Recommendations for reducing risk of coronary artery disease have been jointly issued by the British Cardiac, Hyperlipidaemia, Hypertension and Diabetic Associations/Societies.
Risk Factors for Tables
Data needed to use risk tables:
(1) gender
(2) age
(3) presence or absence of diabetes mellitus
(4) presence or absence of smoking
(5) serum cholesterol measurements
(6) systolic blood pressure
Smoking status should reflect lifelong exposure to tobacco.
ratio of total cholesterol to HDL cholesterol =
= (total cholesterol in mmol/L) / (HDL cholesterol in mmol/L)
If HDL cholesterol results are not available, use 1.0 mmol/L as an approximate value. The ratio is then equal to the total cholesterol in mmol/L.
If the patient is already being treated for hyperlipidemia or for hypertension, then the risk tables should not be used.
First degree blood relatives should be screened if there is evidence of a familial hyperlipidemia or premature coronary heart disease (men < 55 years, women < 65 years of age).
Determination of Risk (see Table below)
The charts on pages 706-707 reflect the risk of developing a cardiovascular event in the next 10 years. The 15%, 20% and 30% lines were analyzed and approximating lines derived in JMP. These were plotted with systolic blood pressure as y-axis and cholesterol ratio as the x-axis.
Table ranges:
(1) cholesterol ratio from 3.0 to 11.0
(2) systolic blood pressure from 110 to 190 mm Hg
If the patient's systolic blood pressure < (systolic blood pressure from 15% risk equation), then risk of an event in next 10 years is < 15%.
If the patient's systolic blood pressure >= (systolic blood pressure from 15% risk equation) AND <= (systolic blood pressure from 20% risk equation) , then risk of an event in next 10 years is 15-20%.
If the patient's systolic blood pressure >= (systolic blood pressure from 20% risk equation) AND <= (systolic blood pressure from 30% risk equation) , then risk of an event in next 10 years is 20-30%.
If the patient's systolic blood pressure > (systolic blood pressure from 30% risk equation), then risk of an event in next 10 years is > 30%.
Risk for a patient may be greater than indicated in the charts if:
(1) there is a family history of premature coronary heart disease (< 55 years in men, < 65 years in women). A history of premature coronary heart disease increases the risk by about 1.5 times.
(2) there are elevated triglyceride levels
(3) there is impaired glucose tolerance without overt diabetes mellitus
(4) the patient is a woman with premature menopause
The predicted risk may not be valid for patients with ethnic/racial backgrounds different from the British general population.
|
Group |
Risk |
Equation for Systolic Pressure for Risk Line |
|---|---|---|
|
male, nondiabetic, nonsmoker, 35-45 |
15% |
(0.9223 * ((ratio)^2)) – (29.926 * (ratio)) + 359.567 |
|
0001 |
20% |
(1.5476 * ((ratio)^2)) – (42.36 * (ratio)) + 453.538 |
|
|
30% |
NA |
|
