atherosclerosis
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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
Silent atherosclerosis
- atherosclerosis may begin in early adulthood and remain clinically silent for decades before manifesting mainly as a heart attack, stroke or sudden cardiac death
- the 2026 REACT cross-sectional study used different imaging modalities (carotid and femoral US, CTCA) to measure silent atherosclerosis in 16,808 adults without known CVD aged 18 to 70 years old from Denmark and Spain:1)
- prevalence of silent atherosclerosis found in the study:
- 1 in 13 participants aged 18–29 years
- 9 out of 10 participants aged 60–70 years
- prevalence increasing with age in an S-shaped curve
- prevalence increased earlier in men, whereas women showed a later and particularly steep midlife increase, around the typical age of menopause
- increasing age was associated with expansion of atherosclerosis and an exponential increase in age-related atherosclerotic plaque volume
- most individuals with silent atherosclerosis in their heart had atherosclerosis in their neck and/or leg arteries
- they found that the SCORE2 risk tool classified only a small minority of participants with silent atherosclerosis as high risk for CVD, with a marked lack among younger participants
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. 2)
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 3)
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 profiles4)
- “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 haemorrhage5)
- men aged 45 to 79 yrs if benefit of acute myocardial infarction (AMI/STEMI/NSTEMI) reduction outweighs risk of GIT haemorrhage6)
- do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years 7)
- 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 8)
prevent hyperhomocystinaemia if present:
- ensure folic acid & B12 deficiency is recognised & treated
anti-oxidants & other nutrients:
perhaps not 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.9)
- 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.10)
- interleukin-6 (IL-6) blockers may have a role in those at high risk such as chronic renal failure
atherosclerosis.1788173118.txt.gz · Last modified: 2026/08/31 10:45 by gary1