International Task Force for Prevention of Coronary Heart Disease

International Task Force for Prevention of
Coronary Heart Disease

table of contents

1 Introduction

1.1 Foreword 1.2 The economic burden of CHD 1.3 Risk factors as causes of CHD
1.3.1 Future trends
1.3.2 Nutrition and CHD
1.3.3 Contribution of socioeconomic and psychosocial factors to CHD risk
1.3.3.1 Socioeconomic status
1.3.3.2 Stress
1.3.3.3 Depression
1.3.3.4 Social Support 1.4 CHD and stroke
1.4.1 Primary and secondary prevention of stroke 1.5 Strategies of prevention 1.6 The physician's contribution to CHD prevention 1.7 The concept of global risk

2 The assessment of global risk

2.1 Personal and family history 2.1.1 Age
2.1.2 Sex
2.1.3 Physical activity and diet
2.1.4 Personal history of atherosclerotic disease
2.1.5 Family history of CHD
2.1.6 Cigarette smoking 2.2 Physical examination 2.2.1 Body weight 2.2.1.1 Central obesity 2.2.2 Blood pressure
2.2.3 Clinical evidence of cardiovascular disease 2.3 Biochemical and laboratory risk factors 2.3.1 Plasma lipids and lipoproteins
2.3.2 Blood glucose
2.3.2.1 Diabetes mellitus 2.3.2.2 The metabolic syndrome 2.3.3 Thrombogenic risk factors
2.3.4 Homocysteine
2.4 Future directions 2.4.1 Parameters of inflammation 2.5 The risk review 2.5.1 Grades of increased risk 2.5.1.1 small increase in risk
2.5.1.2 moderate increase in risk
2.5.1.3 high risk 2.5.2 The Risk Calculator 2.6 Assessment of risk factors in secondary prevention 2.7 Classification and causes of hyperlipidaemia 2.8 The future of risk assessment 2.8.1 Genetic polymorphisms and abnormalities
2.8.2 Endothelial function
2.8.3 Further mechanisms currently under active investigation 2.8.3.1 Plaque instability and inflammation
2.8.3.2 Oxidized LDL
2.8.3.3 Alcohol and CHD risk 3 Management of CHD risk factors 3.1 Smoking cessation 3.2 Management of overweight and obesity 3.3 Physical exercise 3.4 Treatment of hyperlipidaemia 3.4.1 Introduction
3.4.2 Target levels for lipid-lowering therapy
3.4.3 The cholesterol-lowering diet 3.4.3.1 Special recommendations for hypertriglyceridaemia 3.4.4 Calorie-restricted lipid-lowering diet 3.4.4.1 Recommended foods
3.4.4.2 Foods permitted in controlled quantities 3.4.5 Avoidance of drugs that can cause hyperlipidaemia
3.4.6 Drug treatment of hyperlipidaemia 3.4.6.1 HMG CoA reductase inhibitors (statins)
3.4.6.2 Bile acid sequestrants (resins)
3.4.6.3 Fibric acid derivatives (fibrates)
3.4.6.4 Nicotinic acid
3.4.6.5 Fish oil 3.5 Management of hypertension 3.5.1 Goal for blood pressure reduction
3.5.2 Non-pharmacological treatment of hypertension
3.5.3 Drug treatment of hypertension 3.5.3.1 Thiazide diuretics
3.5.3.2 Beta-blockers
3.5.3.3 Angiotensin converting enzyme (ACE)-inhibitors
3.5.3.4 Calcium channel blockers
3.5.3.5 Alpha blockers
3.5.3.6 Angiotensin II (AT₁) receptor antagonists 3.5.4 Hypertension in patients with dyslipidemia
3.5.5 Hypertension in older person
3.6 Management of coronary risk factors in patients with diabetes mellitus 3.7 Management of thrombogenic risk factors 3.7.1 Drug therapy 3.8 CHD prevention in the elderly 3.9 CHD in menopausal women and hormone replacement therapy 3.10 The role of antioxidants

4 Selected literature

4.1 Epidemiology of CHD 4.2 Mechanisms of atherogenesis 4.3 Risk factors for CHD and stroke 4.3.1 Psychosocial risk factors 4.4 Prevention of CHD 4.4.1 Primary prevention
4.4.2 Secondary prevention 4.5 Dietary treatment 4.6 Drug treatment 4.7 Guidelines for CHD prevention

Index of figures

Figure 1 Time trends in mortality from cardiovascular disease in selected countries 1970-92

Figure 2 Estimated risk of a coronary event among men aged 40 to 65 years in the Münster Heart Study, expressed as quintiles of the PROCAM multiple logistic function.

Figure 3 LDL-cholesterol, triglyceride, HDL-cholesterol and body mass index in the Münster Heart Study (PROCAM)

Figure 4 The risk of CHD according to ratio of total to HDL-cholesterol

Figure 5 Relationship between plasma LDL cholesterol and CHD risk.

Figure 6 Insulin resistance and the metabolic syndrome.

Figure 7 World-wide prevalence of type 2 diabetes mellitus.

Figure 8 Event rates in the 4S, CARE, and WOSCOPS studies as a function of plasma cholesterol levels at baseline and on-treatment.

Figure 9 The relation between the LDL cholesterol level and the relative risk of CHD.

Index of tables

Table 1 Cut-off points for body mass index

Table 2 Upper limits for waist circumference in men and women.

Table 3 Criteria for diagnosis of diabetes mellitus.

Table 4 Criteria for the diagnosis of the prediabetic state

Table 5 Classification of the primary dyslipidaemias

Table 6 Causes of secondary hyperlipidaemia

Table 7 Appropriate pulse rate during aerobic exercise.

