Medical Pharmacology Chapter 41:  Evaluation, Risk Assessment and  Anesthesia for Cardiovascular Procedures

 

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Risk Factors for Atherosclerosis
  • 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.
 

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