© S. ZH. URAZALINA, 2012 UDC 616.1-02]:005
S. Zh. Urazalina *
STRATIFICATION OF CARDIOVASCULAR RISK, CURRENT STATE OF THE PROBLEM
Federal State Institution Russian Cardiology Research and Production Complex of the Ministry of Health and Social Development of Russia, Moscow
*Urazalina Saule Zhaksylykovna, Ph.D. honey. Sciences, doctoral student. E-taD:[email protected]
Forecasting based on accounting and risk assessment occupies a central place in the system of prevention of cardiovascular diseases (CVD), including acute cardiovascular events (myocardial infarction - MI, stroke and sudden cardiac death - SCD), which remain the main causes of morbidity and mortality in developed countries. The most recent European studies show that up to 7% of all deaths in people aged 1 to 35 years are associated with SCD, a figure significantly higher than in previous studies.
At the same time, there is some inconsistency in the systematization of the list and classification of the CVD risk system among both domestic and foreign authors.
Cardiovascular risk factors, their contribution to the risk value
A risk factor is a characteristic and essential feature of an individual and his environment, which determines an increase in the likelihood of the occurrence, development and unfavorable outcome of any disease in a person.
Note that an individual risk factor determines only one of all possible causes of the development of the disease and thereby differs from the causative factor. In relation to CVD, a risk factor determines the increase in the likelihood of CVD or a complicated course (acute cardiovascular event) of an existing disease.
Based on the above definition, the most obvious dichotomies of risk factors are:
♦ internal (features of the body and personality) and external (habitat and lifestyle) factors;
♦ simple and complex (composite) factors;
♦ risk factors for morbidity and mortality;
♦ significant and insignificant (primary and secondary), i.e. factors that directly affect the risk of developing the disease, and secondary factors that modulate the values of the primary ones;
♦ changeable and unchangeable, i.e. factors that can be influenced (lifestyle) and those that cannot be changed (gender, age, genetics). Further classification of internal factors
risk of CVD leads to the identification of biochemical, physiological, psychological (features of nerve-
organization) and individual (gender, age, social, etc.) factors. External factors risk are divided into two large groups - features of a person’s lifestyle (nutrition, activity regime) and habitat (ecological and social factors).
In practice, patients often have two or three or more simultaneous risk factors, most of which are interrelated. The role of each of these factors may be insignificant, but due to their combined influence on each other, a high risk of developing CVD may arise. In this regard, the assessment of overall cardiovascular risk (CVR) is of great importance, the degree of which depends on the presence or absence of associated risk factors, target organ damage and associated clinical conditions. Currently, more than 200 such factors are identified.
An analysis of the available literature shows that in foreign practice, in addition to the above, an additional classification of CVD risk factors has been developed, implying their division into traditional (i.e., generally recognized, conventional) and new (novel). To date, more than 100 new and different risk factors have been proposed to improve existing stratification systems, but the 1998 and 2002 consensus conferences did not recommend any of the new factors due to the lack of convincing evidence to predict the development of complications. Therefore, when further considering CVD risk factors, we will adhere to this division.
Traditional risk factors
An analysis of the available works of domestic and foreign authors allows us to state significant discrepancies in the classification of certain CVD factors as traditional. Thus, a number of factors that have already become traditional for foreign researchers have not yet received recognition in the domestic literature. Nevertheless, an analysis of the intersections of the lists of factors proposed by different authors made it possible to identify the following list of traditional CVD risk factors (given in accordance with the classification discussed above). I. Internal risk factors 1. Physiological ♦ Increased body mass index (BMI) and obesity. Accompanying illnesses,
especially cardiovascular diseases, as a rule, develop in obese patients even in at a young age. This factor is associated with 44% of diabetes cases and 23% of coronary heart disease (CHD). In Russia, this factor is the most common; in the study, it was noted in 35.3% of those examined.
♦ Increased blood pressure (BP), arterial hypertension (AH). Hypertension is detected in 25-30% of the adult population of industrialized countries and is one of the most important risk factors. As a result of the study, elevated blood pressure in Russia was observed in 12.7% of those examined. Hypertension in a variety of age groups largely determines cardiovascular morbidity and mortality. Among hypertensive patients with higher blood pressure levels, the proportion of individuals with a low risk of death (less than 5%) from cardiovascular diseases decreases and the proportion of individuals with a high risk of death exceeding 5% increases. Elevated systolic blood pressure is associated with 51% of strokes (cerebrovascular diseases) and 45% of deaths from coronary artery disease.
♦ Concomitant diseases, inflammation and infections (diabetes, insulin resistance, rheumatoid arthritis, asymptomatic target organ damage). Patients with diabetes have a multiple (2-8 times) increased risk of future cardiovascular events compared to those without diabetes. 75% of all deaths due to coronary artery disease are associated with diabetes in patients. Pre-existing CVD or kidney disease (ventricular hypertrophy, thickening of the carotid artery wall, plaques, increased arterial stiffness, microalbuminuria or proteinuria, etc.) are criteria for classifying people as high and very high risk.
2. Biochemical
♦ Hypercholesterolemia. Globally, a third of CHD cases are associated with high levels of total cholesterol (TC) in the blood, which also increases the risk of CVD, stroke and other vascular diseases. Hypercholesterolemia is detected in 4.4% of those examined during clinical examination in Russia.
♦ Hyperglycemia. High blood glucose is associated with all deaths from diabetes, 22% of deaths from ischemic heart disease and 16% of deaths from stroke. Hyperglycemia is detected in 1.6% of those examined during clinical examination in Russia.
♦ Disorders of the lipoprotein spectrum (LP), dyslipidemia, hyperhomocysteinemia. This factor is expressed in low levels of high-density lipoprotein (HDL), high levels of low-density lipoprotein (LDL) and triglycerides - TG (apolipoprotein A - apoA and apolipoprotein B - apoB). A low level of HDL characterizes a low rate of cholesterol (C) turnover at the level of the cell membrane, changing the transmembrane potential and exacerbating cellular energy deficiency. In general, a 1 mg/dL increase in HDL cholesterol is associated with a 2-3% reduction in total CVD risk. Dyslipidemia plays a primary role in the development of atherosclerosis and related CVDs. These risk factors are currently controversial and a number of researchers classify them as new.
3. Individual
A group of individual factors is characterized by their immutability, i.e., the impossibility of changing the values of their indicators.
♦ Gender. Males have a higher risk of CVD.
♦ Age. The risk of CVD morbidity and mortality increases with age.
♦ Family and individual history, for example, a family history of early coronary atherosclerosis.
♦ Genetic predisposition. Genetic factors can predetermine almost all other internal risk factors.
