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Understanding Cardiovascular Disease Risk factors: Detailed analysis

Heart, Men's Health, Stroke, Women's Health | October 13, 2015 | Author: The Super Pharmacist

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Understanding Cardiovascular Disease Risk factors: Detailed analysis

Cardiovascular disease is the leading cause of death and disability worldwide. The term cardiovascular disease (CVD) covers all diseases and conditions of the heart and blood vessels. The main types of CVD in Australia are coronary heart disease, stroke and heart failure/cardiomyopathy. In developed countries such as Australia, the main underlying cause of CVD is a process known as atherosclerosis.

Atherosclerosis is a disease in which plaque builds up inside the arteries. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows the arteries. This limits the flow of oxygen-rich blood to body organs and tissues. Atherosclerosis is most serious when it leads to reduced or blocked blood supply to the heart (causing angina or a heart attack) or to the brain (causing a stroke). The process leading to atherosclerosis is slow and complex, often starting in childhood and progressing with age.

In many ways, cardiovascular disease can be considered Australia’s most costly disease. It costs more lives than any other disease and has the greatest level of health expenditure. It also imposes a burden of disease, measured in terms of disability and premature death, second only to cancer.

What Are the Risk Factors for Cardiovascular Disease?

A risk factor is any factor which increases the likelihood of a person developing a health disorder or health condition. Along with their opposites, protective factors, risk factors are known as determinants of disease or illness. There are different types of risk factors, some of which cannot be altered (non-modifiable risk factors) and others which can be altered (modifiable risk factors). Three major studies are responsible for our current understanding of the risk factors for CVD. These pioneering studies included the Framingham Heart Study, the Global Burden of Disease and Risk Factors report, and the INTERHEART study.

Framingham Heart Study

In 1948, the Framingham Heart Study was initiated by the USA Public Health Service to study the epidemiology and risk factors for CVD. The Framingham Heart Study is a long-term, ongoing cardiovascular study on residents of the town of Framingham, Massachusetts. The study is now on its third generation of participants. Prior to the study, almost nothing was known about the epidemiology of hypertensive or arteriosclerotic cardiovascular disease. Before Framingham, most physicians believed that atherosclerosis was an inevitable part of the ageing process and were taught that blood pressure was supposed to increase with age enabling the heart to pump blood through an elderly person's narrowed arteries. The origins of the study were closely linked to the cardiovascular health of President Franklin D Roosevelt and his premature death from hypertensive heart disease and stroke in 1945.

Risk factors identified by the Framingham Heart Study included

  • age
  • total cholesterol
  • high-density lipoprotein cholesterol (HDL)
  • tobacco smoking
  • diabetes
  • systolic blood pressure (both treated and untreated).

Importantly, risk factors for the incidence of CVD and those associated with CVD severity or mortality are not synonymous. Risk factors for incidence become important starting very early in life and accumulate with behavioural, social, and economic factors over the life course to culminate in biological risks for CVD such as increased cholesterol, blood pressure, blood glucose, and clinical disease. Over the past few decades, the effectiveness of early screening and long-term treatment for biological risks or early disease has contributed to the sharp declines in CVD mortality seen in many countries

Global Burden of Disease and Risk Factors report.

This report provides additional analysis of the relative contribution of individual risk factors specifically to CVD burden. Using 2001 data, the report estimates the percentage decrease in ischaemic heart disease (IHD) and stroke burden that could be expected if population exposure to a risk factor were reduced to zero by calculating the population attributable fraction for each of the key CVD risk factors. The report found that hypertension, high cholesterol, overweight and obesity, smoking, low fruit and vegetable intake, and physical inactivity were the leading contributors to IHD and stroke burden worldwide. However, it should be noted that the report did not examine the role of elevated blood glucose in its analyses.

INTERHEART

In the landmark case-control study called INTERHEART, researchers determined the association between potential risk factors and acute myocardial infarction (MI) in 29,972 subjects (15,152 patients and 14,820 controls) from 52 countries in Asia, Europe, the Middle East, Africa, Australia, North America and South America.

Nine modifiable risk factors were associated with MI in women and men.

These are: hypertension, diabetes, physical activity, moderate alcohol use, abnormal lipids, current smoking, abdominal obesity, high-risk diet, and psychosocial stress factors.

