Transcript 5161-5171

Cardiovascular Risk Factor
Overview and Management
Nathan D. Wong, PhD, FACC
Associate Professor and Director,
Heart Disease Prevention Program,
University of California, Irvine
Cardiovascular Disease: The Leading
Cause of Death in US Women in 1995
Heart disease
375
Cerebrovascular disease
96.4
Lung cancer
60.6
COPD*
48.9
Pneumonia/Influenza
45.1
Breast cancer
43.8
Accidents
31.9
Diabetes
33.1
Ovarian cancer
9.9
0
50
100 150 200 250 300 350 400
Deaths (1,000)
*COPD=chronic obstructive pulmonary disease.
Adapted from Anderson RN et al. Monthly Vital Statistics Report.
Vol 45(suppl 2):June 12, 1997.
CHD in the United States
• CHD is the single largest killer of men and women
• ~13.9 million have history of MI and/or angina
• Each year 1.1 million people have MI
– 370,000 die of MI, 250,000 die within 1 hr
• By age 60, every 5th man and 17th woman develops CHD
• 1998 estimated direct and indirect costs of heart disease are
$95.6 billion
• 53.3 million adults have elevated LDL-C and warrant
intervention (1994 NHANES data)
– 22.3 million qualify for drug therapy, 5.5 million receive therapy
AHA. 1998 Heart and Stroke Statistical Update; 1997.
National Center for Health Statistics. National Health and Nutrition
Examination Survey (III); 1994. (Data collected 1991-1994.)
CVD Mortality Trends for Males and
Females*
520
500
480
Deaths in
460
thousands
440
420
20
0
1979 81
83
85
87 89
Years
Males
*United States: 1979-1996 mortality.
AHA. 1999 Heart and Stroke Statistical Update; 1998.
91
93
Females
95 1996
PDAY: Percentage of Right Coronary Artery Intimal
Surface Affected With Early Atherosclerosis
30
Intimal
surface
(%)
Men
Raised lesions
Fatty streaks
30
20
20
10
10
0
30
0
15-19 20-24 25-29 30-34
White
30
20
20
10
10
0
0
15-19 20-24 25-29 30-34
Black
Women
15-19 20-24 25-29 30-34
White
15-1920-2425-2930-34
Black
Age (y)
PDAY= Pathobiological Determinants of Atherosclerosis in Youth.
Strong JP, et al. JAMA. 1999;281:727-735.
Beyond Cholesterol: Predicting Cardiovascular
Risk In the 21st Century
Cardiovascular Risk
Lipids
HTN
Diabetes
Behavioral
Hemostatic
Inflammatory Genetic
Thrombotic
Continuum of Patients at Risk for a
CHD Event
Secondary
Prevention
Post MI/Angina
Other Atherosclerotic
Manifestations
Primary
Prevention
Subclinical
Atherosclerosis
Multiple Risk
Factors
Low Risk
Courtesy of CD Furberg.
Total Cholesterol Distribution:
CHD vs Non-CHD Population
Framingham Heart Study—26-Year Follow-up
No CHD
35% of CHD
Occurs in
People with
TC<200 mg/dL
CHD
150
200
250
300
Total Cholesterol (mg/dL)
Castelli WP. Atherosclerosis. 1996;124(suppl):S1-S9.
1996 Reprinted with permission from Elsevier Science.
14-y incidence
rates (%) for CHD
Low HDL-C Levels Increase CHD Risk Even
When Total-C Is Normal (Framingham)
14
12
10
8
6
4
2
0
< 40 40–49 50–59  60
HDL-C (mg/dL)
 260
230–259
200–229
< 200
Risk of CHD by HDL-C and Total-C levels; aged 48–83 y
Castelli WP et al. JAMA 1986;256:2835–2838
% change in risk per 1 mg/dL
increment in HDL-C
CHD Incidence Related to HDL-C
Levels in Various Trials
CHD incidence
Men
Women
0
-2
-4
-6
-8
-10
FHS
CPPT
LRCF
MRFIT
FHS
LRCF
95% confidence intervals (CIs) for adjusted
proportional hazards regression coefficients.
