Browse the corpus

Epidemiology and Risk Factors Diabetes Mellitus use and eating habits, lifestyle, and social lactors. contributing Diabetes increases cardiovascular risk and is an independent to a dramatic increase in obesitv and diabetes. indication for statin therapy. Sixty eight percent of individu als with diabetes eventually die of heart disease. Diabetes I(EY POIXI increases ischemic stroke incidence at all ages. but this risk . Beyond age and gender, risk for cardiovascular disease is most prominent (risk ratio >5) before age 65 years. In per is strongly attributed to modifiable risk factors. includ sons with diabetes, CAD is likely to be more extensive. and ing dyslipidemia, smoking, diabetes mellitus. hyperten the incidence of multivessel disease is increased. patients sion, obesity, inadequate exercise, and poor diet. with diabetes also have worse outcomes when hospitalized for any CVD. Calculating Cardiovascular Risk Obesity and Metabolic Syndrome Cardiovascular risk scores can be used to assess an individual In 2016, 39.6% of U.S. adults had class I obesity (BMI, 30 35). patient's risk for major cardiovascular events and to identify and7.7"/o had class III obesity (BMI, >40). Obesity may increase preventive interventions. Traditionally the Framingham risk the risk for CVD events. even in the absence of n.retabolic risk score. r.thich includes the data inputs of age. sl,stolic blood factors. pressure. total cholesterol level, HDL cholesterol level. smok Metabolic syndrome is characterized by the presence of at ing status, and presence ofdiabetes. has been used to estimate Ieast three of the following conditions: elevated glucose level, the 10 year risk for a major coronary heart disease event central obesity, low HDL cholesterol level. elevated triglyceride (MI or coronary death). The Reynolds risk score (http: uu'u,. level, and elevated blood pressure. The hallmark feature of reynoldsriskscore.org/) is a sex-specific calculator and metabolic syndrome is glucose intolerance. Approximately includes family history and high sensitivity C reactive protein 34"1, of adults meet the criteria for metabolic syndrome. The Ievel. Another tool, the Multi Ethnic Stud)' of Atherosclerosis highest prevalence is among Hispanic and Latino persons (MESA) risk score (https:irr.lrvn:mesa nhlbi.org CAC Tools. (34'7,). Metabolic syndrome is associated with increased risk aspx), uses coronary artery calcium score and traditional risk for CVD and diabetes, with risk increasing as the number of factors to calculate risk. component conditions increases. The Americar.r College of Cardiology American Heart Association (ACC/AHA) Pooled Cohort Equations (PCE) is a lnherited Factors risk assessment instrument derived from several diverse In addition to the risk for CVD as predicted by the traditional community based cohorts. The ACC/AHA CVD risk calculator risk elements, inherited factors may increase the risk based on the PCE (https:irtools.acc.org ASCVD Risk Estimator

Diabetes Mellitus use and eating habits, lifestyle, and social lactors. contributing Diabetes increases cardiovascular risk and is an independent to a dramatic increase in obesitv and diabetes. indication for statin therapy. Sixty eight percent of individu als with diabetes eventually die of heart disease. Diabetes I(EY POIXI increases ischemic stroke incidence at all ages. but this risk . Beyond age and gender, risk for cardiovascular disease is most prominent (risk ratio >5) before age 65 years. In per is strongly attributed to modifiable risk factors. includ sons with diabetes, CAD is likely to be more extensive. and ing dyslipidemia, smoking, diabetes mellitus. hyperten the incidence of multivessel disease is increased. patients sion, obesity, inadequate exercise, and poor diet. with diabetes also have worse outcomes when hospitalized for any CVD. Calculating Cardiovascular Risk Obesity and Metabolic Syndrome Cardiovascular risk scores can be used to assess an individual In 2016, 39.6% of U.S. adults had class I obesity (BMI, 30 35). patient's risk for major cardiovascular events and to identify and7.7"/o had class III obesity (BMI, >40). Obesity may increase preventive interventions. Traditionally the Framingham risk the risk for CVD events. even in the absence of n.retabolic risk score. r.thich includes the data inputs of age. sl,stolic blood factors. pressure. total cholesterol level, HDL cholesterol level. smok Metabolic syndrome is characterized by the presence of at ing status, and presence ofdiabetes. has been used to estimate Ieast three of the following conditions: elevated glucose level, the 10 year risk for a major coronary heart disease event