Czarnecka, Danuta

Drygas, Wojciech

Godycki-Ćwirko, Maciej

Gąsior, Zbigniew

Kopeć, Grzegorz

Kozek, Elżbieta

Małecki, Maciej

Naruszewicz, Marek

Opala, Grzegorz

Pająk, Andrzej

Pasowicz, Mieczysław

Podolec, Piotr

Rynkiewicz, Andrzej

Sieradzki, Jacek

Stańczyk, Jerzy

Torbicki, Adam

Undas, Anetta

Zdrojewski, Tomasz

Kardiologia Polska

English

Via Medica Journals

Epidemilogy and preventionPolish Forum for Prevention Guidelines on the so-called new cardiovascular risk factors and markers, which have a potentially significant role in the strategy for the prevention of cardiovascular diseases

Jagiellonian Univeristy Repository

Kardiologia Polska 2007; 65: 11Polish Forum for Prevention Guidelines on the so-callednew cardiovascular risk factors and markers, which have a potentially significant role in the strategy for theprevention of cardiovascular diseasesAnetta Undas1, Piotr Podolec2, Grzegorz Kopeć3, Andrzej Pająk4, Zbigniew Gąsior5, Maciej Małecki6, Mieczysław Pasowicz7, Andrzej Rynkiewicz8, Adam Torbicki9, Tomasz Zdrojewski10, Danuta Czarnecka11,Wojciech Drygas12, Maciej Godycki-Ćwirko13, Elżbieta Kozek14, Marek Naruszewicz15, Grzegorz Opala16, Jerzy Stańczyk17, Jacek Sieradzki181 Coordinator of the PFP Guidelines on new cardiovascular risk factors and markers (Polish Society of Internal Medicine)2 Chairman of the PFP Editorial Board 3 Secretary of the PFP Editorial Board4 Member of the PFP Editorial Board (Polish Cardiac Society)5 Expert on new cardiovascular risk factors and markers (Polish Cardiac Society)6 Expert on new cardiovascular risk factors and markers (Polish Diabetes Society)7 Expert on new cardiovascular risk factors and markers (Polish Cardiac Society)8 Expert of the PFP Editorial Board, Chairman of the Polish Cardiac Society9 Expert on new cardiovascular risk factors and markers, Honorary Member of PFP (Polish Cardiac Society)10 Expert of the PFP Editorial Board (Polish Cardiac Society)11 Member of the PFP Editorial Board (Polish Society of Hypertension)12 Expert of the PFP Editorial Board (Polish Cardiac Society)13 Member of the PFP Editorial Board (The College of Family Physicians in Poland)14 Member of the PFP Editorial Board (Polish Diabetes Society)15 Member of the PFP Editorial Board (Polish Society for Atherosclerosis Research)16 Member of the PFP Editorial Board (Polish Society of Neurology)17 Member of the PFP Editorial Board (Polish Paediatric Society)18 PFP Coordinator 2007 (Polish Diabetes Society)Kardiol Pol 2007; 65: 1396–1398Address for correspondence:Piotr Podolec MD, Klinika Chorób Serca i Naczyń Instytutu Kardiologii, Collegium Medicum UJ, KSS im. Jana Pawła II, ul. Prądnicka 80, 31-202 Kraków, tel.: +48 12 614 33 99, faks: +48 12 614 34 23, e-mail: ppodolec@interia.plIntroductionThe large case-control study INTERHEART [1], whichenrolled over 15 thousand patients from every inhabitedcontinent, showed that nine modifiable risk factorsaccounted for at least 90% of the risk of myocardialinfraction, which suggested that the role of additional riskfactors in the prediction of coronary events was minor.However, it is estimated that about 20% of patients withcardiovascular events do not have any of the main cardio-vascular risk factors and 50% have only one of them [2]. So far about 200 new risk factors have been identified.Many of them do not have standardized methods ofmeasurement or are not associated with cardiovascularrisk independently of the main cardiovascular risk factors. The search for new plasma risk factors which couldimprove detection of subjects at risk of atherosclerosisand its thromboembolic complications was bi-directionaland comprised:1) assessment of the markers of inflammation andendothelial function, because atherogenesis is a chronicinflammatory process of the arterial wall,2) assessment of the markers of activation of thrombosisand fibrinolysis, because myocardial infarction andischaemic stroke are consequences of thromboembolicprocesses. The so-called new risk factors for which the mostreliable evidence of their association with the risk ofcardiovascular events is available [3] are as follows.Epidemiologia i prewencja/Epidemiology and preventionKardiologia Polska 2007; 65: 11Serologic factors1) lipid risk factors:a) apolipoprotein