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CHAPTER 1 Atherothrombosis
atherosclerosis. In the REACH registry, the 1-year rates of atherothrombotic
events (cardiovascular death, nonfatal myocardial infarction, stroke, or hospi-
talization for atherothrombotic events) increased signifi cantly with the higher
number of vascular beds with symptomatic atherosclerosis (5.31 percent in
patients with risk factors only, 12.58 percent in patients with one, 21.14 percent
in patients with two, and 26.27 percent in patients with three disease locations,
p for trend <0.001).
60
Furthermore, the incurred cost of health care is signifi -
cantly higher for patients with polyvascular disease compared to patients with
risk factors only or with disease in a single vascular bed.
61
Polyvascular disease
is also a predictor of worse outcomes in patients admitted to the hospital with
ACS. In CRUSADE, a large registry of patients admitted to the hospital with
non-ST-elevation acute coronary syndrome (NSTE-ACS), a total of 13 percent
of patients had prior known atherosclerosis in two or three vascular territories.
Increasing number of territories with preexistent atherosclerotic involvement
(zero, one, two, or three prior territories) was associated with a signifi cant
increase in rates of in-hospital death (3.4, 4.2, 6.3, and 7.3 percent respectively,
p < 0.001) and the composite of in-hospital death, congestive heart failure, re-
infarction, and stroke (9.9, 13.4, 18.9, and 21.9 percent respectively, p < 0.001).
This trend remained signifi cant even in multivariable analysis (Fig. 1.4).
62
Despite
being at a higher risk of adverse outcomes, NSTE-ACS patients with polyvas-
cular disease were less likely to receive guideline-recommended therapies,
such as cardiac catheterization, even after adjusting for co-morbidities.
62,63
Similar results were seen in a Canadian registry of patients with NSTE-ACS,
Death
Death/MI
Stroke
CHF
Composite
Transfusion
Major
bleeding
0.5 1 1.5 2.523
P-value: <0.001
OR: 0.99, 1.19, 1.25
Lower: 0.91, 1.07, 1.02
Upper: 1.07, 1.32, 1.54
P-value: <0.001
OR: 1.00, 1.22, 1.27
Lower: 0.94, 1.11, 1.07
Upper: 1.07, 1.33, 1.52
P-value: <0.001
OR: 1.07, 1.20, 1.25
Lower: 1.02, 1.13, 1.10
Upper: 1.12, 1.28, 1.42
P-value: <0.001
OR: 1.07, 1.25, 1.30
Lower: 1.02, 1.18, 1.15
Upper: 1.12, 1.33, 1.46
P-value: <0.001
OR: 1.11, 1.28, 1.30
Lower: 1.04, 1.18, 1.10
Upper: 1.17, 1.38, 1.53
P-value: 0.051
OR: 0.96, 1.07, 1.02
Lower: 0.91, 0.99, 0.85
Upper: 1.02, 1.17, 1.22
P-value: 0.329
OR: 1.11, 1.14, 1.61
Lower: 0.90, 0.87, 0.98
Upper: 1.36, 1.49, 2.64
One vascular bed
Two vascular beds
Three vascular beds
Figure 1.4 Adjusted odds ratios for various outcomes as a function of 1, 2, or 3 prior
vascular territories involved (vs. none). CHF, congestive heart failure; MI, myocardial
infarction. From Bhatt DL, Peterson ED, Harrington RA, et al. Prior polyvascular disease:
risk factor for adverse ischemic outcomes in acute coronary syndromes. Eur Heart J
2009 ;30(10):1195–1202.
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CHAPTER 1 Atherothrombosis
where patients with more extensive vascular disease had worse outcomes and
were less likely to receive evidence-based treatments.
64
Primary prevention of atherothrombosis
As discussed previously, cardiovascular disease, including atherothrombosis, is
a major cause of global morbidity and mortality. Primary prevention includes
the early identifi cation and treatment of modifi able cardiovascular risk factors,
and promoting healthy lifestyle changes. The pharmacologic management of
modifi able risk factors will be discussed in other chapters.
