Cardiovascular Risk Overview

This past year the American College of Cardiology, the American Heart Association and the National Heart Lung and Blood Institute released guidelines dealing with prevention of cardiovascular disease, and for managing lifestyle choices, cholesterol and weight. Prevention of heart attack and stroke is the overall goal.

These guidelines include a calculator (available as an app on a smartphone) developed to estimate an individual’s risk of a heart attack or stroke over the next 10 years. Also, lifetime risk for those less than 59 years old can also be calculated. The calculator uses age, sex, race, total and HDL cholesterol, blood pressure treatment, diabetes and smoking to determine risk, and will allow the physician better identify people who will benefit from lifestyle changes and medical therapies.

          Lifestyle management emphasizes the importance of a healthy diet and exercise regimen. Three major recommendations are made:

Eat a diet rich in fruit, vegetables, whole grains, fish, low fat dairy, lean poultry, nuts,legumes and nontropical vegetable oils consistent with the American Heart Association, USDA, DASH and Mediterranean diets. Web sites for these diets provide recipes and other details.

Avoid saturated and trans- fats, sweets, sugar sweetened beverages and excess sodium intake especially in processed foods. Consume no more than 2400 mg/day of sodium, and further reduction to 1500 mg/day is desirable.

Engage in aerobic physical activity of moderate to vigorous intensity lasting 40 minutes per session three to four times a week.

Measurements of body mass index (BMI - ratio of weight in kilograms to body surface area) and waist circumference are used to identify overweight people (BMI 25 to 30, waist circumference of 40 inches for men and 35 inches for women), and obesity (BMI over 30). Weight loss should be encouraged in those with a BMI over 25 and one additional risk factor. As little as 2-5% weight loss can achieve meaningful health improvement, although 5-10% is encouraged. Structured weight loss behavioral programs for patients have the best results, but no particular diet was found to be superior to the others. There is a place for bariatric surgery for those with a BMI greater than 35 and one additional risk factor, or a BMI of 40 or more.

Treatment of blood cholesterol to reduce the risk of heart attack and stroke emphasizes the intensity of treatment for a particular patient instead of targeting a specific LDL cholesterol number. Statin therapy rather than other cholesterol lowering drugs are considered the best. Four groups of patients are felt to benefit from statin therapy:

Those with a history of coronary or vascular disease.

Those with an LDL cholesterol level of 190 mg/dl or more

Patients with diabetes who are aged 40-75 with no known cardiovascular disease and LDL cholesterol level of greater than 70 mg/dl.

Those with a 10 year cardiovascular risk using the new calculator of 7.5% or higher and an LDL cholesterol of greater than 70mg/dl and no know cardiovascular disease.

If possible high intensity statin therapy (atorvastatin 80 mg - Lipitor, or rosuvastatin 20- 40 mg - Crestor) should be used for the first two groups to achieve at least a 50% reduction in LDL cholesterol. Moderate or high intensity statin therapy can be used for the last two groups. These new guidelines help the physician guide patients to a healthier and hopefully longer life.