The American Journal of Medicine
Volume 122, Issue 1, Supplement , Pages S60-S62, January 2009

Clinical Management of Atherosclerosis: A Checklist

  • William Insull Jr., MD

      Affiliations

    • Section of Atherosclerosis and Vascular Medicine, Department of Medicine, and Lipid Research Clinic, Baylor College of Medicine, Houston, Texas, USA
    • Corresponding Author InformationRequests for reprints should be addressed to William Insull, Jr., MD, Lipid Research Clinic, Baylor Faculty Center, 1709 Dryden Road, Suite 08.08, Houston, Texas 77030-3411
    • ,
  • Sandra J. Lewis, MD

      Affiliations

    • Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA; and Division of Cardiac Rehabilitation, Legacy Good Samaritan Hospital Northwest Cardiovascular Institute, Portland, Oregon, USA

Article Outline

Abstract 

This article provides a checklist designed to aid the busy clinician in organizing and implementing an effective course of atherosclerosis evaluation and treatment, and a compendium highlighting a selection of useful guidelines for the general practitioner.

Keywords: Atherosclerosis, Checklist, Evaluation, Guidelines, Treatment

 

The purpose of this checklist (Table 1)1, 2, 3 is to aid the busy clinician in organizing and implementing an effective course of atherosclerosis evaluation and treatment for each patient. We hope that this checklist will be useful to practitioners as a reminder and guide of how to combine their standard procedures of good medical care with procedures necessary for the safe and effective management of atherosclerosis. The practitioner can adapt this outlined checklist to his or her needs. It is always important for the practitioner to use his or her own clinical judgment in evaluating and treating each patient. Table 2 highlights a selection of some of the most useful guidelines for the general practitioner.1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13

Table 1. Checklist guide to clinical management of atherosclerosis
YesNo
1. Assess contributing factors
Age——
Hypertension——
Lipids——
Smoking——
Diabetes mellitus——
Family history——
Obesity——
Novel risk (e.g., CRP, imaging)——
2. Calculate level of risk based on NCEP ATP III guidelines1, 2,⁎——
0–1 risk factor (low risk)——
2 risk factors (moderate risk)——
CHD equivalent or >2 risk factors (high risk)——

ATP = Adult Treatment Panel; CRP = C-reactive protein; NCEP = National Cholesterol Education Program.

⁎See also Figure 2 in the article by Lewis3 in this supplement.

Table 2. Treatment goals for major coronary heart disease (CHD) risk factors requiring applications tailored for each patient's needs, and using lifestyle changes and drugs⁎
Risk Factors4, 5Treatment Goal†CommentsMost Recent Reference
Serum lipids
• LDL cholesterol, by CVD risk

— Low risk

— Intermediate risk

— High risk

— Very high risk


<160 mg/dL

<130 mg/dL

<100 mg/dL

<70 mg/dL


For 10-yr risk of <10%

For 10-yr risk of 10%–20%

For 10-yr risk of >20%

For ACS or established CVD + ≥1 major risk factor

NCEP ATP III (2002, 2004)1, 2; AHA/ACC (2006)6
• HDL cholesterol>40 mg/dL men, >50 mg/dL women
• TGs<150 mg/dL
• Non-HDL cholesterol<130 mg/dLFor TGs 200–499 mg/dL, and for diabetes mellitus
Hypertension
All individuals<120/80 mm HgGoal for primary preventionJNC-7 (2002)7
Lower risk<140/90 mm Hg
High risk<130/80 mm HgWith CHD, diabetes, or chronic renal disease
Cigarette smokingCessationCounseling and drugsUSPHS (2000)8, 9
Diabetes
Fasting plasma glucose≤126 mg/dLIn nonpregnant adults, and with caution in selected othersADA (2008)10
Pre-diabetes with impaired fasting glucose<100 mg/dLIn nonpregnant adults, and with caution in selected others
HbA1c<7.0%In nonpregnant adults, and with caution in selected others
Body weight control USDHHS and USDA (2005)11; AHA (2006)12
BMI<25 kg/m2Requires diet and exercise prescriptions and instructions
Abdominal obesityMen ≤40 in (101.6 cm), women ≤35 in (88.9 cm)
Metabolic syndromeTreat syndrome's 5 potential parts as indicatedTreat abdominal obesity, elevated TGs, low HDL cholesterol, hypertension, and impaired fasting glucoseAHA/NHLBI (2005)13