The INTERHEART study found that an abnormal ratio of blood lipids (apolipoprotein B to apolipoprotein A1) is the most important contributor to CVD globally. Tobacco was the second most important risk factor, coequal to lipids in men but lower in women. These two factors considered together predict two-thirds (66%) of the global risk of heart attack. The additional seven risk factors for MI are diabetes, hypertension, abdominal obesity (waist to hip ratio), psychosocial factors (depression and stress), a lack of daily fruit and vegetable consumption, a lack of physical exercise and the amount of alcohol consumed.

The combination of all 9 risk factors accounted for over 90% of the risk of acute myocardial infarction. While the INTERHEART study showed that the top risk factors contributing to CVD are generally consistent globally, the study also found distinct regional differences. For example, while abdominal obesity was the greatest or second-greatest contributor to CVD risk in 8 of the 10 regions studied, it was the smallest contributor in China. In addition, while psychosocial factors were among the top three risk factors in Western Europe, the Middle East, China, and North America, they appeared to be much less influential in Central and Eastern Europe and South Asia.

Non-modifiable risk factors

Non-modifiable risk factors include age, gender, heredity, family history, ethnicity, and race.

Age: The World Health Organization recognises ageing as the most powerful risk factor for CVD with the risk of stroke doubling every decade after the age 55 years.

Heredity and family history: Heredity and family history are important non-modifiable risk factors. For example, risk is increased if a first-degree blood relative has had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative). 

Gender: Gender is a non-modifiable risk factor. Higher rates of coronary heart disease affect men compared with women of premenopausal age.

Ethnicity and race: Ethnicity and race are believed to play a role in cardiovascular disease risk. Nearly half of all black adults have some form of cardiovascular disease, compared with about one-third of all white adults. A genetic difference that predisposes black adults to high blood pressure might play a role. Some researchers suspect that people who lived in equatorial Africa developed a genetic predisposition to being salt-sensitive, which means their bodies retain more sodium. This condition increases blood volume, which, in turn, raises blood pressure. Hispanics and Latinos have higher rates of obesity, diabetes, and other cardiovascular risk factors compared with whites. Yet, they appear to have lower rates of heart disease. This so-called ‘Hispanic paradox’ is not well understood and may reflect underreporting of heart disease rates as well as possible inaccuracies on death certificates as to cause of death. When compared to other ethnicities, South Asians have a high prevalence of coronary artery disease and associated risk factors. South Asians are individuals originally from the countries comprising the Indian subcontinent including India, Pakistan, Nepal, Bangladesh and Sri Lanka. South Asians have a three to five fold increased risk of myocardial infarction. South Asians also present with more severe disease and at an earlier age than Caucasians.

The prevalence of coronary artery disease is high among native South Asians as well as migrant South Asians. There are two leading explanations for the high disease burden in South Asians. The first is that South Asians have a high prevalence of traditional risk factors, which leads to developing coronary disease at a young age. The second is that South Asians have novel risk factors, usually biomarker based, that account for the variation in risk independent of traditional risk factors. These biomarkers include lipoprotein(a), apolipoprotein B100, and CRP levels. These biomarkers have been primarily studied among Caucasians, although there have been reports of increased prevalence of these novel risk factors in the South Asian population.

Modifiable risk factors 

The majority of cardiovascular disease is caused by risk factors that can be controlled, treated or modified.

High blood pressure: Hypertension is the leading modifiable risk factor for CVD worldwide. As raised blood pressure throughout its range is a major cause of cardiovascular disease, a reduction in salt intake is known to lower blood pressure, would reduce cardiovascular risk. Indeed, both prospective cohort studies and outcome trials have shown that a lower salt intake is related to a reduced risk of cardiovascular disease. The current public health recommendations in most countries are to reduce salt intake from about 9-12 g/day to 5-6 g/day. 

Tobacco smoking: As its components are absorbed into the bloodstream, tobacco smoke increases the risk of CVD through many mechanisms.

Modifiable risk factors It damages blood vessels, increases the risk of plaques, increases the risk of clots at the site of plaques and reduces the blood’s oxygen levels. The risk of developing CVD is higher in female smokers, young men, and heavy smokers. 

Within two years of quitting, the risk of coronary heart disease is substantially reduced, and within 15 years the risk of CVD returns to that of a non-smoker.