The majority of the modifi able cardiovascular risk factors are silent and do
not cause symptoms until end-organ damage occurs. As such, periodic clinical
assessment of patients and early identifi cation of cardiovascular risk factors are
important components of primary health care. While various guidelines tend
to focus on the diagnosis and management of single cardiovascular risk fac-
tors, clinicians should evaluate the overall risk of future cardiovascular events
and identify all opportunities to reduce this risk. Patient assessment should
include a thorough history, focused physical examination, and basic investiga-
tions (Table 1.2).
65
Generally, this assessment should be considered for all
male patients older than 40 and female patients older than 50 years of age.
The presence of one cardiovascular risk factor or documented atherosclerosis
should trigger a global assessment regardless of the patient’s age or gender.
The frequency of this assessment should vary according to the patient’s risk
profi le, with frequent assessment and follow-up in high-risk patients.
Unfortunately, several studies of outpatient care have shown that treatment
goals are frequently not achieved among patients at high risk of cardiovascular
events
66,67
or with prior documented atherothrombotic events.
68
Global risk
assessment tools have been developed that incorporate multiple risk factors
and help clinicians identify patients at highest risk of cardiovascular events
who would benefi t most from aggressive risk factor modifi cation and close
follow-up. The revised Framingham risk score incorporates several risk fac-
tors, including age, total cholesterol, HDL, systolic blood pressure, diabetes,
and smoking status, to predict overall 10-year risk of cardiovascular events.
69
The Reynolds score incorporates family history disease and high-sensitivity
C-reactive protein levels in its algorithm for improved accuracy.
70,71
The use of
cardiovascular risk assessment tools is recommended by guidelines to identify
high-risk patients who would benefi t most from aggressive risk modifi cation
and help determine treatment targets.
26,31
In addition to risk factor modifi cation, clinicians should encourage their
patients to adopt healthy lifestyle habits. The components of a healthier life-
style include regular physical activity, achieving a normal weight, and a healthy
diet. The American Heart Association, emphasizing the importance of achieving
and maintaining a healthy lifestyle, suggests seven ideal cardiovascular health
metrics:
72
• Not smoking
• Being physically active
• Eating a healthy diet
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CHAPTER 1 Atherothrombosis
• Achieving and maintaining a normal weight
• Having a normal blood pressure
• Having a normal blood glucose level
• Having a normal total cholesterol level
While achieving all seven metrics may prove elusive (only 2 percent of the
population in one observational study),
73
meeting a greater number of these
parameters is associated with a lower risk of cardiovascular events, including
atherothrombosis.
74
A healthy diet should be balanced, reasonable, and focused on the diet
as a whole, as opposed to focusing on specifi c nutrients or supplements.
The following dietary measures are recommended by the American Heart
Association:
• Balance caloric intake and physical activity to maintain a normal weight.
• Consume a diet rich in vegetables and fruits.
• Consume whole-grain, high-fi ber food.
• Reduce intake of saturated fats.
Table 1.2 Components of Patient Cardiovascular Risk Assessment
History
• Prior documented atherothrombosis events
• Prior documented risk factors
• Family history of prior atherothrombosis, particularly premature coronary
artery disease in fi rst-degree relatives
• Systemic review for symptoms of atherosclerosis (e.g., claudication, angina,
transient neurological defi cits, erectile dysfunction)
• Smoking habits
• Physical activity level
Physical Assessment
• Blood pressure measurement
• Body mass index, waist circumference
• Arcus senilis, xanthelasmas
• Retinal exam
• Peripheral pulse assessment
• Auscultation for renal, iliac, and carotid bruits
Investigations
• Fasting cholesterol profi le
• Fasting blood glucose, HbA1c
• 12-lead ECG*
• High-sensitivity C-reactive protein*
• Stress test*
• Ankle–brachial index*
• Measurement of carotid intima-media thickness*
• Microalbuminuria*
• Coronary artery calcium score*
* May be considered in selected patient populations and high-risk individuals.
