Stress risk factor

Criteria for initiation of drug treatment now take into consideration total cardiovascular risk rather than blood pressure alone, such that treatment is now recommended for persons whose blood pressure is in the normal range but still bear a heavy burden of cardiovascular risk factors. Thus, the role of simultaneous reduction of multiple cardiovascular risk factors in improving prognosis in hypertensive patients is stressed. In addition, more aggressive blood pressure goals are recommended for hypertensive patients with comorbid conditions such as diabetes mellitus or renal insufficiency. 

Because problems of stress, high temperature, and deposition generally coexist (and may be considered interdependent risk factors), thermal fatigue is often associated with long-term overheating. 

Moderate risk Has three or more risk factors for coronary artery disease Has moderate, stable angina Had a recent myocardial infarction or stroke within the past 6 weeks Has moderate congestive heart failure (NYHA Class 2) Fbtient should undergo a complete cardiovascular work-up and treadmill stress testing to determine tolerance to increased myocardial energy consumption associated with increased sexual activity... 

Careful monitoring and preventative care of high-risk patients can begin once these patients are identified. Intrinsic, or host-related, risk factors for the development of pressure sores include age greater than 75 years, limited mobility, loss of sensation, unconsciousness or altered sense of awareness, and malnutrition. Extrinsic, or environmental, risk factors include pressure, friction, shear stress, and moisture.37,42... 

Shear stress A risk factor for pressure ulcers that is generated when the head of a patient s bed is elevated, causing deeper blood vessels to crimp, which leads to ischemia. 

Oxidized low-density lipoprotein (LDL) may play a key role in the initiation and progression of atherosclerosis. Risk factors for elevated levels of oxidized LDL are not well established and may be important in identifying individuals who may benefit from antioxidant supplementation or interventions to reduce oxidant stress. 

Exercise tolerance (stress) testing (ETT) is recommended for patients with an intermediate probability of CAD. Results correlate well with the likelihood of progressing to angina, occurrence of acute MI, and cardiovascular death. Ischemic ST-segment depression during ETT is an independent risk factor for cardiovascular events and mortality. Thallium myocardial perfusion scintigraphy may be used in conjunction with ETT to detect reversible and irreversible defects in blood flow to the myocardium. 

In this new scenario much attention is being paid to the investigation of a series of markers of inflammation as reliable indicators of coronary risk. Their value is stressed by the observation that up to one third of events occurs in subjects without traditional risk factors. The C-reactive protein (CRP) seems to provide the strongest risk prediction for CHD in women (Albert 2000 Ridker 2001), although homocysteine, interleukin-6 (IL-6), and lipoprotein (a) [ Lp (a) ], among others, have each been independently associated with increased risk for CHD in women (for a review see Davison and Davis 2003 Rader 2000). 

Diet/Exercise In initiating treatment for type 2 diabetes, emphasize diet as the primary form of treatment. Caloric restriction and weight loss are essential in the obese diabetic patient. Also, stress the importance of regular physical activity and aid the patient in identifying cardiovascular risk factors and taking corrective measures where possible. 

Many patients with anxiety disorders experience an increased susceptibihty to psychosocial stress. Behavioral sensitization may account for these cHnical phenomena, hi the laboratory model of sensitization, single or repeated exposure to physical stimuU or pharmacological agents sensitizes an animal to subsequent stressors (reviewed in Charney et al. 1993). For example, in animals with a history of prior stress, there is a potentiated release of NE in the hippocampus with subsequent exposure to stressors (Nisenbaum et al. 1991). Similar findings were observed in medial prefrontal cortex (Finlay and Abercrombie 1991). The hypothesis that sensitization is underlying neural mechanism contributing to the course of anxiety disorders is supported by clinical studies demonstrating that repeated exposure to traumatic stress is an important risk factor for the development of anxiety disorders, particularly PTSD (Table 1). 

Yehuda R (1999a) Risk factors for posttraumatic stress disorder. American Psychiatric Press, Washington... 

Bland RC, Orn H, Newman SC (1988b) Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 77(Suppl 338) 24-32 Bourdon KH, Boyd JH, Rae DS, Burns BJ, Thompson JW, Locke BZ (1988) Gender differences in phobias results of the ECA community study. J Anxiety Disord 2 227-241 Breslau N, KUbey MM, Andreski P (1994) DSM-lll-R nicotine dependence in yoimg adults prevalence, correlates and associated psychiatric disorders. Addiction 89 743-754 Bromet E, Sonnega A, Kessler RC (1998) Risk factors for DSM-lll-R posttraumatic stress disorder findings from the National Comorbidity Survey. Am J Epidemiol 147 353-361 Brown TA, Barlow DH (2002) Classification of anxiety and mood disorders. In Barlow D (ed) Anxiety and its disorders the nature and treatment of anxiety and panic, 2nd edn. Guillford Press, New York, pp 292-327... 

Fahlke, C., Lorenz, J.G., Long, J., Champoux, M., Suomi, S.J., and Higley, J.D. (2000) Rearing experiences and stress-induced plasma cortisol as early risk factors for excessive alcohol consumption in nonhuman primates. Alcohol Clin Exp Res 24 644-650. 

Deykin, E.Y. and Buka, S.L. (1997) Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents. Am J Psychiatry 154 752-757. 

Breslau, N. (1998) Epidemiology of trauma and posttraumatic stress disorder in psychological trauma. In Yehuda, R, ed. Risk factors for Post-traumatic stress disorder Washington, DC American Psychiatric Press pp. 1—29. 

Cigarette smoking is a major risk factor for coronary disease. It is associated with reduced levels of HDL, impairment of cholesterol retrieval, cytotoxic effects on the endothelium, increased oxidation of lipoproteins, and stimulation of thrombogenesis. Diabetes, also a major risk factor, is another source of oxidative stress. 

Epidemiologic, experimental, and in vitro mechanistic data indicate that lead exposure elevates blood pressure in susceptible individuals. In populations with environmental or occupational lead exposure, blood lead concentration is linked with increases in systolic and diastolic blood pressure. Studies of middle-aged and elderly men and women have identified relatively low levels of lead exposure sustained by the general population to be an independent risk factor for hypertension. In addition, epidemiologic studies suggest that low to moderate levels of lead exposure are risk factors for increased cardiovascular mortality. Lead can also elevate blood pressure in experimental animals. The pressor effect of lead may be mediated by an interaction with calcium mediated contraction of vascular smooth muscle, as well as generation of oxidative stress and an associated interference in nitric oxide signaling pathways. 

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