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SECTION 1—CARDIOVASCULAR RISK FACTOR MANAGEMENT

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CASE 47-1

A 58-year-old woman is hospitalized for a flare-up of progressive relapsing multiple sclerosis (MS) with motor symptoms. Her past medical history includes arterial hypertension, prediabetes, osteoporosis, and a previous gastric ulcer treated medically. She never smoked, and does not drink alcohol or take illicit drugs. Her father had a nonfatal myocardial infarction at 52 years, and her mother is alive and in good health. Her current medications include amlodipine, risedronate, omeprazole, and calcium and vitamin D supplements. Upon physical examination, she appears in good health. Her vital signs are normal, including her blood pressure at 110/82 mmHg in the right arm and 112/82 mmHg in the left arm. Cardiopulmonary auscultation and abdominal examination are unremarkable. Upon palpation, her apical impulse lasts one third of the systole and is not displaced. She has no peripheral edema, eyelids xanthelasmas, or tendinous xanthomas.

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Why is cardiovascular risk factor management important?

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Even though age-standardized death rates attributable to cardiovascular diseases are decreasing in the United States,1 ischemic heart diseases and strokes represent the first and second causes of mortality worldwide, respectively, accounting for 25% of deaths when taken together.2 The combination of active smoking, abdominal obesity, diabetes, arterial hypertension, psychosocial stressors, irregular consumption of fruits and vegetables, sedentary lifestyle, absence of alcohol intake, and raised ApoB/ApoA1 ratio accounts for 90.4% of the population attributable risk of myocardial infarction,3 suggesting that most of the cases could be prevented through control of modifiable risk factors in primary and secondary prevention. The American Heart Association identified 7 components of ideal cardiovascular health to reduce the rates of cardiovascular diseases and stroke: smoking status, body mass index, physical activity, diet, cholesterol, blood pressure, and fasting plasma glucose.4 Data from 2007 to 2009 indicate that in all age groups, 0% of the people in the United States had an ideal profile for all 7 components,1 showing that many education efforts are still necessary to improve the cardiovascular health of the population.

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What is the importance of dyslipidemia in cardiovascular diseases, including cerebrovascular diseases?

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High blood cholesterol levels are strongly and independently associated with the incidence of cardiovascular diseases and mortality.5,6 Low-density lipoprotein cholesterol (LDL-C) levels are positively correlated with the aortic atherosclerosis plaque thickness in patients with idiopathic ischemic stroke,7 which might put patients with high levels at higher risks of recurrent ischemic cerebral event.8,9Dyslipidemia is thus an important target for prevention of cardiovascular diseases, including stroke. In the Unites States, dyslipidemia reached an epidemic level, with only 47.3% of the adults meeting the criteria for normal untreated total cholesterol, and 5.6% of adults with undiagnosed hypercholesterolemia.1 Nearly half of the American population ≥ 20 years old with high LDL-C levels is currently treated for high LDL-C levels.10

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Who should be evaluated for ...

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