Diet: Dietary factors of the most concern in the prevention of CVD have historically included saturated fat and trans fat. There are four kinds of fats in the foods we eat: saturated, polyunsaturated, monounsaturated, and trans fatty acids. Monounsaturated and polyunsaturated are the healthy types of fat that can improve cholesterol levels, decreasing the risk of cardiovascular disease.

  • Saturated fat is a type of fat that comes mainly from animal products, such as meat and dairy products. The National Institutes of Health reports that saturated fat is the main dietary cause of high LDL cholesterol (the “bad” form of cholesterol).
  • Polyunsaturated fat include omega-3 and omega-6 fatty acids, which are essential fats your body needs.
  • Monounsaturated fat - found in nuts, avocados and olive oil - promote better sugar control and insulin levels.
  • Trans fat is the most unhealthful type of fat. Most of the trans fat in the foods we eat is formed through a manufacturing process that adds hydrogen to vegetable oil, which converts the liquid into a solid fat at room temperature. This process is called hydrogenation. Partially hydrogenated oils are the major source of artificial trans fats in the food supply. They are the most often used in commercial baked goods because they prolong the shelf life of these foods.

Trans fat both increases the “bad” type of cholesterol (LDL cholesterol) and decreases the “good” type of cholesterol (HDL cholesterol). Trans fats are found in many fried foods and baked goods such as pastries, pizza dough, pie crust, cookies and crackers. The amount of trans fats in a particular packaged food can be determined by looking at the Nutrition Facts panel. The US Food and Drug Administration is ordering food companies to phase out the use of heart-clogging trans fats over the next three years.

Saturated fat: The public has largely been led to believe that saturated fat causes heart disease. Much of what we think we know about the supposed dangers of high fat intake comes from a single research project by a charismatic Minnesota pathologist named Ancel Keys. His Seven Countries Study compared the health and diet of nearly 13,000 middle-aged men in the U.S., Japan and Europe, and ostensibly found that populations that consumed large amounts of saturated fats in meat and dairy had high levels of heart disease, while those who eat more grains, fish, nuts and vegetables did not. The problem is that Keys had intentionally left out countries where people eat a lot of fat but have little heart disease, such as Holland and Norway and countries where fat consumption is low but the rate of heart disease is high, such as Chile. Basically, he only used data from the countries that supported his theory. Nonetheless, Keys was credited with inventing the lipid theory of heart disease, which led to the highly political McGovern Report in the 1970s which recommended a low fat diet to supposedly reduce heart disease.

The influential Keys relentlessly advocated the theory that fat caused heart disease, persuading the American Heart Association in 1961 to issue the country’s first-ever guidelines targeting saturated fat. Keys’ highly flawed observational study gained massive media attention and had a major influence on the dietary guidelines of the next few decades. Several recent studies, however, refute the long held lipid theory of heart disease. For example, a meta-analysis of 72 published studies totalling 530,525 participants, looked at observational studies of dietary intake of fatty acids, observational studies of measured fatty acid levels in the blood, and intervention studies of polyunsaturated fat supplementation. The authors of the review concluded that, ″Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.″

Another meta-analysis of 16 studies with CHD as an endpoint and 8 studies with stroke as the endpoint showed no association of dietary saturated fat on disease prevalence. Authors concluded that that there is insufficient evidence from prospective epidemiologic studies to conclude that dietary saturated fat is associated with an increased risk of CHD, stroke, or CVD. Additional studies that have failed to demonstrate significant associations of dietary saturated fat intake with CHD.  One comprehensive systematic review and meta-analysis of large generally well designed observational studies found no clear association between higher intake of saturated fats and all-cause mortality, CHD, CHD mortality, ischaemic stroke, or type 2 diabetes among apparently healthy adults.

Consumption of trans fatty acids, however, was associated with a 34% increase in all-cause mortality, a 28% increased risk of CHD mortality, and a 21% increase in the risk of CHD. This was the first meta-analysis of prospective observational studies to examine associations of saturated and trans fats with all-cause mortality and confirms the findings of five previous systematic reviews of saturated and trans fats and CHD. These findings have been confirmed in several other studies. 

Replacement of saturated fat with high glycemic index carbohydrate (such as sugar, white bread and many cereals) has been found to increase the risk of CVD. Replacement of saturated fat with low glycemic index carbohydrate (such as whole fruits, vegetables, pulses, and grains) decreases the risk. Replacement of saturated fat by polyunsaturated fat (with a corresponding increase in the polyunsaturated:saturated (P:S) ratio conferred the greatest reduction in risk of CVD.

Physical activity: Physical inactivity is associated with an increased risk of ill health and death, particularly relating to CVD. 

People who do not participate in regular physical activity are almost twice as likely to die from coronary heart disease as those who do participate. Insufficient physical activity is linked to other CVD risk factors such as being overweight or obesity, high blood pressure, unfavourable levels of high-density lipoprotein and total blood cholesterol, and Type 2 diabetes.

Regular physical activity, whether deliberate or incidental, has a protective effect, lowering the risk of developing CVD and other CVD risk factors.                                                                                                          

Alcohol: Most Australians drink alcohol at levels that cause few adverse effects. Regular consumption of alcohol at high levels, however, increases the risk of alcohol-related harm and can contribute to the development of chronic conditions such as liver disease, some cancers, oral health problems and cardiovascular disease. Alcohol consumption can also play a part in excess intake of kilojoules, contributing to excess body weight. Reducing alcohol consumption reduces the risk of developing these conditions and other health problems. Moderate alcohol consumption is associated with a reduced risk of cardiovascular disease, through affecting the atherosclerosis process and heart rhythm, and increasing levels of HDL cholesterol—the good cholesterol. The National Health and Medical Research Council (NHMRC) advises drinking no more than 2 standard drinks per day.

Obesity: Being overweight or obese is associated with increased risk of hypertension, CHD, stroke and other cardiovascular conditions. Intentional weight loss can assist in lowering the incidence of cardiovascular events and mortality. Weight loss can also favourably influence CVD risk factors such as high blood pressure and dyslipidaemia.

Lipid abnormalities (dylipidaemia): Lipid abnormalities, including high levels of LDL (bad) cholesterol, elevated triglycerides and low levels of HDL (good) cholesterol, are associated with an increased risk of developing cardiovascular conditions, such as CHD, angina and stroke. High levels of LDL cholesterol contribute to plaque build-up within arteries, referred to as atherosclerosis.          

Diabetes: Around the world, diabetes is increasingly common and is a significant contributor to CVD risk. People with diabetes have a more than two-fold greater risk of fatal and nonfatal CVD compared to non-diabetics, with some indication that diabetes mellitus may confer an equivalent risk of having had a cardiovascular event. In fact, CVD is the leading cause of morbidity and mortality in people with diabetes. The magnitude of the risk of CVD associated with diabetes is even greater in women and younger individuals. Indeed, there is substantial evidence that diabetes mellitus may erase, or substantially attenuate, the “female advantage” in the risk of CVD observed in non-diabetics, and that having diabetes may be equivalent to aging by at least 15 years with regard to the clinical manifestations of CVD. Cardiovascular risk associated with blood glucose is continuous; thus, individuals without established clinical diabetes, but who are at increased risk of developing diabetes in the future, also have a higher risk of CVD. 

Obesity is the single most important risk factor for type 2 diabetes, but unhealthy diet and physical inactivity also independently raise the population risk for diabetes. 

Recently conducted meta-analyses of relevant trials in people with type 2 diabetes have also consistently shown that intensive glucose control reduces the risk of major cardiovascular events by approximately 10%, primarily driven by a 10 to 15% reduction in the risk of CHD, compared with standard treatment in people with diabetes.

Psychosocial risk and mental health: Psychosocial factors have been consistently associated with both the onset and the progression of CVD in large prospective and epidemiologic studies in multiple populations and regions, yet they remain under-recognised when compared with more traditional CVD risk factors. The factors that have been associated with CVD include depression, anxiety, anger, hostility, acute and chronic life stressors, and lack of social support. Of all the psychosocial stressors associated with CVD, the link between depression and CVD is probably the best documented. There have been more than 100 published reviews and numerous meta-analyses since the early 1990s that have consistently found that depression and depressive symptoms are associated with an increased likelihood of developing CVD, a higher incidence of CVD events, poorer outcomes after CVD treatment and prevention efforts, and increased mortality from CVD. According to one meta-analysis, clinical depression increased risk of MI or coronary death by more than 2.5-fold and that depressed mood increased the likelihood of a future cardiac event by approximately 1.5-fold.

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