Rationale for multiple risk intervention: the need to move from theory to practice

Abstract

Incidence of cardiovascular (CV) and metabolic disease is increasing, in parallel with associated risk factors. These factors, such as low-density lipoprotein (LDL)-cholesterol, elevated blood pressure, obesity, and insulin resistance have a continuous, progressive impact on total CV risk, with higher levels and numbers of factors translating into greater risk. Evaluation of all known modifiable risk factors, to provide a detailed total CV disease (CVD) and metabolic risk-status profile is therefore necessary to ensure appropriate treatment of each factor within the context of a multifactorial, global approach to prevention of CVD and metabolic disease. Effective and well-tolerated pharmacotherapies are available for the treatment of risk-factors. Realization of the potential health and economic benefits of effective risk factor management requires improved risk factor screening, early and aggressive treatment, improved public health support (ie, education and guidelines), and appropriate therapeutic interventions based on current guidelines and accurate risk assessment. Patient compliance and persistence to available therapies is also necessary for successful modulation of CVD risk.

Figure 1

Cumulative effects of modifiable risk factors in the INTERHEART study – risk of acute MI associated with exposure to multiple risk factors. Copyright © 2004. Reprinted with permission from Elsevier from Yusuf S, Hawken S, Ounpuu S, et al 2004. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 362:937–52.

Figure 2

Relative risk for cardiovascular disease mortality in men (aged 42 and 60 years at baseline) with and without metabolic syndrome. Copyright © 2002 American Medical Association. All rights reserved. Reprinted from Lakka HM, Laaksonen DE, Lakka TA, et al 2002. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA, 288:2709–16.

Figure 3

Change in risk for cardiovascular disease deaths with increasing age (based on the European Society of Cardiology (ESC) SCORE chart) for a woman in a high-risk population who smokes and has high cholesterol and high blood pressure, compared with a nonsmoker with lower cholesterol and blood pressure values. Data drawn from Conroy RM, Pyorala K, Fitzgerald AP, et al 2003. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J, 24:987–1003.

Figure 4

Comparison of actual versus perceived 10-year risk among 80 Swedish general practitioners when asked to estimate the risk of specific patient profiles. Data drawn from Backlund L, Bring J, Strender L-E. 2004. How accurately do general practitioners and students estimate coronary risk in hypercholesterolaemic patients? Primary Health Care Research and Development, 5:145–52.

Figure 5

Emergency resource utilization in fully compliant and partial/non compliant patients with high risk for coronary heart disease. Data drawn from Goldman DP, Joyce GF, Karaca-Mandic P. 2006. Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. Am J Manag Care, 12:21–8.