Gordon DJ et al. Circulation 1989;79:8–15
Clinical Benefits of Cholesterol Reduction
• A recent meta-analysis of 38 trials demonstrated
that for every 10% reduction in TC
– CHD mortality decreased by 15% (P<0.001)
– total mortality decreased by 11% (P<0.001)
• Decreases were similar for all treatment modalities
• Cholesterol reduction did not increase non-CHD
mortality
Gould AL et al. Circulation. 1998;97:946-952.
Major CHD Risk Factors Other Than
LDL-C According to NCEP ATP-III
Positive risk factors
Negative risk factor
• Age
• High HDL-C: 60
– male 45
mg/dL
– female 55
• Family Hx of CHD: 1st-degree relative
with MI or sudden cardiac death male relative: <age 55
– female relative: <age 65
• Current cigarette smoking
• Hypertension: BP 140/90 mm Hg or
on antihypertensive meds
• Low HDL-C: <40 mg/dL
• Diabetes IS A CHD QUIVALENT
IDENTIFYING PT AS HIGH RISK
Other Recognized Risk Factors
• Obesity: traditionally determined by body
mass index >30 kg/m2 with overweighted
defined as 25-<30 kg/m 2.
• Abdominal obesity involves waist
circumference >40 in. in men, >35 in. in
women
• Physical inactivity: various definitions
JNC VI: Risk Stratification and Treatment*
Group A
Uncomplicated HTN
Group B
HTN w/Risk Factors
Diabetes
High-normal
therapy‡
(130-139/85-89)
Lifestyle
Lifestyle
modification
modification
Stage 1
therapy
(140-159/90-99)
Lifestyle
Lifestyle
modification
(up to 12 mo)
modification†
(up to 6 mo)
Stages 2 and 3
therapy
(160/ 100)
Drug therapy
Drug therapy
JNC VI. November 1997:chapter 2. NIH publication 98-4080.
Group C
TOD/ CCD/
Drug
Drug
Drug
Probability of Death From CHD in Patients
With NIDDM and in Nondiabetic Patients,
With and Without Prior MI
100
Survival (%)
80
60
40
Nondiabetic subjects without prior MI
Diabetic subjects without prior MI
Nondiabetic subjects with prior MI
Diabetic subjects with prior MI
20
0
0
1
2
3
4 5
Years
6
7
Kaplan-Meier estimates
Haffner SM et al. N Engl J Med 1998;339:229–234
8
Definitions of Diabetes and
Impaired Fasting Glucose
• New ADA definition (1998) defines fasting
blood sugar of > 126 mg/dl as diabetes,
casual blood glucose > 200 mg/dl.
Impaired fasting glucose is 110-125 mg/dl
• Diabetic control generally defined as
HgbA1c <8%.
• BP recommended <130/80 mmHg, LDL-C
goal <100 mg/dl
Secondary CHD Prevention in Women:
Results from the CARE Trial
• CARE was a secondary prevention trial of
pravastatin versus placebo treatment in 4159 men
and women with average lipid levels over 5 years
• 576 post-menopausal women were randomized;
average age 61; 10% on HRT
• Average baseline lipids: TC 215 mg/dL, LDL-C
140 mg/dL, HDL 45 mg/dL
• 5 year treatment results: 46% reduction in all
coronary events, 48% reduction in PTCA, 40%
reduction in CABG, 56% reduction in stroke
JACC 1998;32:140-146
Heart and Estrogen/Progestin Replacement
Study (HERS): Secondary Prevention of CHD
in Women
• Randomized, placebo-controlled trial of E/P
therapy vs. placebo in 2763 women with CHD;
average age 67 years
• Treatment was 0.625 mg CEE + 2.5 mg
medroxyprogesterone daily for 4 years
• Primary endpoint: nonfatal MI and CHD death
• Secondary endpoints: CABG, PTCA, unstable
angina, CHF, PVD, TIA
JAMA 1998;280:605-613
HERS Results
• Non-fatal MI
CHD death
• End of Year 1
years
HRT 116
Placebo 129
HRT 71
Placebo 58
CHD events (HRT) 42.5/1000 womenCHD events (Plac) 28/1000 women-
years
• Year 4-5:
years
CHD events (HRT) 23/1000 womenCHD events (Plac) 34.3/1000 women-
years
• DVT/PE
Cholelithiasis
JAMA 1998;280:605-613
HRT 6.3 vs. Plac 2.2
HRT 84 vs. Plac 62
HERS Results
• No statistically significant difference between HRT
and placebo in both primary and secondary endpoints after
4 years.
