Joan M. Fair

AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases

The initial Guide to the Primary Prevention of Cardiovascular Diseases was published in 1997 as an aid to healthcare professionals and their patients without established coronary artery disease or other atherosclerotic diseases.1 It was intended to complement the American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for Preventing Heart Attack and Death in Patients with Atherosclerotic Cardiovascular Disease (updated2) and to provide the healthcare professional with a comprehensive approach to patients across a wide spectrum of risk. The imperative to prevent the first episode of coronary disease or stroke or the development of aortic aneurysm and peripheral arterial disease remains as strong as ever because of the still-high rate of first events that are fatal or disabling or require expensive intensive medical care. The evidence that most cardiovascular disease is preventable continues to grow. Results of long-term prospective studies consistently identify persons with low levels of risk factors as having lifelong low levels of heart disease and stroke.3,4⇓ Moreover, these low levels of risk factors are related to healthy lifestyles. Data from the Nurses Health Study,5 for example, suggest that in women, maintaining a desirable body weight, eating a healthy diet, exercising regularly, not smoking, and consuming a moderate amount of alcohol could account for an 84% reduction in risk, yet only 3% of the women studied were in that category. Clearly, the majority of the causes of cardiovascular disease are known and modifiable. This 2002 update of the Guide acknowledges a number of advances in the field of primary prevention since 1997. Research continues to refine the recommendations on detection and management of established risk factors, including evidence against the safety and efficacy of interventions once thought promising (eg, antioxidant vitamins).6 This, in turn, has …

Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP).

BACKGROUND Recent clinical trials have shown that modification of plasma lipoprotein concentrations can favorably alter progression of coronary atherosclerosis, but no data exist on the effects of a comprehensive program of risk reduction involving both changes in lifestyle and medications. This study tested the hypothesis that intensive multiple risk factor reduction over 4 years would significantly reduce the rate of progression of atherosclerosis in the coronary arteries of men and women compared with subjects randomly assigned to the usual care of their physician. METHODS AND RESULTS Three hundred men (n = 259) and women (n = 41) (mean age, 56 +/- 7.4 years) with angiographically defined coronary atherosclerosis were randomly assigned to usual care (n = 155) or multifactor risk reduction (n = 145). Patients assigned to risk reduction were provided individualized programs involving a low-fat and -cholesterol diet, exercise, weight loss, smoking cessation, and medications to favorably alter lipoprotein profiles. Computer-assisted quantitative coronary arteriography was performed at baseline and after 4 years. The main angiographic outcome was the rate of change in the minimal diameter of diseased segments. All subjects underwent medical and risk factor evaluations at baseline and yearly for 4 years, and reasons for all hospitalizations and deaths were documented. Of the 300 subjects randomized, 274 (91.3%) completed a follow-up arteriogram, and 246 (82%) had comparative measurements of segments with visible disease at baseline and follow-up. Intensive risk reduction resulted in highly significant improvements in various risk factors, including low-density lipoprotein cholesterol and apolipoprotein B (both, 22%), high-density lipoprotein cholesterol (+12%), plasma triglycerides (-20%), body weight (-4%), exercise capacity (+20%), and intake of dietary fat (-24%) and cholesterol (-40%) compared with relatively small changes in the usual-care group. No change was observed in lipoprotein(a) in either group. The risk-reduction group showed a rate of narrowing of diseased coronary artery segments that was 47% less than that for subjects in the usual-care group (change in minimal diameter, -0.024 +/- 0.066 mm/y versus -0.045 +/- 0.073 mm/y; P < .02, two-tailed). Three deaths occurred in each group. There were 25 hospitalizations in the risk-reduction group initiated by clinical cardiac events compared with 44 in the usual-care group (rate ratio, 0.61; P = .05; 95% confidence interval, 0.4 to 0.9). CONCLUSIONS Intensive multifactor risk reduction conducted over 4 years favorably altered the rate of luminal narrowing in coronary arteries of men and women with coronary artery disease and decreased hospitalizations for clinical cardiac events.

American Heart Association Guide for Improving Cardiovascular Health at the Community Level A Statement for Public Health Practitioners, Healthcare Providers, and Health Policy Makers From the American Heart Association Expert Panel on Population and Prevention Science

This Guide for Improving Cardiovascular Health at the Community Level (Community Guide) is intended to provide persons and organizations interested in improving the cardiovascular health of their communities with a comprehensive list of goals, strategies, and recommendations that might be implemented on a community-wide basis. It targets not only health professionals but also public health practitioners, voluntary health agencies, and community leaders in general. The Community Guide will complement the American Heart Association (AHA) Guidelines for Primary Prevention of Cardiovascular Disease and Stroke,1 the American Stroke Association Scientific Statement on the Primary Prevention of Ischemic Stroke,2 AHA/American College of Cardiology (ACC) Guidelines for Preventing Heart Attack and Death in Patients with Atherosclerotic Cardiovascular Disease,3 and the Guidelines for Preventing Ischemic Stroke in Patients with Prior Stroke and Transient Ischemic Attack.4 This Guide differs from these four clinical guidelines because it provides a comprehensive approach to reducing the burden of cardiovascular disease (CVD) through improving the local policies and environment as a means to promote cardiovascular health. Changes toward a healthier environment could be expected to enhance the clinically oriented guidelines because both the primary and secondary prevention guidelines recommend that healthcare providers encourage behavior change in individual patients. Improvements in facilities and resources in the places where people work and live should enhance the achievement of many goals, including: cessation of tobacco use and avoidance of environmental tobacco smoke; reduction in dietary saturated fat, cholesterol, sodium, and calories; increased plant-based food intake; increased physical activity; access to preventive healthcare services; and early recognition of symptoms of heart attack and stroke. Healthcare providers and their patients have better opportunities for successfully implementing the clinical guidelines when they live in such communities. Although complementary to and supportive of the clinical guidelines, the Community Guide provides a fundamentally different …

