International Journal of Cardiology 217 (2016) S7–S9
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International Journal of Cardiology
journal homepage: www.elsevier.com/locate/ijcard
Risk factors' management to impact on acute coronary syndromes
Lina Badimon a,b,⁎, Judit Cubedo a
a
Cardiovascular Research Center (CSIC-ICCC) and Biomedical Research Institute Sant Pau (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, c/Sant Antoni MªClaret 167, 08025 Barcelona, Spain
b
Cardiovascular Research Chair UAB, c/Sant Antoni MªClaret 167, 08025 Barcelona, Spain
a r t i c l e i n f o
Article history:
Received 31 May 2016
Accepted 25 June 2016
Available online 27 June 2016
Keywords:
Cardiovascular risk factors
Lifestyle
Progression
Management
Cardiovascular risk factors (CRF) directly determine cardiovascular
disease (CVD) progression and clinical event presentation. In the con-
text of acute coronary syndromes (ACS), their presence at the moment
of plaque disruption or erosion significantly influences the size and
composition of the coronary thrombus, its fibrinolytic potential and its
tentative resolution, finally impacting on patients' prognosis [1]. The
identification of what is known as modifiable CRF (Fig. 1) has enabled
to design targeted prevention strategies in order to reduce their impact
on disease progression. Furthermore, it has led to the emergence of the
concept of “cardiovascular health factors”, to identify the favorable
levels of modifiable CRF that have demonstrated benefits in reducing
CVD mortality and morbidity [2]. Indeed, results from the Multinational
Monitoring of Trends and Determinants in Cardiovascular Disease
(MONICA) and the Health Alcohol and Psychosocial factors in Eastern
Europe (HAPIEE) studies in Lithuania have revealed that men and
women with low or intermediate levels of CRF, including non-
smoking, normal weight, normal arterial blood pressure, normal total
cholesterol levels, normal level of physical activity and normal level of
fasting glucose, had significantly lower CVD risk and coronary heart dis-
ease (CHD) mortality than persons with high CRF profile [3]. Thus, stud-
ies on the prevalence of modifiable CRF in each country offer a vision of
the tentative room for improvement in their profile and the potential
benefit from global strategies to reduce their impact in the disease
state of the population.
⁎ Corresponding author at: Cardiovascular Research Center (CSIC-ICCC) and Biomedical
Research Institute Sant Pau (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, c/Sant
Antoni MªClaret 167, 08025 Barcelona, Spain.
E-mail address: lbadimon@csic-iccc.org (L. Badimon).
http://dx.doi.org/10.1016/j.ijcard.2016.06.216
0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
Several studies have analyzed the potential impact of non-
modifiable CRF in the management of ACS patients. Specifically, sex-
related differences are associated to some controversy. Some studies
have reported that women are less aggressively treated and have a
worse prognosis after an ischemic cardiac event than men [4]. This
under-diagnosis and under-treatment in women has been partly attrib-
uted to their atypical early symptoms and ambiguous diagnostic test re-
sults [5]. However, other studies have reported a lack of sex-related
differences in the evolution of ACS patients [6]. On the other hand, age
is one of the most important CRF determining both, prevalence and
prognosis of ACS. Contradictorily, elderly patients are usually less ag-
gressively treated when presenting with an acute ischemic event [7].
In a study recruiting coronary patients hospitalized in five city hospitals
with cardiology departments in southern Poland no association was
found between sex and the control of major CRF in the post-discharge
period. On the contrary, age was related to the presence of high blood
pressure and lower incidence of smoking [8].
Dyslipemia is recognized as one of the key modifiable CRF affecting
CVD progression. Accordingly, the EuroObservational Research Pro-
gramme has recently shown that lipid management has been improved
mainly due to an increase in the use of high intensity statin treatment
[9]. Indeed, statin-induced low low-density lipoprotein cholesterol
(LDL-C) levels at admission have been associated with better short-
and long-term outcomes in ST-elevation myocardial infarction
(STEMI) patients [10]. Furthermore, reduced high-density lipoprotein
cholesterol (HDL-C) levels are considered a residual lipid risk factor as-
sociated to worse prognosis in ACS patients. Thus, together with age and
cardiac function parameters, reduced HDL-C levels have shown to be
significantly associated to 1-year mortality after ACS [11]. In relation
to glucose levels, a non-linear relation between this parameter, both
at admission and during hospital stay, and mortality has been reported
in high risk cardiac patients admitted to an intensive cardiac care unit
[12]. Specifically, increases in admission glucose levels (N9 mmol/l)
were associated with a 10% increase in mortality. Furthermore,
sustained hyperglycemia (N8 mmol/l) provided additional prognostic
information to that of glucose levels at admission. Indeed, it is known
that insulin treatment in hyperglycemic patients significantly improves
their outcome after suffering an acute myocardial infarction (AMI), even
in the context of unrecognized diabetes [13].
Regarding obesity, different results have been reported in relation to
the evolution of patients after ACS, the so called “obesity paradox” and
even more depending on the anthropometric parameter used for its
measurement. When the waist circumference (WC) parameter is ana-
lyzed to measure abdominal obesity, some authors have reported a