Chronic Coronary Disease: Difference between revisions

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== Introduction ==
Even though coronary disease mortality rates have declined since 1970, it is still the leading cause of death in many western countries and in an increasing number of non western countries. <Cite>REFNAME1</Cite>
Even though chronic coronary disease mortality rates have declined since 1970 it is still the leading cause of death in many western countries and in an increasing number of non western countries. PMID 20177011


The reduction in mortality rates is the result of improved acute care and improved primary and secondary prevention. <Cite>REFNAME2</Cite>, <Cite>REFNAME3</Cite>


The cause of the reduction in mortality rates is mainly due to rapid recognition at special cardiac care units and the possibility of early intervention.  PMID 11004141, PMID 11182101
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The following risk factors for chronic coronary disease are modifiable and should be dealt with. <Cite>REFNAME4</Cite>


But because survivors of a myocardial infarction still face a substantial risk of further cardiovascular events recognizing and reducing of risk factors is very important.  
==Cigarette smoking==
Damages the endothelium of the blood vessels potentially facilitating cholesterol adherence. Smoking is a reversible and therefore a leading preventable cause of coronary disease.  All patients who smoke should be counselled to give up smoking. Nicotine replacement therapy and behavioural therapy can assist. [ OR 2.87 for current vs never, PAR 35.7% for current and former vs never.] <Cite>REFNAME4</Cite>


==Hypertension==
Is defined as a systolic pressure >140 mmHg and/or diastolic pressure >90 mmHg. Patients with hypertension should be first treated with non pharmacologic therapies, including salt restriction, weight reduction in overweight/obese patients, and avoidance of excess alcohol intake. Antihypertensive drugs are indicated in patients with persistent hypertension despite non pharmacologic therapy. Most patients will require multiple antihypertensive drug therapies. [ OR 1.91, PAR 17.9%] <Cite>REFNAME4</Cite>


The following risk factors for chronic coronary disease are modifiable and should be tackled. PMID 15364185
==Cholesterol==
Is the felon in the atherosclerosis tale and therefore cholesterol levels in the blood should be optimal, meaning low LDL levels and high HDL levels. Secondary causes of dyslipidemia should be excluded. The target level of LDL is 2,5 mmol/L in stable patients and 1.8 mmol/L in high risk patients, including post ACS patient. This can be achieved by the use of lipid lowering therapy particularly statins. [ OR 3.25 for top vs lowest quintile, PAR 49.2% for top four quintiles vs lowest quintile] <Cite>REFNAME4</Cite>


== Risk Factors ==  
==Exercise==
=== Cigarette Smoking ===
Lowers morbidity and mortality from coronary disease. [ OR 0.86, PAR 12.2%] <Cite>REFNAME4</Cite> Patients should be encouraged to exercise 5 times a week during 30 minutes. Referral to fitness program may be useful.  
Cigarette smoking damages the endothelium of the blood vessels potentially facilitating cholesterol adherence. Smoking is a reversible and therefore a leading preventable cause of coronary disease.  All patients who smoke should be counselled to give up smoking. Nicotine replacement therapy and behavioural therapy can assist . [ OR 2.87 for current vs never, PAR 35.7% for current and former vs never.]
=== Hypertension  ===
Hypertension is defined as a systolic pressure >140 mmHg and/or diastolic pressure >90 mmHg. Patients with hypertension should be first treated with non pharmacologic therapies, including salt restriction, weight reduction in overweight/obese patients, and avoidance of excess alcohol intake. Antihypertensive drugs are indicated in patients with persistent hypertension despite non pharmacologic therapy. Most patients will require multiple antihypertensive drug therapies. [ OR 1.91, PAR 17.9%]


