One-quarter of heart attack victims have no prior symptoms, notes Philip Greenland, M.D., Sidney C. Smith, M.D., and Scott M. Grundy, M.D. Ph.D., in a "Current Perspectives" article. Adopting proven measures to reduce their heart-attack risk factors might save many people with symptomless coronary heart disease.
Well-established risk factors that people can modify include smoking, high blood pressure, high total blood cholesterol, high LDL (the bad cholesterol), low HDL (the good cholesterol), obesity, and a sedentary lifestyle. Studies have confirmed the benefits of several risk reducing strategies in preventing heart attacks. "We propose that in a global risk assessment, patients age 20 or older will fall into three distinct categories," says Greenland, a prevention medicine specialist at Northwestern University Medical School in Chicago.
"Low risk." About 35 percent of adults over age 20 have no elevated risk factors. Physicians can reassure them of their low risk without more extensive risk assessment tests.
"Intermediate risk." Roughly 40 percent of U.S. adults have one or more elevated risk factors levels, but are not currently regarded as targets for the most intensive risk-reduction interventions. This group could benefit most from non-invasive tests to further define their risks, the authors state.
Such tests include the ankle-brachial index, which compares blood pressure in the arm to that in the ankle; ultrasound examination of the carotid artery in the neck; electron-beam tomography, or exercise stress testing on a treadmill. Selection of these tests is considered a medical decision rather than one patients should undertake.
"High risk." Approximately 25 percent of patients will have established coronary heart disease, other forms of atherosclerotic disease, type 2 diabetes, or are older and have multiple risk factors.
"These patients either have coronary heart disease or are considered to have the same heart-attack risk as someone with heart disease, and therefore, they should be treated with the same prevention measures as someone who has survived a heart attack," Greenland says. Further risk assessment in these patients is not required to determine that an intensive strategy is needed. The risk of a heart attack can be improved by routine assessment of cardiac risk factors and by selective use of medical tests in intermediate risk patients. The patient and the doctor can work together to improve the quality of care for these problems, Greenland says.
The authors encourage adoption of these approaches to improve risk assessment and reduction.
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