Vascular disease: Difference between revisions

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In [[medicine]], '''vascular disease''' is "pathological processes involving any of the blood vessels in the [[coronary artery|cardiac]] or peripheral circulation.<ref>{{MeSH}}</ref> They include diseases of arteries; veins; and rest of the vasculature system in the body." Examples of vascular diseases include [[coronary heart disease]], [[cerebrovascular disorder]]s, and [[peripheral vascular disease]].
In [[medicine]], '''vascular disease''' is "pathological processes involving any of the blood vessels in the [[coronary artery|cardiac]] or peripheral circulation. They include diseases of arteries; veins; and rest of the vasculature system in the body."<ref>{{MeSH}}</ref> Examples of vascular diseases include [[coronary heart disease]], [[cerebrovascular disorder]]s, and [[peripheral vascular disease]].


==Prevention==
==Prevention==
===Exercise===
===Exercise===
Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)], based on a [[systematic review]] of [[randomized controlled trials]], found 'insufficient evidence' to recommend that doctors counsel patients on exercise.<ref name="pmid12160370">{{cite journal |author= |title=Behavioral counseling in primary care to promote physical activity: recommendation and rationale |journal=Ann. Intern. Med. |volume=137 |issue=3 |pages=205-7 |year=2002 |pmid=12160370 |doi=}}</ref> However, the [[American Heart Association]], based on a non-systematic review, recommends that doctors counsel patients on exercise <ref name="pmid12821592">{{cite journal |author=Thompson PD, Buchner D, Pina IL, ''et al'' |title=Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) |journal=Circulation |volume=107 |issue=24 |pages=3109-16 |year=2003 |pmid=12821592 |doi=10.1161/01.CIR.0000075572.40158.77}} http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=5360&string=#s23</ref>  
Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)], based on a [[systematic review]] of [[randomized controlled trial]]s, found 'insufficient evidence' to recommend that doctors counsel patients on exercise.<ref name="pmid12160370">{{cite journal |author= |title=Behavioral counseling in primary care to promote physical activity: recommendation and rationale |journal=Ann. Intern. Med. |volume=137 |issue=3 |pages=205-7 |year=2002 |pmid=12160370 |doi=}}</ref> However, the [[American Heart Association]], based on a non-systematic review, recommends that doctors counsel patients on exercise <ref name="pmid12821592">{{cite journal |author=Thompson PD, Buchner D, Pina IL, ''et al'' |title=Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) |journal=Circulation |volume=107 |issue=24 |pages=3109-16 |year=2003 |pmid=12821592 |doi=10.1161/01.CIR.0000075572.40158.77}} [http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=5360&string=#s23 Summary at guidelines.gov]</ref>


===Preventive diets===
===Preventive diets===
Dietary changes can potentially lead to large changes in the cholesterol.<ref name="pmid1944471">{{cite journal |author=McMurry MP, Cerqueira MT, Connor SL, Connor WE |title=Changes in lipid and lipoprotein levels and body weight in Tarahumara Indians after consumption of an affluent diet |journal=N. Engl. J. Med. |volume=325 |issue=24 |pages=1704-8 |year=1991 |pmid=1944471 |doi=|url=http://content.nejm.org/cgi/content/abstract/325/24/1704}}</ref>
Dietary changes can potentially lead to large changes in the cholesterol.<ref name="pmid1944471">{{cite journal |author=McMurry MP, Cerqueira MT, Connor SL, Connor WE |title=Changes in lipid and lipoprotein levels and body weight in Tarahumara Indians after consumption of an affluent diet |journal=N. Engl. J. Med. |volume=325 |issue=24 |pages=1704-8 |year=1991 |pmid=1944471 |doi=|url=http://content.nejm.org/cgi/content/abstract/325/24/1704}}</ref>
===Alcohol===
The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary heart disease.<ref>http://www.who.int/nutrition/topics/5_population_nutrient/en/index12.html</ref>


===Aspirin===
===Aspirin===
Aspirin, in doses of less than 75 to 81 mg/d<ref name="pmid17488967">{{cite journal |author=Campbell CL, Smyth S, Montalescot G, Steinhubl SR |title=Aspirin dose for the prevention of cardiovascular disease: a systematic review |journal=JAMA |volume=297 |issue=18 |pages=2018-24 |year=2007 |pmid=17488967 |doi=10.1001/jama.297.18.2018}}</ref>, can reduce the incidence of cardiovascular events.<ref name="pmid16418466">{{cite journal |author=Berger J, Roncaglioni M, Avanzini F, Pangrazzi I, Tognoni G, Brown D |title=Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials |journal=JAMA |volume=295 |issue=3 |pages=306-13 |year=2006 |pmid=16418466 | url=http://jama.ama-assn.org/cgi/content/full/295/3/306 |doi=10.1001/jama.295.3.306}}</ref> The [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force] 'strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease'.<ref name="pmid11790071">{{cite journal |author= |title=Aspirin for the primary prevention of cardiovascular events: recommendation and rationale |journal=Ann Intern Med |volume=136 |issue=2 |pages=157-60 |year=2002 |pmid=11790071 | url=http://www.annals.org/cgi/content/full/136/2/157}}</ref> The Task Force defines increased risk as 'Men older than 40 years of age, postmenopausal women, and younger persons with risk factors for coronary heart disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy'. More specifically, high-risk persons are 'those with a 5-year risk ≥ 3%'. A risk calculator is available.<ref>http://www.med-decisions.com/</ref>


