Original ArticlesDid grandma give you heart disease? The new battle against coronary artery disease
Section snippets
Much of heart disease is due to inheritance
The inherited nature of the common traits contributing to CAD has implications not only for the patient, but for family members as well. The presence of these inherited disorders is common in the CAD population: 77% of CAD patients and 54% of their first- and second-degree relatives express a genetically linked dyslipidemia.6 Thus, screening first-degree relatives can identify the high-risk family members who express the same trait(s) as the family member with CAD. Atherosclerosis and CAD are
Reduction of LDL cholesterol is not enough to stem the tide of coronary artery disease
Although elevated LDL cholesterol is powerfully linked to atherosclerosis risk, it is important to consider that 80% of patients with CAD have the same blood cholesterol values as those who did not develop CAD (Figure 2 ).9 Equally important is the finding that even with a 25–35% reduction in clinical events attributed to LDL cholesterol reduction, a large number of patients treated with cholesterol-lowering medications, and who achieve lower LDL cholesterol values, continue to have clinical
The most common metabolic disorders contributing to coronary artery disease are not detected by a routine lipid profile
Unfortunately, the 3 most common disorders contributing to CAD are not detected by the routine blood tests for total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides.1 Laboratory tests more sophisticated than the common “lipid profile” are now available to clinicians for making the diagnosis, selecting therapy, and monitoring treatment. These tests are frequently more costly than a routine lipid profile. However, the trade-off is the fact that the 3
Dietary fat reduction
LDL subclass pattern B, elevated Lp(a), and homocyst(e)inemia are treated with either lifestyle modification or inexpensive vitamins and medications. Knowledge of LDL subclass pattern is useful since patterns A and B respond differently to many lipid-altering treatments. Pattern B subjects respond with a greater LDL cholesterol and apoB reduction in response to dietary fat reduction than pattern A subjects.3 Following the low-fat diet, apoB decreased 10-fold more in the pattern B subjects
Sophisticated detection of disorders and treatment are cost effective
With the ability to treat CAD metabolically comes concern that such an approach will increase the cost of health care, in part because of the potential for increased use of relatively expensive medications. What is important for clinicians and healthcare administrators to appreciate is that the most common metabolic causes of CAD can be treated by the least expensive therapies, and proper diagnosis of the individual disorder allows the appropriate therapy to be used. An approach that suggests
Conclusions
Although physicians must remain vigilant for elevations in blood LDL cholesterol, it is now clear that attention to cholesterol alone will not be sufficient to prevent heart disease in those individuals at risk, nor will it be enough to adequately treat atherosclerosis in most CAD patients. Atherosclerosis is the result of complex gene–environment interactions and the most common disorders linked to atherosclerosis are not detected by the routine lipid panel. This has important implications for
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2001, American Journal of CardiologyCitation Excerpt :Investigations of LDL cholesterol reduction have demonstrated significant decreases in clinical events that appear to be concentrated in patients with higher LDL cholesterol values.14,15 Attention paid primarily to the percent reduction in clinical events obscures the fact that many patients assigned to medication continued to have cardiovascular events.1 For example, in 1 study, the 24% risk reduction in fatal coronary heart disease or nonfatal myocardial infarction was 274 events in the placebo group versus 212 events in the treated group.15