Coronary Heart Disease: Primary and Secondary Prevention

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AN ONGOING CE PROGRAM OF THE UNIVERSITY OF FLORIDA

COLLEGE OF PHARMACY AND DRUG TOPICS

Heart disease is the leading cause of death in the United States. Over 79 million Americans have one or more types of cardiovascular disease (CVD), and over 15 million have diagnosed coronary heart disease (CHD) as manifested by chest pains or myocardial infarction (MI). According to the National Center for Health Statistics, if all forms of major CVD were eliminated, average life expectancy would rise from 78 years to 85 years. The NHANES Epidemiologic Follow-up Study found a decrease in CVD mortality due to a decrease in the incidence of CVD and the case fatality rate.

In light of this study, prevention is crucial to improving morbidity and mortality for many Americans. Risk factors for heart disease can be targeted via pharmacologic and nonpharmacologic means. Early risk factor assessment and detection can significantly impact the incidence of future CHD. Pharmacists can play an important role in ensuring appropriate treatments are prescribed and taken to minimize CHD risk and decrease mortality.

Risk factors

Risk factors are classified as modifiable or nonmodifiable. Nonmodifiable risk factors include age, family history, and gender. Modifiable risk factors include smoking, diet, obesity, physical inactivity, hypertension, dyslipidemia. diabetes mellitus, and metabolic syndrome (Table 1). Most factors that place individuals at risk are modifiable. Patients with multiple risk factors are at greater risk. Heart disease may be prevented if modifiable risk factors are eliminated.

Smoking. Smoking is an important risk factor for heart disease. Approximately 23% of men and 18% of women age 18 and older in the U.S. are smokers. The incidence of heart disease is 2 to 4 times higher for smokers versus nonsmokers, depending on quantity of cigarettes smoked. Smoking damages the inner lining of blood vessel walls and constricts the arteries elevating blood pressure and heart rate. The effects of smoking can be fatal; about 35% of smoking-related deaths are due to CVD.

Diet. Poor nutrition plays a role in the development of heart disease. Excessive daily calorie consumption from increased portion sizes and sugar-sweetened beverages has made a significant impact on health in the U.S. Many eat more than the recommended daily intake of fat and cholesterol while not consuming enough fruits, vegetables, and fiber.

Obesity. Obesity is epidemic in U.S. adults, children, and adolescents. Being overweight means being at risk for insulin resistance, high blood pressure, and high cholesterol thus elevating risk for heart disease. Patients with abdominal obesity are at greatest risk and need to be closely monitored.

Physical inactivity. A sedentary lifestyle is a significant risk factor for heart disease. Physical inactivity puts individuals at risk for CHD via weight gain, and development of diabetes, hypertension, and dyslipidemia. Only 31% of adults in the U.S. exercise regularly. This problem is confounded in heart disease, because physical activity declines with age.

Hypertension. High blood pressure is an independent risk factor for heart disease, stroke, and renal failure. One in 3 persons in the U.S. has hypertension and many are unaware that they have this disease. Of those diagnosed, less than half are at Lheir blood pressure target. The incidence of hypertension increases with age and can directly increase risk of CHD. In patients younger than age 50, diastolic blood pressure (DBP) is the major predictor for heart disease, whereas after age 60, systolic blood pressure (SBP) is more important. Hypertension leads to heart disease by increasing resistance against blood flow in the arteries, which increases workload for the heart. Hypertension can impair the vascular endothelium, thus inhibiting vasodilation and promoting inflammation, platelet aggregation, and vascular smooth muscle cell proliferation. …