• Within first year, greater incidence in CHD events in HRT
group. In years 3 and 4, lower CHD events in
HRT group compared to placebo.
• HRT lowered LDL 11% and increased HDL 10%
compared to placebo.
• Approximately 50% of randomized women were on lipidlowering drugs.
• Higher incidence of VTE and cholelithiasis in HRT group.
JAMA 1998;280:605-613
Is there clinical evidence that
inflammatory markers predict future
coronary events and provide additional
predictive information beyond traditional
risk factors?
hs-CRP and Risk of Future MI in Apparently
Healthy Men
P Trend
<0.001
3
Relative Risk of MI
P<
0.001
2
P<
0.001
P = 0.03
1
0
1
<0.055
2
3
4
0.056–
0.115–
>0.211
0.114
0.210
Quartile of hs-CRP (range, mg/dL)
Ridker PM et al. N Engl J Med 1997;336:973-979.
hs-CRP and Risk of Future Cardiovascular
Events in Apparently Healthy Women
P Trend
<0.002
7
Any Event
5
MI or Stroke
4
3
2
Relative Risk
6
1
0
1
<0.15
2
3
4
0.15–0.37 0.37–0.73
>0.73
Quartile of hs-CRP (range, mg/dL)
Ridker PM et al. Circulation 1998;98:731-733.
Lp(a) in Atherogenesis: Another Culprit?
• Identical to LDL particle except for addition of apo(a)
• Plasma concentration predictive of atherosclerotic
disease in many epidemiologic studies, although
not all
• Accumulates in atherosclerotic plaque
• Binds apo B-containing lipoproteins and proteoglycans
• Taken up by foam cell precursors
• May interfere with thrombolysis
Lp(a): An Independent CHD Risk Factor in
Men of the Framingham Offspring Cohort
10
5
2
RR
2.7
1.9
1.8
1.8
1.2
1
0.5
Lp(a)
C HT
TC
GI
HDLSmoking
0.2
0.1
RR=relative risk; HT=hypertension; GI=glucose intolerance.
3.6
Homocysteine: Role in Atherogenesis
• Linked to pathophysiology of arteriosclerosis in 1969
• CVD patients have elevated levels of plasma
homocysteine
• May cause vascular damage to intimal cells
• Elevated levels linked to:
– genetic defects
– exposure to toxins
– diet
• Increased dietary intake of folate and vitamin B6 may
reduce CVD morbidity and mortality
Adult Population Not Reaching LDL-C
Targets
100
80
NHANES III
L-TAP
82.5
82
63
% not at
LDL-C
targets
60
54.6
40
20
0
2 RF
CHD
Risk profile
LDL-C target levels (mg/dL)
2 RF: <130
CHD: 100
ATP III: New Features of Guidelines—
Focus on Multiple Risk Factors
• Persons with diabetes without CHD raised to
level of CHD risk equivalent
• Framingham 10-year absolute CHD risk
projections used to identify certain patients with
2 risk factors for more intensive treatment
• Persons with multiple metabolic risk factors (the
metabolic syndrome) identified as candidates for
intensified therapeutic lifestyle changes (TLC)
ATP III: New Features of Guidelines—
Updated Lipid/Lipoprotein Classifications
• Optimal LDL-C level: identified as <100 mg/dL
• Categorical low HDL-C: raised to <40 mg/dL to more
accurately define patients at increased risk
• TG classification cutpoints: lowered to focus more
attention on moderate elevations
– normal: <150 mg/dL
– borderline high: 150–199 mg/dL
– high: 200–499 mg/dL
– very high: 500 mg/dL
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: New Features of Guidelines—
Applying the Recommendations
• Complete fasting lipoprotein profile (TC, LDL-C, HDL-C, TG)
recommended as preferred initial test
• Use of plant stanols/sterols and viscous fiber encouraged as
therapeutic dietary options to enhance LDL-C lowering
• Strategies presented to improve adherence to therapeutic
lifestyle changes (TLC), drug therapies
• Intensive TLC recommended for persons with the metabolic
syndrome
• Non–HDL-C (TC minus HDL-C) goal recommended as
secondary target for persons with high TG levels (200 mg/dL)
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: LDL-C, HDL-C, TC
Classification
LDL-C (mg/dL)
<100
100–129
130–159
160–189
190
HDL-C (mg/dL)
<40
60
TC (mg/dL)
<200
200–239
240
Optimal
Above, near optimal
Borderline high
High
Very high
Low
High
Desirable
Borderline high
High
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: Major CHD Risk Factors
Other Than LDL-C
• Cigarette smoking
• Hypertension: BP 140/90 mm Hg or on antihypertensive
medication
• Low HDL-C: 40 mg/dL*
• Family history of premature CHD (1st-degree relative):
– male relative age 55 years
– female relative age 65 years
• Age
– male 45 years
– female 55 years
*HDL-C 60 mg/dL is a negative risk factor
and negates one other risk factor.
