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• W2029963313 abstract "During the last 2 decades, numerous epidemiologic and intervention studies have established the role of various risk factors with the hazard of major coronary artery disease (CAD) events, including lipid disorders (elevated levels of low-density lipoprotein [LDL] cholesterol and low levels of high-density lipoprotein [HDL] cholesterol), hypertension (and left ventricular hypertrophy), smoking, diabetes mellitus, obesity, and physical inactivity.1Lavie CJ Lipid and lipoprotein fractions and coronary artery disease.Mayo Clin Proc. 1993; 68: 618-619Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 2Lavie CJ Milani RV High-density lipoprotein cholesterol and coronary risk in the elderly.Cardiology in the Elderly. 1994; 2: 251-252Google Scholar, 3O'Keefe JH Lavie CJ McCallister BD Insights into the pathogenesis and prevention of coronary artery disease.Mayo Clin Proc. 1995; 70: 69-79Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 4Lavie CJ Milani RV Messerli FH Prevention and reduction of left ventricular hypertrophy in the elderly.in: Holland KK Aronow WS Tresch DD Clinics in geriatric medicine: coronary artery disease in the elderly. W.B. Saunders Company, Philadelphia1996: 57-68Google Scholar, 5Lavie CJ Milani RV Effects of cardiac rehabilitation and exercise training in obese patients with coronary artery disease.Chest. 1996; 109: 52-56Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 6Lavie CJ Milani RV Squires RW et al.Exercise and the heart: good, benign, or evil?.Postgrad Med. 1992; 91: 130-150Crossref PubMed Scopus (23) Google Scholar Interestingly, in this issue of CHEST (see page 680), Nomori and colleagues demonstrated that a secretory protein of Clara cells, nonciliated, nonmucous epithelial cells of bronchioles, is associated with abnormal lipids (higher levels of total cholesterol and triglycerides, and lower levels of HDL cholesterol), obesity, and increased risk of atherosclerosis. Several additional risk factors also are associated with increased risk of CAD events, which, if modified, might lower the incidence of CAD events.7Pasternak RC Grundy SM Levy D et al.Task force 3: spectrum of risk factors for coronary heart disease.J Am Coll Cardiol. 1996; 27: 964-1047Abstract Full Text PDF PubMed Scopus (80) Google Scholar Although substantial evidence has indicated the detrimental effects of increasing LDL cholesterol on CAD risk, recent evidence demonstrates the differing atherogenic risk of various LDL particles.1Lavie CJ Lipid and lipoprotein fractions and coronary artery disease.Mayo Clin Proc. 1993; 68: 618-619Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3O'Keefe JH Lavie CJ McCallister BD Insights into the pathogenesis and prevention of coronary artery disease.Mayo Clin Proc. 1995; 70: 69-79Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 7Pasternak RC Grundy SM Levy D et al.Task force 3: spectrum of risk factors for coronary heart disease.J Am Coll Cardiol. 1996; 27: 964-1047Abstract Full Text PDF PubMed Scopus (80) Google Scholar, 8Lavie CJ Milani RV Effects of cardiac rehabilitation and exercise training on low-density lipoprotein cholesterol in patients with hypertriglyceridemia and coronary artery disease.Am J Cardiol. 1994; 74: 1192-1195Abstract Full Text PDF PubMed Scopus (59) Google Scholar Substantial evidence indicates that small, dense LDL particles (pattern B), which are strongly associated with high levels of triglycerides, low HDL cholesterol, and insulin resistance, are oxidized more easily and are considerably more atherogenic than large, more bouy-ant LDL particles. This is consistent with data from lipid lowering trials suggesting that the greatest reduction in CAD morbidity and mortality occurs with LDL cholesterol lowering in patients with hypertriglyceridemia and low HDL cholesterol.2Lavie CJ Milani RV High-density lipoprotein cholesterol and coronary risk in the elderly.Cardiology in the Elderly. 1994; 2: 251-252Google Scholar, 7Pasternak RC Grundy SM Levy D et al.Task force 3: spectrum of risk factors for coronary heart disease.J Am Coll Cardiol. 1996; 27: 964-1047Abstract Full Text PDF PubMed Scopus (80) Google Scholar, 9Manninen V Tenkanen L Koskinen P et al.Joint effects of serum triglyceride and LDL cholesterol and HDL cholesterol concentrations on coronary heart disease risk in the Helsinki Heart Study: implications for treatment.Circulation. 