Regarding healthy women, the more recent [[Women's Health Study]] [[randomized controlled trial]] found [[statistical significance|insignficant]] benefit from aspirin in the reduction of cardiac events; however there was a [[statistical significance|signficant]] reduction in [[stroke]].<ref name="pmid15753114">{{cite journal |author=Ridker P, Cook N, Lee I, Gordon D, Gaziano J, Manson J, Hennekens C, Buring J |title=A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women |journal=N Engl J Med |volume=352 |issue=13 |pages=1293-304 |year=2005 |pmid=15753114 | rul=http://content.nejm.org/cgi/content/full/352/13/1293 | doi=10.1056/NEJMoa050613}}</ref> [[Subgroup analysis]] showed that all benefit was confined to women over 65 years old.<ref name="pmid15753114" /> In spite of the [[statistical significance|insignficant]] benefit for women < 65 years old, recent [[Clinical practice guideline|practice guidelines]] by the [[American Heart Association]] recommend to 'consider' aspirin in 'healthy women' <65 years of age 'when benefit for ischemic stroke prevention is likely to outweigh adverse effects of therapy'.<ref>http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.181546v1</ref>
====Clinical practice guidelines====
The [[U.S. Preventive Services Task Force]] has addressed this topic.<ref name="pmid19293072">{{cite journal |author=U.S. Preventive Services Task Force |title=Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement |journal=Ann. Intern. Med. |volume=150 |issue=6 |pages=396–404 |year=2009 |month=March |pmid=19293072 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=19293072 |issn=}}</ref><ref name="pmid19293073">{{cite journal |author=Wolff T, Miller T, Ko S |title=Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume=150 |issue=6 |pages=405–10 |year=2009 |month=March |pmid=19293073 |doi= |url=http://www.annals.org/cgi/content/full/150/6/405 |issn=}}</ref>
{| class="wikitable"
|+ USPSTF: Risk level at which benefit of aspirin exceeds harm.<ref name="pmid19293072">{{cite journal |author=U.S. Preventive Services Task Force |title=Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement |journal=Ann. Intern. Med. |volume=150 |issue=6 |pages=396–404 |year=2009 |month=March |pmid=19293072 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=19293072 |issn=}}</ref><ref name="pmid19293073">{{cite journal |author=Wolff T, Miller T, Ko S |title=Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume=150 |issue=6 |pages=405–10 |year=2009 |month=March |pmid=19293073 |doi= |url=http://www.annals.org/cgi/content/full/150/6/405 |issn=}}</ref>
! colspan="2"|Men!! colspan="2"|Women
|-
! Age!! 10 year CHD risk!! Age!! 10 year stroke risk
|-
| 45-59 years||align="center"| ≥ 4%|| 50-59 years||align="center"| ≥ 3%
|-
| 60-69 years||align="center"| ≥ 9%|| 60-69 years||align="center"| ≥ 8%
|-
| 70-79 years||align="center"| ≥ 12%|| 70-79 years||align="center"| ≥ 11%
|-
| colspan="2"|[https://openrules.ocpu.io/home/www/cardiovascularrisk.html  calculator]||colspan="2"| [http://www.westernstroke.org/index.php?header_name=stroke_tools.gif&main=stroke_tools.php Stroke calculator]
|}


===Antilipemic drugs===
* If on NSAID: multiple rates by 4
The [http://www.ahrq.gov/clinic/uspstfix.htm U.S. Preventive Services Task Force (USPSTF)] estimated that after 5 to 7 years of treatment with [[statins]], the  [[relative risk reduction]] of coronary heart disease events is decreased by approximately 30%<ref name="pmid11306236">{{cite journal |author=Pignone MP, Phillips CJ, Atkins D, Teutsch SM, Mulrow CD, Lohr KN |title=Screening and treating adults for lipid disorders |journal=American journal of preventive medicine |volume=20 |issue=3 Suppl |pages=77–89 |year=2001 |pmid=11306236 |doi=}}</ref><ref name="webPignone">{{cite web |url=http://www.ahrq.gov/clinic/ajpmsuppl/lipidrr.htm |title=Screening for Lipid Disorders: Recommendations and Rationale |accessdate=2007-10-17 |format= |work=}}</ref>. More recently, a [[meta-analysis]] reported an almost identical  [[relative risk reduction]] of 29.2% in low risk patients treated for 4.3 years <ref name="pmid17130382">{{cite journal |author=Thavendiranathan P, Bagai A, Brookhart M, Choudhry N |title=Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials |journal=Arch Intern Med |volume=166 |issue=21 |pages=2307-13 |year=2006 |pmid=17130382|doi=10.1001/archinte.166.21.2307}}</ref>. A [[relative risk reduction]] of 19% in coronary mortality was found in a [[meta-analysis]] of patients at all levels of risk.<ref name="pmid16214597">{{cite journal |author=Baigent C, Keech A, Kearney PM, ''et al'' |title=Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins |journal=Lancet |volume=366 |issue=9493 |pages=1267-78 |year=2005 |pmid=16214597 |doi=10.1016/S0140-6736(05)67394-1}}</ref>
* If prior PUD: multiply rates by 2 to 3


Various [[clinical practice guideline]]s have addressed the treatment of [[hypercholesterolemia]]. The [[American College of Physicians]] has addressed hypercholesterolemia in patients with [[diabetes]] <ref name="pmid15096336">{{cite journal |author=Snow V, Aronson M, Hornbake E, Mottur-Pilson C, Weiss K |title=Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians |journal=Ann Intern Med |volume=140 |issue=8 |pages=644-9 |year=2004 |pmid=15096336 | url=http://www.annals.org/cgi/content/full/140/8/644}}</ref>. Their recommendations are:
The European Society of Cardiology has addressed this topic and concluded, "."<ref name="pmid22555213">{{cite journal| author=Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M et al.| title=European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). | journal=Eur Heart J | year= 2012 | volume= 33 | issue= 13 | pages= 1635-701 | pmid=22555213 | doi=10.1093/eurheartj/ehs092 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22555213 }} </ref>
*  Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes.
* Recommendation 2: Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors.
* Recommendation 3: Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin (the accompanying evidence report states "simvastatin, 40 mg/d; pravastatin, 40 mg/d; lovastatin, 40 mg/d; atorvastatin, 20 mg/d; or an equivalent dose of another statin")<ref name="pmid15096337">{{cite journal |author=Vijan S, Hayward RA |title=Pharmacologic lipid-lowering therapy in type 2 diabetes mellitus: background paper for the American College of Physicians |journal=Ann. Intern. Med. |volume=140 |issue=8 |pages=650-8 |year=2004 |pmid=15096337 |doi=|url=http://www.annals.org/cgi/content/full/140/8/650}}</ref>.
* Recommendation 4: For those patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.


The [[National Cholesterol Education Program]] revised their guidelines<ref name="pmid15358046">{{cite journal |author=Grundy SM, Cleeman JI, Merz CN, Brewer HB, Clark LT, Hunninghake DB, Pasternak RC, Smith SC, Stone NJ |title=Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines |journal=J. Am. Coll. Cardiol. |volume=44 |issue=3 |pages=720-32 |year=2004 |pmid=15358046 |doi=10.1016/j.jacc.2004.07.001}}</ref>; however, their 2004 revisions have been criticized for use of nonrandomized, observational data.<ref name="pmid17015870">{{cite journal |author=Hayward RA, Hofer TP, Vijan S |title=Narrative review: lack of evidence for recommended low-density lipoprotein treatment targets: a solvable problem |journal=Ann. Intern. Med. |volume=145 |issue=7 |pages=520-30 |year=2006 |pmid=17015870 |doi=}}</ref>
====Systematic reviews====
The Antithrombotic Trialists' (ATT) Collaboration has conducted a collaborative meta-analysis of individual participant data and concluded that aspirin reduced serious vascular events with a rate ratio [RR] 0·88 (95% CI 0·82–0·94]).<ref name="pmid19482214">{{cite journal| author=Antithrombotic Trialists' (ATT) Collaboration. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J et al.| title=Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9678 | pages= 1849-60 | pmid=19482214 | doi=10.1016/S0140-6736(09)60503-1 | pmc=PMC2715005 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19482214 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19755350 Review in: Ann Intern Med. 2009 Sep 15;151(6):JC3-4, JC3-5] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19949174 Review in: Evid Based Med. 2009 Dec;14(6):172-3] </ref> However, the benefit was not found in patients with projected 5 year risk greater than 10%.
 
