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Comprehensive cardiovascular risk management--what does it mean in practice?

Erhardt L, Moller R, Puig JG - Vasc Health Risk Manag (2007)

Bottom Line: A thorough understanding of the multifactorial nature of CVD is essential to its effective management.In addition to improvements in the "high-risk" strategy, which forms the basis of current CVD management, an increase in the utilization of population-based management strategies needs to be made to attempt to reduce the number of patients falling within the "at-risk" stratum for CVD.This review outlines how a comprehensive approach to CVD management might be achieved.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, University of Lund, Malmö University Hospital, Sweden. Leif.Erhardt@med.lu.se

ABSTRACT
The continued movement away from the treatment of individual cardiovascular (CV) risk factors to managing overall and lifetime CV risk is likely to have a significant impact on slowing the rate of increase in cardiovascular disease (CVD). However, the management of CVD is currently far from optimal even in parts of the world with well-developed and well-funded healthcare systems. Effective implementation of the knowledge, treatment guidelines, diagnostic tools, therapeutic interventions, and management programs that exist for CVD continues to evade us. A thorough understanding of the multifactorial nature of CVD is essential to its effective management. Improvements continue to be made to management guidelines, risk assessment tools, treatments, and care programs pertaining to CVD. Ultimately, however, preventing the epidemic of CVD will require a combination of both medical and public health approaches. In addition to improvements in the "high-risk" strategy, which forms the basis of current CVD management, an increase in the utilization of population-based management strategies needs to be made to attempt to reduce the number of patients falling within the "at-risk" stratum for CVD. This review outlines how a comprehensive approach to CVD management might be achieved.

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Related in: MedlinePlus

The additive effect of cholesterol and systolic blood pressure on the risk of coronary heart disease death. Reproduced with permission from Neaton JD, Wentworth D. 1992. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med, 152:56–64. Copyright © 1992. American Medical Association. All rights reserved.
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fig4: The additive effect of cholesterol and systolic blood pressure on the risk of coronary heart disease death. Reproduced with permission from Neaton JD, Wentworth D. 1992. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med, 152:56–64. Copyright © 1992. American Medical Association. All rights reserved.

Mentions: Another important finding is that the increased risk of CVD resulting from multiple risk factors is frequently greater than simply additive (Neaton and Wentworth 1992; Thomas et al 2002). Using data from the Multiple Risk Factor Intervention Trial (MRFIT), Neaton and colleagues examined the interaction between TC levels, systolic BP, smoking, and CHD death rates (Neaton and Wentworth 1992). Figure 4 illustrates the strong, graded relationship between increasing TC levels and CHD death across systolic BP levels, and the similarly strong relationship between increasing systolic BP and CHD death across TC levels. When risk factors were analyzed together, patients in both the highest TC and the highest systolic BP quintiles had an approximately 11-fold greater risk of CHD death than patients who were in both the lowest TC and lowest systolic BP quintiles (Neaton and Wentworth 1992). Similarly, Liao et al studied a cohort of more than 15,800 Americans and found that the incidence rate of CVD events observed in patients with hypertension and elevated LDL-C was 51 per 10,000 person years (Liao et al 2004). This was significantly larger than the sum of the incidence rates expected due to either condition alone (28 per 10,000 person years). The excess risk of 31% indicates synergism between these two risk factors. Pathophysiology studies have provided potential mechanisms by which hypertension and dyslipidemia might synergistically accelerate atherosclerosis, including increased endothelial permeability (Meyer et al 1996), increased intimal retention of atherogenic lipoproteins (Rakugi et al 1996), exacerbation of inflammation (Barter 2005; Bautista et al 2005), and increased free radical production (Rodriguez-Porcel et al 2003); all of which may contribute to endothelial dysfunction (Bonetti et al 2003).


Comprehensive cardiovascular risk management--what does it mean in practice?

Erhardt L, Moller R, Puig JG - Vasc Health Risk Manag (2007)

The additive effect of cholesterol and systolic blood pressure on the risk of coronary heart disease death. Reproduced with permission from Neaton JD, Wentworth D. 1992. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med, 152:56–64. Copyright © 1992. American Medical Association. All rights reserved.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2291303&req=5

fig4: The additive effect of cholesterol and systolic blood pressure on the risk of coronary heart disease death. Reproduced with permission from Neaton JD, Wentworth D. 1992. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med, 152:56–64. Copyright © 1992. American Medical Association. All rights reserved.
Mentions: Another important finding is that the increased risk of CVD resulting from multiple risk factors is frequently greater than simply additive (Neaton and Wentworth 1992; Thomas et al 2002). Using data from the Multiple Risk Factor Intervention Trial (MRFIT), Neaton and colleagues examined the interaction between TC levels, systolic BP, smoking, and CHD death rates (Neaton and Wentworth 1992). Figure 4 illustrates the strong, graded relationship between increasing TC levels and CHD death across systolic BP levels, and the similarly strong relationship between increasing systolic BP and CHD death across TC levels. When risk factors were analyzed together, patients in both the highest TC and the highest systolic BP quintiles had an approximately 11-fold greater risk of CHD death than patients who were in both the lowest TC and lowest systolic BP quintiles (Neaton and Wentworth 1992). Similarly, Liao et al studied a cohort of more than 15,800 Americans and found that the incidence rate of CVD events observed in patients with hypertension and elevated LDL-C was 51 per 10,000 person years (Liao et al 2004). This was significantly larger than the sum of the incidence rates expected due to either condition alone (28 per 10,000 person years). The excess risk of 31% indicates synergism between these two risk factors. Pathophysiology studies have provided potential mechanisms by which hypertension and dyslipidemia might synergistically accelerate atherosclerosis, including increased endothelial permeability (Meyer et al 1996), increased intimal retention of atherogenic lipoproteins (Rakugi et al 1996), exacerbation of inflammation (Barter 2005; Bautista et al 2005), and increased free radical production (Rodriguez-Porcel et al 2003); all of which may contribute to endothelial dysfunction (Bonetti et al 2003).

Bottom Line: A thorough understanding of the multifactorial nature of CVD is essential to its effective management.In addition to improvements in the "high-risk" strategy, which forms the basis of current CVD management, an increase in the utilization of population-based management strategies needs to be made to attempt to reduce the number of patients falling within the "at-risk" stratum for CVD.This review outlines how a comprehensive approach to CVD management might be achieved.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, University of Lund, Malmö University Hospital, Sweden. Leif.Erhardt@med.lu.se

ABSTRACT
The continued movement away from the treatment of individual cardiovascular (CV) risk factors to managing overall and lifetime CV risk is likely to have a significant impact on slowing the rate of increase in cardiovascular disease (CVD). However, the management of CVD is currently far from optimal even in parts of the world with well-developed and well-funded healthcare systems. Effective implementation of the knowledge, treatment guidelines, diagnostic tools, therapeutic interventions, and management programs that exist for CVD continues to evade us. A thorough understanding of the multifactorial nature of CVD is essential to its effective management. Improvements continue to be made to management guidelines, risk assessment tools, treatments, and care programs pertaining to CVD. Ultimately, however, preventing the epidemic of CVD will require a combination of both medical and public health approaches. In addition to improvements in the "high-risk" strategy, which forms the basis of current CVD management, an increase in the utilization of population-based management strategies needs to be made to attempt to reduce the number of patients falling within the "at-risk" stratum for CVD. This review outlines how a comprehensive approach to CVD management might be achieved.

Show MeSH
Related in: MedlinePlus