Kannel W B, Larson M
Boston University School of Medicine, Evans Memorial Department of Clinical Research, University Hospital, Boston University Medical Center, Mass.
Cardiology. 1993;82(2-3):137-52. doi: 10.1159/000175864.
Atherosclerotic cardiovascular disease is a complex problem involving lipid deposition, pressure, rheologic forces, carbohydrate tolerance and thrombogenesis. The major contributors identified through epidemiologic research include atherogenic personal attributes, living habits which promote them, signs of a compromised coronary circulation and host susceptibility to these risk factors. Of the atherogenic risk attributes, such as blood lipids, blood pressure, glucose tolerance and fibrinogen, each independently contributes to risk, and the risk associated with any one is compounded by the presence of the others. The risk associated with hypertension, hyperlipidemia or diabetes varies widely depending on the level of associated risk factors. Also, at a given level of total cholesterol, risk is greatly affected by the total/HDL cholesterol ratio, which provides a practical means for assessing the two-way traffic of cholesterol. In addition, living habits, such as cigarette smoking or lack of exercise, can independently affect the risk associated with any of the atherogenic traits. These living habits, obesity and diet can also affect the level of atherogenic risk factors and must be taken into account in assessing risk and implementing preventive measures. Finally, preclinical indicators of silent myocardial ischemia greatly augment the risk associated with a poor cardiovascular risk profile. Hence, ECG left ventricular hypertrophy, blocked intraventricular conduction, repolarization abnormalities and abnormal response to exercise on monitoring must be taken into consideration. Optimal risk predictions require a quantitative synthesis of risk factors into a composite estimate. Handbooks, hand calculators and PC software have been devised for office use based on multiple logistic risk formulations. These have been shown to accurately predict disease risk in a variety of American population samples, in elderly as well as young coronary candidates. Preventive management as well as risk estimation should be multifactorial if optimal results are to be achieved. Preventive strategies should include public health measures to alter the ecology so as to shift the distribution of risk factors to a more favorable level, health education to enable people to protect their own health and preventive medicine for high-risk candidates. Greater skill must be developed to carry out such interventions. In selecting drugs to correct hypertension, diabetes and lipid disorders, it is important to choose agents which do not adversely affect the composite risk profile.
动脉粥样硬化性心血管疾病是一个复杂的问题，涉及脂质沉积、血压、流变学因素、碳水化合物耐受性和血栓形成。通过流行病学研究确定的主要促成因素包括致动脉粥样硬化的个人特质、促进这些特质的生活习惯、冠状动脉循环受损的迹象以及宿主对这些风险因素的易感性。在致动脉粥样硬化的风险特质中，如血脂、血压、糖耐量和纤维蛋白原，每一项都独立地增加风险，并且与任何一项相关的风险会因其他项的存在而加剧。与高血压、高脂血症或糖尿病相关的风险因相关风险因素的水平不同而有很大差异。此外，在总胆固醇水平给定的情况下，风险受总胆固醇/高密度脂蛋白胆固醇比值的极大影响，该比值为评估胆固醇的双向运输提供了一种实用方法。此外，生活习惯，如吸烟或缺乏运动，可独立影响与任何一种致动脉粥样硬化特征相关的风险。这些生活习惯、肥胖和饮食也会影响致动脉粥样硬化风险因素的水平，在评估风险和实施预防措施时必须予以考虑。最后，无症状心肌缺血的临床前指标会大大增加与不良心血管风险状况相关的风险。因此，必须考虑心电图左心室肥厚、室内传导阻滞、复极异常以及运动监测时的异常反应。最佳风险预测需要将风险因素进行定量综合以形成综合估计。基于多种逻辑风险公式，已设计出用于办公室的手册、手持计算器和个人电脑软件。这些已被证明能准确预测美国各种人群样本（包括老年人以及年轻的冠心病候选者）的疾病风险。如果要取得最佳效果，预防管理以及风险评估应该是多因素的。预防策略应包括改变生态环境的公共卫生措施，以便将风险因素的分布转移到更有利的水平，开展健康教育以使人们能够保护自己的健康，并为高危人群提供预防医学服务。必须提高实施此类干预措施的技能。在选择纠正高血压、糖尿病和脂质紊乱的药物时，选择不会对综合风险状况产生不利影响的药物很重要。