Table 8 Target levels for plasma LDL cholesterol-lowering treatment.

Table 9 The results of lipid-lowering trials using angiographic primary end-points

Table 10 Methods of treating hyperlipidaemia

Table 11 Choice of foods in the cholesterol-lowering diet.

Table 12 Results of major recent randomized controlled clinical trials of cholesterol lowering.

Table 13 Suggested target lipid levels in diabetic patients.

Abbreviations used in this document

BP: Blood pressure
CABG: coronary artery bypass graft
CE: cholesteryl ester
CHD: coronary heart disease
CRP: C-reactive protein
CVD: cerebrovascular disease
DHEAS: dehydroepiandrosterone
ECG: electrocardiogram
FC: free cholesterol
FFA: free fatty acids
FSH: follicle-stimulating hormone
HDL: high density lipoprotein
ICH: intracerebral haemorrhage
ISH: International Society of Hypertension
JNC IV: 4th Joint National Council on Hypertension
LDL: low density lipoprotein
Lp(a): lipoprotein (a)
LH: luteinizing hormone
MI: myocardial infarction
MUFA: monounsaturated fatty acids
NHLBI: National Heart, Lung, and Blood Institute
PAI-I: plasminogen activator inhibitor I
PUFA: polyunsaturated fatty acids
RR: relative risk
SAH: subarachnoid haemorrhage
TC: total cholesterol
TG: triglyceride
VLDL: very low density lipoproteins
WHO: World Health Organization
WHR: waist:hip ratio

Study acronyms used in this document

4S: Scandinavian Simvastatin Survival Study
AFCAPS/TexCAPS: Air Force/Texas Armed Forces Coronary Atherosclerosis Prevention Study
BECAIT: Bezafibrate Coronary Atherosclerosis Intervention Trial
BUPA: British United Provident Association Limited
CAPRIE: Clopidogrel vs. Aspirin in Patients at Risk of Ischemic Events
CARE: Cholesterol and Recurrent Events Trial
CAST-1: Cardiac Arrhythmia Suppression Trial-1
CHAOS: Cambridge Heart Antioxidant Study
CCAIT: Canadian Coronary Atherosclerosis Intervention Trial
CLAS: Cholesterol-Lowering Atherosclerosis Study
DART: Diet and Reinfarction Trial
DASH: Dietary Approaches to Stop Hypertension
ENRICHD: Enhancing Recovery in Coronary Heart Disease Trial
FATS: Familial Atherosclerosis Treatment Study
GISEN: Gruppo Italiano di Studi Epidemiologici in Nefrologia
HARP: Harvard Atherosclerosis Reversibility Project
HOT: Hypertension Optimal Treatment Trial
INTERSALT: International Study of Salt and Blood Pressure
LCAS: Lipid and Coronary Atherosclerosis Study
LCAS: Lipoprotein and Coronary Atherosclerosis Study
LIPID: Long Term Intervention with Pravastatin in Ischemic Disease
LOCAT: Lopid (gemfibrozil) Coronary Angiography Trial
LRCPPT: Lipid Research Clinics Primary Prevention Trial
MAAS: Multicentre Anti-Atheroma Study
MARS: Monitored Atherosclerosis Regression Study
MONICA: World Health Organization Multinational Monitoring of Trends and Determinants of Cardiovascular Disease
MRFIT: Multiple Risk Factor Intervention Trial
NHANES I: First National Health and Nutrition Examination Survey
NHANES II: Second National Health and Nutrition Examination Survey
PLAC: Pravastatin Limitation of Atherosclerosis in the Coronary Arteries
POSCH: Program on the Surgical Control of the Hyperlipidaemias
PROCAM: Prospective Cardiovascular M�nster Study
SCRIP: Stanford Coronary Risk Intervention Project
SHEP: Systolic Hypertension in the Elderly Trial
STARS: St. Thomas'Atherosclerosis Regression Study
UCSF-SCOR: University of California at San Francisco Specialized Centers of Research Trial

Footnotes

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Figure 1	Time trends in mortality from cardiovascular disease in selected countries 1970-92
Figure 2	Estimated risk of a coronary event among men aged 40 to 65 years in the Münster Heart Study, expressed as quintiles of the PROCAM multiple logistic function.
Figure 3	LDL-cholesterol, triglyceride, HDL-cholesterol and body mass index in the Münster Heart Study (PROCAM)
Figure 4	The risk of CHD according to ratio of total to HDL-cholesterol
Figure 5	Relationship between plasma LDL cholesterol and CHD risk.
Figure 6	Insulin resistance and the metabolic syndrome.
Figure 7	World-wide prevalence of type 2 diabetes mellitus.
Figure 8	Event rates in the 4S, CARE, and WOSCOPS studies as a function of plasma cholesterol levels at baseline and on-treatment.
Figure 9	The relation between the LDL cholesterol level and the relative risk of CHD.

Table 1	Cut-off points for body mass index
Table 2	Upper limits for waist circumference in men and women.
Table 3	Criteria for diagnosis of diabetes mellitus.
Table 4	Criteria for the diagnosis of the prediabetic state
Table 5	Classification of the primary dyslipidaemias
Table 6	Causes of secondary hyperlipidaemia
Table 7	Appropriate pulse rate during aerobic exercise.
Table 8	Target levels for plasma LDL cholesterol-lowering treatment.
Table 9	The results of lipid-lowering trials using angiographic primary end-points
Table 10	Methods of treating hyperlipidaemia
Table 11	Choice of foods in the cholesterol-lowering diet.
Table 12	Results of major recent randomized controlled clinical trials of cholesterol lowering.
Table 13	Suggested target lipid levels in diabetic patients.