Physician strategies for the prevention of coronary heart disease

Epidemiological studies have identified a number of factors associated with increased risk of coronary heart disease (CHD). Some risk factors, such as age or family history of CHD, are beyond the control of patient or physician. But hypercholesterolemia, hypertension and cigarette smoking, the three major risk factors, are remediable. So are the somewhat less important factors: obesity, physical inactivity and the use of oral contraceptives. Individuals positive for more than one factor have a particularly high risk. The increased likelihood of contracting CHD does not persist when cigarette smoking is stopped. Despite the lack of definitive proof that lowering serum cholesterol or blood pressure reduces the risk of CHD, the close association between their presence and CHD justifies efforts to control them. Risk factors possibly correctable by patient or physician action are Type A personality, clotting abnormalities and diabetes mellitus, which is most clearly associated with premature CHD. Special attention must be directed to elimination of other risk factors in diabetic patients. Although high intake of sugar or coffee and a diet low in fiber have been suggested as possible risk factors, present evidence does not support these as important factors. In patients who have suffered a myocardial infarction, elimination of cigarette smoking and the use of beta-blocking agents show the greatest promise for preventing a second attack. A prevention strategy, rather than focusing on single abnormalities, begins with identification and control of all positive risk factors, but should look beyond 'case-finding' to more general education programs aimed at modifications of individual lifestyles.