Prospects for primary prevention of coronary heart disease

Abstract

Major contributors to coronary heart disease have been identified through epidemiologic research. These risk factors fall into a number of interdependent categories including: atherogenic personal attributes, living habits which promote them, signs of a compromised circulation and host susceptibility to these risk factors. Modifiable atherogenic risk attributes include blood lipids, blood pressure, glucose tolerance and fibrinogen. The risk associated with each is markedly affected by those others which coexist. Modifiable living habits exist which promote these atherogenic traits including overeating, unrestrained weight gain, faulty diet, cigarette smoking, and lack of exercise. Innate susceptibility is signified by a family history of premature vascular disease, identifying persons in particular need of risk factor control. At a given level of serum total cholesterol risk varies widely depending on total/HDL-cholesterol ratio providing an efficient and practical means for assessing the joint effect of the two-way traffic of total cholesterol. Optimal treatment must improve this lipid profile. Diabetes on average doubles CHD mortality imparting greater risk in women than men and exerting an independent effect. Risk in diabetics varies widely depending on coexistent risk factors providing a means for reducing the risk. The same applies for hypertension and dyslipidemia. Preclinical indicators of a compromised coronary circulation and ischemic myocardial involvement include ECG evidence of left ventricular hypertrophy, blocked intraventricular function, repolarization abnormality and abnormal response to exercise. Such persons are in dire need of correction of modifiable risk factors. Optimal risk predictions require a quantitative synthesis of risk factors into a composite estimate. Handbooks, hand calculators and P.C. software, based on multiple logistic risk formulations have been devised for office use requiring only ordinary office procedures and simple laboratory tests to measure the risk factor ingredients. Preventive management as well as risk estimation should be multifactorial if good results are to be acheived. Preventive strategies should include public health measures to alter the ecology so as to shift the whole distribution of risk factors to a more favorable level, health education to enable people to protect their own health and preventive medicine for high risk candidates. Greater skill at modifying behavior must be developed to carry out such risk factor interventions.