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Atherosclerosis is one of the main causes of morbidity and mortality world-wide and specifically in Israel. These guidelines update the previous guidelines of the Israeli Society for Research, Prevention and Treatment of Atherosclerosis, published in 2005. The need for an update is based on new scientific data published in recent years necessitating changes in the recommendations for preventing and treating atherosclerosis. These guidelines were written in collaboration between all the societies outlined here and the content of this statement was approved by the delegates of these societies. The recommendations were written taking into consideration guidelines published by other international medical societies and also the specific needs of the Israeli medical system. Due to limitations of space, in the current paper we present: assessment of cardiovascular risk, smoking cessation and the treatment of dyslipidemia. Other sections including: recommendations to the general population, nutritional and physical activity recommendations, treatment of hypertension, prevention of ischemic stroke and the metabolic syndrome are available at http://www.ima.org.il/harefuah.

The reduction of elevated low-density lipoprotein cholesterol (LDL-c) and mainly dense LDL, is the main target in reducing CHR closely associated with coronary heart disease (CHD). The findings of epidemiological and clinical investigations have, however, revealed that it poses a cardiovascular risk in only half of CHD patients and that a more effective marker is required. Lipoprotein associated phospholipase A2 (Lp-PLA2) is an inflammatory biomarker which provides information on plaque inflammation and stability. It hydrolyzes oxidized phospholipids, resulting in lysophosphatidylcholine, which is pro-inflammatory in a theoretic plaque. It is an enzyme that is expressed in macrophages and foam cells in rupture-prone atherosclerotic plaque. In plasma, 80% of it is attached to LDL and 20% to HDL. Twenty five epidemiological studies have established that Lp-PLA2 is a unique biomarker that is highly vascular-specific and that it is directly related to plaque instability and rupture. The results of a meta-analysis of 20,000 patients established a high relative risk for cardiovascular events in patients with high Lp-PLA2 Levels. Data from epidemiological studies have shown that Lp-PLA2 is a risk factor for primary and secondary ischemic stroke. Studies on drapalib, which is a direct inhibitor of Lp-PLA2, have shown that Lp-PLA2 prevents necrotic core progression and reduces plaque inflammation. Patients who are at moderate or high risk of CHD, and who have high levels of Lp-PLA2, should be considered as high and very high risk, respectively, and receive the appropriate treatment.

Aim: To compare the predictive power of different endothelial progenitor cell (EPC) phenotypic markers for future cardiovascular events., Methods: Peripheral blood was collected from 76 consecutive patients with acute coronary syndromes (ACS) who underwent percutaneous coronary intervention in our institute. The various EPC phenotypes of peripheral blood mononuclear cells were CD34+CD133+, CD34+KDR+, and CD 133+KDR+. The outcome endpoint included cardiovascular mortality, recurrent ACS, and hospitalization for decompensated heart failure during a 24-mo follow-up period., Results: CD34+CD133+ cells (P = 0.034), but not CD34+KDR+ (P = 0.35) or CD 133+KDR+ cells (P = 0.19), were found to predict recurrent ACS. We found no correlation between EPCs measured by any of the three phenotypic combinations of accepted CD markers and the total combination of these separate outcomes., Conclusion: The EPC CD34+CD133+ phenotype, but not the CD34+KDR+ or the CD 133+KDR+ phenotypes, is predictive of future adverse cardiovascular outcomes.

Background: Myeloperoxidase levels were shown to reflect endothelial dysfunction, inflammation, atherosclerosis and oxidative stress., Objectives: To examine the role of circulating myeloperoxidase, a leukocyte-derived enzyme, as a predictor of mortality in patients with congestive heart failure., Methods: Baseline serum MPO levels were measured in 285 consecutive CHF patients and 35 healthy volunteers. N-terminal pro-brain natriuretic peptide and high sensitivity C-reactive protein concentrations were also measured. The primary outcome endpoint was overall mortality., Results: MPO levels were significantly elevated in patients with CHF compared to healthy volunteers (P = 0.01). During a mean follow-up of 40.9 +/- 11.3 months there were 106 deaths. On a univariate Cox regression analysis MPO levels were of marginal value (P = 0.07) whereas NT-proBNP was of considerable value (P < 0.0001) in predicting all-cause mortality. By dividing our cohort according to NT-proBNP levels into high, intermediate and low risk groups a clear difference in mortality was shown. By further dividing the patient cohort according to MPO levels above or below the median (122.5 ng/ml), mortality prediction improved in the patients with intermediate NT-proBNP values., Conclusions: MPO levels are elevated in CHF and correlate with disease severity. MPO has an additive predictive value on mortality in patients with intermediate NT-proBNP levels.

Background: Endothelial dysfunction is recognized as a major factor in the development of atherosclerosis and it has a prognostic value., Objectives: To detect the long-term association of peripheral vascular endothelial function and clinical outcome in healthy subjects and patients with cardiovascular disease., Methods: We prospectively assessed brachial artery flow-mediated dilatation in 110 consecutive subjects (46 CVD patients and 64 healthy controls), mean age 57 +/- 11 years; 68 were men. After an overnight fast and discontinuation of all medications for > or = 12 hours, percent improvement in FMD and nitroglycerin-mediated vasodilatation were assessed using high resolution ultrasound., Results: %FMD but not %NTG was significantly lower in CVD patients (9.5 +/- 8.0% vs. 13.5 +/- 8.0%, P = 0.012) compared to healthy controls (13.4 +/- 8.0% vs. 16.7 +/- 11.0%, P = 0.084; respectively). In addition, an inverse correlation between %FMD and the number of traditional CVD risk factors was found among all study participants (r = -0.23, P = 0.015) and healthy controls (r = -0.23, P = 0.036). In a mean follow-up of 15 +/- 2 months, the composite CVD endpoints (all-cause mortality, myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting and percutaneous coronary interventions) were significantly more common in subjects with FMD < 6% compared to subjects with FMD > 6% (33.3% vs. 12.1%, P < 0.03, respectively)., Conclusions: Thus, brachial artery %FMD provides important prognostic information in addition to that derived from traditional risk factor assessment.

Atherosclerosis is one of the principal causes of morbidity and mortality worldwide. The recent decades have witnessed great advances both in the identification of risk factors for the development of atherosclerosis and the treatment of its complications. This effort was rewarded with the reduction of mortality rates from cardiovascular diseases. The need for an update of the recommendations for the prevention of atherosclerosis and cardiovascular diseases stems from a large body of recently published trials, leading to fundamental changes in the way we treat patients with various levels of risk. The second part of the guidelines deals with the treatment of diabetes mellitus, dyslipidemia and the prevention of stroke.

Atherosclerosis is one of the principal causes of morbidity and mortality worldwide. The recent decades have witnessed great advances both in the identification of risk factors for the development of atherosclerosis and the treatment of its complications. This effort was rewarded with the reduction of mortality rates from cardiovascular diseases. The need for an update of the recommendations for the prevention of atherosclerosis and cardiovascular diseases stems from a large body of recently published trials, leading to fundamental changes in the way we treat patients with various levels of risk. The first part of the guidelines deals with general recommendations, applicable to the population as a whole, at all levels of risk, together with recommendations for the treatment of hypertension.