Cardiovascular Disease Prevention

Modifiable Risk Factors

• Hypertension, defined as a blood pressure ≥140/90 mmHg or the use of antihypertensive medication, contributes significantly to cardiovascular events, being responsible for 25% of events in the general population, with a higher attribution in women (32%) than in men (19%) and in black individuals (36%) than in white individuals (21%) 1
• High total cholesterol (≥240 mg/dL) or high LDL-C (≥130 mg/dL) increases the risk of cardiovascular disease, with low HDL-C (<40 mg/dL in men, <50 mg/dL in women) and high triglycerides (>150 mg/dL) also being risk factors, according to the American Heart Association 2, 3
• Diabetes mellitus increases the risk of cardiovascular disease, with 71% of adults with diagnosed diabetes having hypertension, and is considered a coronary heart disease equivalent 2, 1
• Smoking is a direct risk factor for cardiovascular disease, and the American Heart Association recommends assessing tobacco use at every medical visit 4, 3
• Obesity, particularly abdominal obesity, contributes to changes in arterial structure and function, with 35.7% of obese individuals having hypertension, and is a risk factor for cardiovascular disease 1, 5
• Regular physical activity is a key intervention for prevention, and inactivity is an underlying risk factor that contributes to the development of other risk factors, as recommended by the American College of Cardiology 4, 3
• Lifestyle changes, including reducing saturated fats, losing weight, increasing dietary fiber, and physical activity, as well as pharmacological treatment when necessary, such as statins, antihypertensives, and antiplatelet therapy, are recommended to control modifiable risk factors 3, 5

Non-Modifiable Risk Factors

• Age is an independent risk factor for cardiovascular disease, with advanced age contributing significantly to the risk of cardiovascular events 4
• Family history of premature coronary heart disease (in a first-degree male relative <55 years or female relative <65 years) is an independent risk factor that should be considered in risk assessment 2

Risk Assessment

• The American College of Cardiology recommends using validated risk equations, such as the Pooled Cohort Equations, to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) in adults 40-79 years old, with risk categories of low (<5%), borderline (5% to <7.5%), intermediate (7.5% to <20%), and high (≥20%) 1
• The presence of multiple risk factors increases the risk of cardiovascular events, with ≥3 factors present in 17% of patients, and the risk of coronary events increasing exponentially with two or more risk factors present 1
• The Pooled Cohort Risk Equations incorporate factors such as age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, diabetes, and current smoking status, with patients categorized into low, intermediate, high, and very high risk groups based on their risk factor profile 6, 7

Prevention and Treatment

• The American Heart Association recommends early intervention, with lifestyle changes and pharmacological treatment when necessary, to control modifiable risk factors and prevent cardiovascular disease, with regular measurement and updating of risk factors every 4-6 years to improve prediction of short- and long-term risk 3, 5
• The American College of Cardiology/American Heart Association (ACC/AHA) defines ASCVD risk categories as low risk (<5% 10-year ASCVD risk), borderline risk (5% to <7.5% 10-year ASCVD risk), intermediate risk (7.5% to <20% 10-year ASCVD risk), and high risk (≥20% 10-year ASCVD risk), with a recommended ASCVD score threshold for guiding preventive interventions of 7.5% for 10-year risk 8, 9
• High-intensity statin to reduce LDL-C by ≥50% is recommended for high-risk patients, and moderate-intensity statin for intermediate-risk patients, with statin therapy generally not recommended for low-risk patients unless risk-enhancing factors are present 9, 10, 11

• Coronary artery calcium (CAC) scoring can guide statin decisions, particularly for borderline and intermediate-risk patients, with the following guidelines:

  CAC Score	Statin Therapy Recommendation
  0	Low risk, statin therapy potentially not necessary
  1-99	Moderate-intensity statin therapy
  ≥100 or ≥75th percentile for age/sex/race	Moderate to high-intensity statin therapy

  8, 11

• Incorporating CAC scoring into risk assessment can significantly impact treatment decisions, with approximately 57% of borderline-risk patients having CAC = 0 and an ASCVD event rate of only 1.5% (statins not recommended), and borderline-risk patients with CAC > 0 having a 7.4% event rate (statins recommended) 8
• Risk-enhancing factors, such as family history of premature ASCVD, elevated inflammatory markers, and others, should be considered when ASCVD risk calculation falls in borderline zones 9
• Traditional risk factors for ASCVD include tobacco smoking, hypertension, dyslipidemia, diabetes mellitus, and advancing age, which together explain 75-90% of cardiovascular events, with additional risk factors including premature menopause, pregnancy-associated conditions, and polycystic ovarian syndrome, as well as socioeconomic status, education level, income, and geographic location/zip code 12, 13, 4