II. External risk factors
1. Lifestyle
♦ Tobacco smoking, including passive smoking. IHD is associated with 35-40% of all smoking-related deaths. Another 8% of deaths are attributed to secondhand smoke. The prevalence of this risk factor in Russia is 25.3%.
♦ Dietary factors. A diet high in saturated fat leads to increased cholesterol levels. Insufficient consumption of fruits and vegetables, according to some estimates, may be responsible for about 11% of deaths from coronary heart disease. Consumption of salty foods increases the risk of hypertension and, as a result, CVD.
♦ Level and character physical activity. Lack of physical activity and a sedentary lifestyle are the cause of up to 30% of cases of coronary artery disease and 27% of cases of diabetes. A number of recent studies challenge the traditional view of the benefits of prolonged and vigorous physical activity for the prevention of CVD. So, for men and women, only 30 minutes of daily walking is recommended to ensure the necessary condition of cardio-vascular system.
2. Factors external environment
♦ Psychosocial and environmental factors. The presence of depression and mental stress tends to increase cardiovascular risk. Neuropsychic stress significantly increases the heart's need for oxygen and aggravates myocardial ischemia, and is associated with the development of metabolic syndrome and the induction of ventricular arrhythmias. Stress is a recognized risk factor for acute cardiovascular events. An increased level of anxiety is observed in 10.5-21% of the population (19-20% of women and 8-10% of men), while in patients with hypertension it is noted increased level both reactive anxiety (moderate - in 48%, high - 43.5%) and personal anxiety (moderate - in 41.5%, high - in 55.5%).
7 risk factors - smoking, high blood pressure, high BMI, hypercholesterolemia, hyperglycemia, low consumption of fruits and vegetables, and physical inactivity - account for 61% of deaths from CVDs, which, in turn, account for about 30% of all deaths in the world . The same risk factors together predetermine more than 75% of deaths from ischemic and hypertension hearts The combination of risk factors, including smoking and obesity, with low ventricular activation rate index scores is associated with the lowest rates of patient survival
Some deaths from CHD can be prevented by lowering blood pressure or cholesterol levels, but in the presence of any form of CHD in men over 60 years of age, traditional risk factors do not make a statistically significant contribution to the increase in mortality, and only low levels of HDL cholesterol are significant. reduced levels apoA1 and an increase in the apoB/apoA1 ratio.
However, in modern conditions Identification of traditional risk factors is not sufficient to predict the occurrence of cardiovascular complications. In particular, monitoring traditional risk factors alone will not identify the majority of patients who are predicted to have a heart attack in the near future. Consequently, they will not be offered adequate preventative treatment. Therefore, in recent years there has been evidence that risk stratification can be improved by assessing a number of new risk factors.
New risk factors
A significant volume of scientific medical publications over the past decade has been devoted to new factors of CVD, which are primarily promising predictors of coronary artery disease, atherosclerosis and acute cardiovascular events, as well as data for predicting the outcome of patients with CVD. Initially, new risk factors were considered only as additional ones in existing standard models for calculating risks based on traditional factors, since they are significantly correlated with them and serve to increase the accuracy of calculations in subgroups of diseases, in particular, to increase the reliability of the Bayesian criterion. However, in Lately a number of new factors are proposed as candidates for the role of signs of damage to the cardiovascular system and risk factors for CVD and its complications, which can be used in risk stratification systems in individuals who do not have clinical manifestations of CVD.
Biochemical markers of chronic inflammation and the state of electrical activity of the heart as an integral marker of stability are considered as new factors of cardiovascular risk. cell membranes cardiomyocytes, immunological factors and a number of others. Based on the above division, the list of the most discussed new risk factors is as follows.
1. Biochemical (laboratory) markers
♦ Increased levels of high-sensitivity C-reactive protein (CRP). Elevated CRP levels have been shown to be an independent factor of atherosclerotic risk and adverse outcome in patients after a cardiovascular event.
♦ Increased levels of lipoprotein-associated phospholipase (LP-PLA2), which plays an important role in the pathogenesis of atherosclerotic plaque instability and is therefore a potential risk marker.
♦ Elevated levels of homocysteine, measured in serum taken from the liver. This indicator can be used as a continuous variable when assessing SSR.
♦ Drug concentration (a). The concentration of this drug in the blood determines the incidence of CVD.
It shows the level of cardiovascular risk in the adult population, regardless of age, diet, physical activity, smoking or lack thereof, alcohol consumption and gender.
♦ Lipid spectrum (apoproteins apoA, apoB, apoC, TG, LP remnants, small LDL particles, HDL subtypes, ratio of LDL cholesterol to HDL cholesterol - LDL cholesterol/HDL cholesterol).
♦ Thrombogenic/antithrombogenic factors (platelet and coagulation factors, fibrinogen, activated factor VII, plasminogen activator inhibitor-1, tissue plasminogen activator, von Willebrand factor, factor V Leiden, protein C, antithrombin III).
2. Physiological (instrumental) factors
♦ Thickness of the intima-media complex (IMT) of the carotid arteries. The indicator is measured in specialized centers using high-resolution ultrasound at points in the carotid arteries. Currently, there is a debate about the prognostic properties and uniformity of measurements of this indicator.
♦ Ankle-brachial index (ABI), calculated as the ratio of systolic blood pressure at each ankle to systolic blood pressure at the right arm.
♦ Coronary calcium index, which allows you to assess the calcium content in the walls of the coronary arteries. It is calculated in points based on the results of processing radiographic images or by measuring using electron beam computed tomography. Currently, no standards have been established for this indicator.
♦ Pulse wave propagation velocity (PWV). Many studies show the high significance of this indicator as a marker of damage to the vascular wall by atherosclerosis and, consequently, the risk of morbidity and mortality from CVD, including in patients with asymptomatic atherosclerosis.
In practice, the assessment and consideration of any one risk factor is not promising and is carried out in a complex, which is reflected in a number of CVD risk assessment scales. In this case, it is advisable to consider the content and characteristics of the applied CVD risk stratification scales.
Comparative analysis modern scales used for stratification of SSR
Currently, the assessment of the total risk becomes a necessary condition reliable determination of the probability of developing cardiovascular events in the next 5-10 years in patients with existing CVD and in persons without clinical manifestations of cardiovascular pathology.
There are several models for calculating population risk. All of them are based on multivariate analysis of disease risk in large populations followed over a long period of time.
These systems certainly cannot be considered perfect. First of all, they do not take into account all currently known risk factors. The emphasis is on factors such as blood pressure level, serum total cholesterol, smoking, age and gender, and less important risk factors such as family history, obesity, overweight and others are not taken into account -
Xia. The same can be said about emerging risk factors; their use in risk assessment using known systems is not envisaged. Another problem is that most of these systems do not take into account regional characteristics, nutritional patterns and some other factors that undoubtedly affect the prognosis. Finally, a significant drawback of many systems is that they mainly take into account coronary events, MI, angina pectoris and therefore are mainly focused on determining the risk not of all CVDs, but coronary disease.
