and vegetables, regular alcohol consumption, and regular physical activity.Thank You: Thank You You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.