Susceptibility locus for clinical and subclinical coronary artery disease at chromosome 9p21 in the multi-ethnic ADVANCE study

A susceptibility locus for coronary artery disease (CAD) at chromosome 9p21 has recently been reported, which may influence the age of onset of CAD. We sought to replicate these findings among white subjects and to examine whether these results are consistent with other racial/ethnic groups by genotyping three single nucleotide polymorphisms (SNPs) in the risk interval in the Atherosclerotic Disease, Vascular Function, and Genetic Epidemiology (ADVANCE) study. One or more of these SNPs was associated with clinical CAD in whites, U.S. Hispanics and U.S. East Asians. None of the SNPs were associated with CAD in African Americans although the power to detect an odds ratio (OR) in this group equivalent to that seen in whites was only 24-30%. ORs were higher in Hispanics and East Asians and lower in African Americans, but in all groups the 95% confidence intervals overlapped with ORs observed in whites. High-risk alleles were also associated with increased coronary artery calcification in controls and the magnitude of these associations by racial/ethnic group closely mirrored the magnitude observed for clinical CAD. Unexpectedly, we noted significant genotype frequency differences between male and female cases (P = 0.003-0.05). Consequently, men tended towards a recessive and women tended towards a dominant mode of inheritance. Finally, an effect of genotype on the age of onset of CAD was detected but only in men carrying two versus one or no copy of the high-risk allele and presenting with CAD at age >50 years. Further investigations in other populations are needed to confirm or refute our findings.

Saturated fat intake and insulin resistance in men with coronary artery disease. The Stanford Coronary Risk Intervention Project Investigators and Staff.

Background To determine whether there is an association between diet and plasma insulin concentration that is independent of obesity, we studied the relation of dietary composition and caloric intake to obesity and plasma insulin concentrations in 215 nondiabetic men aged 32–74 years with angiographically proven coronary artery disease. Methods and Results After adjusting for age, the intake of saturated fatty acids and cholesterol were positively correlated (p < 0.05) with body mass index (r = 0.18, r = 0.16), waist-to-hip circumference ratio (r = 0.21, r = 0.22), and fasting insulin (r = 0.26, r = 0.23). Carbohydrate intake was negatively correlated with body mass index (r = −0.21), waist-to-hip ratio (r = −0.21), and fasting insulin (r = −0.16). Intake of monounsaturated fatty acids did not correlate significantly with body mass index or waist-to-hip circumference ratio but did correlate positively with fasting insulin (r = 0.24). Intake of dietary calories was negatively correlated with body mass index (r = −0.15). In multivariate analysis, intake of saturated fatty acids was significantly related to elevated fasting insulin concentration independently of body mass index. Conclusions These cross-sectional findings in nondiabetic men with coronary artery disease suggest that increased consumption of saturated fatty acids is associated independently with higher fasting insulin concentrations.

Promoting prevention: skill sets and attributes of health care providers who deliver behavioral interventions.

Preventive therapies have been shown to reduce morbidity and mortality from cardiovascular disease. However, health care providers are not addressing prevention and not treating patients according to evidence-based guidelines. Reasons frequently cited for not delivering health promotion/disease prevention oriented care is lack of training or skills to provide counseling, and a lack of confidence in health care provider skills. This article outlines the skills and attributes considered essential for a health care provider to promote behavioral change and risk reduction. The skills and attributes of the health care provider, such as expertise and knowledge, skills for assessing readiness for behavior change, relationship building skills, and skill in considering the patients attitudes and beliefs about the disease or treatment are discussed. Principles of communication to guide the patient-provider encounter, key behavioral change strategies, and use of technology are reviewed and resources available to support prevention goals are presented.

Insulin resistance independently predicts the progression of coronary artery calcification.