1. Framingham risk assessment scale
The Framingham Risk Score (FRS) is
a type of multidimensional intelligent assessment of the risk level of cardiovascular events based on traditional CVD factors, which are successfully used by health care professionals as predictors of CVD; Factor modification interventions have been shown to be effective in these models, and it is recognized that scales such as the FRS should be used to determine risk in individuals without CVD symptoms.
Many studies have demonstrated the high value of this risk assessment system in various demographic and ethnic groups. The predictive ability of FSR varies depending on the place of residence of patients. So, in Framingham itself it is 0.79 for men and 0.83 for women, and in New York it is 0.68 for both sexes. The predictive ability of the FSR in Denmark is 0.75, in Italy - 0.72, in France - 0.68, in the UK - 0.62. A review of 27 studies that used FRS scores found that the ratio of predicted to actual events ranged from an underestimation of about 0.43 in a high-risk population to an overestimation of about 2.87 in a low-risk population.
Since the FSR was compiled on the basis of a study conducted in the USA in Framingham, its data are most reliable directly for this area. However, this does not mean that it cannot be used in other regions and even countries. Many modifications of this system make it possible to use it throughout the world and apply it to the black and white populations of Europe, Asian Americans, Indians, as well as residents of some Asian countries (for example, China).
Currently, there is a sufficient number of publications indicating that when using FSR data, for example in the European Region, the observed absolute risk is often significantly lower than that predicted using the Framing-Gem algorithm, i.e., the real absolute risk is overestimated.
Over the years, the European Society
Hypertension (ESH) and the European Society of Cardiology (ESC) were guided by the recommendations issued by WHO and the International Society of Hypertension (ISH), slightly adapting them to the situation in Europe. In 2003, the decision was made to publish ESH/ESC's own guidelines, since the WHO/ISH guidelines are intended for countries that differ significantly in the organization of medical care and economic situation, and contain some diagnostic and treatment recommendations that may be insufficient
but adequate for European countries. The 2003 ESH/ESC guidelines have been well received by the medical community and have been widely cited in the medical literature in recent years. However, since 2003, approaches to the diagnosis and treatment of hypertension have changed, which served as the basis for revising these recommendations.
For a long time, blood pressure indicators served as the only or main criterion for assessing the need for antihypertensive therapy and choosing its regimen. Although this approach was retained in the JNC 7 report, the 2003 ESH/ESC guidelines stated that total CV risk should be taken into account when diagnosing and treating hypertension. This is due to the fact that only a small proportion of patients with hypertension experience an isolated increase in blood pressure, while the vast majority of patients have additional CV risk factors.
The 2003 ESH/ESC guidelines classify overall CVR based on WHO/ISH guidelines, including patients with “normal” or “high normal” BP. This classification is retained in these recommendations. The terms “low,” “moderate,” “high,” and “very high” risk reflect the estimated risk of CVD and mortality over the next 10 years, similar to the increase in CVD estimated from the Framingham Study or the SCORE model. The term "additional" or "added" indicates that in all categories the relative risk is increased compared to the average.
Key clinical parameters that should be used for risk stratification include risk factors (demographic, anthropometric, family history of early CVD, blood pressure, smoking, glucose and lipid levels), end-organ damage, presence of diabetes mellitus and associated clinical conditions highlighted in the guidelines 2003 (see table).
Implementation of ESH/ESC recommendations involves the following steps diagnostic examination: measuring blood pressure, establishing family and medical history, physical examination, laboratory tests, genetic analysis and identifying signs of damage to target organs (heart, blood vessels, kidneys, brain and fundus).
It is necessary to pay attention to the following points:
1. Metabolic syndrome is a combination of factors that are often combined with high blood pressure and significantly increase cardiovascular risk. This does not mean that it is an independent nosological form.
2. Additionally, the importance of identifying target organ damage is emphasized, since their asymptomatic changes indicate progression of shifts within the cardiovascular continuum and a significant increase in risk compared with that in the presence of risk factors alone.
3. The list of markers of kidney damage has been expanded and includes creatinine clearance, which is calculated using the Cockcroft-Gault formula, or glomerular filtration rate, calculated
System of forecast factors according to the EOAS/EOC scale 2003
Risk factors
♦ Systolic and diastolic blood pressure values
♦ Pulse blood pressure (for older people)
♦ Age > 55 years for men and > 65 years for women
♦ Smoking
♦ Dyslipidemia (cholesterol > 5.0 mmol/l or LDL cholesterol > 3.0 mmol/l) or HDL cholesterol< 1,0 ммоль/л у мужчин и < 1,2 ммоль/л у женщин или ТГ >1.7 mmol/l
♦ Fasting plasma glycemia 5.6-6.9 mmol/l
♦ Impaired glucose tolerance
♦ Abdominal obesity (waist circumference > 102 cm in men and > 88 cm in women)
♦ Family history of early CVD (< 55 лет у мужчин и < 65 лет у женщин)
Asymptomatic target organ damage
♦ ECG signs of hypertrophy left ventricle- LV (Sokolov-Lyon index > 38 mm, Cornell index > 2440 mm ms)
♦ Echocardiographic signs of LV hypertrophy (LV myocardial mass index > 125 g/m2 in men and > 110 g/m2 in women)
♦ Thickening of the carotid artery wall (IMT > 0.9 mm) or plaque
♦ kfSPV > 12 m/s
♦ Ankle-brachial index (ABI)< 0,9
♦ A slight increase in plasma creatinine levels - up to 115-133 mmol/l in men and 107-124 mmol/l in women
♦ Low estimated glomerular filtration rate (< 60 мл/ мин) или низкий клиренс креатинина (< 60 мл/мин)
♦ Microalbuminuria 30-300 mg/day or albumin/creatinine ratio > 22 mg/g in men and > 31 mg/g in women
Diabetes
♦ Fasting plasma glucose > 7.0 mmol/L with repeated measurements
♦ Post-exercise plasma glucose > 11 mmol/l
Cardiovascular diseases and nephropathy
♦ Cerebrovascular diseases: ischemic stroke, cerebral hemorrhage, transient ischemic attack
♦ Heart diseases: MI, angina, heart failure, coronary revascularization
♦ Kidney damage: diabetic nephropathy, renal dysfunction, proteinuria
♦ Damage to peripheral arteries
♦ Severe retinopathy: hemorrhages and exudates, swelling of the nipple optic nerve
according to the MORN formula, since these indicators allow a more accurate assessment of CV risk associated with renal dysfunction.
