Coronary Artery Disease – leading cause of death in the US

• ½ of all deaths in the US are due to CV disease; 600,000 deaths/ year in the US to CAD
• 6 million people in US under active treatment of cardiovascular (CV) disease
• 1.2 million myocardial infarctions (MI)/year Þ of these, 400,000 are fatal before the person makes it to the hospital
• ½ to 1/3 of first MI are fatal; 27% of men and 44% of women die within one year post MI
• in many individuals the first presentation of CAD may be death from an MI
• MI first described in 1912 with the peak incidence of CAD in US in the 1950s Þ declining since

• Known: Diabetes, Smoking, ß Exercise, Alcohol, HTN, Stress, Family Hx, Age, Male sex, ß HDL, Ý LDL, Ý Total cholesterol (no cholesterol level is too low)
• Emerging: Lipoprotein(a), Estrogen deficiency (post menopause), Hepatic lipase
• Primary Prevention: treatment of people who are healthy
• Secondary Prevention: treatment of people have disease
• Additive effects of many low risk factors can cause high total risk
• (1) Cholesterol – identified as a risk by cross cultural, migration and longitudinal studies
• Cross cultural studies have identified Ý risk of CAD in certain countries
• Migration Studies - Japanese immigrants in Hawaii have much greater risk of CAD than Japanese living in Japan
• Framingham Longitudinal Study – established in 1948; followed 5127 people without heart disease between the ages of 30 and 59 and has provided a great deal of information about risk factors to CV disease
• (2) Smoking – smoking cessation has the most important impact on ß the risk of CAD; smoking Ý risk 3 to 4 fold
• excess risk in the young or in association with other risk factors
• quitting smoking also ß the risk of arrhythmias
• 2 to 3 years after quitting the risk of CV disease returns to the level of someone who has never smoked; the risk of lung cancer does not ß significantly
• only 40% of people who undergo group therapy and medication therapy (Wellbutrin) to quit are successful
• (3) HTN – Ý risk 2-fold
• 50 million Americans are currently being treated for HTN
• only 70% of people with HTN know it; of these people only 50% are being treated so of these people only 37-30% are actually lowering their BP
• (4) Exercise – ½ of all adults get no exercise and only 15% of adults get optimum exercise (30 min. 4 to 5 times a week)
• people with no exercise can reduce risk by 1/3 if they begin exercising at moderate levels
• less people exercise in Ohio than any other state in the US
• (5) Alcohol–modest EtOH consumption ß risk by raising HDL levels; lots of alcohol Ý BP and Ý risk of stroke
• 5 to 10 drinks/wk is thought to be ideal amount
• 
• (6) Stress – Ý stress is related to CV disease, but it is also related to how people control stress; Þ people who internalize stress or project it as aggression are at a higher risk for CV disease
• (7) Diabetes – Ý risk of CV disease
• survival post MI is significantly reduced; women more than men

• Vulnerable Plaque – often does not produce lumen narrowing and therefore not symptomatic
• as inflammatory cells invade the plaque it becomes susceptible to rupture
• Stable Plaque – causes lumen narrowing and more likely to cause symptoms such as angina
• calcified and fibrotic with ß lipid concentration

• Cholesterol lowing drugs:
• Simvastatin: ß LDL 35%; in people with CV disease it ß coronary mortality 42% and total mortality 30% after 5 years
• Lovastatin: ß LDL 25% and ß first major coronary event by 37% in healthy people
• cholesterol lowering medications are expensive and produce an ethical dilemma as to when people should be put on a drug that may only slightly reduce the risk of an MI
• Aspirin – very effective
• Vit E – no proven effect
• must consider issues of: Community vs individualized approaches; Changes in many that only affect a few; differences between "normal" vs. "optimal" lab values; safety of the intervention