Aspirin, in doses of less than 75 to 81 mg/d<ref name="pmid17488967">{{cite journal |author=Campbell CL, Smyth S, Montalescot G, Steinhubl SR |title=Aspirin dose for the prevention of cardiovascular disease: a systematic review |journal=JAMA |volume=297 |issue=18 |pages=2018-24 |year=2007 |pmid=17488967 |doi=10.1001/jama.297.18.2018}}</ref>, can reduce the incidence of cardiovascular events.<ref name="pmid16418466">{{cite journal |author=Berger J, Roncaglioni M, Avanzini F, Pangrazzi I, Tognoni G, Brown D |title=Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials |journal=JAMA |volume=295 |issue=3 |pages=306-13 |year=2006 |pmid=16418466 | url=http://jama.ama-assn.org/cgi/content/full/295/3/306 |doi=10.1001/jama.295.3.306}}</ref> In most cases the net benefit is less than 1 patient among 100.<ref name="pmid19293073">{{cite journal |author=Wolff T, Miller T, Ko S |title=Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force |journal=Ann. Intern. Med. |volume=150 |issue=6 |pages=405–10 |year=2009 |month=March |pmid=19293073 |doi= |url=http://www.annals.org/cgi/content/full/150/6/405 |issn=}}</ref> A more recent meta-analysis suggests the benefit is not clear, especially for patients on statins.<ref name="pmid19482214">{{cite journal |author=Baigent C, Blackwell L, Collins R, ''et al.'' |title=Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials |journal=Lancet |volume=373 |issue=9678 |pages=1849–60 |year=2009 |month=May |pmid=19482214 |doi=10.1016/S0140-6736(09)60503-1 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(09)60503-1 |issn=}}</ref> An accompanying editorial<ref name="pmid19482200">{{cite journal |author=Algra A, Greving JP |title=Aspirin in primary prevention: sex and baseline risk matter |journal=Lancet |volume=373 |issue=9678 |pages=1821–2 |year=2009 |month=May |pmid=19482200 |doi=10.1016/S0140-6736(09)61003-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(09)61003-5 |issn=}}</ref>, offers a cost-benefit analysis that recommends aspirin if the 10 year risk of vascular disease is at least 30%.<ref name="pmid19482200">{{cite journal |author=Algra A, Greving JP |title=Aspirin in primary prevention: sex and baseline risk matter |journal=Lancet |volume=373 |issue=9678 |pages=1821–2 |year=2009 |month=May |pmid=19482200 |doi=10.1016/S0140-6736(09)61003-5 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(09)61003-5 |issn=}}</ref>
 
The benefit for diabetics is not clear.<ref name="pmid19897665">{{cite journal| author=De Berardis G, Sacco M, Strippoli GF, Pellegrini F, Graziano G, Tognoni G et al.| title=Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials. | journal=BMJ | year= 2009 | volume= 339 | issue= | pages= b4531 | pmid=19897665 | doi=10.1136/bmj.b4531 | pmc=PMC2774388 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19897665 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20404367 Review in: Ann Intern Med. 2010 Apr 20;152(8):JC4-10] </ref>
 
====Other studies====
In a trial of patients with [[ankle brachial index]] of less than 0.9, aspirin did not help although 11% of patients had events at 8 years.<ref>JAMA 2010 [[http://jama.ama-assn.org/cgi/content/full/303/9/841 Aspirin for Prevention of Cardiovascular Events in a General Population Screened for a Low Ankle Brachial Index]]</ref>
 
Aspirin should be considered even if bleeding [[peptic ulcer disease]] has occurred.<ref name="pmid19949136">{{cite journal| author=Sung JJ, Lau JY, Ching JY, Wu JC, Lee YT, Chiu PW et al.| title=Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 1 | pages= 1-9 | pmid=19949136
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19949136 | doi=10.1059/0003-4819-152-1-201001050-00179 }} </ref>
 
===Anticholesteremic agents===
{{main|Hypercholesterolemia}}


===Antioxidant vitamins===
===Antioxidant vitamins===
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A [[meta-analysis]] concluded that lowering [[homocysteine]] with folic acid and other supplements may reduce [[stroke]].<ref name="pmid17544768">{{cite journal |author=Wang X, Qin X, Demirtas H, ''et al'' |title=Efficacy of folic acid supplementation in stroke prevention: a meta-analysis |journal=Lancet |volume=369 |issue=9576 |pages=1876-82 |year=2007 |pmid=17544768 |doi=10.1016/S0140-6736(07)60854-X}}PMID 17544768</ref> However, the two largest [[randomized controlled trial]]s included in the meta-analysis had conflicting results. Lonn reported positive results<ref name="pmid16531613">{{cite journal |author=Lonn E, Yusuf S, Arnold MJ, ''et al'' |title=Homocysteine lowering with folic acid and B vitamins in vascular disease |journal=N. Engl. J. Med. |volume=354 |issue=15 |pages=1567-77 |year=2006 |pmid=16531613 |doi=10.1056/NEJMoa060900}}PMID 16531613</ref>; whereas the trial by Toole was negative.<ref name="pmid14762035">{{cite journal |author=Toole JF, Malinow MR, Chambless LE, ''et al'' |title=Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial |journal=JAMA |volume=291 |issue=5 |pages=565-75 |year=2004 |pmid=14762035 |doi=10.1001/jama.291.5.565}}PMID 14762035</ref>
A [[meta-analysis]] concluded that lowering [[homocysteine]] with folic acid and other supplements may reduce [[stroke]].<ref name="pmid17544768">{{cite journal |author=Wang X, Qin X, Demirtas H, ''et al'' |title=Efficacy of folic acid supplementation in stroke prevention: a meta-analysis |journal=Lancet |volume=369 |issue=9576 |pages=1876-82 |year=2007 |pmid=17544768 |doi=10.1016/S0140-6736(07)60854-X}}PMID 17544768</ref> However, the two largest [[randomized controlled trial]]s included in the meta-analysis had conflicting results. Lonn reported positive results<ref name="pmid16531613">{{cite journal |author=Lonn E, Yusuf S, Arnold MJ, ''et al'' |title=Homocysteine lowering with folic acid and B vitamins in vascular disease |journal=N. Engl. J. Med. |volume=354 |issue=15 |pages=1567-77 |year=2006 |pmid=16531613 |doi=10.1056/NEJMoa060900}}PMID 16531613</ref>; whereas the trial by Toole was negative.<ref name="pmid14762035">{{cite journal |author=Toole JF, Malinow MR, Chambless LE, ''et al'' |title=Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial |journal=JAMA |volume=291 |issue=5 |pages=565-75 |year=2004 |pmid=14762035 |doi=10.1001/jama.291.5.565}}PMID 14762035</ref>