4. Microalbuminuria is currently considered a necessary component in the assessment of target organ damage, given the simplicity and relative cheapness of the method for its determination.
5. Concentric hypertrophy of the left ventricle is a structural parameter that causes a more significant increase in cardiovascular risk.
7. Risk factors include an increase in pulse wave velocity, which is an early sign of increased stiffness of large arteries, although this method is not widely available in clinical practice.
8. Low ankle-brachial index (ABI)< 0,9) - достаточно простой показатель атеросклероза и повышенного общего ССр.
9. It is recommended to evaluate target organ damage not only before (for the purpose of risk stratification), but also during treatment, since regression of left ventricular hypertrophy and a decrease in proteinuria reflect a protective effect on the cardiovascular system.
10. There is a rationale for including elevated heart rate (HR) as a risk factor because it is associated with the risk of CVD and mortality, as well as all-cause mortality. An increase in heart rate increases the risk of developing hypertension and is often combined with metabolic disorders and metabolic syndrome. However, given the wide range of normal resting heart rate values (60–90/min), it is currently impossible to identify indicators that could improve the accuracy of stratification of total heart rate.
11. The main criteria for identifying high and very high risk groups in the scale under consideration are:
♦ systolic blood pressure > 180 mm Hg. Art. and/or diastolic blood pressure > 110 mm Hg. Art., as well as systolic blood pressure > 160 mm Hg. Art. in combination with low diastolic blood pressure< 70 мм рт. ст.;
♦ diabetes mellitus;
♦ metabolic syndrome;
♦ existing CVD or kidney disease;
♦ three SSR factors or more;
♦ at least one of the following indicators of asymptomatic target organ damage: electrocardiographic (especially with overload) or echocardiographic signs of left ventricular hypertrophy; sonographic signs of thickening of the carotid artery wall or plaque; increased arterial stiffness; moderate increase in serum creatinine levels; decreased glomerular filtration rate or creatinine clearance; microalbuminuria or proteinuria. It should be noted that the presence of multiple
risk factors, diabetes mellitus or target organ damage clearly indicates a high risk, even with high normal blood pressure.
The proposed recommendations have specific conceptual limitations. Thus, overall SVR depends largely on age. In young adults (especially women), the risk is rarely high even when more than one risk factor is present, but their relative risk (compared with their peers) is clearly increased. In contrast, most people over 70 years of age often have a high overall risk, although it is only slightly increased compared with that of patients of the same age. As a result, funds are spent primarily on older people who have limited life expectancy despite treatment, while little attention is paid to younger people with a high relative risk. If left untreated, long-term exposure to risk factors can lead to partially irreversible changes and a possible reduction in life expectancy.
relative risk. For this purpose, the HeartScore index (www.escardio.org) can be used, taking into account the recommendations for the prevention of CVD in clinical practice proposed by the fourth joint working group of European societies. 3. SCORE scale (2003)
The easiest to use is the currently proposed European SCORE system. This system, adopted in 2003 by the European Society of Cardiology, and the results of its use were already reported at the European Congress of Cardiology in 2005, was created based on the results of 12 epidemiological European studies, including Russian ones, including 250,000 patients, 3 million person-years of observation and recording of 7000 fatal cardiovascular events.
The system is presented in two tables for calculating risk in countries with low and high levels of risk. In addition to color division by risk level, each cell of the graph contains a number for a more accurate quantitative risk assessment. The scale includes such CVD factors as age, gender, TC level, systolic blood pressure and smoking. The risk indicator is the probability of death from any CVD in the next 10 years of the patient’s life. The risk is considered low (< 1%) и средним, если при проекции данных пациента на карту SCORE он составляет менее 5%, высоким, если он находится в пределах 5-9%, и очень высоким, если равен 10% или более.
This system is more progressive, since it does not have some of the disadvantages of other systems. First, it can be used to calculate CV risk, not just coronary disease risk, which expands its application. It is also the first to attempt to take into account regional differences by offering different risk calculation tables for different high- and low-risk regions of Europe.
A significant difference in this system is that risk indicators were calculated not according to the Framingham study, but based on data from 12 European epidemiological studies.
Features of the SCORE system include its applicability only to individuals without clinical manifestations of CVD, ease of use, and the availability of special versions for countries with high and low cardiovascular mortality. For countries classified as high risk (countries of Northern and Eastern Europe, former Soviet republics), high risk exceeds 5%, moderate (intermediate) is 2-4%, and low is less than 2% probability fatal outcome from any CVD over the next 10 years. However, this system only considers the risk of a fatal outcome of the disease.
The SCORE risk assessment scale, included in the European recommendations for the prevention of CVD in clinical practice, 2003, despite all the obvious advantages, has a number of limitations. The risk of CVD, calculated by SCORE, may be underestimated by: examination of an elderly patient, preclinical atherosclerosis, unfavorable heredity, decreased HDL cholesterol levels, increased levels of TG, CRP, apoB/Lp(a), obesity and physical inactivity. Despite this fact, we can conclude that in
Doctors have a simple tool for determining the total risk of fatal CVD, which can be used directly at the workplace during an outpatient appointment - the SCORE scale.
4. ATP III scale
The National Cholesterol Education Program Adult Treatment Panel III is designed as a tool to assess the risk of CVD severity over a 10-year period based on the FRS using population data and cost-effectiveness assessments.
The concept of vascular age was tested in studies that preceded this program. It was noted that ART III identifies women and young men at low risk of CVD (< 10%), даже если они имеют несколько факторов риска.
IN latest version NCEP ATP III (based on 5- and 10-year studies) included such CV risk factors as age (for men over 45 years old, for women over 55 years old), gender, total cholesterol level, HDL cholesterol, systolic blood pressure and smoking. TC levels were included in this system because the Framingham study database demonstrated a higher association with CV risk than LDL levels. Diabetes mellitus according to this system is regarded as equivalent to CVD, so patients with this disease are classified as high risk.
What's different about this system is that it distinguishes "medium-high" risk (defined as a 10% risk of 10-year mortality) as opposed to high risk (20% risk). This category, according to the authors, is necessary to improve the quality of prevention and treatment of CVD at the level of both medical care and healthcare organization.
For almost all combinations of risk factors, even extreme values, nonsmoking men under 45 and virtually all women under 65 have a 10-year risk of less than 10%. Thus, many high-risk young patients are included in the population who do not require preventive therapy. Such data certainly requires reclassification to more reliably determine the level of risk.
The system for identifying risk groups in the ATP III program coincides with the system for identifying risk groups in the SCORE scale.
NCEP-ATP III notes the need and high importance of searching for biomarkers that increase or decrease HDL levels.
