Table of Contents
atherosclerosis and primary prevention
see also:
Source: JAHA 2026: Sex Differences in Age of Onset of Premature Cardiovascular Disease and Subtypes: The Coronary Artery Risk Development in Young Adults Study via https://www.sciencealert.com/study-reveals-a-turning-point-when-mens-heart-attack-risk-accelerates
Primary prevention:
dental care
-
- see also the oral microbiome
- childhood dental caries and periodontitis appears to increase risk of adult atherosclerosis substantially
- of children with moderate to severe dental caries, boys with worsening disease had a 26 % higher incidence of ASCVD as adults. For girls, the risk was 45 % higher. With stable disease, the risk was 21 % higher in males and 41 % higher in females, compared to a stable low-caries history.
- of children with moderate to severe gingivitis showed similar trends but with a more muted pattern. Improving disease trajectories in males was associated with a modestly increased risk of ASCVD in adult life, at 8 %. Worsening or stable disease was associated with a 13 % increased risk. In females, worsening and stable disease were associated with a 27 % and 25 % increase in ASCVD risk, respectively. 1)
dietary:
- “prudent” diet is generally regarded as safe & desirable for all adults:
- < 30% of energy from fat
- maintenance of ideal weight (BMI 20-25):
- abdominal obesity is associated with adverse changes in several major risk factors including diabetes, hyperlipidaemia, and hypertension
- thus obesity is a useful marker for cardiovascular disease risk although nor always an independent risk factor
- if diabetes then avoidance of simple carbohydrates
- avoid dietary saturated fat, cholesterol & salt
- stress importance of variety in diet
- avoid foods with high energy density but low nutrient density
- ⇒ use lean meat, low fat dairy products, skinless poultry & fish
- ⇒ use cereals, fruit & vegetables with plentiful soluble fibre allows a more generous food intake
- ⇒ use mono- or polyunsaturated fats instead of unsaturated fats
- ⇒ avoid adding extra butter, sour cream, cheese, gravy to food
- ⇒ avoid fried dishes, cream sauces, frequent take-aways
- avoid carnitine (red meat, energy drinks)
- benefits of Mediterranean diet (olive oil-based, minimal red meat, minimal simple carbohydrates)
- a large US study published in 2022 suggests eating 1 avocado a week may reduce heart attacks by 16-21% but did not seem to reduce risk of stroke 2)
alcohol
- avoid alcohol if hyperTG, abdominal adiposity, hypertension or obstructive sleep apnoea is contributing to cardiovascular disease risk
cigarette smoking
- stop smoking - see also nicotine and nicotine replacement Rx for smokers
manage hyperlipidaemia
- see hyperlipidaemia
manage persistent raised serum CRP
- this is a marker of chronic inflammation and may be as important as hyperlipidaemia in causing atherosclerosis and heart attacks
- whilst CRP > 10 suggests an acute illness, cancer or auto-immune disease, persistent low levels of CRP between 1-10 suggest chronic low grade inflammation which increases atherosclerosis and coronary artery disease risk even in those with normal lipid profiles3)
- “a single measurement of hsCRP (>3 mg/L) can be used in routine clinical practice to identify individuals at increased inflammatory risk if the patient is not acutely ill.”
- “because clinicians will not treat what they do not measure, universal screening of hsCRP in both primary and secondary prevention patients, in combination with cholesterol, represents a major clinical opportunity and is therefore recommended.”
- “in individuals with increased inflammatory burden, an early initiation of lifestyle interventions is recommended to reduce inflammatory risk.”
- “among individuals with known cardiovascular disease both treated and not treated with statins, hsCRP is at least as powerful a predictor of recurrent vascular events as that of LDL cholesterol, demonstrating the importance of “residual inflammatory risk” ”
- “among individuals taking statin therapy, consideration should be given to increase dosage into the higher intensity range if hsCRP levels remain >2 mg/L, irrespective of LDL cholesterol.”
treat hypertension
- see hypertension
control diabetes
environmental control
- air pollution, in particular iron-rich nanoparticles from traffic, etc may have a significant role
regular aerobic exercise:
- important because of effects on cardiorespiratory fitness and energy balance
- it may assist development of collateral circulation
- improves caloric balance & may restore the link between appetite & energy requirements, thereby reducing obesity
oestrogen replacement therapy:
- IHD is uncommon in premenopausal women
- HRT has been shown to decrease risk of atherosclerotic disease - oral effect may be greater than patch
- benefits of HRT in reducing atherosclerosis may be outweighed by its risks
aspirin:
- low dose (75mg/day) may be associated with significant reductions in CVS disease but small increased risk of GIT bleeding and haemorrhagic stroke
- aspirin for primary prevention if benefits outweigh risks:
- women aged 55 to 79 yrs if benefit of stroke (CVA) reduction outweighs risk of GIT haemorrhage4)
- men aged 45 to 79 yrs if benefit of acute myocardial infarction (AMI/STEMI/NSTEMI) reduction outweighs risk of GIT haemorrhage5)
- do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years 6)
- evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older 7)
prevent hyperhomocystinaemia if present:
- ensure folic acid & B12 deficiency is recognised & treated
anti-oxidants & other nutrients:
Vitamin E:
- In 1993, 2 large studies showed that Vit E could reduce the risk of heart disease in both men & women by around 35%, with best results from those that took at least 100IU per day for 2 years. NEJM 1993; 328:1450-56; NEJM 1993; 328:1444-9.
- In 1995, a study suggested that in pts with Hx of IHD, vitamin E intake of > 100IU/day was able to reduce coronary artery lesion progression when studied with serial angiography. JAMA 1995; 273:1849-54;
- In 1996, a study of > 11,000 elderly persons (>67yrs old), found that combined supplement use of Vit E & C seemed to offer significant protection from both heart disease mortality (down 42%) and all-cause mortality (down 53%) Am.J.Clin.Nutr. 1996:190-6.
- In 1996, Cambridge Heart Antioxidant Study (CHAOS) Lancet 1996; 347:781-86 studied 2000 pts with existing heart problems & found that supplementation with 400IU or 800IU per day for at least 1 year, reduced the risk of non-fatal heart attacks by up to 75%.
- In 2008, it now seems that supplemental antioxidants of vitamin A group or vitamin E actually INCREASES mortality!!
Secondary prevention:
aspirin:
- low dose aspirin 100-300mg/day unless C/I
beta blockers:
- offer prognostic benefit post-AMI
ACE inhibitors:
- offer prognostic benefit if significant LV dysfunction
fish oil n-3 fatty acids & other anti-oxidants post-revascularisation
- in 2018, the Cochrane review found that there is little evidence to support these fish oil supplements as benefiting reducing cardiovascular disease
statins:
- help stabilise plaque and may induce plaque regression
anti-inflammatory agents
- low dose colchicine
- Low-dose colchicine reduces cardiovascular events among individuals with chronic stable atherosclerosis and is the first FDA approved anti-inflammatory agent for this purpose.8)
- Low-dose colchicine is intended to be used as an adjunct to lipid lowering; however, colchicine has not proven effective when initiated at the time of acute ischemia and should be avoided among individuals with significant liver or renal disease.9)
- interleukin-6 (IL-6) blockers may have a role in those at high risk such as chronic renal failure