Cardiac Risk Factor: Family History of Coronary Artery Disease

Strong family history of coronary artery disease is a very high-risk situation. Pay maximum attention to reducing all other cardiac risk factors. This is one situation where screening for novel cardiac risk factors is indicated. I have observed that in a good many of the patients with strong family history of coronary artery disease, the coronary arteries are small, at times very small, and when afflicted by atherosclerosis, it is often diffuse rather than discrete.

A strong family history of coronary artery disease with several members sustaining MI or sudden death is of utmost concern for the members of that family. Whereas family history of coronary artery disease obviously is not a reversible situation, the members of the family must be extremely careful to reduce all other cardiac risk factors, if at all possible. Genetic counseling has not been advocated in this situation.

Smoking cessation is an absolute must; low-density cholesterol is to be kept below 90 mg/dl; and blood sugar levels in diabetics are to be corrected to near-normal levels. Weight reduction and daily exercise programs are also helpful to ward off this deadly disease.

After listening to the theory of evolution by his science teacher, the boy came home and asked his mother, "Mom, is it true that we are all descendants of monkeys?" After a moment, the mother replied, "Well, my son, I am not quite sure. However, I don’t know the full family history of your father."

I thought everything was done right. The patient was a 36- year-old man of Mediterranean descent, 62 inches tall and weighing 170 pounds. He bore a very strong family history of coronary artery disease, in that no man survived in the family beyond the age of 45; all had succumbed to heart disease and sudden cardiac death. He had a very beautiful wife and three children, physically very active, a hard worker, who never had angina or anginal equivalent symptoms.

He was bald-headed with brownish-yellow nodules of xanthelasma below both the eyelids. He had a broad chest and very thin waist with an abundance of thick and long hair all over the torso and limbs. His physical examination was normal for pulse, blood pressure, heart sounds, and the rest. A treadmill test revealed barely 1.0 mm of ST depression on the eleventh minute with no symptoms. However, he had a cholesterol level of 300 and triglycerides of 800. He was treated with aspirin, beta blockers, and a fibrate for cholesterol reduction.

I saw him two years later. He looked exactly the same, except the hairline had receded below the occiput in a crescent shape. He had complaints of increasing fatigue towards the end of the day, and his sexual life was significantly affected. His physical examination was normal and unchanged. On the treadmill he had shortness of breath from the eighth minute onwards, although the EKG still showed barely 1.0 mm ST depression, but he had profuse sweating. After the test, during the family conference, I found his wife somewhat melancholic; not at all worried about the sex, but there was this feeling in both of them that something was not right.

I performed an angiogram on him. His coronary arteries were very small with diffuse disease, where several of the major conduit vessels looked like rosary beads. A cardiac surgeon agreed to operate on him. He had a five-vessel bypass graft surgery. All went well, and he returned to his work within two months.

A year later I received a call from his wife saying that he passed away in his sleep, and that she and the family were thankful for everything I did.

On several occasions I have thought about this patient and several others with similar scenarios. There is something about a very strong family history of coronary artery disease and premature coronary death that is inexplicable, maybe fate.