B (Apo B)b) lipoprotein (a) [Lp(a)]c) lipoprotein-associated phospholipase A2 (Lp-PLA2)d) oxidised LDL2) inflammatory risk factors:a) C-reactive protein (CRP)b) serum amyloid A (SAA)c) interleukin 6 (IL-6) and interleukin 18 (IL-18)d) CD40 ligande) myeloperoxidase3) homocysteine4) asymmetric dimethylarginine (ADMA)5) matrix metalloproteinase 9 (MMP-9)6) tissue inhibitor of metalloproteinase 1 (TIMP-1)7) glutathione peroxidase activityStructural and functional risk factors1) intima-media thickness of carotid arteries (IMT)2) coronary calcium score3) arterial stiffness4) brachial-ankle index5) endothelial dysfunction6) albuminuria Haemostatic risk factors1) fibrinogen2) D-dimer 3) tissue plasminogen activator – tPA and plasminogenactivator inhibitor 1 (PAI-1)4) von Willebrand factor (vWF)Regarding the current guidelines of the EuropeanSociety of Cardiology, American Heart Association andAmerican College of Cardiology, it is not recommended toassess the so-called new risk factors in order to improveprediction of cardiovascular risk.No methods of clinically significant modification ofthese factors are currently available.It is unlikely that one new risk factor will improveprediction models based on the traditional risk factors,whose position is invariably strong. It is probablehowever that in the future a panel of biomarkers will beavailable, which will make possible an individualizedapproach to the therapy of cardiovascular diseases. Guidelines1. Haemostatic factors. The following factors have beenshown to increase cardiovascular disease (CVD) risk:fibrinogen (an increase in plasma fibrinogen concentrationof 1 g/l increases the risk of CVD incidence twofold),clotting factor VII, von Willebrand factor (vWF),plasminogen activator inhibitor (PAI-1), tissue plasminogenactivator (tPA). These factors can usually be improved bystandard preventive interventions. In some conditions it isjustified to introduce pharmacological treatment thatinfluences the haemostatic system as a preventive tool.Currently no specific intervention aimed at reduction ofCVD risk by modulating the aforementioned haemostaticfactors in the general population is available and theirroutine measurement to estimate CVD risk is notrecommended.2. Inflammatory markers. Elevated plasma levels ofCRP >3 mg/dl increase the risk of CVD events by about50%. Higher CVD risk has also been attributed to someother inflammatory markers such as: interleukins (IL-6,IL-10, IL-18), tumour necrosis factor α (TNF-α), solubleCD40 ligand (sCD40L), matrix metalloproteinase 9(MMP-9), myeloperoxidases. In clinical practice it is notrecommended to measure the aforementionedinflammatory markers in order to estimate CVD risk.3. Homocysteine. Homocysteine plasma levelselevation of 3 μmol/l increases the risk of coronary heartdisease and stroke by about 11–30% and about 20%respectively. A diet including at least 400 μg of folic acidper day reduces blood homocysteine concentration;however, no beneficial effect of folic acid supplementationon CVD risk has been achieved. In clinical practice it is notrecommended to measure the homocysteine level in orderto estimate CVD risk.4. Imaging methods such as B-mode ultrasoundmeasurement of intima-media thickness andendothelium dependent dilation of the vessel wall aswell as a quantitative assessment of artery calcificationby multislice computed tomography may contribute toestimation of the extent of atherosclerosis, to diagnosisof CVD in asymptomatic subjects and to assessment ofCVD risk. The role of these methods in populationscreening programmes has not been established.5. Intima-media thickness (IMT) of carotid arteriesreflects progression of the atherosclerotic process andmay be helpful in prediction of cardiovascular events inasymptomatic patients at intermediate CVD risk. IMTranging from 0.9 to 1.5 mm is classified as intima-mediacomplex thickening while IMT >1.5 mm is classified as anatherosclerotic plaque. 