Primary prevention of coronary heart disease - Integrating risk assessment with intervention
Primary prevention of coronary heart disease - Integrating risk assessment with intervention
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DOI：
10.1161/01.cir.100.9.988
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发表时间：
1999-08-31
期刊：
影响因子：
37.8
通讯作者：
Grundy, SM
中科院分区：
文献类型：
--
作者：
Grundy, SM
降低试验提供了一个例子。服用安慰剂的胆固醇和复发事件(CARE)研究9和普伐他汀在缺血性疾病(LID)研究中的长期干预的患者，10他们应该是美国冠心病患者的代表，预测重大冠状动脉事件的10年风险为26%。一个相关的标准可能是稳定型心绞痛患者；最近的分析16，17预测在10年内稳定型心绞痛患者发生致命性或非致命性心肌梗死的平均风险为20%。因此，对于一级预防，高短期风险可能被定义为在未来10年内发展为20%的致命性或非致命性心肌梗死的概率。临床动脉粥样硬化性疾病存在于其他动脉床，亚临床动脉粥样硬化的存在，或多种危险因素的存在，可以确定短期内冠心病的高风险。长期的高风险可以定义为在较长时期(10年)甚至一生中冠心病风险的增加。18几个风险因素可能导致高的长期风险，但即使是单一的风险因素，如果多年不治疗，也可能加速冠心病的发生。因此，具有单一或多个分类危险因素的患者不应被他们的医生忽视；初级预防既是长期的，也是短期的。长期处于高危状态的患者应该在医疗监督下减少风险。最后，较低的风险可以归因于基本上没有风险因素的患者。例如，弗雷明翰心脏研究19的研究人员最近将低风险个人定义为不吸烟、非糖尿病的人，他们具有理想的低密度脂蛋白胆固醇水平(100至129毫克/分升)、理想的血压(120/80毫米汞柱)和相对较高的高密度脂蛋白胆固醇(男性为45毫克/分升，女性为55毫克/分升)。即使是根据这些标准处于低风险的人，也应该得到医生的一些关注。需要定期监测，以评估风险状态是否发生了变化。此外，由于绝对风险随着年龄的增长而增加，应将降低风险的信息传达给低风险人群，以符合公共卫生努力，以降低一般人群的风险。相对风险是两个绝对风险水平的比率。分子是所考虑的个人的绝对风险；分母是基线人群的平均绝对风险，即低风险组或平均风险组。根据弗雷明翰调查人员的定义，低风险状态19是评估风险因素对特定个人的影响的一个有吸引力的分母。相对风险的估计在风险评估中具有一定的优势。例如，年轻人的高相对风险意味着长期高水平的绝对风险；这可能需要及早加强风险降低。此外，由于绝对风险随着年龄的增长而上升，65岁以后的高相对风险意味着特别高的绝对风险，并表明需要对风险因素进行更积极的干预。
lowering trials provides 1 example. Patients on placebo of the Cholesterol and Recurrent Events (CARE) study9 and the Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) study, 10 who should be representative of American patients with CHD, had a projected 10-year risk for major coronary events of 26%. A related standard could be the patient with stable angina pectoris; recent analyses16, 17 project an average risk of fatal or nonfatal myocardial infarction in patients with stable angina to be 20% in 10 years. Thus, for primary prevention, a high short-term risk might be defined as a probability of developing a fatal or nonfatal myocardial infarction of 20% in the next 10 years. High risk for CHD in the short term can be identified by the presence of clinical atherosclerotic disease in other arterial beds, by the presence of subclinical atherosclerosis, or by multiple risk factors. High risk in the long term can be defined by an elevated risk for CHD over a longer period (10 years) or even over a lifetime. 18 Several risk factors may contribute to a high long-term risk, but even single risk factors, if left untreated for many years, can hasten the onset of CHD. Thus, patients with single or multiple categorical risk factors should not be ignored by their physicians; primary prevention is for the long term as well as the short term. Patients at high risk in the long term deserve risk reduction under medical supervision. Finally, a lower risk can be ascribed to patients who are largely devoid of risk factors. For instance, investigators of the Framingham Heart Study19 recently defined low-risk individuals as being nonsmoking, nondiabetic persons who have a desirable level of LDL cholesterol (100 to 129 mg/dL), an optimal blood pressure (120/80 mm Hg), and a relatively high HDL cholesterol (45 mg/dL for men and 55 mg/dL for women). Even persons who are at low risk by these criteria deserve some attention by physicians. Periodic monitoring is needed to assess whether risk status has changed. Also, because absolute risk rises with advancing age, riskreduction messages should be conveyed to low-risk persons in accord with the public health effort to reduce risk in the general population.Relative risk is the ratio of 2 levels of absolute risk. The numerator is the absolute risk of the individual under consideration; the denominator is the average absolute risk of a baseline population, ie, either a low-risk group or an averagerisk group. The low-risk state, as defined by Framingham investigators, 19 makes an attractive denominator for evaluating the impact of risk factors in given individuals. Estimates of relative risk carry certain advantages in risk assessment. For instance, a high relative risk in a young adult signifies a high level of absolute risk over the long term; such may call for early, intensified risk reduction. Moreover, because of a rising absolute risk with advancing age, a high relative risk after age 65 signifies a particularly high absolute risk and suggests the need for more aggressive intervention on risk factors.