central obesity, low HDL cholesterol level. elevated triglyceride (MI or coronary death). The Reynolds risk score (http: uu'u,. level, and elevated blood pressure. The hallmark feature of reynoldsriskscore.org/) is a sex-specific calculator and metabolic syndrome is glucose intolerance. Approximately includes family history and high sensitivity C reactive protein 34"1, of adults meet the criteria for metabolic syndrome. The Ievel. Another tool, the Multi Ethnic Stud)' of Atherosclerosis highest prevalence is among Hispanic and Latino persons (MESA) risk score (https:irr.lrvn:mesa nhlbi.org CAC Tools. (34'7,). Metabolic syndrome is associated with increased risk aspx), uses coronary artery calcium score and traditional risk for CVD and diabetes, with risk increasing as the number of factors to calculate risk. component conditions increases. The Americar.r College of Cardiology American Heart Association (ACC/AHA) Pooled Cohort Equations (PCE) is a lnherited Factors risk assessment instrument derived from several diverse In addition to the risk for CVD as predicted by the traditional community based cohorts. The ACC/AHA CVD risk calculator risk elements, inherited factors may increase the risk based on the PCE (https:irtools.acc.org ASCVD Risk Estimator for CVD. A history of premature CAD (males younger than Plus) may be used to calculate 10-year atherosclerotic CVD risk.

Diabetes Mellitus use and eating habits, lifestyle, and social lactors. contributing Diabetes increases cardiovascular risk and is an independent to a dramatic increase in obesitv and diabetes. indication for statin therapy. Sixty eight percent of individu als with diabetes eventually die of heart disease. Diabetes I(EY POIXI increases ischemic stroke incidence at all ages. but this risk . Beyond age and gender, risk for cardiovascular disease is most prominent (risk ratio >5) before age 65 years. In per is strongly attributed to modifiable risk factors. includ sons with diabetes, CAD is likely to be more extensive. and ing dyslipidemia, smoking, diabetes mellitus. hyperten the incidence of multivessel disease is increased. patients sion, obesity, inadequate exercise, and poor diet. with diabetes also have worse outcomes when hospitalized for any CVD. Calculating Cardiovascular Risk Obesity and Metabolic Syndrome Cardiovascular risk scores can be used to assess an individual In 2016, 39.6% of U.S. adults had class I obesity (BMI, 30 35). patient's risk for major cardiovascular events and to identify and7.7"/o had class III obesity (BMI, >40). Obesity may increase preventive interventions. Traditionally the Framingham risk the risk for CVD events. even in the absence of n.retabolic risk score. r.thich includes the data inputs of age. sl,stolic blood factors. pressure. total cholesterol level, HDL cholesterol level. smok Metabolic syndrome is characterized by the presence of at ing status, and presence ofdiabetes. has been used to estimate Ieast three of the following conditions: elevated glucose level, the 10 year risk for a major coronary heart disease event central obesity, low HDL cholesterol level. elevated triglyceride (MI or coronary death). The Reynolds risk score (http: uu'u,. level, and elevated blood pressure. The hallmark feature of reynoldsriskscore.org/) is a sex-specific calculator and metabolic syndrome is glucose intolerance. Approximately includes family history and high sensitivity C reactive protein 34"1, of adults meet the criteria for metabolic syndrome. The Ievel. Another tool, the Multi Ethnic Stud)' of Atherosclerosis highest prevalence is among Hispanic and Latino persons (MESA) risk score (https:irr.lrvn:mesa nhlbi.org CAC Tools. (34'7,). Metabolic syndrome is associated with increased risk aspx), uses coronary artery calcium score and traditional risk for CVD and diabetes, with risk increasing as the number of factors to calculate risk. component conditions increases. The Americar.r College of Cardiology American Heart Association (ACC/AHA) Pooled Cohort Equations (PCE) is a lnherited Factors risk assessment instrument derived from several diverse In addition to the risk for CVD as predicted by the traditional community based cohorts. The ACC/AHA CVD risk calculator risk elements, inherited factors may increase the risk based on the PCE (https:irtools.acc.org ASCVD Risk Estimator for CVD. A history of premature CAD (males younger than Plus) may be used to calculate 10-year atherosclerotic CVD risk. 55 years, females younger than 65 years) in parents doubles thereby identifying persons u,ho would benefit lrom preven the risk fbr myocardial infarction (MI) in men and increases tive measures. including statin therapy