5. PROCAM model
This model, recommended by the International Society of Atherosclerosis for calculating risk, is based on the results epidemiological research, which involved 40,000 patients. With the help of new algorithms, it has become possible to recognize the preclinical stage of atherosclerosis. The PROCAM score is more relevant for use in patients with metabolic disorders or diabetes mellitus. This system takes into account age, smoking, LDL and HDL levels, systolic blood pressure, family history of CVD (MI), diabetes mellitus and TG levels. In this case, the points assigned for each risk factor are calculated: age - from 0 to 26, LDL cholesterol level - from 0 to 20, HDL cholesterol - from 0 to 11, TG - from 0 to 4, smoking - from 0 to 8, diabetes mellitus - from 0 to 6, heredity -
from 0 to 4, systolic blood pressure - from 0 to 8. Ultimately, the data is added up and the result is checked against a table that indicates the 10-year risk for a given number of points.
6. D'Agustino risk stratification system Recent publication by R. D'Agostino et al. opens up the possibility of introducing into clinical practice a new unified algorithm for assessing CVD risk. The authors believe that this algorithm is a universal tool for assessing cardiovascular risk and will be useful for general practitioners. The study authors developed an algorithm for estimating total cardiovascular risk separately for men and women. According to the data obtained, the risk of developing CVD was determined by factors such as age, total cholesterol level in the blood, HDL cholesterol levels, systolic blood pressure levels, use of antihypertensive drugs, smoking, and diabetes mellitus. Depending on the presence (severity) of a particular factor, scores were calculated, the sum of which allows us to determine the degree of risk and the “cardiovascular age” of the patient.
This scale allows you to approximately estimate the cardiovascular risk even at the first visit to the doctor and determine the need to prescribe additional studies. However, this algorithm for determining CVR has not taken root in real practice due to low accuracy, due to the fact that it is purely indirect in nature, since it does not contain a single parameter that directly describes the properties of the arterial wall.
Thus, in modern conditions, determining traditional risk factors is not enough to predict the occurrence of cardiovascular complications. Therefore, it is promising to use a number of new factors as candidates for the role of signs of damage to the cardiovascular system, which can be used in risk stratification systems in individuals who do not have clinical manifestations of CVD. The modern CVS stratification systems considered cannot be considered perfect, since they do not take into account all currently known risk factors, but focus on traditional factors. At the same time, the most promising in terms of refinement and use of new CVD risk factors is the scale of the EHS/ESC Recommendations (2003, 2007).
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central nervous system
Kidneys
Heart
What does increased blood pressure lead to?
Catecholamines and angiotensin II cause hypertrophy of arterial walls and myocardium ( remodulation of the cardiovascular system). The hypertrophied myocardium lacks oxygen (relative coronary insufficiency), chronic ischemia occurs, which stimulates the growth of connective tissue and leads to diffuse cardiosclerosis(irreversible).
Prolonged spasm of the renal vessels ends hyalinosis And arteriolosclerosis(also irreversible), which leads to the development of a primary wrinkled kidney and, further, to chronic renal failure (transformation of primary hypertension into secondary - renal) occurs.
In the central nervous system, chronic cerebrovascular insufficiency is observed, which causes encephalopathy.
Without changing (suspension) remodulation of the cardiovascular system (at least myocardial hypertrophy), treatment of hypertension cannot be considered effective even if it keeps blood pressure at the same level.
Classification of blood pressure (WHO and MOAG, 1999, IV Congress of Cardiologists of the Republic of Belarus, 2000):
| Categories | SBP mm Hg Art. | DBP mmHg Art. |
| Optimal | < 120 | < 80 (до 60) |
| Normal blood pressure | < 130 | < 85 |
| High normal blood pressure | < 130-139 | < 85-89 |
| Arterial hypertension: | ||
| Grade I (mild) | 140-159 | 90-99 |
| Border subgroup | 140-149 | 90-94 |
| Grade II (moderate) | 160-179 | 100-109 |
| Grade III (severe) | > 180 | > 110 |
| Isolated systolic hypertension | > 140 | < 90 |
| Border subgroup | 140-149 | < 90 |
Notes:
at different SBP and DBP, they focus on a higher value;
against the background of antihypertensive therapy, the degree of hypertension increases by 1 level.
The probability of developing cardiovascular complications in this patient in the next 10 years is:
risk 1: up to 15%;
risk 2: 15-20%
risk 3: 20-30%
risk 4: more than 30%.
Determination of risk level:
Factors influencing the forecast:
1) risk factors;
2) target organ damage (TOD);
3) associated clinical conditions (ACS).
I. Risk factors:
1. Used for risk stratification in hypertension:
levels of SBP and DBP (grades 1-3);
age: men > 55 years, women > 65 years;
smoking;
total cholesterol > 6.5 mmol/L (250 mg/dL);
DM (immediate risk 4);
family history of early (up to 55 years for men, up to 65 years for women) development of cardiovascular diseases.
2. Other factors that adversely affect the prognosis:
reduced HDL cholesterol;
increased LDL cholesterol;
microalbuminuria in diabetes;
impaired glucose tolerance;
obesity;
sedentary lifestyle;
increased fibrinogen levels;
high-risk socioeconomic factors;
high-risk ethnic group;
high-risk geographic region.
II. Target organ damage:
left ventricular hypertrophy (ECG, radiography, echocardiography);
proteinuria and/or a slight increase in plasma creatinine concentration (1.2-2.0 mg/dL);
ultrasound or radiological signs of atherosclerotic plaque (carotid, iliac and femoral arteries, aorta);
generalized or focal narrowing of the retinal arteries, hemorrhages.
III. Concomitant (associated) clinical conditions:
Cerebrovascular diseases:
ischemic stroke;
transient ischemic attack.
Heart diseases:
myocardial infarction;
angina pectoris;
revascularization of the coronary arteries (for example, after CABG, balloon angioplasty);
congestive heart failure.
Vascular diseases:
dissecting aortic aneurysm;
damage to peripheral arteries (clinically);
stage III-IV hypertensive retinopathy – hemorrhagic and exudative swelling of the optic nerve nipple.
Kidney diseases:
diabetic nephropathy;
glomerular hyperfiltration (>130 ml/min);
plasma creatinine > 0.11 mmol/l (> 2.0 mg/dl);
microalbuminuria (30-300 mg/day or 20-200 mcg/min), proteinuria.
In patients with hypertension, the prognosis depends not only on blood pressure levels. The presence of associated risk factors, the degree of involvement of target organs in the process, as well as associated clinical conditions are no less important than the degree of increase in blood pressure, and therefore stratification of patients depending on the degree of risk has been introduced into the modern classification.
It is advisable to abandon the term “stage”, since in many patients it is not possible to register the “stages” of the development of the disease. Thus, instead of the stage of the disease, determined by the severity of organ damage, a division of patients according to the degree of risk has been introduced, which makes it possible to take into account a significantly larger number of objective parameters, facilitates the assessment of individual prognosis and simplifies the choice of treatment tactics.