Since the meta-analysis, two additional trials have shown no reduction in cardiovascular endpoint despite successfully lowering the plasma homocysteine level.<ref name="pmid">{{cite journal |author= |title= |journal= |volume= |issue= |pages= |year= |pmid= |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18460663 |issn=}}</ref><ref>Ebbing M, Bleie O, Ueland PM, Nordrehaug JE, Nilsen DW, Vollset SE, et al. [http://jama.ama-assn.org/cgi/content/full/300/7/795 Mortality and Cardiovascular Events in Patients Treated With Homocysteine-Lowering B Vitamins After Coronary Angiography: A Randomized Controlled Trial]. JAMA. 2008 Aug 20;300(7):795-804.</ref>
Since the [[meta-analysis]], two additional [[randomized controlled trial]]s have shown no reduction in cardiovascular endpoint despite successfully lowering the plasma homocysteine level.<ref name="pmid18460663">{{cite journal |author=Albert CM, Cook NR, Gaziano JM, ''et al'' |title=Effect of folic acid and B vitamins on risk of cardiovascular events and total mortality among women at high risk for cardiovascular disease: a randomized trial |journal=JAMA |volume=299 |issue=17 |pages=2027–36 |year=2008 |month=May |pmid=18460663 |doi=10.1001/jama.299.17.2027 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18460663 |issn=}}</ref><ref name="pmid18714059">{{cite journal |author=Ebbing M, Bleie Ø, Ueland PM, ''et al'' |title=Mortality and cardiovascular events in patients treated with homocysteine-lowering B vitamins after coronary angiography: a randomized controlled trial |journal=JAMA |volume=300 |issue=7 |pages=795–804 |year=2008 |month=August |pmid=18714059 |doi=10.1001/jama.300.7.795 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18714059 |issn=}}</ref>
 
===Vitamin D===
[[Vitamin D]] may help prevent vascular disease.<ref name="pmid20194238">{{cite journal| author=Wang L, Manson JE, Song Y, Sesso HD| title=Systematic review: vitamin d and calcium supplementation in prevention of cardiovascular events. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 5 | pages= 315-23 | pmid=20194238
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=20194238 | doi=10.1059/0003-4819-152-5-201003020-00010 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
===Angiotensin-converting enzyme inhibitors===
The Heart Outcomes Prevention Evaluation (HOPE) study suggested that the [[angiotensin-converting enzyme inhibitor]] [[ramipril]] could reduce vascular disease and mortality among patients at increased risk. This effect was thought to be independent of control of blood pressure.<ref name="pmid10639539">{{cite journal| author=Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G| title=Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. | journal=N Engl J Med | year= 2000 | volume= 342 | issue= 3 | pages= 145-53 | pmid=10639539
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=10639539 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid11784631">{{cite journal| author=Sleight P, Yusuf S, Pogue J, Tsuyuki R, Diaz R, Probstfield J et al.| title=Blood-pressure reduction and cardiovascular risk in HOPE study. | journal=Lancet | year= 2001 Dec 22-29 | volume= 358 | issue= 9299 | pages= 2130-1 | pmid=11784631
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=11784631 | doi=10.1016/S0140-6736(01)07186-0 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid10675071">{{cite journal| author=| title=Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. | journal=Lancet | year= 2000 | volume= 355 | issue= 9200 | pages= 253-9 | pmid=10675071
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=10675071 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref> However, subsequent studies have shown this result was more likely due to the administration of ramipril at night and recording blood pressures during the day when the least effect of ramipril was present.<ref name="pmid11751742">{{cite journal| author=Svensson P, de Faire U, Sleight P, Yusuf S, Ostergren J| title=Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy. | journal=Hypertension | year= 2001 | volume= 38 | issue= 6 | pages= E28-32 | pmid=11751742
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=11751742 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref><ref name="pmid12574079">{{cite journal| author=Kurtz TW| title=False claims of blood pressure-independent protection by blockade of the renin angiotensin aldosterone system? | journal=Hypertension | year= 2003 | volume= 41 | issue= 2 | pages= 193-6 | pmid=12574079
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=12574079 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>