The PCE is the single risk in women by 7O"/,,. Stroke in a first-degree relative most robust tool for estimating 10 year risk in U.S. adults aged increases risk for stroke by 50'/.. A parental history of atrial 40 to 75 years and is recommended by the U.S. Preventive fibrillation increases odds of this condition by B0'){,. In addi Services Task Force and other organizations to assess athero tion to the shared environment (i.e., lifestyle), genetics may sclerotic CVD risk. contribute to increased risk in family members, although no According to the ACCIAHA. in patients with borderline (5'x, to <7.5'7,) or intermediate (>7.5')(, to <20'l,) l0-year athero genetic profile has been shown to explain a significant per centage of CVD incidence. sclerotic CVD risk based on the PCE. it is reasonable to further refine individual risk based on the presence of risk enhancing f.actors. such as chronic kidney disease (CKD). selected testing Ethnicity (e.g., high-sensitivity C reactive protein level. ankle brachial There are significant racial and ethnic disparities in the risk index), and lamily history of premature CAD. The U.S. and prevalence for CVD in the United States. The prevalence of Preventive Services Task Force concluded that there is insuf- CVD is highest among American Indian or Alaska Native ficient evidence to recommend using nontraditional risk fac (74.6y.\, white (11.5",{,), Black (10.0'U,), and Asian (7.791,) races. tors fbr cardiovascular risk calculation. Those with Hispanic or Latino ethnicity have a lower preva Ience of CVD (8.2%) than non llispanic persons (11.7"1,). I(EY POIIIT Prevalence of hypertension is highest among non Hispanic . Validated risk prediction tools, such as the Pooled Black men (58.6')(,) and lowest among Asian women (So.q'L). Cohort Equations, can be used to identiff persons at The risk for diabetes is highest among American Indians and risk for the development of cardiovascular disease r,r,ho Alaska Natives (15.1'l.). would benefit from preventive measures, including GIobally, the prevalence ofcardiovascular risk factors and statin therapy. subsequent CVD is increasing because of changes in tobacco

55 years, females younger than 65 years) in parents doubles thereby identifying persons u,ho would benefit lrom preven the risk fbr myocardial infarction (MI) in men and increases tive measures. including statin therapy The PCE is the single risk in women by 7O"/,,. Stroke in a first-degree relative most robust tool for estimating 10 year risk in U.S. adults aged increases risk for stroke by 50'/.. A parental history of atrial 40 to 75 years and is recommended by the U.S. Preventive fibrillation increases odds of this condition by B0'){,. In addi Services Task Force and other organizations to assess athero tion to the shared environment (i.e., lifestyle), genetics may sclerotic CVD risk. contribute to increased risk in family members, although no According to the ACCIAHA. in patients with borderline (5'x, to <7.5'7,) or intermediate (>7.5')(, to <20'l,) l0-year athero genetic profile has been shown to explain a significant per centage of CVD incidence. sclerotic CVD risk based on the PCE. it is reasonable to further refine individual risk based on the presence of risk enhancing f.actors. such as chronic kidney disease (CKD). selected testing Ethnicity (e.g., high-sensitivity C reactive protein level. ankle brachial There are significant racial and ethnic disparities in the risk index), and lamily history of premature CAD. The U.S. and prevalence for CVD in the United States. The prevalence of Preventive Services Task Force concluded that there is insuf- CVD is highest among American Indian or Alaska Native ficient evidence to recommend using nontraditional risk fac (74.6y.\, white (11.5",{,), Black (10.0'U,), and Asian (7.791,) races. tors fbr cardiovascular risk calculation. Those with Hispanic or Latino ethnicity have a lower preva Ience of CVD (8.2%) than non llispanic persons (11.7"1,). I(EY POIIIT Prevalence of hypertension is highest among non Hispanic . Validated risk prediction tools, such as the Pooled Black men (58.6')(,) and lowest among Asian women (So.q'L). Cohort Equations, can be used to identiff persons at The risk for diabetes is highest among American Indians and risk for the development of cardiovascular disease r,r,ho Alaska Natives (15.1'l.). would benefit from preventive measures, including GIobally, the prevalence ofcardiovascular risk factors and statin therapy. subsequent CVD is increasing because of changes in tobacco 2

