Management of risk factors
Cholesterol
Recommendations:
if this is raised it should be managed in line with published guidelines (C)
Davey Smith et al. (1991) demonstrated that the benefit of lowering cholesterol was limited to those patients who were at high risk of cardiovascular disease.
They felt that the subsequent management of the patient with a raised level was beyond the scope of this guideline and, in the absence of explicit evidence based guidelines, should be addressed through published consensus guidelines on the management of hypercholesterolaemia. There was disagreement within the group as to whether the diagnosis of hypercholesterolaemia should be based on a single or multiple measurements of serum cholesterol.
Blood pressure
Recommendations:
Recommendations:
A group of studies (Doyle et al., 1964; Daly et al., 1985; Hagman et al., 1987; Seltzer, 1989) suggest that the association between smoking and angina is not as strong as is the association with death from ischaemic heart disease. Two of these are from the Framingham Study.
Three other studies (Willett et al., 1987; Vander Zwaag et al., 1988; Barry et al., 1989) showed relative risk of smokers for angina of 2.6, coronary artery stenosis of 2.8 and angina of 3. Overall they suggest that smokers are more likely to have angina. However stopping smoking may not affect the symptoms of angina.
Daly, L.E., Graham, I.M., Hickey, N. and Mulcahy, R. (1985) Does stopping smoking delay onset of angina after infarction? British Medical Journal 291:935-937.
Doyle, J.T., Dawber, T.R., Kannel, W.B., Kinch, S.H. and Kahn, H.A. (1964) The relationship of cigarette smoking to coronary heart disease. Journal of the American Medical Association 90:108-112.
Hagman, M., Wilhelmsen, L., Wedel, H. and Pennert, K. (1987) Risk factors for angina pectoris in a population study of Swedish men. Journal of Chronic Diseases 40:265-275.
Seltzer, C.C. (1989) Framingham Study data and 'established wisdom' about cigarette smoking and coronary heart disease [see comments]. Journal of Clinical Epidemiology 42:743-750.
Vander Zwaag, R., Lemp, G.F., Hughes, J.P., Ramanathan, K.B., Sullivan, J.M., Schick, E.C. and Mirvis, D.M. (1988) The effect of cigarette smoking on the pattern of coronary atherosclerosis. A case-control study. Chest 94:290-295.
Willett, W.C., Green, A., Stampfer, M.J., Speizer, F.E., Colditz, G.A., Rosner, B., Monson, R.R., Stason, W. and Hennekens, C.H. (1987) Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. New England Journal of Medicine 317:1303-1309.
The only experimental study identified that looked solely at interventions to stop smoking demonstrated that in a group of 1,445 male smokers randomised to receive or not receive individual advice from a doctor, the group that received advice showed a 13% greater reduction in coronary heart disease mortality over 20 years though wide 95% confidence intervals rendered this not significant (Rose and Colwell, 1992).
A further study (Holme et al., 1985) showed a 47% reduction in coronary heart disease events over five years in a trial of high risk men randomised to receive or not receive advice on stopping smoking and reduction of dietary fat.
The evidence from cohort studies again suggests benefit from stopping smoking. A group of 4,165 patients with angiographically documented coronary heart disease followed over five years demonstrated an adjusted mortality of 22% in the smokers and 15% in those who had stopped smoking (Vlietstra et al., 1986).
Two papers from the CASS study (Hermanson et al., 1988; Omenn et al., 1990) found in those quitting smoking a >30% reduction in mortality in those over 70 years and >54% reduction in younger groups.
Neaton and Wentworth (1992) demonstrated that smokers of up to 25 cigarettes a day had a risk ratio of coronary heart disease events of 2.1 and smokers of greater than 46 cigarettes a day had a risk ratio of 3.4, both compared to non-smokers. Both of these were over a five year period. Doll et al. (1994) following a cohort of 34,000 British doctors over 40 years demonstrated non-smokers having 30% less ischaemic heart and other heart disease.
Hermanson, B., Omenn, G.S., Kronmal, R.A. and Gersh, B.J. (1988) Beneficial six year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS registry [see comments]. New England Journal of Medicine 319:1365-1369.
Holme, I., Hjermann, I., Helgeland, A. and Leren, P. (1985) The Oslo Study: diet and anti smoking advice. Additional results from a 5 year primary preventive trial in middle-aged men. Preventive Medicine 14:279-292.
Neaton, J.D. and Wentworth, D. (1992) Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Archives of Internal Medicine 152:56-64.
Omenn, G.S., Anderson, K.W., Kronmal, R.A. and Vlietstra, R.E. (1990) The temporal pattern of reduction of mortality risk after smoking cessation. American Journal of Preventive Medicine 6:251-257.
Rose, G. and Colwell, L. (1992) Randomised controlled trial of anti-smoking advice: final (20 year) results. Journal of Epidemiology and Community Health 46:75-77.