ATP III: Additional CHD Risk Factors
•
Life-habit risk factors: targets for intervention; not used
to set lower LDL-C goal
– obesity
– physical inactivity
– atherogenic diet
Emerging risk factors: can help guide intensity of riskreduction therapy; do not categorically alter LDL-C
goals
– lipoprotein(a)
– impaired fasting glucose
– subclinical atherosclerotic
factors
– homocysteine
– prothrombotic and
proinflammatory
disease
ATP III: Assessment of Risk
For persons without known CHD, other forms
of atherosclerotic disease, or diabetes:
• Count the number of risk factors.
• Use Framingham scoring for persons with 2
risk factors* to determine the absolute 10-year
CHD risk.
*For persons with 0–1 risk factor, Framingham calculations are
not necessary.
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: Risk Categories, LDL-C
Goals
Risk Category
CHD and CHD risk equivalents
(10-year risk >20%)
2 risk factors
(10-year risk 20%)
0–1 risk factor*
LDL-C Goal (mg/dL)
<100
<130
<160
*Almost all people with 0–1 risk factor have a 10-year risk <10%;
thus, Framingham risk calculations are not necessary.
ATP III: LDL-C Treatment Cutpoints for
Therapy
Risk Category
Initiate
TLC*
Consider Drug Therapy
CHD and CHD
risk equivalents
100 mg/dL
2 risk factors
130 mg/dL 10-year risk 10%–20%: 130 mg/dL
0–1 risk factor
160 mg/dL
130 mg/dL
(100–129 mg/dL: drug optional)†
10-year risk 10%: 160 mg/dL
190 mg/dL
(160–189 mg/dL: LDL-C–lowering
drug optional)
*Therapeutic lifestyle changes
†Some authorities use LDL-C–lowering drugs if TLC does not achieve
LDL-C <100 mg/dL; others use drugs to modify HDL-C and TG.
ATP III: Nutritional Components of the TLC Diet
Nutrient
Recommended Intake
Saturated fat*
<7% of total calories
Polyunsaturated fat
Up to 10% of total calories
Monounsaturated fat
Up to 20% of total calories
Total fat
25%–35% of total calories
Carbohydrate(esp.complex carbs) 50%–60% of total calories
Fiber
20–30 g/d
Protein
~15% of total calories
Cholesterol
<200 mg/d
*Trans fatty acids also raise LDL-C and should be kept at a low intake.
Note: Regarding total calories, balance energy intake and expenditure to
maintain desirable body weight.
ATP III: Management of Very High LDL-C
• LDL-C 190 mg/dL usually traced to genetic forms
of hypercholesterolemia
• Recommended actions:
– early detection in young adults through cholesterol
screening to prevent premature CHD
– family cholesterol testing to identify affected
relatives
– combination drug therapy usually required to achieve
target LDL-C levels
ATP III: Management of Low HDL-C
• Low HDL-C: <40 mg/dL (no specific goal defined for
raising HDL-C)
• Targets of therapy:
– all persons with low HDL-C: achieve LDL-C goal;
then  weight,  physical activity (if metabolic
syndrome is present)
– those with TG 200–499 mg/dL: achieve non–HDL-C
goal* as secondary priority
– those with TG <200 mg/dL: consider drugs for raising
HDL-C (fibrates, nicotinic acid)
*Non–HDL-C goal is set at 30 mg/dL higher than LDL-C goal.
