An essential part of the cardiac history involves
obtaining detailed information about a patient’s risk
factors—the patient’s cardiovascular risk factor profile
(see Questions box 4.4).
Previous ischaemic heart disease is the most
important risk factor for further ischaemia. The patient
may know of previous infarcts or have had a diagnosis
of angina in the past.
Hypercholesterolaemia is the next most important risk
factor for ischaemic heart disease. Many patients now
know their serum cholesterol levels because widespread
testing has become fashionable. The total serum
cholesterol is a useful screening test, and levels above
5.2 mmol / L are considered undesirable. Cholesterol
measurements (unlike triglyceride measurements) are
accurate even when a patient has not been fasting.
Patients with established coronary artery disease
benefit from lowering of total cholesterol to below
4 mmol / L with the low-density lipoprotein (LDL) of
1.8 mmol / L or less. An elevated total cholesterol level
is even more significant if the high-density lipoprotein
(HDL) level is low (less than 1.0 mmol / L). Significant
elevation of the triglyceride level is a coronary risk
factor in its own right and also adds further to the
risk if the total cholesterol is high. If a patient already
has coronary disease, hyperlipidaemia is even more
important. Control of risk factors for these patients is
called secondary prevention. Patients who have multiple
risk factors for ischaemic heart disease (e.g. diabetes and
hypertension) should have their cholesterol controlled
aggressively. If the patient’s cholesterol is known to beQUESTIONS TO ASK ABOUT POSSIBLE.
CARDIOVASCULAR RISK FACTORS:
1. Have you had angina or a heart attack
in the past?
2. Do you know what your cholesterol level
is? Before or after treatment?
3. Are you a diabetic? How well controlled
is your diabetes?
4. Have you had high blood pressure and
has it been treated?
5. Are you now or have you been a
smoker? How long since you stopped?
6. Have you had kidney problems?
7. Do you have rheumatoid arthritis?
8. Do you drink alcohol? How much?
9. For men: Have you had any problems
with sex? Obtaining erections?
10. Have people in your family had angina
or heart attacks? Who? How old were
they?
QUESTIONS BOX 4.4
h Hypertension is more important as a risk factor for stroke and cholesterol
for ischaemic heart disease.
Hypertensionh is another important risk factor for
coronary artery disease. Find out when hypertension
was first diagnosed and what treatment, if any, has
been instituted (see Questions box 4.4). Treatment
of hypertension reduces the risk of ischaemic heart
disease, hypertensive heart disease, cardiac failure
and cerebrovascular disease (stroke). Treatment of
hypertension has also been shown to reverse left
ventricular hypertrophy.
A family history of coronary artery disease increases
a patient’s risk, particularly if it has been present in
first-degree relatives (parents or siblings) and if it has
affected these people before the age of 60. Not all heart
disease, however, is ischaemic; a patient whose relatives
suffered from rheumatic heart disease is at no greater
risk of ischaemic heart disease than anybody else.
A history of diabetes mellitus increases the risk of
ischaemic heart disease very substantially. A diabetic
without a history of ischaemic heart disease has the
same risk of myocardial infarction as a non-diabetic
who has had an infarct. It is important to find out how
long a patient has been diabetic and whether insulin
treatment has been required. Good control of the blood
sugar level in diabetes mellitus may reduce this risk.
An attempt should therefore be made to find out how
well a patient’s diabetes has been controlled.
Chronic kidney disease is associated with a very high
risk of vascular disease. This is possibly related to high
calcium-×-phosphate product. The risk may be reduced
by dietary intervention, ‘phosphate binders’, efficient
dialysis or renal transplant. Ischaemic heart disease is
the most common cause of death in patients with kidney
disease on dialysis.
Chronic inflammatory diseases such as rheumatoid
arthritis, psoriasis, poor dentition and gingivitis, and
HIV infection significantly increase the risk of vascular
disease too.
Erectile dysfunction is a sensitive indicator of arterial
endothelial abnormality and is a risk factor for, or
indicator of, vascular disease.
The presence of multiple risk factors makes control
of each one more important. Aggressive control of risk
factors is often indicated in these patients.
It is interesting to note that in the diagnosis of angina
the patient’s description of typical symptoms is more
high, it is worth obtaining a dietary history. This can be
very trying. It is important to remember that not only
foods containing cholesterol but also those containing
saturated fats contribute to the serum cholesterol level.
High alcohol consumption and obesity are associated
with hypertriglyceridaemia.
Smoking is probably the next most important
risk factor for cardiovascular disease and peripheral
vascular disease. Some patients describe themselves
as non-smokers even though they stopped smoking
only a few hours ago. The number of years the patient
has smoked and the number of cigarettes smoked
per day are both very important (and are recorded
as packet-years; p 16). The significance of a history
of smoking for a patient who has not smoked for
many years is controversial. The risk of symptomatic
ischaemic heart disease falls gradually over the years
after smoking has been stopped. After about 2 years the
risk of myocardial infarction falls to the same level as for
those who have never smoked. After 10 years the risk
of developing angina falls close to that of non-smokers.