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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.

Practical Approaches to Managing Cardiovascular Risk Factors in Primary Care

To provide primary care physicians with practical information regarding the management of cardiovascular risk factors.

This activity is designed for primary care physicians. No prerequisites required.

The Johns Hopkins University School of Medicine takes responsibility for the content,
quality, and scientific integrity of this CME activity. At the conclusion of this activity,
participants should be able to:

  • Determine key cardiovascular disease risk factors relative impact, alone and combined, on overall cardiovascular risk.
  • Analyze the National Cholesterol Education Program Adult Treatment Panel III
    guidelines and devise effective strategies for identifying, screening, and treating patients with dyslipidemia.
  • Review the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and determine its
    application to the treatment of hypertension in patients with multiple risk factors.
  • Identify the most optimal strategies for managing patients with multiple cardiovascular risk factors.

The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education
for physicians.

The Johns Hopkins University School of Medicine designates this educational activity for
a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award.
Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity:  2 hours.

Release date: May 15, 2004. Expiration date: May 15, 2006.

The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review
of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an unrestricted educational grant from Pfizer Inc.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:


Steven P. Schulman, MD
Professor of Medicine
Director, Coronary Care Unit
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Schulman reports receiving honoraria from Bristol-Myers Squibb Company and Pfizer Inc.


Keith C. Ferdinand, MD, FACC
Medical Director
Heartbeats Life Center
Professor of Clinical Pharmacology
Xavier University College of Pharmacy
New Orleans, Louisiana
Dr Ferdinand reports receiving grants/research support from AstraZeneca LP, Merck & Co, Inc, and Pfizer Inc.

Peter H. Jones, MD, FACP
Associate Professor
Department of Medicine/Section of Atherosclerosis and Lipid Research
Codirector, Center for Cardiovascular Disease Prevention
Medical Director
Methodist Wellness Services
Baylor College of Medicine
Houston, Texas
Dr Jones reports receiving grants/research support from AstraZeneca LP, GlaxoSmithKline, and Pfizer Inc.

In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Practical Approaches To Managing Cardiovascular Risk Factors In Primary Care
Steven P. Schulman, MD*

Our understanding of the pathophysiology of coronary artery disease and acute coronary syndromes has grown considerably in recent years. Rupture of vulnerable plaques with subsequent thrombosis accounts for the majority of cases of acute coronary syndrome. Causal or conventional risk factors account for half of the coronary disease in patients. Nonconventional risk factors for coronary disease are also being identified, including lipid markers (eg, Lp[a]), thrombotic markers (eg, fibrinogen), inflammatory markers (eg, C-reactive protein, homocysteine), and others. Each of these factors has been associated with coronary artery disease and acute coronary syndromes. C-reactive protein has also been studied in most patients, and elevated levels add modestly to low-density lipoprotein (LDL) cholesterol and the Framingham risk score in predicting disease. However, no data suggest that lowering any of these unconventional risk factors, such as C-reactive protein, lowers the risk of events.

The causal risk factors for cardiovascular disease (CVD), the leading cause of mortality in the United States, deserve the most attention. These include hypertension, dyslipidemia, diabetes, and smoking. Eliminating or decreasing one of these risk factors decreases risk. Many patients have more than one causal risk factor, which, in turn, interact to amplify risk. Extensive epidemiologic studies have demonstrated each causal risk factor to be associated with the risk of developing coronary heart disease (CHD) morbidity and mortality. Furthermore, randomized, placebo-controlled trials in hypertension and dyslipidemia show that aggressive therapy decreases cardiovascular risk. A global approach to the management of risk factors utilizing tools such as the Framingham risk score allows physicians to determine the impact of one or more causal risk factors on future risk of developing CHD. An aggressive interventional approach to risk factors is imperative to reducing cardiovascular risk.

The Framingham risk score predicts a 10-year risk of developing CHD based on age, sex, lipid profile, smoking status, and systolic blood pressure. The causal risk factors discussed previously often occur together in patients and amplify risk. This finding developed appreciation for how different risk factors, when combined, produce global risk. The Framingham risk score helps healthcare providers stratify risk in patients to determine the goals of risk factor modification therapies. Importantly, age has the greatest point range in this model and remains a powerful predictor of future cardiovascular events.

Aggressive risk factor evaluation and treatment benefit high-risk patient populations, especially patients with diabetes. Recent data from the Heart Protection Study of 6000 patients with diabetes who did not have preexisting CVD demonstrated that statin therapy reduced the incidences of CHD, stroke, or need for coronary revascularization. The benefit of statin therapy was not affected by the baseline LDL cholesterol value (ie, ≤=100 mg/dL, 100-130 mg/dL, or ≥=130 mg/dL). The relative and absolute benefit of statin therapy in patients with diabetes is far greater than that achieved with aggressive glycemic control.

The information in this issue of Advanced Studies in Medicine reflects the latest developments in managing patients with cardiovascular disease. In the following articles, I help identify key risk factors for CVD and ascertain their relative impact, alone and combined, on global cardiovascular risk and assess implications for effective multiple–risk–factor management. Dr Peter H. Jones describes the National Cholesterol Education Program Adult Treatment Panel III guidelines; analyzes new clinical trial results; and devises effective strategies for the identification, screening, and treatment of dyslipidemia in a primary care practice. Finally, Dr Keith C. Ferdinand outlines new national hypertension guidelines and clinical trial results. He also determines their treatment applications and clinical management strategies in hypertensive patients with multiple risk factors.

In summary, although recent studies have focused on novel risk factors for CHD, we cannot lose our perspective on the importance of the causal risk factors for disease. We know that the Framingham risk score is a good predictor of cardiovascular events. We also know that therapy for these risk factors reduces risk of future cardiovascular events. To determine risk and optimize therapeutic recommendations, we need to think about the patient's overall condition and not just individual risk factors. An aggressive global approach to risk factors may be the optimal approach to reduce risk of cardiovascular events.

*Professor of Medicine, Director, Coronary Care Unit, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Steven P. Schulman, MD, Johns Hopkins University School of Medicine, Carnegie 568 Cardiology, 600 North Wolfe Street, Baltimore, MD 21287. E-mail:

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