Prevention of Cardiovascular Diseases

DefinitionTop

Cardiovascular disease (CVD) prevention is based on the assessment or identification and modification or elimination of cardiovascular risk factors.

Modifiable cardiovascular risk factors:

1) Atherogenic diet.

2) Smoking.

3) Physical inactivity.

4) High blood pressure.

5) Dyslipidemia (elevated low-density lipoprotein cholesterol [LDL-C] and possibly hypertriglyceridemia).

6) Diabetes mellitus.

7) High body mass index (BMI) and waist circumference.

Nonmodifiable cardiovascular risk factors:

1) Age and sex (an additional decade of life >40 years approximately doubles the risk, which for the same age is higher in men).

2) Family history of early (<55 years in men and <65 years in women) ischemic heart disease (IHD) or atherosclerosis of other arteries.

3) Chronic kidney disease (CKD).

4) Chronic inflammatory disease (eg, systemic lupus erythematosus, rheumatoid arthritis).

5) Ethnicity (eg, South Asian, indigenous populations).

6) Menopause at an age <40 years.

7) History of preeclampsia.

8) HIV.

Perform screening at least once in the presence of the above-listed risk factors and use clinical judgement to address modifiable risk factors.

Risk AssessmentTop

The frequency of cardiovascular risk assessment should depend on the degree of risk and presence of borderline indications for treatment. It should be performed at least every 5 years.

In persons with no additional risk factors (such as CVD, diabetes mellitus, CKD, or a markedly expressed individual risk factor), the 10-year CVD risk assessment can be calculated using the Framingham risk score, which takes into account age, sex, systolic blood pressure (treated or untreated), high-density lipoprotein cholesterol (HDL-C), and smoking status (Table 1). Of note, there are many modifications of this risk score, some taking into account BMI or diabetes (for details, consult the official website of the Framingham Heart Study).

PreventionTop

Prevention goals based on the Canadian Cardiovascular Society guidelines:

1) Nonsmoking status.

2) Healthy diet (minimizing intake of processed food, refined carbohydrates, trans fats, and unsaturated fats).

3) Physical activity reduces individual risk factors for CVD; however, the absolute effect of physical activity on reducing the risk of developing CVD remains unclear. Exercising or performing activities that increase the heart rate for 30 to 45 minutes daily 5 days per week is recommended.

4) Body weight reduction: Optimally maintain BMI within 20 to 25 kg/m2 and waist circumference <94 cm in men and <80 cm in women. Recommend weight loss if waist circumference is >102 cm in men and >88 cm in women.

5) Blood pressure <140/90 mm Hg: see Hypertension.

6) LDL-C levels: see Lipid Disorders and Table 1 in Hypercholesterolemia.

7) Glycated hemoglobin (HbA1c): see Diabetes Mellitus.

8) Acetylsalicylic acid (ASA): ASA does reduce the risk of CVD as primary prevention, but it increases the risk of nonfatal bleeding and is currently not recommended.

9) Omega-3 fatty acids: Some evidence from REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial) shows that omega-3 fatty acids may reduce the risk for cardiovascular events and mortality but increase the risk for atrial fibrillation.Evidence 1Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to indirectness.Bhatt DL, Steg PG, Miller M, et al; REDUCE-IT Investigators. Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med. 2019 Jan 3;380(1):11-22. doi: 10.1056/NEJMoa1812792. Epub 2018 Nov 10. PMID: 30415628. Note that this is a purified formulation that is costly and is not the over-the-counter formulation many patients take. There is no cardiovascular benefit from regular use of over-the-counter omega-3 fatty acids.

10) Although elevated triglyceride levels are likely an independent risk factor, there is still no definitive evidence that lowering those levels will translate into benefits. Several ongoing studies are investigating this question.

11) Secondary prevention: Note that similar principles occur in the presence of established atherosclerosis, defined as acute coronary syndrome, stable angina, or angiographically documented coronary artery disease (CAD); stroke; transient ischemic attack; or carotid or peripheral vascular disease, including abdominal aortic aneurysm. Patients with acute coronary syndrome within the last 3 months have lower treatment targets for LCD-C (1.8 mmol/L [1.4 mmol/L according to the European Society of Cardiology]; Table 1 in Hypercholesterolemia).

TablesTop