ACC = American College of Cardiology; ACS = acute coronary syndromes; ADA = American Diabetes Association; AHA = American Heart Association; BMI = body mass index; CVD = cardiovascular disease; HbA1c = hemoglobin A1c; HDL = high-density lipoprotein; JNC-7 = Seventh Report of Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure; LDL = low-density lipoprotein; NCEP ATP III = National Cholesterol Education Program Adult Treatment Panel III; NHLBI = National Heart, Lung, and Blood Institute of the National Institutes of Health; Non–HDL = non- high-density lipoprotein; TG = triglyceride; USDA = US Department of Agriculture; USDHHS = US Department of Health and Human Services; USPHS = US Public Health Service.

⁎Goals must be selected on the basis of patient age, sex, ethnicity, risk factors, lifestyle (diet, exercise, weight control, smoking), and concomitant diseases and treatments, as well as therapeutic aim for primary prevention or secondary prevention of CHD.

†For cholesterol, 1 mg/dL = 0.02586 mmol/L; for TG, 1 mg/dL = 0.01129 mmol/L.

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Author disclosures 

The authors who contributed to this article have disclosed the following industry relationships:

William Insull, Jr., MD, serves on the Speakers' Bureau for Abbott Laboratories, Merck & Co., Inc., and Schering-Plough Corporation and as a consultant/advisory board participant for Daiichi Sankyo, Inc., Merck & Co., Inc., and Merck/Schering-Plough, Inc. He is an investigator for Pfizer Inc and has received research support from AstraZeneca Pharmaceuticals LP, Kos Pharmaceuticals, Inc., Merck & Co., Inc., and Pfizer Inc. In addition, Dr. Insull has received honoraria from Merck & Co., Inc., and from Merck/Schering-Plough, Inc., and is an editor/writer for AstraZeneca Pharmaceuticals LP.

Sandra J. Lewis, MD, is a consultant and investigator for AstraZeneca Pharmaceuticals LP and Pfizer Inc, and serves as a consultant for Merck & Co., Inc.

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Supplementary data 

Supplementary material cited in this article is available online.

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Supplementary data 

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References 

  1. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. Circulation. 2002;106:3143–3421Available at: www.nhlbi.nih.gov/guidelines/cholesterol. Accessed April 8, 2008
  2. Grundy S, Cleeman JI, Merz NB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227–239Available at: www.nhlbi.nih.gov/guidelines/cholesterol. Accessed April 8, 2008
  3. Lewis SJ. Prevention and treatment of atherosclerosis: a practitioner's guide for 2008. Am J Med. 2008;(supp):S38–S50
  4. Gaziano JM, Manson JE, Ridker PM. Primary and secondary prevention of coronary heart disease. In:  Libby P, et al. editor. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed.. Philadelphia, PA: Saunders; 2008;p. 1119–1148Fig 45-6, Risk assessment algorithm, p 1125
  5. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–1847Framingham Study CVD Risk Tables
  6. Smith SC, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation. 2006;113:2363–2372
  7. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. JAMA. 2003;289:2560–2572Available at: www.nhlbi.nih.gov/guidelines/hypertension/. Accessed April 8, 2008
  8. Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service Report. JAMA. 2000;283:3244–3254
  9. US Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Caused Disease: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Quality; 2003;Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=4314. Accessed April 8, 2008
  10. American Diabetes Association. Executive summary: standards of medical care in diabetes—2008. Diabetes Care. 2008;31:S5–S11Available at: http://care.diabetesjournals.org/content/vol31/Supplement_1/. Accessed April 8, 2008
  11. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans 2005. Washington, DC: US Government Printing Office; 2005;Available at: http://www.health.gov/dietaryguidelines/dga2005/document/. Accessed April 8, 2008
  12. Poirier P, Giles TG, Bray GA, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association scientific statement on obesity and heart disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113:898–918Available at: http://www.americanheart.org/presenter.jhtml?identifier=3004565. Accessed April 8, 2008
  13. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112:2735–2752Available at: http://www.americanheart.org/presenter.jhtml?identifier=3030263. Accessed April 8, 2008

 Statement of author disclosure: Please see the Author Disclosures section at the end of this article.

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PII: S0002-9343(08)01022-X

doi:10.1016/j.amjmed.2008.10.018

The American Journal of Medicine
Volume 122, Issue 1, Supplement , Pages S60-S62, January 2009

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