ATP III: Management of Elevated TG
Classification
TG Level (mg/dL)
Treatment Strategy
Borderline high*
150–199
 weight, physical activity
High*
200–499
 weight, physical activity,
consider drug treatment to
reach non–HDL-C goal‡
Very high†
500
Very low-fat diet,  weight,
physical activity, nicotinic
acid or fibrate
ATP III: The Metabolic Syndrome*
Risk Factor
Abdominal obesity†
(Waist circumference‡)
Men
Women
TG
HDL-C
Men
Women
Blood pressure
Fasting glucose
Defining Level
>102 cm (>40 in)
>88 cm (>35 in)
150 mg/dL
<40 mg/dL
<50 mg/dL
130/85 mm Hg
110 mg/dL
ATP III: Management of Diabetic
Dyslipidemia
• Primary target of therapy: identification of LDL-C; goal
for persons with diabetes: <100 mg/dL
• Therapeutic options:
– LDL-C 100–129 mg/dL: increase intensity of TLC; add
drug to modify atherogenic dyslipidemia (fibrate or
nicotinic acid); intensify risk factor control
– LDL-C 130 mg/dL: simultaneously initiate TLC and
LDL-C–lowering drugs
• TG 200 mg/dL: non–HDL-C* becomes secondary target
ATP III: LDL-C Measurements in Patients
Hospitalized for Major Coronary Events
• Measure LDL-C on admission or within 24 hours
• General recommendations at discharge:
– LDL-C 130 mg/dL: discharge on drug therapy
– LDL-C 100–129 mg/dL: use clinical judgment*
• Advantages of initiating drug therapy at discharge:
– motivates patients to begin/continue risk-lowering
therapy
– emphasizes consistency and continuous follow-up;
no “treatment gap”
– may reduce early clinical events
ATP III Framingham Risk Scoring
Step 1: Age
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Assessing CHD Risk in Men
Step 4: Systolic Blood Pressure
Points
-9
-4
0
3
6
8
10
11
12
13
Systolic BP
(mm Hg)
<120
120-129
130-139
140-159
160
Points
Points
if Untreated if Treated
0
0
0
1
1
2
1
2
2
3
HDL-C
(mg/dL)
60
Points
-1
50-59
0
40-49
1
<40
2
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 7: CHD Risk
Step 2: Total Cholesterol
TC
Points at
at Points at
(mg/dL)
Age 20-39
70-79
<160
0
160-199
4
200-239
7
240-279
9
280
11
Step 3: HDL-Cholesterol
Step 6: Adding Up the Points
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
3
5
6
8
0
2
3
4
5
0
1
1
2
3
0
0
0
1
1
Step 5: Smoking Status
at
70-79
Nonsmoker
Smoker
Points at
Points at
Age 20-39
0
8
Points at
Point Total 10-Year Risk
Risk
<0
<1%
0
1%
1
1%
2
1%
3
1%
4
1%
5
2%
6
2%
7
3%
8
4%
9
5%
10
6%
Points at
Point Total 10-Year
11
12
13
14
15
16
17
8%
10%
12%
16%
20%
25%
30%
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
5
Note: Risk estimates were derived from the experience of the Framingham Heart Study,
a predominantly Caucasian population in Massachusetts, USA.
0
3
0
0
1 2001,
1
©
Professional
Postgraduate Services®
www.lipidhealth.org
ATP III Framingham Risk Scoring
Assessing CHD Risk in Women
Step 1: Age
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Step 4: Systolic Blood Pressure
Points
-7
-3
0
3
6
8
10
12
14
16
Systolic BP
(mm Hg)
<120
120-129
130-139
140-159
160
Points
Points
if Untreated if Treated
0
0
1
3
2
4
3
5
4
6
50-59
0
40-49
1
<40
2
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 7: CHD Risk
Step 2: Total Cholesterol
TC
Points at
at Points at
(mg/dL)
Age 20-39
70-79
<160
0
160-199
4
200-239
8
240-279
11
Step 3: HDL-Cholesterol
280
13
HDL-C
(mg/dL)
Points
60
-1
Step 6: Adding Up the Points
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
3
6
8
10
0
2
4
5
7
0
1
2
3
4
0
1
1
2
2
Step 5: Smoking Status
at
70-79
Nonsmoker
Smoker
Points at
Points at
Age 20-39
0
Points at
Point Total 10-Year Risk
Risk
<9
<1%
9
1%
10
1%
11
1%
12
1%
13
2%
14
2%
15
3%
16
4%
17
5%
18
6%
19
8%
Points at
Point Total 10-Year
20
21
22
23
24
25
11%
14%
17%
22%
27%
30%
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
0
0
0
Note: Risk estimates were derived
from
the
of the
9
7
4 experience
2
1
Framingham Heart Study, a predominantly Caucasian population
in Massachusetts, USA.