1992; 85: 37-45Crossref PubMed Scopus (1215) Google Scholar Weight reduction and exercise training, which beneficially alters the atherogenic properties of these LDL particles without necessarily lowering absolute LDL levels, may have a substantial impact on CAD risk in patients with this LDL subtype.8Lavie CJ Milani RV Effects of cardiac rehabilitation and exercise training on low-density lipoprotein cholesterol in patients with hypertriglyceridemia and coronary artery disease.Am J Cardiol. 1994; 74: 1192-1195Abstract Full Text PDF PubMed Scopus (59) Google Scholar, 10Wilhams PT Krauss RM Vranizan KM et al.Changes in lipoprotein subfractions during diet-induced and exercise-induced weight loss in moderately overweight men.Circulation. 1990; 81: 1293-1304Crossref PubMed Scopus (169) Google Scholar Niacin therapy markedly reduces the levels of small, dense LDL particles along with improving other aspects of the lipoprotein profile (lowering LDL cholesterol and triglycerides and raising HDL cholesterol).3O'Keefe JH Lavie CJ McCallister BD Insights into the pathogenesis and prevention of coronary artery disease.Mayo Clin Proc. 1995; 70: 69-79Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 11Superko HR Wilhams PT Alderman EL SCRIP Investigators Differential effect on HDL of niacin and resin in LDL subclass pattern A and B subjects [abstract].Circulation. 1993; 88: I-386Google Scholar Lipoprotein(a) (Lp[a]) consists of an LDL molecule linked to an additional large glycoprotein designated as apo(a). Lp(a), which is structurally homologous with plasminogen, is a potential inhibitor of fibrinolysis, which may affect thrombosis and acute CAD events, as well as the chronic atherosclerotic process.1Lavie CJ Lipid and lipoprotein fractions and coronary artery disease.Mayo Clin Proc. 1993; 68: 618-619Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 7Pasternak RC Grundy SM Levy D et al.Task force 3: spectrum of risk factors for coronary heart disease.J Am Coll Cardiol. 1996; 27: 964-1047Abstract Full Text PDF PubMed Scopus (80) Google Scholar Lp(a) levels largely are determined genetically through autosomal dominant inheritance, making it the most common inherited lipoprotein disorder associated with premature CAD. Levels of Lp(a) increase slightly with age and after menopause in women, and they are higher in blacks. Among conventional therapies, only estrogen therapy and niacin lower Lp(a) levels. Although substantial evidence implicates Lp(a) in the acute and chronic atherosclerotic processes, prospective interventional trials aimed at lowering Lp(a), as well as information on the relative risk of Lp(a) and its various isoforms (as well as the various laboratory methods to assess this) need to become available before this lipoprotein is assessed routinely and treated in clinical practice. Homocysteine, an amino acid dependent in part on the enzyme cystathionine B-synthase, has been associated with increased CAD, peripheral vascular disease, as well as venous thromboembolism.7Pasternak RC Grundy SM Levy D et al.Task force 3: spectrum of risk factors for coronary heart disease.J Am Coll Cardiol. 1996; 27: 964-1047Abstract Full Text PDF PubMed Scopus (80) Google Scholar From both mechanistic and epidemiologic standpoints, homocysteine appears to be unrelated to other CAD risk factors. Elevated homocysteine levels are present in 20% of the Framingham Heart Study population12Selhub J Jacques PF Wilson PW et al.Vitamin status and intake as primary determinants of homocysteinemia in an elderly population.JAMA. 1993; 270: 2693-2698Crossref PubMed Scopus (1849) Google Scholar and in 30 to 50% of patients with vascular disease.13Clarke R Daly L Robinson K et al.Hyperhomocysteinemia: an independent risk factor for vascular disease.N Engl J Med. 1991; 324: 1149-1155Crossref PubMed Scopus (2043) Google Scholar In addition, elevated homocysteine levels are associated with deficiencies of vitamin β6, β12, and folate, and they can be lowered by supplementing these vitamins. We are currently assessing the effects of cardiac rehabilitation and exercise training on homocysteine levels in patients with established CAD. Prospective clinical trials have been proposed to assess various interventions to reduce homocysteine levels. At present, some experts advocate the use of folate supplements (with vitamin β12 in the elderly), particularly in patients with mildly elevated homocysteine levels