===Evidence table===
===Evidence table===
{| class="wikitable"
{| class="wikitable"
|+ Interventions to prevent all-cause mortality<br/>among patients at risk of vascular disease
|+ Interventions to prevent all-cause mortality<br/>among patients at risk of vascular disease
! &nbsp;!! Study type!![[Relative risk ratio]] or [[odds ratio]] for all death
! &nbsp;!! Study type!![[Relative risk ratio]] or [[odds ratio]]<br/>for all-cause mortality
|-
| [[Aspirin]]<ref name="pmid16418466"/>|| [[Systematic review]] of 6 [[randomized controlled trial|RCTs]] through 2005<br/>(Does not include negative JPAD trial<ref name="pmid18997198">{{cite journal |author=Ogawa H, Nakayama M, Morimoto T, ''et al'' |title=Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial |journal=JAMA |volume=300 |issue=18 |pages=2134–41 |year=2008 |month=November |pmid=18997198 |doi=10.1001/jama.2008.623 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18997198 |issn=}}</ref>)|| Men [[Odds ratio|OR]]=0.93<br/>Women  [[Odds ratio|OR]]=0.94
|-
|-
| [[Aspirin]]|| [[Systematic review]] of 6 [[randomized controlled trial|RCTs]] through 2005|| Men [[Odds ratio|OR]]=0.93<br/>Women  [[Odds ratio|OR]]=0.94
| [[Hydroxymethylglutaryl-coenzyme A reductase inhibitor|Statin]]<ref name="pmid17130382">{{cite journal| author=Thavendiranathan P, Bagai A, Brookhart MA, Choudhry NK| title=Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials. | journal=Arch Intern Med | year= 2006 | volume= 166 | issue= 21 | pages= 2307-13 | pmid=17130382 | doi=10.1001/archinte.166.21.2307 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17130382  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17607829 Review in: J Fam Pract. 2007 Mar;56(3):174] </ref> || [[Systematic review]] of 7 [[randomized controlled trial|RCTs]] through 2005<br/>(Does not include positive Jupiter<ref name="pmid18997196">{{cite journal |author=Ridker PM, Danielson E, Fonseca FA, ''et al'' |title=Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein |journal=N. Engl. J. Med. |volume=359 |issue=21 |pages=2195–207 |year=2008 |month=November |pmid=18997196 |doi=10.1056/NEJMoa0807646 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18997196&promo=ONFLNS19 |issn=}}</ref> or negative GISSI-HF<ref name="pmid18757089">{{cite journal |author=Gissi-HF Investigators, Tavazzi L, Maggioni AP, ''et al'' |title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial |journal=Lancet |volume=372 |issue=9645 |pages=1231–9 |year=2008 |month=October |pmid=18757089 |doi=10.1016/S0140-6736(08)61240-4 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)61240-4 |issn=}}</ref> trials)||[[Relative risk ratio|RR]]=0.92
|-
|-
| [[Hydroxymethylglutaryl-coenzyme A reductase inhibitor|Statin]] || [[Systematic review]] of 7 [[randomized controlled trial|RCTs]] through 2005||[[Relative risk ratio|RR]]=0.92
| [[Fish oil]]<ref name="pmid19106137">{{cite journal |author=León H, Shibata MC, Sivakumaran S, Dorgan M, Chatterley T, Tsuyuki RT |title=Effect of fish oil on arrhythmias and mortality: systematic review |journal=BMJ |volume=337 |issue= |pages=a2931 |year=2008 |pmid=19106137 |pmc=2612582 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19106137 |issn=}}</ref> || [[Systematic review]] of 12 [[randomized controlled trial|RCTs]] through 2006<br/>(Does not include positive GISSI-HF<ref name="pmid18757090">{{cite journal |author=Gissi-Hf Investigators |title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial |journal=Lancet |volume= |issue= |pages= |year=2008 |month=August |pmid=18757090 |doi=10.1016/S0140-6736(08)61239-8  |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)61239-8 |issn=}}</ref>)||[[Odds ratio|OR]]=0.92
|-
|-
| [[Fish oil]] || [[Systematic review]] of 12 [[randomized controlled trial|RCTs]] through 2006<br/>(Does not include GISSI-HF<ref name="pmid18757090">{{cite journal |author=Gissi-Hf Investigators |title=Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial |journal=Lancet |volume= |issue= |pages= |year=2008 |month=August |pmid=18757090 |doi=10.1016/S0140-6736(08)61239-8  |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)61239-8 |issn=}}</ref>)||[[Odds ratio|OR]]=0.92
| colspan="3" | No [[systematic review]] reported a significant decrease in mortality.
|}
|}
==Prognosis==
Many new biomarkers have been studied for their ability to improvement upon prediction based on traditional risk factors.<ref name="pmid17182988">{{cite journal |author=Wang TJ, Gona P, Larson MG, ''et al'' |title=Multiple biomarkers for the prediction of first major cardiovascular events and death |journal=N. Engl. J. Med. |volume=355 |issue=25 |pages=2631–9 |year=2006 |month=December |pmid=17182988 |doi=10.1056/NEJMoa055373 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17182988 |issn=}}</ref>
{| class="wikitable"
|+ Prediction of vascular disease
! &nbsp;!! Outcome |!! Result
|-
| Framingham plus [[ankle brachial index]]|| 10-year  total mortality, cardiovascular mortality, and major coronary  event|| Total reclassification: 19% (men); 36% (women)<ref name="pmid18612117">{{cite journal |author=Fowkes FG, Murray GD, Butcher I, ''et al'' |title=Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis |journal=JAMA |volume=300 |issue=2 |pages=197–208 |year=2008 |month=July |pmid=18612117 |doi=10.1001/jama.300.2.197 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18612117 |issn=}}</ref>
|-
| Traditional  risk factors (Framingham) plus coronary  calcium score|| [[coronary heart disease]] events|| [[sensitivity  and specificity|Net reclassification improvement]] 25%<ref name="pmid20424251">{{cite journal| author=Polonsky TS,  McClelland RL, Jorgensen NW, Bild DE, Burke GL, Guerci AD et al.|  title=Coronary artery calcium score and risk classification for coronary  heart disease prediction. | journal=JAMA | year= 2010 | volume= 303 |  issue= 16 | pages= 1610-6 | pmid=20424251 |  url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20424251  | doi=10.1001/jama.2010.461}}</ref>
|-
| Traditional risk factors (Framingham) plus [[c-reactive protein]]||"myocardial infarction and CHD-related death"||[[sensitivity and specificity|Net reclassification improvement]] = 12%<ref>{{Cite journal | doi = 10.1161/CIRCOUTCOMES.108.831198 | volume = 1 | issue = 2 | pages = 92-97 | last = Wilson | first = Peter W.F. | coauthors = Michael Pencina, Paul Jacques, Jacob Selhub, Ralph D'Agostino, Christopher J. O'Donnell | title = C-Reactive Protein and Reclassification of Cardiovascular Risk in the Framingham Heart Study | journal = Circ Cardiovasc Qual Outcomes | accessdate = 2008-12-08 | date = 2008-11-01 | url = http://circoutcomes.ahajournals.org/cgi/content/abstract/1/2/92 }}</ref>
|-
| Traditional risk factors plus [[c-reactive protein]] and family history of [[myocardial infarction|MI]] before age 60 ([http://www.reynoldsriskscore.org/ Reynolds Score])||All cardiovascular events|| [[sensitivity and specificity|Net reclassification improvement]] = 8% (in men)<ref  name="pmid18997194">{{cite  journal |author=Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook  NR |title=C-reactive protein and parental history improve global  cardiovascular risk prediction: the Reynolds Risk Score for men  |journal=Circulation |volume=118 |issue=22 |pages=2243–51, 4p following  2251 |year=2008 |month=November |pmid=18997194  |doi=10.1161/CIRCULATIONAHA.108.814251 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=18997194  |issn=}}</ref>
|}
Regarding coronary heart disease, about 3/4 of its prognosis is due to three risk factors: [[hypercholesterolemia]] (total cholesterol > 182 mg/dL [4.71 mmol/L]), [[hypertension]] (diastolic blood pressure > 90 mm Hg), and cigarette smoking.<ref name="pmid11732929">{{cite journal |author=Magnus P, Beaglehole R |title=The real contribution of the major risk factors to the coronary epidemics: time to end the "only-50%" myth |journal=Arch. Intern. Med. |volume=161 |issue=22 |pages=2657–60 |year=2001 |pmid=11732929 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11732929 |issn=}}</ref>
===Framingham risk===
The Framingham risk uses clinical risk factors that are combined in an equation developed from the Framingham Heart Study to calculate prognosis. An online calculator is available at http://hp2010.nhlbihin.net/atpiii/calculator.asp.
Although many studies report better models than the Framingham model, the methods of these studies may not be adequate.<ref>(2009) [http://jama.ama-assn.org/cgi/content/full/302/21/2345  Assessment of Claims of Improved Prediction Beyond the Framingham Risk Score]. JAMA</ref>
A 2008 recalculation provides a calculator that includes [[diabetes mellitus]] as a risk factor.<ref name="pmid18212285">{{cite journal| author=D'Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM et al.| title=General cardiovascular risk profile for use in primary care: the Framingham Heart Study. | journal=Circulation | year= 2008 | volume= 117 | issue= 6 | pages= 743-53 | pmid=18212285 | doi=10.1161/CIRCULATIONAHA.107.699579 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18212285  }} </ref>
Asymptomatic adults should not be screened for [[coronary artery disease]] with an [[electrocardiogram]].<ref name="pmid22847227">{{cite journal| author=Moyer VA, on behalf of the U.S. Preventive Services Task Force*| title=Screening for Coronary Heart Disease With Electrocardiography: U.S. Preventive Services Task Force Recommendation Statement. | journal=Ann Intern Med | year= 2012 | volume=  | issue=  | pages=  | pmid=22847227 | doi=10.7326/0003-4819-157-7-201210020-00514 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22847227  }} </ref>
===Ankle brachial index (ABI)===
{{main|Ankle brachial index}}
A [[meta-analysis]] concluded that "measurement of the [[ankle brachial index|ABI]] may improve the accuracy of cardiovascular risk prediction beyond the FRS (Framingham risk score)".<ref name="pmid18612117">{{cite journal |author=Fowkes FG, Murray GD, Butcher I, ''et al'' |title=Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis |journal=JAMA |volume=300 |issue=2 |pages=197–208 |year=2008 |month=July |pmid=18612117 |doi=10.1001/jama.300.2.197 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=18612117 |issn=}}</ref>
===Reynolds Score===
The Reynolds score has been proposed as an improvement to the Framingham risk by incorporating the [[c-reactive protein]].<ref name="pmid17299196">{{cite journal |author=Ridker PM, Buring JE, Rifai N, Cook NR |title=Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score |journal=JAMA |volume=297 |issue=6 |pages=611–9 |year=2007 |month=February |pmid=17299196 |doi=10.1001/jama.297.6.611 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=17299196 |issn=}}</ref><ref name="pmid18997194">{{cite journal |author=Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook NR |title=C-reactive protein and parental history improve global cardiovascular risk prediction: the Reynolds Risk Score for men |journal=Circulation |volume=118 |issue=22 |pages=2243–51, 4p following 2251 |year=2008 |month=November |pmid=18997194 |doi=10.1161/CIRCULATIONAHA.108.814251 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=18997194 |issn=}}</ref> The score has been validated in the Women's Genome Health Study.<ref name="pmid19153409">{{cite journal |author=Paynter NP, Chasman DI, Buring JE, Shiffman D, Cook NR, Ridker PM |title=Cardiovascular disease risk prediction with and without knowledge of genetic variation at chromosome 9p21.3 |journal=Ann. Intern. Med. |volume=150 |issue=2 |pages=65–72 |year=2009 |month=January |pmid=19153409 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=19153409 |issn=}}</ref> An online calculator is at http://www.reynoldsriskscore.org/.
===C-reactive protein (CRP)===
{{main|C-reactive protein}}
The [[C-reactive protein]] may indicated risk in apparently healthy people due to the theory that chronic inflammation precedes [[atherosclerosis]].<ref name="pmid16818927">Lloyd-Jones DM, Liu K, Tian L, Greenland P. [http://annals.org/cgi/content/full/145/1/35 Narrative review: Assessment of C-reactive protein in risk prediction for cardiovascular disease]. Ann Intern Med. 2006 Jul 4;145(1):35-42. PMID 16818927</ref>
The [[C-reactive protein|CRP]] is part of the Reynolds score.