Diagnostic Testing in CardiologY nonadherence. Patients with well controlled HIV (undetecta- Specific Risk Groups ble viral load, normal CD4 cell count) may still be at increased Women risk. especially in the setting of concomitant metabolic syn 5 Hyperlipiden.ria, type 2 diabetes. obesity, and tobacco use con drome, lipodystrophyrlipoatrophy, fatty Iiver disease, or hepa I ler greater risk for CAD in women compared with men. titis C virus co infection; this increased risk may be related t Beyond those more traditional risk factors. some prior obstet to the effects of antiretroviral therapy. Patients with HIV t ric complications, including preeclampsia, gestational hyper risk enhancing factors should be considered for intensive tension or diabetes, and preternr or lort, birth weight delivery I L therapeutic lifestyle modifi cations, lipid-lowering therapy, or I increase CVD risk in women. CVD risk is also increased in referral to a specialist. \ women with early menopause or polycystic ovary syndrome. CVD remains the leading cause of death in women, result- I s i ing in more deaths than those caused by cancer. diabetes, and I kidney disease combined. Approximately two thirds of women Diagnostic Testing in Cardiology I t who clie of MI are asymptonlatic or have symptoms unrecog nized as cardiac in origin. Chest pain is the most common i presenting anginal symptom in both men and women, but Clinical History and wonren are more likely to report chest pain that is nonexer Physical Examination t

t who clie of MI are asymptonlatic or have symptoms unrecog nized as cardiac in origin. Chest pain is the most common i presenting anginal symptom in both men and women, but Clinical History and wonren are more likely to report chest pain that is nonexer Physical Examination t I I tional, occurs during sleep, or is induced by mental stress. In patients with MI, chest pain is reported less frequently by The diagnostic cornerstone of cardiovascular disease is the i women than by men. ln addition, :rfter an acute coronary clinical history and physical examination. A careful history I syndrome, women undergo f'ewer interventions, have more that includes symptom characteristics, timing, and duration; I con.rplications. and have higher unadjusted mortality. Mortality factors that exacerbate or relieve symptoms; and functional within the first year after a first I\41 is 23% in women versus capaci$/ is critical to ensuring a focused and appropriate diag I nostic evaluation. Abnormal findings on the cardiovascular 18'7, in men. Acute MI mortality is highest among Black I \{,omen. Black women also have a higher prevalence of CVD examination also may raise suspicion for specific cardiac con (10..5'){,) compared with White women (s.l'I,) and Hispanic ditions and guide test selection. \ romen (8.0'7,). Despite this illness burden, women have been Cardiovascular testing can provide both diagnostic and underrepresented in clinical treatment trials, making it chal- prognostic infbrmation, and its use should be guided by symp I lenging to extrapolate treatment decisions. ton.rs, the pretest likelihood of disease, whether testing results will alter patient management, and shared decision making Chronic Kidney Disease with patients. CKD is associated with higher incidence of CVD and worse cardiovascular outconles. In persons with CKD versus without Diagnostic Testing for CKI). the incidence rate (per 1000 person years) for CAD is 24.5 versus 8.4 and fbr stroke is 13.4 versus 4.8. The risk for Atherosclerotic Corona ry CVD related death is 5 to 30 times higher in patients under Artery Disease going dialysis than in those with similar risk factors and pre Diagnostic testing for coronary artery disease (CAD) can be served kidney function. categorized as providing functional and/or anatomic evidence of:rtherosclerotic burden. Functional studies reveal the pres Systemic lnflammation and HIV ence of ischemia (exercise ECG, single photon emission CT The risk for CVD is higher in patients with systemic inflamma. [SPECT], PET), the extent and severity of ischemia (SPECT, tory conditions, such as systemic lupus erythematosus and PET), information on coronary blood llow (PE't fractional flow rheumatoid arthritis. The risk tbr CAD is nearly 607, higher in reserve [FFR]-CT), and developmer.rt of wall motion abnor patients with rheun.ratoid arthritis and is nearly doubled in malities (echocardiography, cardiac magnetic resonance patients with systemic lupus erythematosus. The increased [CMR] imaging). Anatomic infbrmation is obtained from inva risk in these patients may be a result of the inflammatory sive angiography, coronary CT angiography (CTA), and coro process, a prothrombotic state, insulin resistance, and use of nary artery calcium (CAC) scoring. Cardiac diagnostic testing