A careful study of the medical history, including the hiS
tory of the pain, is the key to the differential diagnosis of
ischemic chest pain. The physical examination in
patient with chronic stable angina pectoris is often un
rewarding. The most common finding is arterial hype
tension. In addition, features of general atheroscleros
may be present.
The higher the number of cardiovascular risk factors,
the more likely is the presence of coronary artery
disease. Lack of cardiovascular risk factors decreases
the likelihood, but does not exclude coronary artery
disease.
Endothelial dysfunction and a chronic inflammation re-
sulting in lipid deposition in the arterial wall are part of
the initial pathophysiological processes of athero-
sclerosis. The chronic process of atherosclerosis then
progresses fromfatty streaks, to atherosclerotic plaques,
to diffuse coronary sclerosis and calcification. The
development of atherosclerosis is, inmany cases, caused
or initiated by a genetic predisposition and/or various
cardiovascular risk factors . Cardiovascular risk
factors often accelerate the process of atherosclerosis.
Nonmodifiable, genetic risk factors are responsible for
more than half the individual risk factors. The so-called
modifiable risk factors contribute to the residual risk fac-
tors. Successful control of themodifiable risk factorswill
decrease the risk for atherosclerosis and will slow the
process in the case of established atherosclerosis.
 |
| Some important risk factors for atherosclerosis |
➤ Family history: a genetic predisposition not only ex-
ists for atherosclerosis, but similarly for the most im-
portant, cardiovascular risk factors (hyperlipidemia,
 |
| Canadian Cardiovascular Society classification of stable angina pectoris |
 |
| Braunwald clinical classification of unstable angina pectoris |
diabetes, hypertension). In addition to this combina-
tion of genetic risk factors, many families share a
common high-risk lifestyle with respect to diet,
smoking, and sedentary lifestyle.
Age and sex: age is the most powerful independent
risk factor. Premenopausal women have a lower inci-
dence of coronary artery disease than men. After
menopause, this gender-related difference decreases
with increasing age.
➤ Dyslipoproteinemia: apart from the genetically
caused primary forms of hyperlipidemia, the second-
ary forms of hyperlipidemia due to diet, lifestyle,
drugs, and diseases are the most important modi-
fiable risk factors (see below). High levels of total
cholesterol and/or LDL cholesterol and, to a lesser
degree, high levels of triglycerides and lower HDL
cholesterol, are associated with an increased risk for
atherosclerosis. Since abnormal lipidmetabolismis a
key element in the development of atherosclerosis,
treatment of hyperlipidemia is an essential part of
primary and secondary prevention of atherosclerosis
and coronary artery disease.
➤ Hypertension: the higher the blood pressure, the
higher the risk. Systolic and diastolic hypertension
carry similar risks.
➤ Diabetes mellitus: diabetes, but also insulin re-
sistance and decreased glucose tolerance, cause a
substantial increase in atherosclerosis. Very often
atherosclerosis is not confined to the coronary arter-
ies; the whole vascular system may be affected.
➤ Tobacco: the risk for a myocardial infarction can be
decreased by 65% with smoking cessation. After a
myocardial infarction, smoking cessation improves
the prognosis substantially.
➤ Obesity: obesity, particularly if central or truncal, is
an independent cardiovascular risk factor. This type
of obesity is characterized by an increased ratio of
waist to hip circumference. Obesity is often as-
sociated with insulin resistance, dyslipidemia, hy-
perglycemia, hypertension, and hypercoagulability.
➤ Metabolic syndrome: a state in which in addition to
increased waist circumference (men 94 cm [37 in],
women 88 cm [35 in]) there is an increase in blood
pressure ( 130/85mmHg), plasma triglycerides
( 1.7mmol/L [ 150mg/dL]), fasting blood glucose
levels ( 6.1mmol/L [ 110mg/dL]), and HDL
cholesterol is decreased ( 1.0mmol/L [ 40mg/
dL]), is called metabolic syndrome. For the diagnosis,
three of these five diagnostic criteria must be ful-
filled. Metabolic syndrome is associated with a sub-
stantially increased cardiovascular morbidity and
mortality. Metabolic syndrome is one of the biggest
health problems of modern society.
Other Risk Factors.
Sedentary lifestyle doubles the risk
for coronary artery disease and stroke. Long-lasting psy-
chosocial stress can be a risk factor. Short episodes of stress, however, do not influence the development of
atherosclerosis. Nevertheless, extremely stressful situa-
tions (such as natural disasters, strong emotions) can
precipitate a myocardial ischemia. Some personality
traits (impulsive personality, depression) are associated
with increased incidence of coronary artery disease. The
rare, inherited hyperhomocysteinemia is accompanied
by atherothrombosis.Whether amoremodest hyperho-
mocysteinemia ( 15 μmol/L) results in an increased
risk is not clear. Diet can influence the risk for athero-
sclerosis. A diet high in saturated fat increases the risk, a
diet high in ω-3 polyunsaturated fat decreases the risk.
Modest intake of alcohol also decreases the risk. The im-
portance of prothrombotic, hematologic factors, such as
an elevated fibrinogen or a decreased fibrinolytic activ-
ity, is uncertain. Chronic inflammation contributes to
atherosclerosis. The more active the inflammation, as
assessed by proinflammatory cytokines and C-reactive
protein, the higher the risk
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