Coronary artery disease (CAD) accounts for approximately 610,000 deaths annually (estimated 1 in 4 deaths) and is the leading cause of mortality in the United States.[1] It is the third leading cause of mortality worldwide and is associated with 17.8 million deaths annually.[2][3][4][5] Healthcare services for CAD are estimated to cost greater than 200 billion dollars annually in the United States.[6] While CAD is a significant cause of death and disability, it is preventable.
The Framingham Heart Study enrolled its first participant in 1948 and is currently studying its third generation of participants.[7][8] This was the first study that elucidated risk factors associated with cardiovascular disease. Since then, cohort studies have continued to study the impact of different risk factors on cardiovascular disease. The FINRISK study is an ongoing Finnish population-based observational study that began in 1972.[9] The ULSAM, PIVUS, POEM, EpiHealth, and SCAPIS studies were cohort studies completed at Uppsala University in Sweden. The PREDICT Cardiovascular Disease Cohort study was another study completed in New Zealand.[10] These studies classify CAD into two broad categories: non-modifiable and modifiable risk factors. Non-modifiable risk factors include age, gender, ethnicity, and family history of CAD. Modifiable risk factors include hypertension, hyperlipidemia, diabetes, obesity, smoking, poor diet, sedentary lifestyle, and stress.[7][11]
Given the immense healthcare burden of CAD, modifiable, and non-modifiable risk factors were identified to mitigate the resulting economic and disease-related burden. Risk factor identification, combined with advances in medical technology, has contributed to a significant decrease in CAD mortality rates over the past forty years in western countries. One public health study that gathered mortality data from 1969 to 2014 concluded that by 2020, the number of heart disease-related deaths would decrease by 21.3 percent for men and 13.4 percent in women.[12]
This article will review the impact and management of these risk factors. Ever since the Framingham Heart Study, there has been a plethora of data on coronary artery disease risk factors. This piece will provide a concise summary of the most recent systemic reviews and evidence.
Risk factors for coronary artery disease classify into modifiable and non-modifiable risk factors.
A 2019 article indicated that age, sex, and race captured 63 to80% of prognostic performance, while modifiable risk factors contributed only modestly. Yet, control of modifiable risk factors led to substantial reductions in CAD events.[11] Non-modifiable risk factors are discussed first:
Modifiable risk factors have a smaller but still significant role.[11] Yet, only two-thirds of patients receive optimal medication interventions.[18] If this were achieved, there would be a substantial reduction in CAD events.[11] One study observed that those with optimal risk factor profiles had a substantially lower rate of death from cardiovascular events.[19]
In addition to these traditional cardiovascular risk factors, novel risk factors have also been subject to research. These include:
Socioeconomic status:
Women and coronary artery disease (CAD):
Coronary artery disease remains the number one cause of death in the United States. Given the prevalence of CAD and its risk factors, multi-disciplinary, team-based care may result in significantly improved patient outcomes.[41] Physicians and advanced care clinicians should be aware of screening recommendations and the impact that risk factor mitigation can have on CAD outcomes. Nurses play a central role in routine screening and education. Clinical pharmacists play a pivotal role in the pharmacologic management of modifiable risk factors such as hypertension, hyperlipidemia, diabetes, and smoking cessation. Nutritionists contribute by providing dietary education. Community outreach by all team members can help mitigate the complex, yet crucial role that socioeconomic status can have on CAD risk and outcomes. This section will review screening recommendations, the impact of risk factor mitigation on CAD outcomes, aspirin, and new CAD screening tests.
Hypertension
Hyperlipidemia
Diabetes
Diet
Smoking
Obesity
Exercise
Aspirin in primary prevention:
New CAD screening tests:
Coronary artery calcium (CAC) score:
Carotid intimal medial thickness (CIMT):
Flow-mediated dilation (FMD) and endothelin function:
There are different methods to measure FMD. Protocols involving vasoactive agents via coronary catheterization is a more direct measurement of the coronary artery endothelial function, more specifically referred to as coronary flow reserve (CFR).[128]
Brachial artery flow-mediated dilation and reactive hyperemia-peripheral arterial tonometry (RH-PAT) are more peripheral measurements. A 2015 meta-analysis conferred that these two methods demonstrated similar prognostic value on cardiovascular outcomes. Additional research is necessary to determine whether this screening strategy can improve cardiovascular outcomes.[129]
Novel biomarkers:
Coronary artery disease is the leading cause of death in the United States and many countries worldwide. Given the prevalence of CAD and its risk factors, multi-disciplinary, team-based care may result in significantly improved patient outcomes. Clinicians, nurses, and pharmacists need to remain abreast of the most current research and work together as an interprofessional team to encourage the following long-term treatment recommendations and regular exercise to obtain the best patient outcomes. [Level 5]
The first portion of the encounter identifies the patient's age, gender, ethnicity, and past medical history. Detection of CAD risk factors can occur within the first 5 minutes of the clinical encounter. Vital signs detect elevated blood pressures and excessive weight. Diet and physical activity can also be discussed. Early education on lifestyle modifications can improve outcomes and mitigate risk factors. Screening recommendations can also be provided.
"The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, Department of Defense, or the U.S. government. This document was created free of branding or market affiliations. The author is operating solely as a contributor."
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