New advance in risk prognostication for coronary event

According to 2004 Report of Taiwan Area Main Causes of Death Statistics from the Department of Health, Taiwan; heart disease, the first time, substituted cerebrovascular disease as the second cause of deaths in Taiwan area. The majority of heart disease is coronary heart disease (CHD). Absolute risk of coronary event can be divided into three categories: high, intermediate, and lower risk with a 10-year risk for myocardial infarction (non-fatal + fatal) and sudden death > 20%, 10-20% and <10%, respectively. The absolute risk can be estimated by sum of Framingham risk score (FRS) using the Framingham risk table. Patients at high risk are: clinical CHD, noncoronary forms of clinical atherosclerotic disease include those with peripheral arterial disease, abdominal aortic aneurysm, symptomatic and asymptomatic carotid artery disease with carotid narrowing ≥ 50 %, diabetes and high-risk patients estimated by FRS who have no above clinical manifestation of atherosclerosis and diabetes. Many subjects will be found to be at intermediate-risk FRS. Some of these patients will be reclassified as high risk because of associated emerging risk factors. Subclinical atherosclerotic disease is one of emerging risk factors. Subclinical atherosclerotic disease can be identified by non-imaging and imaging techniques. Non-imaging methods included: (1) Exercise treadmill testing (ETT) identifies patients whose coronary atherosclerosis has advanced sufficiently to produce myocardial ischemia with exercise. Positive ETT identifies a high-risk patients; (2) Ankle- brachial index (ABI) detects peripheral artery disease (PAD). ABI <0.9 indicates a PAD and the risk level can be raised to high-risk. Imaging methods are tests for detecting atherosclerotic plaque burden, included: (1) Electron beam or multidetector computed tomography can be used to identify coronary calcification, patients with intermediate risk FRS plus a coronary artery calcium score (CACS) > the 75th percentile for age and gender may be reclassified as high-risk. The exceedingly low coronary event rate in subjects with a CACS 100, and particularly >400; (2) Carotid sonography, which measures the intima-media thickness could be used to elevate some patients with multiple risk factors to theto high-risk level. Risk factors for which interventions haveSeveral interventions proved to lower risk of coronary events are as follows: lowering LDL-C reduces risk for coronary events and statins head the list of LDL-C lowering drugs. Goals of therapy are dependent on level of LDL-C and risk categories. Use of aspirin is dependent on risk level. Smoking cessation and physical activity are for all primary and secondary prevention.