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Vascular disease

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Contents

In medicine, vascular disease is "pathological processes involving any of the blood vessels in the cardiac or peripheral circulation. They include diseases of arteries; veins; and rest of the vasculature system in the body."[1] Examples of vascular diseases include coronary heart disease, cerebrovascular disorders, and peripheral vascular disease.

Prevention

Exercise

Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force (USPSTF), based on a systematic review of randomized controlled trials, found 'insufficient evidence' to recommend that doctors counsel patients on exercise.[2] However, the American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise [3]

Preventive diets

Dietary changes can potentially lead to large changes in the cholesterol.[4]

Alcohol

The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary heart disease.[5]

Aspirin

Clinical practice guidelines

The U.S. Preventive Services Task Force has addressed this topic.[6][7]

USPSTF: Risk level at which benefit exceeds harm.[6][7]
MenWomen
Age 10 year CHD risk Age 10 year stroke risk
45-59 years ≥ 4% 50-59 years ≥ 3%
60-69 years ≥ 9% 60-69 years ≥ 8%
70-79 years ≥ 12% 70-79 years ≥ 11%
calculator Stroke calculator
  • If on NSAID: multiple rates by 4
  • If prior PUD: multiply rates by 2 to 3

The European Society of Cardiology has addressed this topic and concluded, "."[8]

Systematic reviews

The Antithrombotic Trialists' (ATT) Collaboration has conducted a collaborative meta-analysis of individual participant data and concluded that aspirin reduced serious vascular events with a rate ratio [RR] 0·88 (95% CI 0·82–0·94]).[9] However, the benefit was not found in patients with projected 5 year risk greater than 10%.

Aspirin, in doses of less than 75 to 81 mg/d[10], can reduce the incidence of cardiovascular events.[11] In most cases the net benefit is less than 1 patient among 100.[7] A more recent meta-analysis suggests the benefit is not clear, especially for patients on statins.[9] An accompanying editorial[12], offers a cost-benefit analysis that recommends aspirin if the 10 year risk of vascular disease is at least 30%.[12]

The benefit for diabetics is not clear.[13]

Other studies

In a trial of patients with ankle brachial index of less than 0.9, aspirin did not help although 11% of patients had events at 8 years.[14]

Aspirin should be considered even if bleeding peptic ulcer disease has occurred.[15]

Anticholesteremic agents

For more information, see: Hypercholesterolemia.


Antioxidant vitamins

For more information, see: Antioxidant.

Antioxidant vitamins are not beneficial.

Omega-3 fatty acids (fish oil)

For more information, see: Fish oil.


Omega-3 fatty acids may have small benefit[16][17], but results of randomized controlled trials are not consistent. The benefit may be at conferred on 2% of patients who take omega-3 fatty acids.[16]

Homocysteine lowering

Lowering of homocystein blood concentration with folic acid, vitamin B12, and vitamin B6 is not beneficial.

A meta-analysis concluded that lowering homocysteine with folic acid and other supplements may reduce stroke.[18] However, the two largest randomized controlled trials included in the meta-analysis had conflicting results. Lonn reported positive results[19]; whereas the trial by Toole was negative.[20]

Since the meta-analysis, two additional randomized controlled trials have shown no reduction in cardiovascular endpoint despite successfully lowering the plasma homocysteine level.[21][22]

Vitamin D

Vitamin D may help prevent vascular disease.[23]

Angiotensin-converting enzyme inhibitors

The Heart Outcomes Prevention Evaluation (HOPE) study suggested that the angiotensin-converting enzyme inhibitor ramipril could reduce vascular disease and mortality among patients at increased risk. This effect was thought to be independent of control of blood pressure.[24][25][26] However, subsequent studies have shown this result was more likely due to the administration of ramipril at night and recording blood pressures during the day when the least effect of ramipril was present.[27][28]

Evidence table

Interventions to prevent all-cause mortality
among patients at risk of vascular disease
  Study typeRelative risk ratio or odds ratio
for all-cause mortality
Aspirin[11] Systematic review of 6 RCTs through 2005
(Does not include negative JPAD trial[29])
Men OR=0.93
Women OR=0.94
Statin[30] Systematic review of 7 RCTs through 2005
(Does not include positive Jupiter[31] or negative GISSI-HF[32] trials)
RR=0.92
Fish oil[33] Systematic review of 12 RCTs through 2006
(Does not include positive GISSI-HF[17])
OR=0.92
No systematic review reported a significant decrease in mortality.

Prognosis

Many new biomarkers have been studied for their ability to improvement upon prediction based on traditional risk factors.[34]

Prediction of vascular disease
  Outcome Result
Framingham plus ankle brachial index 10-year total mortality, cardiovascular mortality, and major coronary event Total reclassification: 19% (men); 36% (women)[35]
Traditional risk factors (Framingham) plus coronary calcium score coronary heart disease events Net reclassification improvement 25%[36]
Traditional risk factors (Framingham) plus c-reactive protein"myocardial infarction and CHD-related death"Net reclassification improvement = 12%[37]
Traditional risk factors plus c-reactive protein and family history of MI before age 60 (Reynolds Score)All cardiovascular events Net reclassification improvement = 8% (in men)[38]

Regarding coronary heart disease, about 3/4 of its prognosis is due to three risk factors: hypercholesterolemia (total cholesterol > 182 mg/dL [4.71 mmol/L]), hypertension (diastolic blood pressure > 90 mm Hg), and cigarette smoking.[39]

Framingham risk

The Framingham risk uses clinical risk factors that are combined in an equation developed from the Framingham Heart Study to calculate prognosis. An online calculator is available at http://hp2010.nhlbihin.net/atpiii/calculator.asp.

Although many studies report better models than the Framingham model, the methods of these studies may not be adequate.[40]

A 2008 recalculation provides a calculator that includes diabetes mellitus as a risk factor.[41]

Asymptomatic adults should not be screened for coronary artery disease with an electrocardiogram.[42]

Ankle brachial index (ABI)

For more information, see: Ankle brachial index.

A meta-analysis concluded that "measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS (Framingham risk score)".[35]

Reynolds Score

The Reynolds score has been proposed as an improvement to the Framingham risk by incorporating the c-reactive protein.[43][38] The score has been validated in the Women's Genome Health Study.[44] An online calculator is at http://www.reynoldsriskscore.org/.

C-reactive protein (CRP)

For more information, see: C-reactive protein.

The C-reactive protein may indicated risk in apparently healthy people due to the theory that chronic inflammation precedes atherosclerosis.[45]

The CRP is part of the Reynolds score.

References

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