Cardiac Risk Factors:

The commonest cardiac risk factors include: smoking, hypertension, high cholesterol, diabetes, and the presence of a family history of coronary disease. The presence of cardiac risk factors increases the chances of developing coronary artery disease, but the absence of risk factors does not exclude the possibility. In the case of suspected coronary artery disease, specific attention in managing these factors is always sought, as it may impact on disease progression.

Smoking:
There is no doubt as to the significance of this risk factor, and how important it is to stop smoking. It is never too late to stop! In addition to nicotine there are thought to be about 3500 toxins within a cigarette that are implicated in either: heart disease, lung disease and cancer. Smoking also contributes to poor blood pressure control.

Hypertension:
When the blood pressure remains elevated over a prolonged period, damage to certain body organs can occur via the small blood vessels. In the eyes this can be visualised directly by examining the blood vessels at the back of the eyes. In the brain, small vessel damage can cause a stroke, and in the kidneys cause kidney damage. In larger vessels such as the aorta, expansion by stretching can cause problems (aneurysm or dissection). Within the heart, prolonged elevation causes the heart muscle to thicken unnaturally. All these above effects can be assessed clinically and with a few tests.

Blood pressure may elevate with stress, or artificially when certain people measure it. In the latter case this can be due to “white coat hypertension”, but various blood pressure monitoring tests can exclude this. Sometimes patients can have variable blood pressure readings; so called labile hypertension. In these cases definite hypertension needs to be excluded clinically.

Treatment of hypertension is initially focussed on excluding obvious causes (although most cases are genetic). In certain cases extra tests may be performed to exclude secondary causes of hypertension that are potentially curable.

Lifestyle modification is paramount in improving blood pressure control, and includes modifying the usual suspects! (weight, smoking, and alcohol). If patients require medication for blood pressure, it is likely that they will need at two types of tablets over a period of time.
With good blood pressure control with lifestyle and medication, the potential problems and complications in the future can be averted.

High cholesterol:
Cholesterol is one of the body’s normal building blocks, and is the “cement” lining the walls of normal cells. Of course, if it accumulates elsewhere in the body such as blood vessels, it can cause problems. The total cholesterol reflects both the ingested amount and the amount being made in the liver. Thus despite eating healthily with a low cholesterol diet, a raised cholesterol is likely to reflect what is being made in the liver. In such cases, medication is usually necessary to lower it.

The total cholesterol value is measured as the sum of both good cholesterol (HDL, or high density lipoprotein), and bad cholesterol (LDL, or low density lipoprotein). The good cholesterol is so called as it helps mop up the bad LDL. Thus we need to ensure that HDL is maintained high enough (> 1.2mmol/l) to achieve this. This is sometimes overlooked in clinical practice where more attention is focused on LDL. One should be reminded that a low HDL is ranked the fourth highest independent risk factor for coronary disease. This especially relevant in the south Asian population, where low HDL can be prevalent. A more recent addition to the series of investigations includes Lp(a). This lipid sub-unit has emerged as an independent predictor of cardiovascular risk. Certainly in patients with a family history of coronary disease, or patients who are reticent about taking statins, this would be helpful.

Treatment for a low HDL includes exercise, weight reduction, red wine! and sometimes medication. For raised LDL, dietary modification with a low cholesterol diet should precede any medication. Statins are the commonest group of tablets to be prescribed. Occasionally statins are not tolerated due to side-effects, but alternatives exist. Triglycerides are another group of chemicals that can accumulate in blood vessels and also cause damage. They are considered the 10th highest independent risk factor for developing coronary disease. Elevation can be secondary to alcohol excess, diabetes or low thyroid activity. If not, it can be uncommonly a genetic problem, and require specific medication.

The most important genetic condition is Familial Hyperlipidaemia (FH). It is now recognised as more prevalent than previously thought. Thus, in a patient with a cholesterol >7.0 mmol/l, screening of family members is recommended. This may include children from the age of 10 years. In addition, one would aggressively reduce cholesterol with medications, despite the absence of other cardiovascular risk factors. Dietary modification should always be pursued in the first instance, but the majority of patients will need statins.