Risk stratification criteria
|
Risk factors |
Target organ damage |
Associated clinical conditions |
Men over 55 years of age; Women over 65 years of age; |
Left ventricular hypertrophy (EchoCG, ECG or radiography); Proteinuria and/or creatinemia 1.2-2 mg/dl; Ultrasound or radiological signs of atherosclerotic plaque; Generalized or focal narrowing of the retinal arteries. |
CEREBROVASCULAR DISEASES Ischemic stroke; Hemorrhagic stroke; Transient ischemic attack; HEART DISEASES Myocardial infarction; Angina; Coronary revascularization; Congestive heart failure; KIDNEY DISEASES Diabetic nephropathy; Renal failure (creatinine more than 2 mg/dl); VASCULAR DISEASES Dissecting aortic aneurysm; Symptomatic damage to peripheral arteries; HYPERTONIC RETINOPATHY Hemorrhages or exudates; Papilledema; DIABETES |
Classifications of essential hypertension Classification of stages of arterial hypertension (according to WHO recommendations)
StageI. No target organ damage.
StageII. Presence of at least one of the following signs of target organ damage:
Left ventricular hypertrophy, detected mainly by echocardiography, as well as by radiography (according to Makolkin V.I., 2000, the method of spatial quantitative vectorcardiography is more sensitive than echocardiography);
Local or generalized narrowing of the retinal arteries;
Microalbuminuria (urinary excretion of more than 50 mg/day of albumin), proteinuria, a slight increase in plasma creatinine concentration (12-2.0 ml/dl);
Ultrasound or angiographic signs of atherosclerotic lesions of the aorta, coronary, carotid, iliac or femoral arteries.
StageIII. Presence of symptoms of dysfunction or damage to target organs:
Heart: angina pectoris, myocardial infarction, heart failure;
Brain: transient cerebrovascular accidents, stroke, hypertensive encephalopathy;
Ocular fundus: hemorrhages and exudates with or without papilledema;
Kidneys: plasma creatinine concentration more than 2 mg/dl, chronic renal failure;
Vessels: dissecting aneurysm, symptoms of occlusive lesions of peripheral arteries.
Name of the disease -"hypertension" or "essential hypertension". It seems incorrect to use the term “arterial hypertension” without specifying its origin.
Flow stage – I, II, III according to WHO classification.
Specific indication of target organ damage(left ventricular hypertrophy, fundus angiopathy, lesion cerebral vessels, kidney damage).
Indication of associated risk factors(hyperlipidemia, hyperuricemia, obesity, hyperinsulinism).
The degree of increase in blood pressure.
Examples of diagnosis formulation
Essential hypertension stage I.
Essential hypertension, malignant course. Chronic heart failure stage IIB. Hypertensive nephroangiosclerosis. Stage II chronic renal failure.
IHD. Stable exertional angina, IIFC. Stage III hypertension.
For quotation: Lupanov V.P. Risk stratification of cardiovascular events in patients with stable coronary heart disease (review) // RMZh. 2014. No. 23. S. 1664
The long-term prognosis of stable coronary heart disease (SCHD) depends on a number of factors, such as clinical and demographic variables, left ventricular (LV) function, stress testing results, and coronary anatomy(determined by angiographic methods).
When discussing risk stratification in patients with SCAD, the risk of events refers primarily to cardiovascular death and myocardial infarction (MI), although some studies have used a broader combination of cardiovascular endpoints. The most obvious hard endpoint is death; other endpoints, including MI, are soft endpoints and should be the guiding principle for event risk stratification. The risk stratification process serves to identify patients at high risk for events who would benefit from myocardial revascularization due to symptomatic relief.
The definition of high-risk patients who would benefit from revascularization has recently changed from the previous version of European guidelines. Previously, the identification of high risk events was based solely on the sum of the treadmill test scores according to the Bruce protocol, and >2% annual estimated risk of cardiac death according to this protocol was accepted as the threshold beyond which coronary angiography (CAG) was recommended to assess the need for revascularization . This index value is based on cardiovascular mortality in placebo studies conducted in “high-risk” patients, such as patients with diabetic microalbuminemia, in the Cardiovascular and Renal Complication Prevention Trials, and outcome measures in the Heart Study. the Hope and Micro-Hope study and the beneficial effects of nicorandil in stable angina, where the annual mortality rate from cardiovascular disease was more than 2%.
In the new 2013 European guidelines for the treatment of SCAD, patients with an estimated annual mortality rate of more than 3% are considered to be at high risk of events.
Event risk stratification using clinical judgment
The patient's medical history and physical examination can provide important prognostic information. ECG can be included in risk stratification for events at this level, as can the results laboratory research, which can change the assessment of the probability of event risk. Diabetes, hypertension, smoking and increased total cholesterol (despite treatment) can predict an unfavorable outcome in a patient with SCAD or in other groups of the population with established CAD. Advanced age is an important factor to suspect the presence of chronic kidney disease or peripheral vascular disease. Previous MI, symptoms and signs of heart failure and the nature of its course (recent onset or progressive course with a detailed clinical picture), as well as the severity of angina (functional class according to the Canadian classification), especially if the patient does not respond to optimal drug therapy, can be used for event risk assessments.
However, the information listed is too complex to be useful for risk assessment and event prediction. Therefore, it is necessary to use clinical data, especially the severity of angina, in conjunction with the results of preliminary testing of the probability of ischemia based on other non-invasive assessment methods and with coronary angiography data.
Risk stratification using ventricular function
A strong predictor of long-term survival is LV function. In patients with SCAD, mortality increases as the LV fraction decreases. In the Coronary Artery Surgery Study (CASS), the 12-year survival rate of patients with EF ≥50% was 35-49% and<35% была равна 73, 54 и 21% соответственно (р<0,0001). Таким образом, у пациентов с ФВ ЛЖ <50% уже определяется высокий риск смерти от сердечно-сосудистых заболеваний (ежегодная смертность >3%), even without taking into account additional factors such as the degree of myocardial ischemia. Therefore, these patients should use stress imaging methods instead of a dosed exercise test. Although the likelihood of preserved systolic function is high in patients with a normal ECG, normal x-ray, and no history of myocardial infarction, asymptomatic myocardial dysfunction is not uncommon, and recording of a resting echocardiogram is recommended in all patients with suspected CAD.