==References==
==References==
<references/>
<references/>

Latest revision as of 11:24, 23 July 2015

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https://en.citizendium.org/wiki/index.php?title=Vascular_disease&printable=yes
This editable Main Article is under development and subject to a disclaimer.

In medicine, vascular disease is "pathological processes involving any of the blood vessels in the cardiac or peripheral circulation. They include diseases of arteries; veins; and rest of the vasculature system in the body."[1] Examples of vascular diseases include coronary heart disease, cerebrovascular disorders, and peripheral vascular disease.

Prevention

Exercise

Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force (USPSTF), based on a systematic review of randomized controlled trials, found 'insufficient evidence' to recommend that doctors counsel patients on exercise.[2] However, the American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise [3]

Preventive diets

Dietary changes can potentially lead to large changes in the cholesterol.[4]

Alcohol

The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary heart disease.[5]

Aspirin

Clinical practice guidelines

The U.S. Preventive Services Task Force has addressed this topic.[6][7]

USPSTF: Risk level at which benefit of aspirin exceeds harm.[6][7]
Men Women
Age 10 year CHD risk Age 10 year stroke risk
45-59 years ≥ 4% 50-59 years ≥ 3%
60-69 years ≥ 9% 60-69 years ≥ 8%
70-79 years ≥ 12% 70-79 years ≥ 11%
calculator Stroke calculator
  • If on NSAID: multiple rates by 4
  • If prior PUD: multiply rates by 2 to 3

The European Society of Cardiology has addressed this topic and concluded, "."[8]

Systematic reviews

The Antithrombotic Trialists' (ATT) Collaboration has conducted a collaborative meta-analysis of individual participant data and concluded that aspirin reduced serious vascular events with a rate ratio [RR] 0·88 (95% CI 0·82–0·94]).[9] However, the benefit was not found in patients with projected 5 year risk greater than 10%.

Aspirin, in doses of less than 75 to 81 mg/d[10], can reduce the incidence of cardiovascular events.[11] In most cases the net benefit is less than 1 patient among 100.[7] A more recent meta-analysis suggests the benefit is not clear, especially for patients on statins.[9] An accompanying editorial[12], offers a cost-benefit analysis that recommends aspirin if the 10 year risk of vascular disease is at least 30%.[12]

The benefit for diabetics is not clear.[13]

Other studies

In a trial of patients with ankle brachial index of less than 0.9, aspirin did not help although 11% of patients had events at 8 years.[14]

Aspirin should be considered even if bleeding peptic ulcer disease has occurred.[15]

Anticholesteremic agents

For more information, see: Hypercholesterolemia.


Antioxidant vitamins

For more information, see: Antioxidant.

Antioxidant vitamins are not beneficial.

Omega-3 fatty acids (fish oil)

For more information, see: Fish oil.


Omega-3 fatty acids may have small benefit[16][17], but results of randomized controlled trials are not consistent. The benefit may be at conferred on 2% of patients who take omega-3 fatty acids.[16]

Homocysteine lowering

Lowering of homocystein blood concentration with folic acid, vitamin B12, and vitamin B6 is not beneficial.

A meta-analysis concluded that lowering homocysteine with folic acid and other supplements may reduce stroke.[18] However, the two largest randomized controlled trials included in the meta-analysis had conflicting results. Lonn reported positive results[19]; whereas the trial by Toole was negative.[20]

Since the meta-analysis, two additional randomized controlled trials have shown no reduction in cardiovascular endpoint despite successfully lowering the plasma homocysteine level.[21][22]

Vitamin D

Vitamin D may help prevent vascular disease.[23]

Angiotensin-converting enzyme inhibitors

The Heart Outcomes Prevention Evaluation (HOPE) study suggested that the angiotensin-converting enzyme inhibitor ramipril could reduce vascular disease and mortality among patients at increased risk. This effect was thought to be independent of control of blood pressure.[24][25][26] However, subsequent studies have shown this result was more likely due to the administration of ramipril at night and recording blood pressures during the day when the least effect of ramipril was present.[27][28]

Evidence table

Interventions to prevent all-cause mortality
among patients at risk of vascular disease
  Study type Relative risk ratio or odds ratio
for all-cause mortality
Aspirin[11] Systematic review of 6 RCTs through 2005
(Does not include negative JPAD trial[29])		 Men OR=0.93
Women OR=0.94
Statin[30] Systematic review of 7 RCTs through 2005
(Does not include positive Jupiter[31] or negative GISSI-HF[32] trials)		 RR=0.92
Fish oil[33] Systematic review of 12 RCTs through 2006
(Does not include positive GISSI-HF[17])		 OR=0.92
No systematic review reported a significant decrease in mortality.