male, nondiabetic, nonsmoker, 45-55 |
15% |
(2.1176 * ((ratio)^2)) – (47.463 * (ratio)) + 368.344 |
|
0002 |
20% |
(1.7896 * ((ratio)^2)) – (43.616 * (ratio)) + 387.512 |
|
|
30% |
(6.545 * ((ratio)^2)) – (149.42 * (ratio)) + 1024.6 |
|
male, nondiabetic, nonsmoker, 55-65 |
15% |
(2.237 * ((ratio)^2)) – (45.037 * (ratio)) + 309.864 |
|
0003 |
20% |
(2.1792 * ((ratio)^2)) – (46.646 * (ratio)) + 348.31 |
|
|
30% |
(1.3247 * ((ratio)^2)) – (36.985 * (ratio)) + 378.73 |
|
male, nondiabetic, nonsmoker, 65-75 |
15% |
(8.4725 * ((ratio)^2)) – (92.641 * (ratio)) + 359.69 |
|
0004 |
20% |
(2.513 * ((ratio)^2)) – (48.197 * (ratio)) + 311.807 |
|
|
30% |
(1.666 * ((ratio)^2)) – (41.1 * (ratio)) + 352.38 |
|
male, nondiabetic, smoker, 35-45 |
15% |
(1.1896 * ((ratio)^2)) – (33.016 * (ratio)) + 319.998 |
|
0011 |
20% |
(1.867 * ((ratio)^2)) – (47.23 * (ratio)) + 422.686 |
|
|
30% |
– (15 * (ratio)) + 349 |
|
male, nondiabetic, smoker, 45-55 |
15% |
(3.002 * ((ratio)^2)) – (51.724 * (ratio)) + 316.65 |
|
0012 |
20% |
(3.2153 * ((ratio)^2)) – (58.514 * (ratio)) + 370.669 |
|
|
30% |
(1.7733 * ((ratio)^2)) – (45.835 * (ratio)) + 412.243 |
|
male, nondiabetic, smoker, 55-65 |
15% |
(2.1673 * ((ratio)^2)) – (39.492 * (ratio)) + 245.894 |
|
0013 |
20% |
(2.4247 * ((ratio)^2)) – (45.996 * (ratio)) + 295.31 |
|
|
30% |
(1.6703 * ((ratio)^2)) – (41.423 * (ratio)) + 349.149 |
|
male, nondiabetic, smoker, 65-75 |
15% |
NA |
|
0014 |
20% |
(6.313 * ((ratio)^2)) – (72.222 * (ratio)) + 300.795 |
|
|
30% |
(4.4521 * ((ratio)^2)) – (71.028 * (ratio)) + 386.574 |
|
male, diabetic, nonsmoker, 35-45 |
15% |
(1.53 * ((ratio)^2)) – (38.285 * (ratio)) + 333.062 |
|
0101 |
20% |
(1.7428 * ((ratio)^2)) – (44.576 * (ratio)) + 424.7 |
|
|
30% |
NA |
|
male, diabetic, nonsmoker, 45-55 |
15% |
(4.2853 * ((ratio)^2)) – (66.525 * (ratio)) + 365.174 |
|
0102 |
20% |
(1.6749 * ((ratio)^2)) – (39.445 * (ratio)) + 332.432 |
|
|
30% |
(2.3485 * ((ratio)^2)) – (56.075 * (ratio)) + 476.029 |
|
male, diabetic, nonsmoker, 55-65 |
15% |
– (24.092 * (ratio)) + 226.528 |
|
0103 |
20% |
(1.694 * ((ratio)^2)) – (39.596 * (ratio)) + 293.85 |
|
|
30% |
(1.837 * ((ratio)^2)) – (43.93 * (ratio)) + 368.743 |
|
male, diabetic, nonsmoker, 65-75 |
15% |
– (22.785 * (ratio)) + 196.053 |
|
0104 |
20% |
(2.07 * ((ratio)^2)) – (38.634 * (ratio)) + 251.408 |
|
|
30% |
(3.1167 * ((ratio)^2)) – (56.764 * (ratio)) + 363.327 |
|
male, diabetic, smoker, 35-45 |
15% |
(4.7616 * ((ratio)^2)) – (71.84 * (ratio)) + 374.285 |
|
0111 |
20% |
(1.5135 * ((ratio)^2)) – (38.06 * (ratio)) + 341.3 |
|
|
30% |
(1.6976 * ((ratio)^2)) – (45.175 * (ratio)) + 446.459 |
|
male, diabetic, smoker, 45-55 |
15% |
(3.1913 * ((ratio)^2)) – (50.826 * (ratio)) + 284.427 |
|
0112 |
20% |
(3.811 * ((ratio)^2)) – (59.852 * (ratio)) + 338.716 |
|
|
30% |
(1.742 * ((ratio)^2)) – (42.567 * (ratio)) + 364.833 |
|
male, diabetic, smoker, 55-65 |
15% |
– (20 * (ratio)) + 182 |
|
0113 |
20% |
– (24.644 * (ratio)) + 220.759 |