Risk stratification using stress testing
Patients with symptoms or suspected of having SCAD should undergo stress testing to stratify the risk of events. The results can be used to make therapeutic decisions if patients are candidates for coronary revascularization. However, no randomized trials have been published demonstrating better outcomes for patients randomized with event risk assessment using stress testing stratification compared with patients without testing, and the evidence base therefore consists only of observational studies. . Since most patients undergo diagnostic testing, these results can be used for risk stratification anyway. Patients with a high likelihood of pretesting (>85%) who have undergone prior invasive coronary angiography for symptomatic reasons may require additional coronary flow fractional reserve testing, if necessary, to stratify the risk of coronary events.
ECG stress testing
The prognosis for patients with a normal exercise ECG test and low clinical risk differs significantly from the prognosis of patients with severe SCAD. In this study, 37% of outpatients referred for noninvasive testing met criteria for low risk of coronary events, but (less than 1% of patients) had main trunk LCA disease and died within 3 years.
Simpler tests, such as the treadmill test, should be used for initial risk stratification of events when possible, and those at high risk should be referred for coronary angiography.
Prognostic markers of exercise testing include: exercise capacity, BP response during exercise and the occurrence of myocardial ischemia (clinical or ECG signs), maximum exercise tolerance. Exercise tolerance depends at least in part on the degree of resting ventricular dysfunction and on the number of new hypokinetic LV segments induced by exercise. However, exercise capacity also depends on the patient's age, general physical condition, comorbidities, and psychological state. Exercise capacity can be measured by the maximum duration of exercise, the maximum metabolic equivalent level achieved, reflecting tissue oxygenation per unit time, the level of maximum load achieved (in watts), and the maximum “double product” (HR max × BP system). For non-invasive assessment of prognosis, scoring proposed by D.B. has become widespread. Mark et al. , it's called the Duke treadmill score. The assessment of the Duke index using the treadmill test is a well-tested indicator, it takes into account: A - duration of the load (in minutes); B – deviation from the ST segment isoline in millimeters (during the load or after its completion); C – angina index (0 – there was no angina during exercise; 1 – angina appeared; 2 – angina was the reason for stopping the study). Treadmill index = A− (5 × B) − (4 × C).
In this case, the high risk of estimated annual mortality (more than 2%) is calculated using a special scale. An approximate assessment of the risk of developing MI and death based on the treadmill index is given in Table 1.
In high-risk patients, myocardial revascularization is indicated. For patients at average risk, imaging may be appropriate. In this case, normal or close to normal myocardial perfusion during exercise in combination with normal heart sizes is considered a sign of a favorable prognosis; these patients are recommended to undergo drug treatment, and in the presence of LV dysfunction, revascularization.
For low-risk patients, subsequent use of stress imaging and coronary angiography is considered inappropriate and medical treatment is recommended.
Stress echocardiography
Stress echocardiography, the visual detection of local LV dysfunction during exercise or pharmacological testing, is an effective method for stratifying patients with SCAD into risk groups for subsequent cardiovascular events. In addition, this method has an excellent negative predictive value in patients with a negative test result (without the occurrence of abnormal left ventricular wall motion) - the event rate (death or MI) is less than 0.5% per year. In patients with normal LV function at baseline, the risk of a future event increases with the severity of wall motion abnormalities during exercise. Patients who develop wall motion abnormalities in 3 or more segments of the 17 standard LV pattern should be considered to be at high risk for the event (corresponding to an annual mortality rate of >3%) and should undergo coronary angiography (CAG). In addition, the stress echocardiography technique makes it possible to determine the symptom-related coronary artery by localizing the zone of transient LV dysfunction.
Stress perfusion scintigraphy (single photon emission computed tomography (SPECT)). Myocardial perfusion scintigraphy is intended to assess the blood supply to the myocardium at the microcirculation level. The absence of significant disturbances in myocardial perfusion according to stress scintigraphy indicates a favorable prognosis even with proven chronic CAD, and pronounced disturbances in perfusion indicate an unfavorable prognosis of the disease and serve as a basis for performing coronary angiography.
Myocardial perfusion imaging using SPECT is a useful noninvasive risk stratification technique that can easily identify those patients who are at greatest risk for subsequent death and MI. Large clinical studies have shown that normal perfusion during exercise is associated with a subsequent probability of cardiac death and MI of less than 1% per year, which is almost as low as that found in the general population. In contrast, large stress-induced perfusion defects, defects in multiple major coronary beds, transient post-stress ischemic LV dilatation, and increased pulmonary uptake of the tracer thallium chloride (201-Tl) on post-stress imaging are unfavorable prognostic indicators. A myocardial perfusion study is indicated for all patients with proven chronic CAD to stratify the risk of developing cardiovascular complications.
Positron emission tomography (PET) allows non-invasively obtaining information at the level of microcirculation and the rate of metabolic processes in cardiomyocytes. PET thanks high quality images, provides comprehensive quantitative information about myocardial blood flow and cellular perfusion of the heart. Studies at rest and in combination with stress (vasodilators), although they have proven high sensitivity and specificity for chronic BSPS are not yet widely used.
Electron beam tomography is used in the diagnosis of atherosclerotic heart disease, especially in the verification of multivessel atherosclerosis and damage to the trunk of the left coronary artery. However, while the technique is not readily available for widespread use, it is expensive and has a number of limitations, so the feasibility of conducting this study in chronic SBS has not yet been proven.
Stress-cardiac magnetic resonance - magnetic resonance imaging (MRI). Multivariate analysis identified an independent association between poor prognosis in patients with a positive stress MRI result and 99% survival in patients without ischemia at 36-month follow-up. Similar results were obtained when using an MRI perfusion test with adenosine triphosphate. The appearance of new LV wall motion abnormalities (in 3 of 17 segments) or the appearance of a perfusion defect of >10% (more than 2 segments) of the LV myocardial region may indicate a high risk of complications.
Multislice computed tomography (MSCT). Screening for coronary artery calcification using MSCT is used for quantification coronary calcium. Calcifications are visualized due to their high density relative to the blood and vessel wall. A high level of calcium index is associated with a significantly greater risk of obstructive coronary disease.
MSCT of the coronary arteries with contrast in most cases allows to identify atherosclerotic plaques, as well as determine the degree of intravascular stenosis. In patients who have previously undergone coronary artery bypass grafting, this method helps to assess the patency of arterial and venous bypass grafts. According to a large meta-analysis devoted to the accuracy of non-invasive diagnosis of the degree of coronary stenosis using MSCT with 64 rows of detectors in comparison with coronary angiography, which included 3142 patients with suspected coronary artery disease, the sensitivity of the method was 83% (79-89%), specificity - 93% (91 -96%). In addition, the MSCT method has demonstrated a high negative predictive accuracy for excluding occlusive lesions of the coronary artery, which, according to different authors, ranges from 97% to 100%. MSCT allows you to evaluate the external and internal contours of the artery, anomalies and aneurysms of the coronary arteries. In elderly patients with multiple calcified intravascular plaques, this method leads to overdiagnosis of coronary artery stenosis.