BACKGROUND Change in coronary artery calcification is a surrogate marker of subclinical coronary artery disease (CAD). In the only large prospective study, CAD risk factors predicted progression of coronary artery calcium (CAC). METHODS We measured CAC at enrollment and after 24 months in a community-based sample of 869 healthy adults aged 60 to 72 years who were free of clinical CAD. We assessed predictors of the progression of CAC using univariate and multivariate models after square root transformation of the Agatston scores. Predictors tested included age, sex, race/ethnicity, smoking status, body mass index, family history of CAD, C-reactive protein and several measures of diabetes, insulin levels, blood pressure, and lipids. RESULTS The mean age of the cohort was 66 years, and 62% were male. The median CAC at entry was 38.6 Agatston units and increased to 53.3 Agatston units over 24 months (P < .01). The CAC progression was associated with white race, diabetes, dyslipidemia, hypertension, lower diastolic blood pressure, and higher pulse pressure. After controlling for these variables, higher fasting insulin levels independently predicted CAC progression. CONCLUSIONS Insulin resistance, in addition to the traditional cardiac risk factors, independently predicts progression of CAC in a community-based population without clinical CAD.

Using direct mail to recruit hispanic adults into a dietary intervention: An experimental study

Identifying strategies for successful recruitment of ethnic minorities into scientific studies is critical. Without effective methods, investigators may fail to recruit the desired sample size, take longer to recruit than planned, and delay progress for research in minority health. Direct mail is an appealing recruitment method because of the potential for reaching large target populations and producing a high volume of inquiries about a study with relatively little staff effort. To determine which of three direct mail strategies yielded higher recruitment, 561 Hispanic employees were randomly assigned to receive either: (a) a flyer about a worksite dietary intervention; (b) the same flyer plus a personalized hand-signed letter containing heart disease risk statistics for the general American population; or (c) the flyer plus a personalized hand-signed letter containing statistics for Hispanics. Two orthogonal chi-square comparisons were examined. The personalized letters plus flyer yielded a significantly higher response rate (7.8%) than the flyer alone (2.1%), X2(1, N=561)=7.5, p=.006. However, the personalized letter with Hispanic heart disease risk statistics did not yield a statistically significant higher response rate (9.1%) than the letter with the general population risk statistics (6.5%), X2(1, N=370)=0.9, p>.34. These findings suggest that personalized approaches can increase the effectiveness of direct mail efforts for recruiting ethnic minorities into interventions and may be particularly helpful for large-scale interventions.

Incidental Findings on Cardiac Multidetector Row Computed Tomography Among Healthy Older Adults: Prevalence and Clinical Correlates

BACKGROUND With the widespread use of cardiac multidetector row computed tomography (MDCT), the issue of incidental findings is receiving increasing attention. Our objectives were to evaluate the prevalence of incidental findings discovered during cardiac MDCT scanning and to identify clinical variables associated with incidental findings. METHODS This cross-sectional analysis involved a population-based sample recruited from an integrated health care delivery system in Northern California as part of the Atherosclerotic Disease, Vascular Function and Genetic Epidemiology (ADVANCE) Study. Healthy men and women aged 60 to 69 years without diagnosed cardiovascular disease underwent cardiac MDCT for the detection and quantification of coronary artery calcification. The images were prospectively evaluated for incidental findings. RESULTS A total of 459 participants underwent MDCT scanning, and the overall prevalence of any incidental finding was 41%. Of the 459 participants, 105 (23%) had at least 1 incidental finding that was recommended for clinical or radiological follow-up examination, the most common of which was single or multiple pulmonary nodules (18%). Participants with and without incidental findings had comparable baseline demographics and selected clinical variables, although there were significantly fewer men and a significantly lower prevalence of the metabolic syndrome in those with incidental findings. CONCLUSIONS Incidental findings, especially pulmonary nodules, are common in cardiac MDCT performed to assess coronary artery calcification in older healthy adults. The net risks and benefits of looking for noncardiac abnormalities during cardiac MDCT should be rigorously evaluated.

Incidental Pulmonary Nodules on Cardiac Computed Tomography: Prognosis and Use

BACKGROUND Small asymptomatic lung nodules are found frequently in the course of cardiac computed tomography (CT) scanning. However, the utility of assessing and reporting incidental findings in healthy, asymptomatic subjects is unknown. METHODS The sample comprised 1023 60- to 69-year-old subjects free of clinical cardiovascular disease and cancer who participated in the Atherosclerotic Disease, VAscular functioN and genetiC Epidemiology Study. All subjects underwent cardiac CT for determination of coronary calcium between 2001 and 2004, and the first 459 subjects were assessed for incidental pulmonary findings. We used health plan clinical databases to ascertain 24-month health care use and clinical outcomes. RESULTS Noncalcified pulmonary nodules were reported in 81 of 459 subjects (18%). Chest CT was performed on 78% of participants in the 24 months after notification, compared with 2.5% in the previous 24 months. Chest x-ray use increased from 28% to 49%. The mean number of chest CT scans per subject was 1.3 (range, 0-5). Although no malignant lesions were diagnosed in the group who had pulmonary findings read, 1 lung cancer case was diagnosed in the group who did not have lung findings read. Among the 63 participants followed up by CT, the original lesion was not identified in 22 participants (35%), the lesion had decreased or remained stable in 39 participants (62%), and there was interval growth in 2 participants (3%). CONCLUSION Reporting noncalcified pulmonary nodules resulted in substantial rescanning that overwhelmingly revealed resolution or stability of pulmonary nodules, arguing for benign processes.