Prognosis

Many new biomarkers have been studied for their ability to improvement upon prediction based on traditional risk factors.[34]

Prediction of vascular disease
  Outcome Result
Framingham plus ankle brachial index 10-year total mortality, cardiovascular mortality, and major coronary event Total reclassification: 19% (men); 36% (women)[35]
Traditional risk factors (Framingham) plus coronary calcium score coronary heart disease events Net reclassification improvement 25%[36]
Traditional risk factors (Framingham) plus c-reactive protein "myocardial infarction and CHD-related death" Net reclassification improvement = 12%[37]
Traditional risk factors plus c-reactive protein and family history of MI before age 60 (Reynolds Score) All cardiovascular events Net reclassification improvement = 8% (in men)[38]

Regarding coronary heart disease, about 3/4 of its prognosis is due to three risk factors: hypercholesterolemia (total cholesterol > 182 mg/dL [4.71 mmol/L]), hypertension (diastolic blood pressure > 90 mm Hg), and cigarette smoking.[39]

Framingham risk

The Framingham risk uses clinical risk factors that are combined in an equation developed from the Framingham Heart Study to calculate prognosis. An online calculator is available at http://hp2010.nhlbihin.net/atpiii/calculator.asp.

Although many studies report better models than the Framingham model, the methods of these studies may not be adequate.[40]

A 2008 recalculation provides a calculator that includes diabetes mellitus as a risk factor.[41]

Asymptomatic adults should not be screened for coronary artery disease with an electrocardiogram.[42]

Ankle brachial index (ABI)

For more information, see: Ankle brachial index.

A meta-analysis concluded that "measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS (Framingham risk score)".[35]

Reynolds Score

The Reynolds score has been proposed as an improvement to the Framingham risk by incorporating the c-reactive protein.[43][38] The score has been validated in the Women's Genome Health Study.[44] An online calculator is at http://www.reynoldsriskscore.org/.

C-reactive protein (CRP)

For more information, see: C-reactive protein.

The C-reactive protein may indicated risk in apparently healthy people due to the theory that chronic inflammation precedes atherosclerosis.[45]

The CRP is part of the Reynolds score.

