One in five of your patients could suffer a heart attack in the near future—unless you take steps to ensure their heart health.
Psychiatric patients have more modifiable risk factors for coronary artery disease (CAD) compared with the general population.When depression treatment goes nowhere,” Current Psychiatry, August 2005.)
To help keep you abreast of constantly changing guidelines and strategies for recognizing and minimizing CAD risk, this article discusses:
- preventive and diagnostic guidelines for managing hypertension, diabetes, and dyslipidemia
- practical advice on convincing at-risk patients to adopt a healthier lifestyle and have a primary care doctor monitor their health.
Case: cigarettes and supersizing
Mr. H, age 54, is receiving cognitive-behavioral therapy for mild depression. He has been smoking one pack of cigarettes per day for 20 years and has never seriously considered quitting.
The patient, a school teacher, says his “busy schedule” keeps him from exercising and eating properly; he eats fast-food hamburgers and fries approximately five times per week. His father had a heart attack at age 52 and died in his sleep 10 years later.
Mr. H says he feels fine and has never seen a physician other than his psychiatrist. He is reluctant to see a primary care physician for a check-up and, because he is asymptomatic, has no incentive to do so. The psychiatrist thus decides to do a routine examination.
Blood pressure is 148/86; other vital signs are normal. Mr. H’s waist size is 42 inches, he weighs 242 lbs, and his body mass index (BMI) is 34 kg/m2, indicating clinical obesity. Cardiovascular, pulmonary, and abdominal exams are unremarkable.
Discussion. Mr. H is at high risk of a myocardial ischemic event in the near future. He has six risk factors for CAD (Table 1)—four of which are modifiable:
- family history
- age
- current cigarette use
- provisional hypertension diagnosis
- obesity
- physical inactivity.
Table 1
Risk factors for coronary artery disease
| Core risk factors |
| Age ≥45 for men* |
| Age ≥55 for women or premature menopause without estrogen-replacement therapy* |
Family history: premature coronary artery disease with myocardial infarction or sudden death before:
|
| Current cigarette smoking |
| Hypertension or antihypertensive treatment* |
| Elevated LDL cholesterol (>130 mg/dL in patients with low cardiac risk) |
| HDL cholesterol |
| Triglycerides >150 mg/dL |
| Total cholesterol >200 mg/dL* |
| Obesity (BMI >30 kg/m2)† |
| Sedentary lifestyle |
| Other risk factors |
| Elevated C-reactive protein |
| Elevated homocysteine |
| Chronic renal failure |
| Depression |
| Negative (cardio-protective) risk factors |
| HDL >60 mg/dL |
| Moderate alcohol use—no more than 1 to 2 drinks per day (1 drink = 12 oz beer or 5 oz of wine) |
| If >1 risk factor, refer to primary care doctor or quantify 10-year risk by using the Framingham/ATP III point system scale (www.nhlbi.nih.gov). |
| * Framingham/ATP III point system scale variables |
| † Use BMI calculator (http://www.nhlbisupport.com/bmi/bmicalc.htm) to determine body mass index. |
| HDL: High-density lipoprotein |
| LDL: Low-density lipoprotein |
| Source: References 9,10 |
Tools for assessing risk
The lifetime risk at age 40 for developing CAD is 49% and 32% in men and women, respectively.6
The National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel) has focused on decreasing heart disease incidence by educating patients and providers. Preventive strategies and standards of care have changed several times over the past decade; the Adult Treatment Panel (ATP III) was last revised in July 2004.7
The American College of Cardiology and American Heart Association both endorse the modified Framingham/ATP III scale to measure CAD risk (see Related resources). Although this somewhat tedious point system has limitations, it can precisely calculate coronary risk across 10 years.8 Variables not included in the scoring system—such as C-reactive protein, homocysteine, and postmenopausal state—may be clinically significant and should be gauged separately.
An easier-to-use alternative, the ATP III “core risk factors” scale, estimates hypertension, hypercholesterolemia, family history, current cigarette smoking, and age as low, intermediate, or high (“risk equivalent”) risks (Table 1).8 Psychiatrists can quickly obtain this information from a brief history, blood pressure assessment, and relatively inexpensive lab studies.
Generally, the more risk factors present, the higher the risk of having a major coronary event. Presence of ≥ 2 risk factors signals intermediate or high risk and necessitates referral to a primary care doctor for monitoring.
Patients with a cardiac “risk equivalent” face a >20% risk of having a cardiac ischemic event within 10 years8 (Table 2). Examples of risk equivalents include diabetes or significant vascular disease in any artery.