=== Cholesterol ===
==Obesity==
Cholesterol is the felon in the atherosclerosis tale and therefore cholesterol levels in the blood should be optimal, meaning low LDL levels and high HDL levels. This can be achieved by the use of lipid lowering therapy which include statins. [ OR 3.25 for top vs lowest quintile, PAR 49.2% for top four quintiles vs lowest quintile]
Is associated with several risk factors for coronary heart disease, including hypertension, high cholesterol and insulin resistance as well as diabetes. Data show a relationship of higher body weight with morbidity and mortality from coronary disease. All patients who are willing to lose weight should receive information about behaviour modification, diet, and increased physical activity. [OR 1.12 for top vs lowest tertile and 1.62 for middle vs lowest tertile, PAR 20.1% for top two tertiles vs lowest tertile] <Cite>REFNAME4</Cite>


=== Obesity === 
==Healthy food choices==
Obesity is associated with several risk factors for coronary heart disease, including hypertension, high cholesterol and insulin resistance as well as diabetes. Data show a relationship of higher body weight with morbidity and mortality from coronary disease. All patients who are willing, ready and able to lose weight should receive information about behaviour modification, diet, and increased physical activity. [OR 1.12 for top vs lowest tertile and 1.62 for middle vs lowest tertile, PAR 20.1% for top two tertiles vs lowest tertile]
Potentially result in a lower risk of coronary disease. A healthy diet consists of high intake of fruit and vegetables, high fiber intake, a low glycemic index and load, unsaturated fat rather than saturated fat, a limited intake of red or processed meat and intake of omega 3 fatty acids. [OR 0.70, PAR 13.7% for lack of daily consumption of fruits and vegetables] <Cite>REFNAME4</Cite>


== Prevention ==
=== Exercise === 
Exercise lowers morbidity and mortality from coronary disease. [ OR 0.86, PAR 12.2%]
=== Healthy Diet ===
A healthy diet potentially results in a lower risk of coronary disease. A healthy diet consists of high intake of fruit and vegetables, high fiber intake, a low glycemic index and load, unsaturated fat rather than saturated fat, a limited intake of red or processed meat and intake of omega 3 fatty acids. [OR 0.70, PAR 13.7% for lack of daily consumption of fruits and vegetables]
Several studies have shown that people who have a high intake of fruit and vegetables have reduced risk coronary disease. It is possible that this is due to specific compounds in vegetables and fruits, or because people who eat more vegetables and fruits tend to eat less meat and saturated fat.
Several studies have shown that people who have a high intake of fruit and vegetables have reduced risk coronary disease. It is possible that this is due to specific compounds in vegetables and fruits, or because people who eat more vegetables and fruits tend to eat less meat and saturated fat.


*'''In diabetes mellitus''' tight glycemic control is important to protect against many vascular complications, including coronary disease. [OR 2.37, PAR 9.9%] <Cite>REFNAME4</Cite>
*A small amount of '''alcohol''' results in a lower risk of morbidity and mortality from coronary disease. Max. 3 units/day for men and 2 units/day for women. [OR 0.91, PAR 6.7%] <Cite>REFNAME4</Cite>


In '''diabetes mellitus''' tight glycemic control is important to protect against many vascular complications, including coronary disease. [OR 2.37, PAR 9.9%]
==Screening==
 


A small amount of '''alcohol''' results in a lower risk of morbidity and mortality from coronary disease. [OR 0.91, PAR 6.7%]
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|-
||Because extensive coronary disease can exist with minimal or no symptoms, screening for coronary disease has been suggested. Although screening results in indentifying patients at increased risk there is no evidence that screening actually improves outcome. <Cite>REFNAME5</Cite>
|-
|align="center" bgcolor="FFFFFF"|[[File:Mortality_risk_for_people_with_heart_disease_and_type_2_diabetes.svg|600px]]
|}


== Screening ==  
== References ==
Because extensive coronary disease can exist with minimal or no symptoms, screening for coronary disease has been suggested. Although screening results in indentifying patients at increased risk there is lack of evidence that screening actually improves outcome. PMID 12392846.
<biblio>
[[File:Mortality_risk_for_people_with_heart_disease_and_type_2_diabetes.png|center]]
#REFNAME1 pmid=20177011
#REFNAME2 pmid=11004141
#REFNAME3 pmid=11182101
#REFNAME4 pmid=15364185
#REFNAME5 pmid=12392846
</biblio>
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