2/1/0/06njm

Greetings, my friends and colleagues:

**History:**

A 62 year old diabetic, hypertensive Navajo gentleman arrives in your
clinic waiting room and is ushered into your office. Through a
translator, he complains that, in addition to the fatigue he has been
feeling, the bloating feeling he gets with the blue pill and the right
knee pain that occurs when he works hard, he has also noticed an unusual
feeling in his lower chest at rest and with exertion, although at times
it may worsen with meals.

His answers related to precipitating factors and duration of episode
through a translator are confusing and seem to change with each time
asked. However, you have a sense that this has been going on 'for a
while' (probably months as best you can tell) and last somewhat less
than a day. He denies any pleuritic component to the pain and has never
had anything like this before.

His current meds include one 81 mg aspirin daily, metformin 500 twice
daily, lisinopril 20 daily. You look in the chart and he has an LDL of
108 and a HgbA1c of 8.0 and a current BP of 138/84.

**Questions:**

-What, in your opinion, is the most important question that was not
asked in the above history?

-How would you proceed to evaluate this patient?

-Do you think a CRP would be particularly helpful? Why or why not?

-Would your approach be different if the patient was not CHS eligible?

-How would you modify this patient's medications for optimal CVD
prevention?

## Perspective:

## With low rates of the risk factors for cardiovascular disease as recently as forty years ago, the rates of cardiovascular disease (CVD) in American Indians and Alaska Natives were exceedingly low. Unfortunately, over the past several decades the incidence and prevalence of cardiovascular risk factors has risen significantly, including the development of an epidemic of diabetes. 

Evidence suggests that these higher rates of cardiovascular risk
factors, including tobacco use, diabetes, high blood pressure, and
elevated cholesterol levels, may be placing an inordinate burden of
cardiovascular disease upon the American Indian and Alaska Native
population. The rates of heart disease and stroke among American Indians
and Alaska Natives are now higher than the general US population as well
as US whites. Recent evaluations suggest that these rates are also even
higher than among other ethnic or racial populations in the United
States. Additionally, American Indians and Alaska Natives have been
found to have a substantially higher proportion of premature death from
heart disease when compared with other ethnic and racial populations.

Please let us know your thoughts at

<PRIMARYCARE@LISTSERV.IHS.GOV>

Regards,

Jim

**Links:**

**ACC/AHA Joint Guidelines**

[http://www.americanheart.org/presenter.jhtml?identifier=3004542]{.underline}

**Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III): ATP III Guidelines**

<http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm>

**Native American Cardiology Program: AI/AN Resources, Guidelines,
etc...**

[http://www.ihs.gov/medicalprograms/cardiology/card/index.cfm]{.underline}

James M. Galloway, M.D., F.A.C.P., F.A.C.C.\
Director, Native American Cardiology Program\
Associate Professor of Clinical Medicine\
Associate Professor of Public Health\
University of Arizona\
Senior Cardiologist\
Indian Health Service\
CAPT., U.S.P.H.S.