Prevention and Risk Factors

Prevention and Risk Factors

Risk Factors

 

A risk factor is something that increases your likelihood of developing a disease or condition. It is certainly possible to develop CVD without risk factors, but having risk factors makes it more likely. Some risk factors for cardiovascular disease are not modifiable, but many are. Being aware of your risk factors and taking steps to reduce them can slow or even arrest the progression of cardiovascular disease at multiple points:

  • Before the atherosclerosis sets in
  • Before atherosclerosis leads to a cardiovascular event, such as a heart attack
  • After the first, but before any subsequent cardiovascular events

 

Non-modifiable risk factors are those that you cannot change. It is still a good idea to be aware of these factors, however, to get a sense of your risk.

  • Age —For men, age 45 or older; for women, age 55 or older.
  • Race —African Americans have a greater incidence of hypertension than Caucasians, and therefore a higher risk of developing CVD. Others at increased risk include Mexican Americans, Native Americans, native Hawaiians, and some Asian Americans.
  • Family History —First-degree relative (father, mother, sister, brother) with premature heart disease (males younger than 55, females younger than 65).
  • Gender —Men tend to suffer cardiovascular events sooner than women. After menopause, however, cardiovascular risk in women quickly catches up to that in men.

Modifiable risk factors can be reduced or eliminated through lifestyle changes, medical treatment, or a combination of the two. Many of these risk factors are interrelated, and attending to one can often have beneficial effects on others.

  • Smoking —Smokers are twice as likely to have a heart attack as nonsmokers. Cigarette smoking is also the biggest risk factor for sudden cardiac death. Even nonsmokers can increase their risk of heart disease if they are constantly exposed to cigarette smoke.
  • High blood cholesterol High total and LDL cholesterol levels and low HDL cholesterol levels increase the risk of atherosclerosis, coronary heart disease, and stroke. In general, a total cholesterol level less than 200 mg/dL (5.2 mmol/L) , an LDL cholesterol level less than 100 mg/dL (2.6 mmol/L), and an HDL cholesterol level greater than 60 mg/dL (1.6 mmol/L) are considered desirable.
  • High blood pressure (hypertension) High blood pressure accelerates the progression of atherosclerosis and increases the risk of coronary heart disease, stroke, and congestive heart failure. Hypertension is defined as a blood pressure equal to or above 140/90 mmHg. However, individuals with blood pressure in the high-normal range (around 130/85 mmHg) are at increased risk of becoming hypertensive and should take steps to lower their blood pressure.
  • Physical inactivity —A sedentary lifestyle increases risk for coronary heart disease, while regular physical activity can prevent it. Exercise also helps control other CVD risk factors, including high LDL-cholesterol, low HDL-cholesterol, type 2 diabetes, obesity, and high blood pressure.
  • Obesity and overweight— Excess body fat, particularly in the abdominal region, is associated with an increased risk for heart disease and stroke. Surplus weight puts additional strain on your heart, and raises blood pressure, blood cholesterol and the risk of type 2 diabetes.
  • Type 2 Diabetes and prediabetes —Type 2 diabetes is a major risk factor for cardiovascular disease. About two-thirds of people with diabetes die of some type of heart or blood vessel disease. Glucose intolerance prior to the onset of type 2 diabetes can also place you at increased risk.
  • Excess alcohol —Drinking too much alcohol can raise your blood pressure, cause heart failure, and lead to stroke. It can contribute to high triglycerides (fats in the blood) and obesity, and may predispose to arrhythmias.
  • Stress —Although it remains unclear exactly how much psychological stress contributes to the development of CVD, if you have already been diagnosed with a cardiovascular condition, you could benefit from stress management.
  • Emerging risk factors— The association of these risk factors with CVD is less well established, but many authorities believe they will become clinically important in the near future.
    • C-reactive protein —C-reactive protein is a marker of inflammation. High levels of the protein have been associated with increased risk of heart disease and stroke, even when total and LDL-cholesterol levels are low. It is not yet known how to reduce C-reactive proteins.
    • Homocysteine —Homocysteine is an amino acid (building block of protein) that appears to contribute to atherosclerosis and blood clotting. High levels of homocysteine have been linked to increased risk of heart disease. Folic acid in the diet is effective at reducing homocysteine levels.

 

The purpose of screening for cardiovascular disease is to detect it and treat it prior to the onset of symptoms. Screening involves the medical history, physical examination, and certain tests designed to assess both your risk for CVD and any evidence that already exists.

  • Medical History —You physician will ask you questions about current and previous illnesses, past surgeries and hospitalizations, medications, diet and other lifestyle factors, social history, and family history in order to gauge your CVD risk.
  • Physical Exam —Your doctor may assess the following:
    • Body Mass Index BMI is a measurement of body mass that takes into account both height and weight.
    • Fat Distribution This is usually measured as a waist-to-hip ratio. Carrying more fat around your abdomen and upper body (an “apple” shape) puts you at greater risk for heart disease, high blood pressure, and diabetes.
    • Blood Pressure Measurement —Blood pressure is measured using a cuff around your arm and a device called a sphygmomanometer. Blood pressure has a tendency to fluctuate and needs to be measured several times before a diagnosis of hypertension can be made.
      Blood Pressure Measurement
      Placement of Blood Pressure Cuff
      © 2011 Nucleus Medical Media, Inc.
  • Blood Tests —For the following tests, blood may be drawn in your doctor’s office or in a laboratory. The blood is then sent to the laboratory for analysis, and you should receive the results within one week.
    • Lipid Profile A complete lipid profile will measure the levels of total cholesterol, LDL and HDL cholesterol, and triglycerides in your blood.
    • Blood Sugar/Glycohemoglobin (HBA1C) —These tests are used to both screen for diabetes and monitor the progress of diabetes treatment.
  • Exercise Tolerance or Stress Test Using an electrocardiogram (ECG) to measure the heart’s electrical activity at rest provides limited information about the oxygen supply to the heart. A stress test, therefore, is often used to evaluate the presence and severity of cardiovascular disorders as the heart responds to the additional demand for oxygen during physical activity.