and established CAD or with very high CAD risk. Extensive laboratory data indicate that the oxidative modification of LDL in the arterial wall represents the final common pathway in the atherosclerotic process.1Lavie CJ Lipid and lipoprotein fractions and coronary artery disease.Mayo Clin Proc. 1993; 68: 618-619Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3O'Keefe JH Lavie CJ McCallister BD Insights into the pathogenesis and prevention of coronary artery disease.Mayo Clin Proc. 1995; 70: 69-79Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 7Pasternak RC Grundy SM Levy D et al.Task force 3: spectrum of risk factors for coronary heart disease.J Am Coll Cardiol. 1996; 27: 964-1047Abstract Full Text PDF PubMed Scopus (80) Google Scholar, 14Lavie CJ O'Keefe Jr, JH Mehra MR et al.Potential role of antioxidants in the primary and secondary prevention of atherosclerosis in the elderly.Cardiology in the Elderly. 1995; 3: 21-25Google Scholar, 15Mehra MR Lavie CJ Ventura HO et al.Prevention of atherosclerosis: the potential role of antioxidants.Postgrad Med. 1995; 98: 175-184PubMed Google Scholar Substantial epidemiologic evidence indicates that various dietary antioxidants, particularly vitamin E and to a lesser extent vitamin C, usually consumed as dietary supplements, protect against CAD in both men and women. Other antioxidants, including estrogens (which also lower LDL cholesterol, increase HDL cholesterol, improve endothelial function, enhance insulin sensitivity, and reduce levels of Lp[a] and possibly fibrinogen), selenium, magnesium, dietary flavinoids, and monounsaturated fats, may also protect against atherosclerosis. A large prospective randomized trial of vitamin E in people with CAD showed a 47% decrease in risk of nonfatal myocardial infarction or cardiovascular death after only 1½ years.16Stephens NG Parsons A Schofield PM et al.Randomized controlled trial of vitamin E in patients with coronary disease: Cambridge Heart Antioxidant Study (CHAOS).Lancet. 1996; 347: 781-786Abstract PubMed Scopus (1976) Google Scholar Although other prospective, randomized trials of antioxidants are currently underway, because of the considerable epidemiologic and laboratory evidence, as well as the low cost and toxicity of these therapies, we currently recommend vitamin E (200 to 800 IU/d), with or without vitamin C (500 to 1,000 IU/d), for patients with known CAD or high CAD risk.3O'Keefe JH Lavie CJ McCallister BD Insights into the pathogenesis and prevention of coronary artery disease.Mayo Clin Proc. 1995; 70: 69-79Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 14Lavie CJ O'Keefe Jr, JH Mehra MR et al.Potential role of antioxidants in the primary and secondary prevention of atherosclerosis in the elderly.Cardiology in the Elderly. 1995; 3: 21-25Google Scholar, 15Mehra MR Lavie CJ Ventura HO et al.Prevention of atherosclerosis: the potential role of antioxidants.Postgrad Med. 1995; 98: 175-184PubMed Google Scholar, 16Stephens NG Parsons A Schofield PM et al.Randomized controlled trial of vitamin E in patients with coronary disease: Cambridge Heart Antioxidant Study (CHAOS).Lancet. 1996; 347: 781-786Abstract PubMed Scopus (1976) Google Scholar, 17O'Keefe Jr, JH Lavie CJ Vitamin E and the risk of coronary disease [letter].N Engl J Med. 1993; 329: 1424Crossref PubMed Scopus (6) Google Scholar Although cardiovascular and CAD morbidity and mortality rates have been declining during the last 2 decades, recent statistics indicate that with the aging of the population, the overall prevalence and mortality from CAD is projected to increase during the next 2 decades; even adjusted for inflation, the cost of managing CAD is projected to increase markedly.18Frye RL Higgins MW Beller GA et al.Major demographic and epidemiologic trends affecting adult cardiology.J Am Coll Cardiol. 1988; 12: 840-846Abstract Full Text PDF PubMed Scopus (21) Google Scholar In addition, in nearly 50% of patients, the first and only presentation of CAD is sudden cardiac death; only preventive cardiology can be expected to intervene in this process. Therefore, vigorous attention at “cost effective” strategies to improve the established and evolving CAD risk factors will continue to be the major focus of most clinicians." @default.
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• W2029963313 title "Update on New Coronary Risk Factors" @default.
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