References

  1. ↑ Anonymous (2024), Vascular disease (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ (2002) "Behavioral counseling in primary care to promote physical activity: recommendation and rationale". Ann. Intern. Med. 137 (3): 205-7. PMID 12160370. [e]
  3. ↑ Thompson PD, Buchner D, Pina IL, et al (2003). "Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity)". Circulation 107 (24): 3109-16. DOI:10.1161/01.CIR.0000075572.40158.77. PMID 12821592. Research Blogging. Summary at guidelines.gov
  4. ↑ McMurry MP, Cerqueira MT, Connor SL, Connor WE (1991). "Changes in lipid and lipoprotein levels and body weight in Tarahumara Indians after consumption of an affluent diet". N. Engl. J. Med. 325 (24): 1704-8. PMID 1944471. [e]
  5. ↑ http://www.who.int/nutrition/topics/5_population_nutrient/en/index12.html
  6. ↑ 6.0 6.1 U.S. Preventive Services Task Force (March 2009). "Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement". Ann. Intern. Med. 150 (6): 396–404. PMID 19293072. [e]
  7. ↑ 7.0 7.1 7.2 Wolff T, Miller T, Ko S (March 2009). "Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force". Ann. Intern. Med. 150 (6): 405–10. PMID 19293073. [e]
  8. ↑ Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M et al. (2012). "European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).". Eur Heart J 33 (13): 1635-701. DOI:10.1093/eurheartj/ehs092. PMID 22555213. Research Blogging.
  9. ↑ 9.0 9.1 Antithrombotic Trialists' (ATT) Collaboration. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J et al. (2009). "Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials.". Lancet 373 (9678): 1849-60. DOI:10.1016/S0140-6736(09)60503-1. PMID 19482214. PMC PMC2715005. Research Blogging. Review in: Ann Intern Med. 2009 Sep 15;151(6):JC3-4, JC3-5 Review in: Evid Based Med. 2009 Dec;14(6):172-3 Cite error: Invalid <ref> tag; name "pmid19482214" defined multiple times with different content
  10. ↑ Campbell CL, Smyth S, Montalescot G, Steinhubl SR (2007). "Aspirin dose for the prevention of cardiovascular disease: a systematic review". JAMA 297 (18): 2018-24. DOI:10.1001/jama.297.18.2018. PMID 17488967. Research Blogging.
  11. ↑ 11.0 11.1 Berger J, Roncaglioni M, Avanzini F, Pangrazzi I, Tognoni G, Brown D (2006). "Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials". JAMA 295 (3): 306-13. DOI:10.1001/jama.295.3.306. PMID 16418466. Research Blogging.
  12. ↑ 12.0 12.1 Algra A, Greving JP (May 2009). "Aspirin in primary prevention: sex and baseline risk matter". Lancet 373 (9678): 1821–2. DOI:10.1016/S0140-6736(09)61003-5. PMID 19482200. Research Blogging.
  13. ↑ De Berardis G, Sacco M, Strippoli GF, Pellegrini F, Graziano G, Tognoni G et al. (2009). "Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials.". BMJ 339: b4531. DOI:10.1136/bmj.b4531. PMID 19897665. PMC PMC2774388. Research Blogging. Review in: Ann Intern Med. 2010 Apr 20;152(8):JC4-10
  14. ↑ JAMA 2010 [Aspirin for Prevention of Cardiovascular Events in a General Population Screened for a Low Ankle Brachial Index]
  15. ↑ Sung JJ, Lau JY, Ching JY, Wu JC, Lee YT, Chiu PW et al. (2010). "Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial.". Ann Intern Med 152 (1): 1-9. DOI:10.1059/0003-4819-152-1-201001050-00179. PMID 19949136. Research Blogging.
  16. ↑ 16.0 16.1 Yokoyama M, Origasa H, Matsuzaki M, et al (2007). "Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis". Lancet 369 (9567): 1090–8. DOI:10.1016/S0140-6736(07)60527-3. PMID 17398308. Research Blogging.
  17. ↑ 17.0 17.1 Gissi-Hf Investigators (August 2008). "Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet. DOI:10.1016/S0140-6736(08)61239-8. PMID 18757090. Research Blogging. Cite error: Invalid <ref> tag; name "pmid18757090" defined multiple times with different content
  18. ↑ Wang X, Qin X, Demirtas H, et al (2007). "Efficacy of folic acid supplementation in stroke prevention: a meta-analysis". Lancet 369 (9576): 1876-82. DOI:10.1016/S0140-6736(07)60854-X. PMID 17544768. Research Blogging. PMID 17544768
  19. ↑ Lonn E, Yusuf S, Arnold MJ, et al (2006). "Homocysteine lowering with folic acid and B vitamins in vascular disease". N. Engl. J. Med. 354 (15): 1567-77. DOI:10.1056/NEJMoa060900. PMID 16531613. Research Blogging. PMID 16531613
  20. ↑ Toole JF, Malinow MR, Chambless LE, et al (2004). "Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial". JAMA 291 (5): 565-75. DOI:10.1001/jama.291.5.565. PMID 14762035. Research Blogging. PMID 14762035
  21. ↑ Albert CM, Cook NR, Gaziano JM, et al (May 2008). "Effect of folic acid and B vitamins on risk of cardiovascular events and total mortality among women at high risk for cardiovascular disease: a randomized trial". JAMA 299 (17): 2027–36. DOI:10.1001/jama.299.17.2027. PMID 18460663. Research Blogging.
  22. ↑ Ebbing M, Bleie Ø, Ueland PM, et al (August 2008). "Mortality and cardiovascular events in patients treated with homocysteine-lowering B vitamins after coronary angiography: a randomized controlled trial". JAMA 300 (7): 795–804. DOI:10.1001/jama.300.7.795. PMID 18714059. Research Blogging.
  23. ↑ Wang L, Manson JE, Song Y, Sesso HD (2010). "Systematic review: vitamin d and calcium supplementation in prevention of cardiovascular events.". Ann Intern Med 152 (5): 315-23. DOI:10.1059/0003-4819-152-5-201003020-00010. PMID 20194238. Research Blogging.
  24. ↑ Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000). "Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators.". N Engl J Med 342 (3): 145-53. PMID 10639539.
  25. ↑ Sleight P, Yusuf S, Pogue J, Tsuyuki R, Diaz R, Probstfield J et al. (2001 Dec 22-29). "Blood-pressure reduction and cardiovascular risk in HOPE study.". Lancet 358 (9299): 2130-1. DOI:10.1016/S0140-6736(01)07186-0. PMID 11784631. Research Blogging.
  26. ↑ (2000) "Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators.". Lancet 355 (9200): 253-9. PMID 10675071.
  27. ↑ Svensson P, de Faire U, Sleight P, Yusuf S, Ostergren J (2001). "Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy.". Hypertension 38 (6): E28-32. PMID 11751742.
  28. ↑ Kurtz TW (2003). "False claims of blood pressure-independent protection by blockade of the renin angiotensin aldosterone system?". Hypertension 41 (2): 193-6. PMID 12574079.
  29. ↑ Ogawa H, Nakayama M, Morimoto T, et al (November 2008). "Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial". JAMA 300 (18): 2134–41. DOI:10.1001/jama.2008.623. PMID 18997198. Research Blogging.
  30. ↑ Thavendiranathan P, Bagai A, Brookhart MA, Choudhry NK (2006). "Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials.". Arch Intern Med 166 (21): 2307-13. DOI:10.1001/archinte.166.21.2307. PMID 17130382. Research Blogging. Review in: J Fam Pract. 2007 Mar;56(3):174
  31. ↑ Ridker PM, Danielson E, Fonseca FA, et al (November 2008). "Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein". N. Engl. J. Med. 359 (21): 2195–207. DOI:10.1056/NEJMoa0807646. PMID 18997196. Research Blogging.
  32. ↑ Gissi-HF Investigators, Tavazzi L, Maggioni AP, et al (October 2008). "Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial". Lancet 372 (9645): 1231–9. DOI:10.1016/S0140-6736(08)61240-4. PMID 18757089. Research Blogging.
  33. ↑ León H, Shibata MC, Sivakumaran S, Dorgan M, Chatterley T, Tsuyuki RT (2008). "Effect of fish oil on arrhythmias and mortality: systematic review". BMJ 337: a2931. PMID 19106137. PMC 2612582. [e]
  34. ↑ Wang TJ, Gona P, Larson MG, et al (December 2006). "Multiple biomarkers for the prediction of first major cardiovascular events and death". N. Engl. J. Med. 355 (25): 2631–9. DOI:10.1056/NEJMoa055373. PMID 17182988. Research Blogging.
  35. ↑ 35.0 35.1 Fowkes FG, Murray GD, Butcher I, et al (July 2008). "Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis". JAMA 300 (2): 197–208. DOI:10.1001/jama.300.2.197. PMID 18612117. Research Blogging.
  36. ↑ Polonsky TS, McClelland RL, Jorgensen NW, Bild DE, Burke GL, Guerci AD et al. (2010). "Coronary artery calcium score and risk classification for coronary heart disease prediction.". JAMA 303 (16): 1610-6. DOI:10.1001/jama.2010.461. PMID 20424251. Research Blogging.
  37. ↑ Wilson, Peter W.F.; Michael Pencina, Paul Jacques, Jacob Selhub, Ralph D'Agostino, Christopher J. O'Donnell (2008-11-01). "C-Reactive Protein and Reclassification of Cardiovascular Risk in the Framingham Heart Study". Circ Cardiovasc Qual Outcomes 1 (2): 92-97. DOI:10.1161/CIRCOUTCOMES.108.831198. Retrieved on 2008-12-08. Research Blogging.
  38. ↑ 38.0 38.1 Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook NR (November 2008). "C-reactive protein and parental history improve global cardiovascular risk prediction: the Reynolds Risk Score for men". Circulation 118 (22): 2243–51, 4p following 2251. DOI:10.1161/CIRCULATIONAHA.108.814251. PMID 18997194. Research Blogging. Cite error: Invalid <ref> tag; name "pmid18997194" defined multiple times with different content
  39. ↑ Magnus P, Beaglehole R (2001). "The real contribution of the major risk factors to the coronary epidemics: time to end the "only-50%" myth". Arch. Intern. Med. 161 (22): 2657–60. PMID 11732929. [e]
  40. ↑ (2009) Assessment of Claims of Improved Prediction Beyond the Framingham Risk Score. JAMA
  41. ↑ D'Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM et al. (2008). "General cardiovascular risk profile for use in primary care: the Framingham Heart Study.". Circulation 117 (6): 743-53. DOI:10.1161/CIRCULATIONAHA.107.699579. PMID 18212285. Research Blogging.
  42. ↑ Moyer VA, on behalf of the U.S. Preventive Services Task Force* (2012). "Screening for Coronary Heart Disease With Electrocardiography: U.S. Preventive Services Task Force Recommendation Statement.". Ann Intern Med. DOI:10.7326/0003-4819-157-7-201210020-00514. PMID 22847227. Research Blogging.
  43. ↑ Ridker PM, Buring JE, Rifai N, Cook NR (February 2007). "Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score". JAMA 297 (6): 611–9. DOI:10.1001/jama.297.6.611. PMID 17299196. Research Blogging.
  44. ↑ Paynter NP, Chasman DI, Buring JE, Shiffman D, Cook NR, Ridker PM (January 2009). "Cardiovascular disease risk prediction with and without knowledge of genetic variation at chromosome 9p21.3". Ann. Intern. Med. 150 (2): 65–72. PMID 19153409. [e]
  45. ↑ Lloyd-Jones DM, Liu K, Tian L, Greenland P. Narrative review: Assessment of C-reactive protein in risk prediction for cardiovascular disease. Ann Intern Med. 2006 Jul 4;145(1):35-42. PMID 16818927
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