Vlietstra, R.E., Kronmal, R.A., Oberman, A., Frye, R.L. and Killip, T. (1986) Effect of cigarette smoking on survival of patients with angiographically documented coronary artery disease. Report from the CASS registry. Journal of the American Medical Association 255:1023-1027.
Silagy et al. (1994), in a meta-analysis, identified methodological concerns about the 53 studies that they included although they concluded that when nicotine replacement was used the odds ratio for abstinence was 1.7.
Tang et al. (1994), in a systematic review, concluded that intervention with nicotine replacement therapy could enable 15% of smokers to stop.
Tang, J.L., Law, M. and Wald, N. (1994) How effective is nicotine replacement therapy in helping people to stop smoking? British Medical Journal 308:21-26.
One double blind randomised controlled trial (Working Group for the Study of Transdermal Nicotine in Patients with Coronary Artery Disease, 1994) examined the safety of transdermal nicotine for smoking cessation in patients with coronary artery disease. There was no difference between treatment and placebo groups in terms of withdrawals, anginal frequency, overall cardiac symptom status, nocturnal events, arrythmias or (in a sub-group) ischaemic ST segment depression.
Recommendation:
The evidence that was identified for the role of exercise in the prevention of
coronary heart disease is conflicting. Three trials suggested some improvement
in myocardial perfusion (Sebrechts et al., 1986; Todd et al., 1991)
coronary blood flow, peak exercise and arteriographic changes (Hambrecht et
al., 1993). Five trials elicited no benefit (Froelicher
et al., 1984; Marra et al., 1985; Kelemen et al., 1986;
Ben-Ari et al., 1987; Siscovick et al., 1988). These trials are
all of different design, have all used different exercise regimes and durations,
and none of them has been designed solely to study patients with stable angina.
The evidence from cohort and case control studies is also
conflicting. These studies showed that people defined as "highly active" lived
on average 2.1 years longer (Pekkanen et al., 1987); that both sedentary
work and sedentary occupation was associated with more ischaemic heart disease
after correcting for the risk factors (Salonen et al., 1988). However, a
cohort study of over 9,000 middle-aged men found that having corrected for
coronary heart disease risk factors there was no association between physical
activity and myocardial infarction (Johansson et al., 1988).
Froelicher, V., Jensen, D.,
Genter, F., Sullivan, M., McKirnan, M.D., Witztum, K., Scharf, J., Strong, M.L.
and Ashburn, W. (1984) A randomised trial of exercise training in patients with
coronary heart disease. Journal of the American Medical Association,
252:1291-1297. Hambrecht, R., Niebauer, J., Marburger,
C., Grunze, M., Kalberer, B., Hauer, K., Schlierf, G., Kubler, W. and Schuler, G.
(1993) Various intensities of leisure time physical activity in patients with
coronary artery disease: effects on cardiorespiratory fitness and progression of
coronary atherosclerotic lesions [see comments]. Journal of the American
College of Cardiology 22:468-477. Johansson, S.,
Rosengren, A., Tsipogianni, A., Ulvenstam, G., Wiklund, I. and Wilhelmsen, L.
(1988) Physical inactivity as a risk factor for primary and secondary coronary
events in Goteborg, Sweden. [Review]. European Heart Journal 9
Suppl. L:8-19. Kelemen, M.H., Stewart, K.J., Gillilan,
R.E., Ewart, C.K., Valenti, S.A., Manley, J.D. and Kelemen, M.D. (1986) Circuit
weight training in cardiac patients. Journal of the American College of
Cardiology 7:38-42. Marra, S., Paolillo, V.,
Spadaccini, F. and Angelino, P.F. (1985) Long-term follow-up after a controlled
randomised post-myocardial infarction rehabilitation programme: effects on
morbidity and mortality. European Heart Journal 6:656-663. Pekkanen, J., Marti, B., Nissinen, A., Tuomilehto, J., Punsar, S.
and Karvonen, M.J. (1987) Reduction of premature mortality by high physical
activity: a 20-year follow-up of middle-aged Finnish men. Lancet
i:1473-1477. Salonen, J.T., Slater, J.S., Tuomilehto, J. and
Rauramaa, R. (1988) Leisure time and occupational physical activity: risk of
death from ischaemic heart disease. American Journal of Epidemiology
127:87-94. Sebrechts, C.P., Klein J.L., Ahnve, S.,
Froelicher, V.F. and Ashburn, W.L. (1986) Myocardial perfusion changes following
1 year of exercise training assessed by thallium-201 circumferential count
profiles. American Heart Journal 112:1217-1226.
Siscovick, D.S., Lars, G.E., Hyde, J.S., Johnson, J.L., Gordon, D.J. and LaRosa,
J.C. (1988) Physical activity and coronary heart disease among symptomatic
hypercholesterolemic men. American Journal of Public Health
78:1428-1431. Todd, I.C., Bradnam, M.S., Cooke, M.B.D.
and Ballantyne, D. (1991) Effects of daily high intensity exercise on myocardial
infarction perfusion in angina pectoris. American Journal of Cardiology
68:1593-1599.
Recommendation: