Cardiovascular prevention

Sergio Caravita, MD, PhD

Department of Management, Information and Production Engineering, University of Bergamo

Cardiology Unit, IRCCS Istituto Auxologico Italiano San Luca Hospital, Milano

sergio.caravita@unibg.it

24/02/2020

• CVDs are the number 1 cause of death globally: more people die annually

from CVDs than from any other cause

• Cardiovascular diseases (CVDs) take the lives of 17.9 million people every

year, 31% of all global deaths. (WHO)

• Most cardiovascular diseases can be prevented by addressing behavioural

risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity

and harmful use of alcohol using population-wide strategies.

Disparities in riskfactors across regions

CVDs due to atherosclerosis

• Ischaemic heart disease or coronary artery disease (e.g.heart attack)

• Cerebrovascular disease (e.g. stroke)

• Diseases of the aorta and arteries

Other CVDs

• Congenital heart disease

• Rheumatic heart disease

• Cardiomyopathies

• Cardiac arrhythmia

Biological Versus Chronological Aging

DOI: 10.1016/j.jacc.2019.11.062

DOI: 10.1016/j.jacc.2019.11.062

DOI: 10.1016/j.jacc.2019.11.062

Cardiovascular disease prevention

Cardiovascular disease prevention is defined as a coordinated set of actions, at the population level or targeted at an individual, that are aimed at eliminating or minimizing the impact of CVDs and their related disabilities.

- General population level: promotion of healthy lifestyle

- Individual level: optimisation of risk factors and tackling unhealthy lifestyle in patients at moderate to high risk of CVD or patients with estabilished CVD

When to assess total

cardiovascular risk?

How to estimate total

cardiovascular risk?

o 12 prospective studies from 11 European countries

o 117 098 men and 88 080 women (age 40-65)

o 10-year risk of CVD mortality (CAD, stroke, aneurysm of the

abdominal aorta). Non fatal CV events (x 4 Men; x 3 Women)

o Sex, Age, total cholesterol/HDL-C ratio, SBP, smoking status

o Version for high and low risk countries

SCORE (high-risk Systemic Coronary Risk Estimation

Low-risk SCORE chart: CVD mortality < 225/100000 in men, < 175/100000 in women

High-risk SCORE chart: CVD mortality > 225/100000 in men, > 175/100000 in women

Advantages and limitations

Example of CV risk estimation

o 55 years old Italian man

o Smoker

o BP: 145/85

o Total cholesterol 230 mg/dl

Low-risk SCORE chart: CVD mortality < 225/100000 in men, < 175/100000 in women

Relative risk SCORE chart

Example of CV risk estimation

o 55 years old Italian man

o Smoker

o BP: 145/85

o Total cholesterol 230 mg/dl

o 10 years risk of fatal CV events: 4%

o Relative risk: 4-fold a 55 years old

men with optimal risk factors

Risk categories

Modifiers with reclassification

potential

Family History/(epigenetics)

o Familial history of premature CVD is a simple indicator

reflecting both the genetic trait and the environment shared

among household members

o Genetic screening and counselling is effective in some

conditions such as familial hypercolesterolemia (FH)

o No role of generalized use of DNA-based tests

Psychosocial risk factors

o Low socio-economic status, lack of social support, stress at work

and in family life, hostility, depression, anxiety and other

mental disorders contribute to the risk of developing CVD and a

worse prognosis of CVD depression and chronic stress

associated with alteration of autonomic function and in

endocrine markers which affects haemostatic and inflammatory

processes, endothelial function and myocardial perfusion

o Psychosocial risk factors act as a barriers to treatment

adherence and efforts to improve lifestyle more frequent

smoking, unhealthy food and less physical activity, low

adherence to behavioural changes or CV medications.

J Am Coll Cardiol 2019 DOI: 10.1016/j.jacc.2019.03.010

Measurment of preclinical

vascular damage

o Routine screening with imaging modalities to predict future CV

events is generally not reccomended in clinical practice

o Imaging methods may be considered as risk modifiers in CV risk

assessment in individuals with calculated CV risk around the

decisional thresholds

o Coronary artery calcium score examined through multislice CT

(AGATSON score) has a very high negative predictive value.

o Many studies demonstrated the grater value of measures of

atherosclerotic plaques in predicting future CVD.

o Arterial stifness measured using Pulse Wave Velocity (PWV) or

arterial augmentation index (AI) improves CV risk prediction for

patients with calculated CV risk around the decisional thresholds.

Measurment of preclinical

vascular damage

Risk factor intervention:behaviour change

o Cognitive behavioural methods are effective in supporting persons

in adopting a healthy lifestyle. Individual and environmental

factors impede the ability to adopt a healthy lifestyle, as does

complex or confusing advice from caregivers.

o Useful tools to enhance adherence are principles of effective

communication, motivational interviews, ”ten strategic step”

strategy.

o Combining the knowledge and skills of caregivers (physician,

nurses, psychologist, expert in nutrition, cardiac rehabilitation and

sport medicine) can optimize preventive efforts

Risk factor intervention:

physical activityo Regular physical activity (PA) is a mainstay of CV prevention;

participation decreases all-cause and CV mortality in healthy and

cardiac patients.

o Aerobic physical activity is the most studied and recommended

modality – its prescription can be adjusted in terms of frequency,

duration and intensity (absolute: MET, VO2; relative: %HR,

%VO2max)

o Isotonic PA is less studied and has less evidence of benefit in lipid

and BP control but stimulates bone formation, preserves and

enhances muscle mass, strenght, power and functional ability

o Inactive adults should start gradually: even short periods of time is

better than no PA. Sessions should include warm up, conditioning,

cool down and stretching/flexibility.

o Risk of adverse CV event during exercise is extremely low,

increased by vigorous PA. Consider exercise testing in sedentary

people who want to engage in vigorous PA.

Risk factor intervention:

physical activity

Risk factor intervention:

smoking cessationo Most cost effective strategy for CVD prevention

o Brief interventions with advice to stop smoking, NRT, bupropion

and varencicline are the most used strategies. New approach is e-

cigarettes (needs more study on possible harmful effects)

o Smoking enhances atheroscerosis and superimposed thrombotic

phenomena: it affects endothelial function, oxidative processes,

platelet function, fibrinolysis, inflammation, lipid oxidation and

vasomotor function fully or partially reversible.

o Stopping smoking reduces CV deaths/MI (RR 0.57 and 0.74)

compared with continued smoking.

o Professional support can increase the odds of stopping. Following

the failure of these strategies, drug interventions should be

offered (RR 1.60 for NRT; 1.62 for bupropion; > 2.0 for

varencicline)

Risk factor intervention:

smoking cessation

Risk factor intervention:

nutrition and body weighto Dietary habits influence CVD risk healthy diet, Mediterranean diet

o Overweight and obesity are associated with an increased CVD death

and all cause mortality. Achieving and mantaining healthy weight has

favourable effect on metabolic risk factors and lower CV risk

o BMI (20-25) and waist circumference (<94 cm in men; < 80 in women)

o Diet, exercise and behaviour modifications are the mainstay therapies

for overweight and obesity. Bariatric surgery demonstrated a reduced

risk of MI, stroke, CV events and mortality.

Risk factor intervention:

nutrition and body weight

Hypertension, dyslipidemia, diabetesmellitus

Treatment of hypertension, dyslipidemia and diabetes mellitusaccording to individual risk and guidelines recommendations

Self care of chronic illness and CV riskfactors

Individuals and their families maintain health through health-promoting practices.

Of 8760 hours in a year, patients spend only around 10 hours (0.001% of their time) with healthcare providers.

All other health maintenance, monitoring, and management activities are done by individuals or patients and their families as self-care activities outside of the clinical or hospital setting

Self-care

maintenance

Adherence to

behaviors needed to

maintain physical and

emotional stability

Self-care

monitoring

Process of

observing oneself

for changes in signs

and symptoms - body

listening

Self-care

management

Respond to signs

and symptoms when

they occur

Riegel B et al JAHA 2017