ATP III Framingham Risk Scoring
Step 1: Age
Women
Men
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
-9
-4
0
3
6
8
10
11
12
13
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
-7
-3
0
3
6
8
10
12
14
16
ATP III Framingham Risk Scoring
Step 2: Total Cholesterol
Men
TC
(mg/dL)
Points at
Age 20-39
Points at
Age 40-49
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
<160
160-199
200-239
240-279
280
0
4
7
9
11
0
3
5
6
8
0
2
3
4
5
0
1
1
2
3
0
0
0
1
1
Women
TC
(mg/dL)
Points at
Age 20-39
Points at
Age 40-49
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
<160
160-199
200-239
240-279
280
0
4
8
11
13
0
3
6
8
10
0
2
4
5
7
0
1
2
3
4
0
1
1
2
2
Note: TC and HDL-C values should be the average of at least two fasting
lipoprotein measurements.
ATP III Framingham Risk Scoring
Step 3: HDL-Cholesterol
Women
Men
HDL-C
(mg/dL)
Points
60
HDL-C
(mg/dL)
Points
-1
60
-1
50-59
0
50-59
0
40-49
1
40-49
1
<40
2
<40
2
Note: HDL-C and TC values should be the average of at least two
fasting lipoprotein measurements.
ATP III Framingham Risk Scoring
Step 4: Systolic Blood Pressure
Men
Systolic BP Points
Points
(mm Hg)if Untreatedif Treated
<120
0
0
120-129
0
1
130-139
1
2
140-159
1
2
160
2
3
Women
Systolic BP
Points
(mm Hg) if Untreated
<120
120-129
130-139
140-159
160
0
1
2
3
4
Points
if Treated
0
3
4
5
6
ATP III Framingham Risk Scoring
Men
Step 5: Smoking Status
Points at
Points at
Age 20-39 Age 40-49
Nonsmoker
Smoker
0
8
0
5
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
0
3
0
1
0
1
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
0
4
0
2
0
1
Women
Points at
Points at
Age 20-39 Age 40-49
Nonsmoker
Smoker
0
9
0
7
Note: Any cigarette smoking in the past month.
ATP III Framingham Risk Scoring
Step 6: Adding Up the Points
(Sum From Steps 1–5)
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services®
ATP III Framingham Risk Scoring
Step 7: CHD Risk for Men
Point Total
10-Year Risk
Point Total
10-Year Risk
<0
0
1
2
3
4
5
6
7
8
9
10
<1%
1%
1%
1%
1%
1%
2%
2%
3%
4%
5%
6%
11
12
13
14
15
16
17
8%
10%
12%
16%
20%
25%
30%
ATP III Framingham Risk Scoring
Step 7: CHD Risk for Women
Point Total
10-Year Risk
Point Total
10-Year Risk
<9
9
10
11
12
13
14
15
16
17
18
19
<1%
1%
1%
1%
1%
2%
2%
3%
4%
5%
6%
8%
20
21
22
23
24
25
11%
14%
17%
22%
27%
30%
Note: Determine the 10-year absolute risk for hard CHD
(MI and coronary death) from point total.
Case History #1
• 46 y.o. man with type II diabetes, blood
pressure, pressure 138/76, total cholesterol
195
• What other medical history information is
needed?
• What other laboratory tests do you order?
• What are risk factor goals and
recommended treatments?
Case History #2
• 50 y.o. female with past history of
myocardial infarction, blood pressure
140/88, total cholesterol 190, HDLcholesterol 35 from 6 mos ago.
• What other medical history would be
helpful, what other lab tests do you order?
• What are risk factor goal levels, treatments
needed or recommended?
Review Questions (Developed by the
Supercourse team)
•
Why has the mortality trends declined
more for men then women?
•What type of cholesterol level is
protective? What determines those levels?
•What is the impact of estrogen on lipids
and MI?
•Calculate your own risk score