|
|
30% |
(2.1796 * ((ratio)^2)) – (44.17 * (ratio)) + 316.52 |
|
male, diabetic, smoker, 65-75 |
15% |
NA |
|
0114 |
20% |
– (27.5 * (ratio)) + 203.5 |
|
|
30% |
(2.851 * ((ratio)^2)) – (46.93 * (ratio)) + 278.514 |
|
female, nondiabetic, nonsmoker, 35-45 |
15% |
NA |
|
1001 |
20% |
NA |
|
|
30% |
NA |
|
female, nondiabetic, nonsmoker, 45-55 |
15% |
(1.5344 * ((ratio)^2)) – (40.352 * (ratio)) + 383.95 |
|
1002 |
20% |
(2.368 * ((ratio)^2)) – (58.982 * (ratio)) + 517.085 |
|
|
30% |
– (12.5 * (ratio)) + 322.5 |
|
female, nondiabetic, nonsmoker, 55-65 |
15% |
(1.9122 * ((ratio)^2)) – (43.78 * (ratio)) + 354.68 |
|
1003 |
20% |
(1.464 * ((ratio)^2)) – (38.45 * (ratio)) + 371.765 |
|
|
30% |
– (12.632 * (ratio)) + 316.95 |
|
female, nondiabetic, nonsmoker, 65-75 |
15% |
(2.67 * ((ratio)^2)) – (53.07 * (ratio)) + 370.545 |
|
1004 |
20% |
(1.191 * ((ratio)^2)) – (34.35 * (ratio)) + 344.20 |
|
|
30% |
(3.407 * ((ratio)^2)) – (81.132 * (ratio)) + 644.25 |
|
female, nondiabetic, smoker, 35-45 |
15% |
(0.9684 * ((ratio)^2)) – (31.932 * (ratio)) + 377.98 |
|
1011 |
20% |
– (11.21 * (ratio)) + 300.276 |
|
|
30% |
NA |
|
female, nondiabetic, smoker, 45-55 |
15% |
(2.887 * ((ratio)^2)) – (54.81 * (ratio)) + 367.899 |
|
1012 |
20% |
(2.3399 * ((ratio)^2)) – (51.48 * (ratio)) + 406.89 |
|
|
30% |
(2.564 * ((ratio)^2)) – (64.359* (ratio)) + 559.692 |
|
female, nondiabetic, smoker, 55-65 |
15% |
(5.843 * ((ratio)^2)) – (84.765 * (ratio)) + 413.655 |
|
1013 |
20% |
(2.5664 * ((ratio)^2)) – (50.98 * (ratio)) + 355.642 |
|
|
30% |
(1.8634 * ((ratio)^2)) – (48.09 * (ratio)) + 432.695 |
|
female, nondiabetic, smoker, 65-75 |
15% |
(6.051 * ((ratio)^2)) – (80.613 * (ratio)) + 375.74 |
|
1014 |
20% |
(2.0154 * ((ratio)^2)) – (44.299 * (ratio)) + 327.97 |
|
|
30% |
(2.0673 * ((ratio)^2)) – (49.75 * (ratio)) + 418.793 |
|
female, diabetic, nonsmoker, 35-45 |
15% |
(1.4265 * ((ratio)^2)) – (38.267 * (ratio)) + 377.326 |
|
1101 |
20% |
(2.162 * ((ratio)^2)) – (55.4 * (ratio)) + 507.826 |
|
|
30% |
NA |
|
female, diabetic, nonsmoker, 45-55 |
15% |
(2.528 * ((ratio)^2)) – (48.057 * (ratio)) + 327.216 |
|
1102 |
20% |
(1.8873 * ((ratio)^2)) – (44.795 * (ratio)) + 366.44 |
|
|
30% |
(3.175 * ((ratio)^2)) – (73.33 * (ratio)) + 571.21 |
|
female, diabetic, nonsmoker, 55-65 |
15% |
(1.5242 * ((ratio)^2)) – (36.783 * (ratio)) + 266.381 |
|
1103 |
20% |
(2.975 * ((ratio)^2)) – (54.55 * (ratio)) + 350.83 |
|
|
30% |
(2.151 * ((ratio)^2)) – (50.24 * (ratio)) + 411.354 |
|
female, diabetic, nonsmoker, 65-75 |
15% |
(4.363 * ((ratio)^2)) – (60.943 * (ratio)) + 305.827 |
|
1104 |
20% |
(5.31 * ((ratio)^2)) – (77.052 * (ratio)) + 388.325 |
|
|
30% |
(1.556 * ((ratio)^2)) – (40.12 * (ratio)) + 360.05 |
|
female, diabetic, smoker, 35-45 |
15% |
(2.158 * ((ratio)^2)) – (45.46 * (ratio)) + 343.602 |
|
1111 |
20% |
(1.8 * ((ratio)^2)) – (44.217 * (ratio)) + 388.552 |
|
|
30% |
– (16.667 * (ratio)) + 346.67 |
|
female, diabetic, smoker, 45-55 |
