Table Of ContentP C
REVENTIVE ARDIOLOGY
C C
ONTEMPORARY ARDIOLOGY
CHRISTOPHER P. CANNON
SERIES EDITOR
Preventive Cardiology: Strategies for the Prevention and Treatment
of Coronary Artery Disease, edited by JoAnne Micale Foody, 2001
Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics,
edited by William B. White, 2001
Vascular Disease and Injury: Preclinical Research, edited by Daniel I. Simon
and Campbell Rogers 2001
Nitric Oxide and the Cardiovascular System, edited by Joseph Loscalzo
and Joseph A. Vita, 2000
Annotated Atlas of Electrocardiography: A Guide to Confident
Interpretation edited by Thomas M. Blake, 1999
Platelet Glycoprotein IIb/IIIa Inhibitors in Cardiovascular Disease,
edited by A. Michael Lincoff and Eric J. Topol, 1999
Minimally Invasive Cardiac Surgery,edited by Mehmet C. Oz and Daniel
J. Goldstein, 1999
Management of Acute Coronary Syndromes,edited by
Christopher P. Cannon, 1999
P
R E V E NTI V E
C
ARDIOLOGY
Strategies for the Prevention and
Treatment of Coronary Artery Disease
Edited by
J A M F ,
O NNE ICALE OODY MD
Yale University School of Medicine
New Haven, CT
SPRINGER SCIENCE+BUSINESS MEDIA, LLC
© 2001 Springer Science+Business Media New York
Originally published by Humana Press Inc. in 2001
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Further, it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each
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Library of Congress Cataloging-in-Publication Data
Preventive cardiology : strategies for the prevention and treatment of coronary artery disease / edited by
JoAnne Micale Foody.
p. ; cm. --(Contemporary cardiology)
Includes bibliographical references and index.
ISBN 978-1-4757-6241-9 ISBN 978-1-59259-001-8 (eBook)
DOI 10.1007/978-1-59259-001-8
1. Coronary heart disease--Prevention. 2. Coronary heart disease--Risk factors. 3. Coronary heart disease-
Pathophysiology. 1. Foody, JoAnne Micale. Il. Contemporary cardiology (Totowa, N.J.)
[DNLM: 1. Coronary Disease--prevention & control. 2. Coronary Disease--therapy. WG 300 P9457 20001]
RC685.C6 P675 20001
616.1 '23--dc21 00-037004
P
REFACE
Preventive cardiology is a newly emerging field that places emphasis on the preven-
tion and treatment of coronary disease. Preventive Cardiology: Strategies for the Preven-
tion and Treatment of Coronary Artery Disease is intended for clinical cardiologists,
internists, and allied health care professionals who wish to extend their knowledge and
expertise in the rapidly expanding field of Preventive Cardiology. It is the mission of this
book to provide clinicians with the understanding and tools necessary to practice preven-
tion in their daily practices.
Recent changes in the delivery of health care in the United States, in conjunction with
new scientific evidence supporting the role of preventive strategies in the maintenance
of cardiovascular health, have focused new attention and efforts on the field of cardio-
vascular disease prevention. The field of cardiology is thus making a gradual transition
from the technology-driven, intervention-oriented perspective of the last several decades
to a new, preventive, molecular-based perspective. As fresh evidence amasses that pre-
ventive measures produce a considerable decrease in the incidence of both primary and
secondary cardiac events and mortality, there is growing, widespread acknowledgment
that health care providers from all arenas must initiate preventive strategies in the man-
agement and care of their patients.
Preventive Cardiology as a field has only come into its own in the last several years
in response to striking new evidence that preventive strategies may prove to be the best
interventions in treatment and prevention of cardiovascular disease.
Cardiovascular disease currently claims the lives of 500,000 men and women each
year and, despite our best efforts, these numbers will continue to increase. Over the past
century, technical advances have provided significant improvements in the treatment of
existing coronary artery disease and have come to generate annual cardiovascular health
care expenditures in the United States that exceed $100 billion, largely resulting from
hospitalizations and revascularization procedures. Cardiology continues to be focused on
acute care. Currently, for every dollar spent on cardiovascular disease in this country,
only six cents of out-of-hospital medical therapy is spent on reinforcing healthy lifestyles.
Increasing costs of medical care have led, in the field of cardiovascular medicine, to cost
shifting and a reevaluation of clinical outcomes, cost-effectiveness, and the development
of effective health care delivery systems. The incorporation of preventive cardiology
strategies into the practice of cardiovascular medicine will be of paramount importance
as we begin this new millennium. It is critical to assess the effectiveness of our current
clinical strategies and to direct health care efforts and resources toward the preventionof
the atherosclerotic process itself.
