Novel risk factors for coronary heart disease: emerging connections.

In only 50% of cases of coronary heart disease (CHD) is the cause attributable to the established risk factors of hypertension, cigarette smoking, and elevated total and low-density lipoprotein (LDL) cholesterol levels. This finding has led to research examining other markers for CHD that may have a causal link to the atherothrombotic process. Several of these "emerging" risk factors are reviewed in this article: lipoprotein(a); small dense LDL particle size; hyperhomocysteinemia; and inflammatory, infectious, and hemostatic factors. Evaluation of each of these factors includes a review of the epidemiologic evidence, examination of the pathologic mechanism(s) by which the factor might participate in atherothrombosis, and the clinical utility of screening. Finally, and most relevant for the practicing clinician, the following is addressed: Does evidence exist that selective modification of these risk factors is associated with net clinical benefit?