15% |
(5.036 * ((ratio)^2)) – (64.01 * (ratio)) + 305.46 |
|
1112 |
20% |
(3.775 * ((ratio)^2)) – (61.65 * (ratio)) + 351.608 |
|
|
30% |
(1.751 * ((ratio)^2)) – (42.85 * (ratio)) + 369.8 |
|
female, diabetic, smoker, 55-65 |
15% |
– (20 * (ratio)) + 190 |
|
1113 |
20% |
(1.533 * ((ratio)^2)) – (34.495 * (ratio)) + 244.11 |
|
|
30% |
(2.579 * ((ratio)^2)) – (51.85 * (ratio)) + 359.05 |
|
female, diabetic, smoker, 65-75 |
15% |
– (18 * (ratio)) + 173 |
|
1114 |
20% |
(8.33 * ((ratio)^2)) – (88.33 * (ratio)) + 340 |
|
|
30% |
(2.944 * ((ratio)^2)) – (53.709 * (ratio)) + 346.899 |
Criteria for Drug Treatment
Drug treatment is justified with one or more of the following:
(1) an absolute risk of coronary artery disease >= 15% (equivalent to cardiovascular risk in 10 years of >= 20%)
(2) hypertension, with systolic pressure > 160 mm Hg or diastolic pressure > 100 mm Hg
(3) hypertension with associated target organ damage (left ventricular hypertrophy, etc.)
(4) familial hypercholesterolemia or other inherited dyslipidemia
(5) strong family history of premature coronary heart disease
(6) diabetes mellitus with associated target organ damage (microalbuminuria, etc.)
Decisions to treat patients with borderline or lower risk factors should be based on repeat measurements of the risk factors over time.
All high risk patients should be evaluated for modifiable risk factors. Lifestyle factors such as smoking, obesity and inactivity should be addressed when feasible.
Drug Treatment and Targets
ACE inhibitors:
(1) in patients with coronary artery disease and evidence of congestive heart failure or left ventricular dysfunction
(2) may benefit patients with microalbuminuria associated with diabetes
Anticoagulation:
(1) in patients with severe heart failure, large anterior MI, left ventricular aneurysm, or paroxysmal tachyarrhythmias
Aspirin:
(1) in all patients with coronary heart disease
(2) in patients with risk factors > 50 years of age and having controlled hypertension
beta-Blockers:
(1) in patients with high risk coronary heart disease
Blood pressure control:
(1) nondiabetic: systolic < 140 mm Hg and diastolic < 85 mm Hg
(2) diabetics without proteinuria: systolic < 130 mm Hg and diastolic < 80 mm Hg
(3) diabetics with proteinuria, systolic < 125 mm Hg and diastolic < 75 mm Hg
Cholesterol control:
(1) total cholesterol < 5.0 mmol/L
(2) LDL cholesterol < 3.0 mmol/L
Diabetes control:
(1) glycated hemoglobin should be kept at < 7%.
Lifestyle changes:
(1) smoking cessation
(2) dietary improvement
(3) moderation in alcohol consumption
(4) increased aerobic exercise
(5) weight loss to BMI < 25 kg per meter squared, with no central obesity
NOTE: The British Heart Foundation has a cardiac risk assessment program to estimate the absolute risk of coronary heart disease on a PC, as well as other resources. The contact numbers (UK) are 020-7935-0185 (phone) and 020-7486-1273 (fax).
Specialty: Cardiology
ICD-10: ,