Preventive Cardiology: Strategies for the Prevention and Treatment of Coronary
Artery Diseasehopes to provide the clinicians with both the knowledge and the impetus
to incorporate preventive strategies into their everyday practices. It will not only provide
practical information for the management of patients at risk for cardiovascular disease,
but also offers an overview of the new paradigms in the pathophysiology of coronary
artery disease. The first part of the book will focus on the unstable atherosclerotic plaque
v
vi Preface
and new strategies for modification of plaque constituents, the important and central role
of the endothelium in the maintenance of cardiovascular health, and the emerging roles
of oxidative stress, infection, and inflammation in coronary artery disease (CAD). This
part will provide novel current perspectives on important emerging concepts in the patho-
physiology of coronary atherosclerosis.
The book’s second part focuses on traditional cardiovascular risk factors and also
provides insights into the gender-specific aspects of CAD risk. These offer thorough,
concise reviews of these various risk factors with preventive strategies outlined for the
clinician. A significant body of evidence exists that strategies incorporating risk modi-
fication provide substantial benefits in patients at risk for or with coronary disease.
Coronary atherosclerosis and its sequelae may be largely preventable if aggressive
multidisciplinary strategies are implemented. Risk modification may prove to be one of
the most significant “interventions” that any physician can perform for their patients with
acute coronary syndromes.
The final part of the book provides an overview of strategies for the identification of
patients at risk for CAD events, a detailed chapter on pharmacologic therapies for easy
reference, as well as a review of antiplatelet agents in the prevention of coronary events.
Finally, given the imperatives of cost-containment and health care resource allocation,
a chapter on the pharmacoeconomics of preventive strategies as well as the implemen-
tation of a preventive cardiology clinic are included. The goal of Preventive Cardiology:
Strategies for the Prevention and Treatment of Coronary Artery Diseaseis to provide an
overview of the exciting opportunities to prevent the progression, and in some instances
to regress the process, of coronary atherosclerosis and to incorporate these strategies into
the daily practice of clinical medicine.
JoAnne Micale Foody, MD
C
ONTENTS
Preface......................................................................................................................... v
Contributors............................................................................................................... ix
Part I New Paradigms in the Pathophysiology
of Coronary Artery Disease
1 The Unstable Plaque: Implications and Opportunities for Prevention............ 3
JoAnne Micale Foody, MD and Steven E. Nissen, MD
2 Endothelial Function and Insights for Prevention ..........................................19
Eric H. Lieberman, MD, Margarita R. Garces, MD,
and Francisco Lopez-Jimenez, MD,MSC
3 Role of Antioxidants in Coronary Artery Disease..........................................29
R. Preston Mason, PHD
4 Inflammation and Infection in Coronary Artery Disease ...............................47
Michael A. Lauer, MD
Part II Risk Factors and Their Management
in Coronary Artery Disease
5 Dyslipidemias and Coronary Artery Disease:
Clinical Evidence and Clinical Implications..............................................67
JoAnne Micale Foody, MD
6 Management of Hypertension: Implications of JNC VI..................................99
Donald G. Vidt, MD
7 Diabetes Mellitus, Hyperinsulinemia, and Coronary Artery Disease ..........117
Byron J. Hoogwerf, MD
8 Exercise in the Prevention of Coronary Artery Disease...............................143
Gordon G. Blackburn, PHD
9 Obesity and Coronary Artery Disease: Implications and Interventions.......159
Kristine Napier, MPH,RD
10 Tobacco as a Cardiovascular Risk Factor.....................................................177
Robyn Bergman Buchsbaum, MHS,CHES
and Jeffrey Craig Buchsbaum MD,PHD
11 Women and Coronary Artery Disease...........................................................193
JoAnne Micale Foody, MD and Cynthia Pordon, DO
12 A Recognized Risk Factor:
Homocysteine and Coronary Artery Disease ...........................................221
Simone Nader, MD and Killian Robinson, MD
vii
viii Contents
Part III Strategies for Prevention
13 Pharmacologic Agents in Preventive Cardiology............................................235
