Physical Activity

•  Habitual physical activity associated with reduced incidence of sudden death

  • lowers blood pressure

  • lowers triglyceride levels

  • raises HDL cholesterol levels

  • reduces/maintains body weight and muscle tissue

•  Beneficial effects may be primarily due to exercise-mediated reduced BP and serum cholesterol levels, reduced weight (decreased body fat), better glucose tolerance and increased fibrinolytic activity.

Obesity

•  Independent risk predictor (Framingham Study) for both sexes

•  Increased weight positively and independently correlated with:

  • coronary artery disease

  • stroke

  • congestive heart failure

  • cardiovascular deaths

•  Obesity is correlated with other risk factors, e.g. hypertension, hypertriglyceridemia, lack of exercise, hyperinsulinemia and varies inversely with serum HDL cholesterol

Platelets

• May promote coronary vasospasm

• Possibly increased platelet coagulant activity in patients with coronary artery disease 

Family History

• Familial aggregation of risk factors: hypercholesterolemia spacer + hypertension + diabetes and obesity

• Homocystinuria-associate disaster disease

• Genetics may influence:

  • extent, time,  course, atherosclerosis severity, and symptoms

 Behavioral Factors Predisposing to Coronary Vascular Disease (CAD) 

• Emotional distress 

• Circadian rhythm variations

• "Educational" Level: inverse relationship between educational level and cardiovascular disease/death

  • Interpretation: relationship between educational level and ability/willingness to modify behavior and alter other CAD risk factors

Stress (type A personality)

• Type "A"personality consistent with competitiveness, impatience, ambition

• Possible positive correlation between CAD and type A personality

  • Independent risk factor possibly a strong as hypertension, serum cholesterol, tobacco use ( smoking)

Glucose Intolerance

• Diabetes mellitus (impaired glucose tolerance)

• Frequency: 20% of the population

• Diabetes: major risk factor highly correlated with obesity, hypertension, and lipid abnormalities (Framingham Study)

  • Additional adverse effects secondary to:

    • platelet dysfunction

    • increased erythrocyte adhesion

•  Cardiovascular morbidity/mortality: increased 4-6-fold in patients with type II diabetes*

  •  High prevalence: due to many factors including specific cardiac risk factors (hypertension and hyperlipidemia)

  •  Characteristics of type II diabetes:

    •  insulin resistance, hyperinsulinemia, altered carbohydrate/lipid metabolism (causing hyperglycemia), increased blood very low density and low-density lipoproteins and decreased blood high-density lipoproteins

  •  Pathophysiology: Type II diabetes:

    •  Vasculopathy-predisposing factors -- vessel wall lipid deposition, resulting/associated with:

      • monocyte infiltration, atrial mural fibrosis, thrombosis, vascular smooth muscle filtration

  • Treatment issues:

    •  Limited efficacy associated with angioplasty andcoronary bypass surgical interventions

    •  Important to reduce other cardiac risk factors, i.e. hypertension

    •  Important to reduce/reverse insulin resistance; improve metabolic control without worsening hyperinsulinemia

    •  Pharmacological treatment: biguanides and thiozolidinediones which sensitize tissues to insulin

    •  Other treatment: diet and exercise

Gender

• Decreased atherosclerosis incidence: women

• Males: increased likelihood for myocardial infarction (10 X)

Alcohol Use:

• Probable inverse relationship between alcohol use (moderate) and coronary vascular disease

  •  > 2 or more drinks/day: elevated blood pressure

  • Heavy drinking: increased mortality, many etiologies

Primary Reference: Katz, J.,  Evaluation Risk Assessment of Patients with Vascular Disease in Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 201-218, 1998.

* Schneider, D.J. and Sobel, B.E. Determinants of Coronary Vascular Disease in Patients with Type II Diabetes Mellitus and their Therapeutic Implications, Clin. Cardiol. May; 20(5): 433-440. Review, 1997.