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CHAPTER 1 Atherothrombosis
• Minimize intake of foods and beverages with added sugar.
• Choose and prepare foods with little or no salt.
• Consume fi sh, particularly oily fi sh, at least twice a week.
Regular physical activity is a major component of a healthy lifestyle. Regular
exercise helps achieve and maintain a healthy weight and increase cardio-
pulmonary fi tness. Exercise also helps improve the control of modifi able
cardiac risk factors, including better blood pressure control, more favorable
cholesterol profi le, and improved glucose tolerance. Studies suggest that the
cardioprotective effects of exercise are graded, with higher physical activi-
ties associated with lower risks of future events.
75
However, even moder-
ate exercise, such as brisk walking for half an hour a day, is associated with
signifi cant reduction of cardiovascular risk.
75
Regular physical activity is also
an important component of secondary prevention: light to moderate activity
in patients with established CHD is associated with a lower risk of all-cause
mortality.
76
A generally accepted exercise prescription for primary prevention recom-
mends aerobic exercise for more than 30 minutes on most, preferably all, days
of the week. The exercise should be intense enough for patients to experi-
ence breathlessness, sweating, and fatigue.
77
The U.S. Department of Health
and Human Services recommends that adults perform at least 150 minutes of
moderate-intensity aerobic exercise or 75 minutes of vigorous aerobic exercise
weekly.
78
The role of aspirin for primary prevention is controversial. Several tri-
als of aspirin use in primary prevention show a signifi cant reduction in the
absolute event rate of cardiovascular events.
79–81
A meta-analysis of 95,000
patients enrolled in trials of aspirin in primary prevention showed a signifi cant
reduction in cardiovascular events (0.51 percent versus 0.57 percent per year,
p = 0.0001), mainly driven by a reduction in rates of non-fatal myocardial infarc-
tion (0.18 percent versus 0.23 percent per year, p < 0.0001), at the expense of
higher rates of gastrointestinal and extracranial bleeds (0.1 versus 0.07 percent
per year, p < 0.0001).
82
Given the low event rate and the small absolute risk
reduction, preventing one myocardial infarction would need a signifi cantly large
number needed to treat, at an increased risk of bleeding events. Furthermore,
several studies included in this meta-analysis were published prior to the wide-
spread use of other primary prevention measures such as statins, which would
probably further reduce the effi cacy of aspirin in risk reduction. Guidelines
vary in their recommendation on aspirin in primary prevention. The Canadian
Cardiovascular Society recommends against the routine use of aspirin for pri-
mary prevention.
83
The U.S. Preventive Task Force recommends aspirin use
for primary prevention in men aged 45–79 years to prevent myocardial infarc-
tion and in women aged 55–79 to prevent ischemic stroke, when the benefi t
of aspirin use outweighs the potential harm of gastrointestinal hemorrhage or
other serious bleeding.
84
The American Heart Association/American College
of Cardiology recommends low-dose aspirin for primary prevention in adults
with diabetes who are at increased risk for cardiovascular events and not at
increased risk for bleeding.
85
Generally, aspirin in primary prevention should
be considered only in high-risk patients after careful assessment of benefi ts and
risks, and taking into account patient preference.
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CHAPTER 1 Atherothrombosis
In conclusion, atherothrombosis is a major cause of global morbidity and
mortality, and its prevalence is climbing, especially in the developing world.
Several risk factors for atherothrombosis have been identifi ed, and aggressive
management and control of these risk factors can lead to a signifi cant reduction
in the burden of atherothrombosis. Furthermore, promoting the adoption of
healthy lifestyle habits is a major component of primary prevention and should
be performed during most doctor–patient interactions.
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