Michael A. Militello, PHARMD and Teresa H. Seo, PHARMD
14 Aspirin and Antiplatelet Agents
in the Prevention of Complications of Coronary Artery Disease ............257
Scott A. Moore, MD and Steven R. Steinhubl, MD
15 Exercise Testing and Risk Assessment............................................................283
Christopher R. Cole, MD and Michael S. Lauer, MD
16 Electron Beam Tomography in the Prevention
of Coronary Artery Disease.......................................................................303
Arthur Agatston, MD
17 A Multidisciplinary Model for Aggressive
Risk Factor Control in Cardiovascular Disease........................................325
Joseph P. Frolkis, MD,PHD
18 Pharmacoeconomics of Cardiovascular Medicine...........................................339
Melanie Oates, PHD,MBA,RN, William F. McGhan, PHARMD,PHD,
and Ron Corey, PHD,MBA,RPH
Index ..........................................................................................................................357
C
ONTRIBUTORS
ARTHUR AGATSTON,MD • Director, Mount Sinai Cardiac Prevention Center,
Mount Sinai Medical Center of Greater Miami; Associate Professor of Medicine,
The University of Miami School of Medicine, Miami, FL
GORDON G. BLACKBURN,PHD • Director, Cardiac Health Improvement
and Rehabilitation Program, Department of Cardiology, The Cleveland Clinic
Foundation, Cleveland, OH
ROBYN BERGMAN BUCHSBAUM,MHS,CHES• Education Coordinator, The Heart Center,
The Cleveland Clinic Foundation, Cleveland OH
JEFFREY CRAIG BUCHSBAUMMD,PHD • Department of Radiation Oncology,
The Cleveland Clinic Foundation, Cleveland OH
CHRISTOPHER R. COLE,MD • Department of Cardiology,
The Cleveland Clinic Foundation, Cleveland OH
RON COREY,PHD,MBA,RPH • Global Director, Economic Strategies, Pharmacia
Corporation, Peapack, NJ
JOANNE MICALE FOODY,MD • Yale University School of Medicine, New Haven, CT
JOSEPH P. FROLKIS,MD,PHD • Staff Physician, Sections of Preventive Cardiology
and Preventive Medicine, Division of Medicine, The Cleveland Clinic Foundation;
Assistant Professor, Department of Medicine,
Case Western Reserve University School of Medicine, Cleveland, OH
MARGARITA R. GARCES,MD • Division of Cardiology, Mount Sinai Medical Center,
Miami Beach Florida and University of Miami School of Medicine, Miami, FL
BYRON J. HOOGWERF,MD • Section of Preventive Cardiology, Department
of Cardiology, Department of Endocrinology, and Division of Internal Medicine,
The Cleveland Clinic Foundation, Cleveland OH
MICHAEL A. LAUER,MD • Department of Cardiology, Borgess Medical Center
Research Institute, Kalamazoo, MI
MICHAEL S. LAUER,MD • Department of Cardiology, The Cleveland Clinic
Foundation, Cleveland, OH
ERIC H. LIEBERMAN,MD • Division of Cardiology, Mount Sinai Medical Center,
Miami Beach Florida and University of Miami School of Medicine, Miami, FL
FRANCISCO LOPEZ-JIMENEZ,MD,MSC • Division of Cardiology, Mount Sinai Medical
Center, Miami Beach Florida and University of Miami School of Medicine,
Miami, FL
R. PRESTON MASON,PHD • Membrane Biophysics Laboratory, Departments
of Biochemistry and Medicine, Cardiovascular and Pulmonary Research Institute,
MCP Hahnemann University School of Medicine, Allegheny Campus,
Pittsburgh, PA
WILLIAM F. MCGHAN,PHARMD,PHD • Professor and Director, Graduate Program
in Pharmacy Administration, University of the Sciences, Philadelphia, PA
MICHAEL A. MILITELLO,PHARMD • Department of Pharmacy, The Cleveland Clinic
Foundation, Cleveland OH
ix
x Contributors
SCOTT A. MOORE,MD • Department of Cardiology, Wilford Hall Medical Center,
San Antonio, TX
SIMONE NADER,MD • Department of Cardiology, The Cleveland Clinic Foundation,
Cleveland, OH
KRISTINE NAPIER,MPH,RD • Section of Preventive Cardiology,
The Department of Cardiology, The Cleveland Clinic Foundation, Cleveland OH
STEVEN E. NISSEN,MD • Vice-Chairman, Department of Cardiology,
Director Intravascular Ultrasound Core Laboratory, Department of Cardiology,
The Cleveland Clinic Foundation, Cleveland, OH
MELANIE OATES,PHD,MBA,RN • Philadelphia College of Pharmacy, University
of the Sciences, Philadelphia, PA
CYNTHIA PORDON,DO • Department of Cardiology, The Cleveland Clinic
Foundation, Cleveland OH
KILLIAN ROBINSON,MD • Department of Cardiology, The Cleveland Clinic
Foundation, Cleveland OH
THERESA H. SEO,PHARMD • Department of Pharmacy, The Cleveland Clinic
Foundation, Cleveland OH
STEVEN R. STEINHUBL,MD • Department of Cardiology, Wilford Hall Medical Center,
San Antonio, TX
DONALD G. VIDT,MD • Department of Nephrology and Hypertension, Cleveland
Clinic Foundation, Cleveland, OH; Professor of Internal Medicine, Ohio State
University, Columbus, OH