Final stratification of the risk of complications in patients with SCHD. The ultimate goal of non-invasive diagnostic studies is to distribute patients with proven coronary artery disease into groups: with high, moderate or low risk of severe complications and fatal outcomes (Table 2). Table 2 shows American (2012) and European (2013) recommendations.
Stratification of patients into risk groups is of important practical importance, since it allows one to avoid unnecessary further diagnostic studies and reduce medical costs in some patients and actively refer other patients for coronary angiography and myocardial revascularization. Myocardial revascularization is justified if the expected benefit, in terms of survival or health outcomes (symptoms, functional status and/or quality of life), outweighs the expected negative consequences of the procedure. In view of this, an important aspect of modern clinical practice, relevant for both doctors and patients, is risk assessment. In the long term, it allows for quality control and assessment of health economics, and helps individual clinicians, institutions and governing bodies evaluate and compare performance. In a group with a low risk of complications (estimated annual mortality<1%) проведение дополнительных визуализирующих исследований с диагностической целью не оправданно. Также нет необходимости в рутинном направлении таких больных на КАГ. Больных с высоким риском осложнений (предполагаемая ежегодная смертность >3%) should be referred for coronary angiography without further non-invasive studies. In patients classified as moderate risk (estimated annual mortality of 1-3%), indications for coronary angiography are determined based on the results of additional studies (imaging stress tests, myocardial perfusion scintigraphy, stress echocardiography) and the presence of left ventricular dysfunction. However, the individual prognosis of a particular patient with SCBS can vary significantly depending on its basic clinical, functional and anatomical characteristics.
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This scale is based on the famous Framingham model and is used to assess overall ten-year cardiovascular risk and influences treatment tactics and the selection of certain drugs. In contrast, it reflects not only the risk of death from cardiovascular disease. General risk stratification determines the chance of the occurrence of any cardiovascular event: the occurrence of a new disease and death from any cardiac cause over the next 10 years. A risk assessment can only be carried out after a full examination has been completed. In this case, low risk - less than 15%, average 15-20%, high 20-30% and very high more than 30% correspond.
In most cases, using this scale requires time and medical resources. Therefore, the post is intended more for medical personnel and medical students.
Risk stratification criteria
| Risk factors | Target organ damage |
|
LVH
|
Vessels
|
|
Kidneys
|
|
| Diabetes | Associated clinical conditions |
|
CVB
|
| Metabolic syndrome | |
|
Heart diseases
|
Kidney diseases
|
|
Peripheral artery diseases
|
|
Hypertensive retinopathy
|
Note: *when diagnosing MS, the criteria specified in this table in the subsection “Metabolic syndrome” are used.
Risk stratification in patients with hypertension *
| FR, POM and SD | Blood pressure (mm Hg) | |||
| High normal 130 - 139/85 - 89 |
AH 1st degree 140 - 159/90 - 99 |
AH 2 degrees 160 - 179/100 - 109 |
AH 3 degrees > 180/110 |
|
| No FR | Insignificant | Low add. risk | Average extra risk | High add. risk |
| 1-2 FR | Low additional** risk | Average extra risk | Average extra risk | Very high add. risk |
| ≥ 3 FR, POM, MSiliSD | High add. risk | High add. risk | High add. risk | Very high add. risk |
| AKS | Very high add. risk | Very high add. risk | Very high add. risk | Very high add. risk |
Note:
* the accuracy of determining the general cardiovascular risk directly depends on how completely the clinical, instrumental and biochemical examination of the patient was carried out. Without cardiac and vascular ultrasound data to diagnose LVH and carotid artery wall thickening (or plaque), up to 50% of hypertensive patients may be erroneously classified as low or moderate risk instead of high or very high;
** add. - additional risk
Abbreviations and explanation of terms:
BP - blood pressure: upper - systolic (SBP) and lower - diastolic (DBP).
pulse blood pressure = SBP - DBP (normally 60 mm Hg or less).
DLP - dyslipoproteinemia: any disorder in the metabolism of fats in the body.
THC - total cholesterol. Its increase is most often interpreted as DLP in small cities.
LDL cholesterol - low-density lipoprotein cholesterol, atherogenic cholesterol, "bad cholesterol". An increase in this indicator is by far the most correlated with an increase in risk and is most often assessed. It is LDL cholesterol that is deposited in the walls of the arteries, forming plaques. Other types of cholesterol are practically not deposited in blood vessels.
HDL cholesterol - high-density lipoprotein cholesterol, non-atherogenic cholesterol, “good cholesterol”. Not only is it not deposited in the walls of blood vessels, but it also slows down the penetration of LDL cholesterol into the vascular wall. Its decrease, along with an increase in LDL cholesterol, increases the risk.
TG - triglycerides. They can be deposited in the vascular wall, like LDL cholesterol.
Plasma glucose is the result of a finger prick blood test for glucose (“sugar”).
IGT - impaired glucose tolerance. A condition when fasting blood glucose is normal, but after a meal/glucose load it is elevated.
CVD - cardiovascular diseases.
AO - abdominal obesity.
OT - waist circumference.
DM - diabetes mellitus.
MS - metabolic syndrome (or "deadly quartet") - increased glucose + increased blood pressure + lipid metabolism disorders + abdominal obesity.
LVH - left ventricular hypertrophy. Thickening of the walls of the left ventricle is almost always an unfavorable factor.
The Sokolov-Lyon sign (the sum of S in V1 and the ratio of R in V5 to R in V6), as well as the Cornell product (the sum of R in AVL and S in V3, multiplied by the QRS duration) are calculated from the ECG.
Ultrasound - ultrasound examination.
EchoCG is the correct name for ultrasound of the heart.
LVMI - left ventricular myocardial mass indexIMT - arterial intima-media thickness. By and large, this is the thickness of the inner layer of the arteries. The larger the atherosclerotic plaque, the larger it is.
The speed of propagation of the pulse wave is measured by an appropriate device.
Ankle/brachial index is the ratio of ankle circumference to shoulder circumference.
GFR - glomerular filtration rate. Those. at what rate the kidneys convert blood plasma into urine.
MDRD formula (mg/dL/1.72 m2) (not intended for use in children under 18 years of age, seniors over 70 years of age, or to evaluate healthy kidneys):
CHF - chronic heart failure.
RF - risk factors are listed in the appropriate section.
POM - target organ damage. Impaired function of individual organs due to arterial hypertension.
ACS - associated clinical conditions appear when POM develop into a separate disease.
AH - arterial hypertension.
Incremental risk means that for any given combination of risk factors, target organ damage, and associated clinical conditions, the risk of a cardiovascular event will be greater than the population average.