6. Coronary calcium score (CS) equal to zero (CS=0)indicates low risk of cardiovascular events in asymptomaticsubjects while in patients with symptoms of ischaemicheart disease it allows the presence of significant coronaryartery stenosis to be excluded with high probability.7. Heart rate – lower heart rate is associated withlower CVD risk. Physically active subjects have lowerheart rate, and an appropriate level of physical activity isone of the main recommendations in primary andsecondary prevention of CVD. An undoubted indicationfor pharmacological intervention is clinically significantelevated heart rate. However, it is not recommended tolower the heart rate by pharmacological means in orderto decrease CVD risk in primary prevention. 1397Polish Forum for Prevention Guidelines on the so-called new cardiovascular risk factors and markersKardiologia Polska 2007; 65: 118. Influenza vaccination – decreases the risk of acutecardiovascular events in patients with establishedcardiovascular disease. These subjects may benefit fromvaccination unless they have a contraindication toreceiving the vaccine. Vaccination with intramuscularlyadministered vaccine should be prescribed annually,optimally before the winter peak in influenza activity. 9. Assessment of genetic predisposition tocardiovascular diseases on the basis of family history isrequired in primary prevention. Premature CVD in firstdegree (parents, siblings, children) male relatives <55years and female relatives <65 years is associated with atleast twofold increase in CVD risk. The presence of CVDin other relatives has lower significance.Genetic studies should be prescribed only in patientssuspected of rare monogenic diseases, especially familiarhypercholesterolaemia. 10. Air pollution, such as a high concentration of smalldiameter particles <2.5 μm, is associated with increasedCVD risk. Air quality monitoring and restrictions onemissions of exhaust fumes from industry should be partof a population strategy in prevention of CVD. Currently, no efficient methods that could be useful inindividual counselling on air pollution in clinical practiceare available. References1. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiablerisk factors associated with myocardial infarction in 52 countries (theINTERHEART study): case-control study. Lancet 2004; 364: 937-52.2. Ridker PM, Libby P. Risk factors for atherothrombotic disease. In:Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s HeartDisease. Elsevier 7th Ed. Philadelphia 2005.3. European guidelines on cardiovascular disease prevention in clinicalpractice. Eur J Cardiovasc Prev Rehab 2003; 10 (Suppl.1): S1-S78.The Polish version of the guidelines as well as the introductory articleand comments from specialists and experts can be read in the seventhissue of Forum Profilaktyki and on the website www.pfp.edu.pl. Authorsof these articles are as follows:prof. dr hab. n. med. Lidia Brydak, prof. dr hab. n. med. Zbigniew Gąsior, prof. dr hab. n. med. Tomasz Grodzicki, prof. dr hab. n. med. Andrzej Rynkiewicz, prof. dr hab. n. med. Andrzej Steciwko, prof. dr hab. n. med. Adam Torbicki, dr hab. n. med. Maciej Małecki, dr hab. n. med. Mieczysław Pasowicz, dr hab. n. med. Piotr Podolec, dr hab. n. med. Anetta Undas, dr n. med. Grzegorz Kopeć, dr n. med. Tomasz Zdrojewski, dr Magdalena Strach, dr Urszula Kozera-Ptaszyńska.Tekst w polskiej wersji językowej jest dostępny pod adresem:www.pfp.edu.pl Errata. We wrześniowym numerze Kardiologii Polskiejw tekście Polish Forum for Prevention Guidelines on Arte-rial Hypertension Rycina 2. (strona 1139) została wydruko-wana z jednym błędem – poniżej wersja poprawiona.thiazide diureticsACE inhibitorsangiotensin--receptor antagonistsbeta-blockersalpha-blockerscalcium antagonistsFigure 2. Possible combinations between someclasses of antihypertensive drugsThe preferred combinations in the general hypertensive populationare represented as thick lines. The frames indicate classes of agents proven to be beneficial incontrolled intervention trials.1398 Anetta Undas et al.

Polish Forum for Prevention Guidelines on the so-called new cardiovascular risk factors and markers, which have a potentially significant role in the strategy for the prevention of cardiovascular diseases

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Polish Forum for Prevention Guidelines on the so-called new cardiovascular risk factors and markers, which have a potentially significant role in the strategy for the prevention of cardiovascular diseases

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