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/hypertension.

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.

The 2023 PREVENT calculator was developed by the American Heart Association (AHA) and is available at professional.heart.org or mdcalc.com (allowing the use of different units, mmol or mg%). The tool allows a 10-year risk calculation for those aged 30 to 79 years and a 30-year risk calculation for those aged 30 to 59 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 also 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).

Numerous other risk calculators take into account similar factors, such as, SCORE2 with its modifications for older adults (SCORE2-OP) or people with diabetes (SCORE2-Diabetes); the ASCVD calculator, or QRISK-3 (used outside North America). Each of these scores attempts to calculate a 10-year risk of significant CVD and stratify individual patients into high, moderate, or low risk categories.

PreventionTop

Prevention goals based on the Canadian Cardiovascular Society guidelines:

1) Nonsmoking status.

2) Healthy diet with more fruits and vegetables, whole grains, plant-based protein (beans, lentils, tofu), lean meats, poultry, more fatty fish, low-fat dairy products, healthy fats and oils (olive oil, avocados, nuts) and trying to eat more home-cooked food. Minimize highly processed foods, fried foods, foods made with white flour, and deserts. Seeing a dietician should also be considered. In general diets may affect the cardiovascular risk factors, but the evidence for clinical outcomes is very limited. 

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. Another suggestion is 150 minutes of moderate-intensity aerobic exercise or 75 minutes of high-intensity aerobic activity (or a combination of those) per week.

4) Body weight reduction: The suggested BMI is 20 to 25 kg/m2 and the 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, or <135/85 mm Hg if measured at home or in ambulatory settings, or < 130/80 mm Hg in patients with diabetes: 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 acid derivate: 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.  This study was performed in people at high risk for cardiovascular events, on statin therapy, and with elevated triglyceride levels. Note that this is a costly purified formulation (icosapent ethyl [IPE]), and 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 lowest treatment targets for LCD-C (1.4 mmol/L); Table 1 in Hypercholesterolemia). Absolute benefits derived from most interventions are likely larger than those observed in primary prevention.

12) Numerous medications are used in high-risk conditions for primary or secondary prevention of cardiovascular events. Details on individual medications (eg, angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], sodium-glucose transport protein-2 [SGLT-2] inhibitors , glucagon-like peptide-1 (GLP-1) receptor agonists, statins, IPE: see Chronic Heart Failure; see Diabetes Mellitus; see Chronic Kidney Disease; see Obesity; see Hypertension.

TablesTop