glucocorticoids or other immunosuppressive therapy in addi modalities are summarized in Table 1. tion to traditional cardiovascular risk factors. Certain HIV related risk enhancing factors may cor.rf'er a Cardiac Stress Testing 1.5 to 2 times higher risk fbr CVD than the calculated risk Cardiac stress testing is commonly performed to stratify risk in using the ACC/AHA CVD risk calculator. HIV risk enhancing those with or suspected of having CAD. Appropriate, cost factors include history of prolonged HIV virernia and/or delay efl'ective stress testing is based on the history. examination in antiretroviral therapy initiation, low current or nadir findings, and pretest probability of CAD (see Coronary Artery CD4 cell count (<350/pL), and HIV treatment failure or Disease). The pretest probability takes into account age, sex,

I I tional, occurs during sleep, or is induced by mental stress. In patients with MI, chest pain is reported less frequently by The diagnostic cornerstone of cardiovascular disease is the i women than by men. ln addition, :rfter an acute coronary clinical history and physical examination. A careful history I syndrome, women undergo f'ewer interventions, have more that includes symptom characteristics, timing, and duration; I con.rplications. and have higher unadjusted mortality. Mortality factors that exacerbate or relieve symptoms; and functional within the first year after a first I\41 is 23% in women versus capaci$/ is critical to ensuring a focused and appropriate diag I nostic evaluation. Abnormal findings on the cardiovascular 18'7, in men. Acute MI mortality is highest among Black I \{,omen. Black women also have a higher prevalence of CVD examination also may raise suspicion for specific cardiac con (10..5'){,) compared with White women (s.l'I,) and Hispanic ditions and guide test selection. \ romen (8.0'7,). Despite this illness burden, women have been Cardiovascular testing can provide both diagnostic and underrepresented in clinical treatment trials, making it chal- prognostic infbrmation, and its use should be guided by symp I lenging to extrapolate treatment decisions. ton.rs, the pretest likelihood of disease, whether testing results will alter patient management, and shared decision making Chronic Kidney Disease with patients. CKD is associated with higher incidence of CVD and worse cardiovascular outconles. In persons with CKD versus without Diagnostic Testing for CKI). the incidence rate (per 1000 person years) for CAD is 24.5 versus 8.4 and fbr stroke is 13.4 versus 4.8. The risk for Atherosclerotic Corona ry CVD related death is 5 to 30 times higher in patients under Artery Disease going dialysis than in those with similar risk factors and pre Diagnostic testing for coronary artery disease (CAD) can be served kidney function. categorized as providing functional and/or anatomic evidence of:rtherosclerotic burden. Functional studies reveal the pres Systemic lnflammation and HIV ence of ischemia (exercise ECG, single photon emission CT The risk for CVD is higher in patients with systemic inflamma. [SPECT], PET), the extent and severity of ischemia (SPECT, tory conditions, such as systemic lupus erythematosus and PET), information on coronary blood llow (PE't fractional flow rheumatoid arthritis. The risk tbr CAD is nearly 607, higher in reserve [FFR]-CT), and developmer.rt of wall motion abnor patients with rheun.ratoid arthritis and is nearly doubled in malities (echocardiography, cardiac magnetic resonance patients with systemic lupus erythematosus. The increased [CMR] imaging). Anatomic infbrmation is obtained from inva risk in these patients may be a result of the inflammatory sive angiography, coronary CT angiography (CTA), and coro process, a prothrombotic state, insulin resistance, and use of nary artery calcium (CAC) scoring. Cardiac diagnostic testing glucocorticoids or other immunosuppressive therapy in addi modalities are summarized in Table 1. tion to traditional cardiovascular risk factors. Certain HIV related risk enhancing factors may cor.rf'er a Cardiac Stress Testing 1.5 to 2 times higher risk fbr CVD than the calculated risk Cardiac stress testing is commonly performed to stratify risk in using the ACC/AHA CVD risk calculator. HIV risk enhancing those with or suspected of having CAD. Appropriate, cost factors include history of prolonged HIV virernia and/or delay efl'ective stress testing is based on the history. examination in antiretroviral therapy initiation, low current or nadir findings, and pretest probability of CAD (see Coronary Artery CD4 cell count (<350/pL), and HIV treatment failure or Disease). The pretest probability takes into account age, sex, 3