Animation Copyright © Milner-Fenwick

Reducing Your Risk

 

Reducing the risk of cardiovascular disease takes two basic forms—lifestyle modification and medications. Both are commonly used simultaneously.
 

  • Lifestyle Modification —Changing health behaviors is, by far, the most challenging way to reduce risk, but it is also the most effective and long-lasting. In fact, successfully modifying your lifestyle can eliminate a risk factor altogether in some cases. The greatest benefit would be gained by:
    • Not Smoking Cigarette smoking kills more Americans than any other health behavior. It won’t be easy, but if you quit smoking, you will halve your chances of developing heart disease.
    • Eating Healthfully Eating healthfully can contribute to lower cholesterol and blood pressure levels, and can reduce the risk of type 2 diabetes by helping to maintain an appropriate weight. To follow a heart-healthy diet, you should:
      • Limit intake of total fat, saturated fat, trans fats, and cholesterol
      • Eat five or more servings of a variety of fruits and vegetables per day

      heart-healthy diet

      • Choose six or more servings per day of a variety of grain products, especially whole grains; reduce your intake of refined carbohydrates
      • Limit intake of foods that are high in calories, but low in nutrition
      • Eat six grams or less of salt per day
    • Exercising Regularly Regular exercise can help you lose weight, lower cholesterol and blood pressure levels, and reduce you risk of type 2 diabetes. Aim for at least 30 minutes of moderate-intensity activity most (preferably all) days of the week.
    • Drink in Moderation Light to moderate alcohol intake has been shown to reduce the risk of heart disease. However, there is not enough evidence to suggest that you should start drinking if you do not already in order to protect your heart. Heavy drinking actually increases your risk of hypertension and heart disease. Women should limit themselves to one alcoholic drink per day and men to two.
    • Maintain a Healthy Weight Maintaining a healthy weight can help you decrease your risk of developing type 2 diabetes and hypertension. First, use the body mass index (BMI) to get a sense of your target weight, keeping in mind the BMI is an imperfect gauge. To lose weight you need to burn more calories than you take in. Maintaining your weight requires a balance between calorie consumption and expenditure. While dieting alone will help you lose weight in the short run, it is difficult to keep the weight off without a combination of diet and regular exercise.
       
  • Medications —While medications are convenient to take, they suffer from two major drawbacks: they cause adverse effects and they tend to compensate for, rather than solve, the underlying problem. For these reasons, medications are usually prescribed only when lifestyle modifications have proved ineffective by themselves.
    • Antihypertensives —A doctor will prescribe an antihypertensive to reduce high blood pressure and to lower overall cardiovascular disease risk. Antihypertensives work in several ways: by ridding the body of excess fluids, by slowing down the pace of the heart, by dilating blood vessels or by blocking the effects of chemicals that cause them to constrict. You may have to go through a trial period with different medications to find out which work best for you. Examples include:
      • Alpha 1-selective adrenoceptor blockers, such as doxazosin and prazosin
      • Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril and lisinopril
      • Angiotensin receptor blockers, such as candesartan and losartan
      • Beta blockers , such as atenolol and pindolol
      • Calcium-channel blockers, such as nicardipine and nisoldipine
      • Centrally acting sympathoplegic drugs, such as clonidine and guanfacine
      • Diuretics, such as acetazolamide and hydrochlorothiazide
      • Ganglion-blocking agents, such as mecamylamine
      • Postganglionic sympathetic nerve terminal blockers, such as guanethidine and reserpine
      • Vasodilators, such as diazoxide and hydralazine
    • Antiplatelets —Antiplatelets interfere with the formation of blood clots that can lead to heart attack, stroke or gangrene.
      • Low-dose aspirin is most commonly prescribed antiplatelet agent used to reduce the risk of CVD. Other more expensive drugs (ex. clopidogrel) are often used in patients already diagnosed with CVD.
    • Cholesterol-lowering Agents —Based on your overall cardiovascular risk and your success with dietary changes, your doctor may recommend drugs to lower cholesterol. Some drugs are better than others at lowering high LDL or total cholesterol, raising low levels of HDL cholesterol, or lowering triglyceride levels. Examples include:
      • Bile-acid sequestrants, such as cholestyramine and colestipol
      • Fibrates, such as gemfibrozil and fenofibrate
      • Nicotinic acid drugs, such as niacin
      • Statins (HMG-CoA Reductase Inhibitors), such as pravastatin and simvastatin
      • Drugs that reduce cholesterol absorption, such as ezetimibe.
    • Hypoglycemic Agents —Many diabetics can control their blood glucose levels through a combination of healthy eating, exercise, and weight loss. If these lifestyle changes don’t work, diabetes medications may be in order. Depending on the agent, anti-diabetic medications may work by stimulating your pancreas to make more insulin, reducing the amount of glucose made by your liver, slowing the absorption of dietary carbohydrates (a major source of blood glucose), or increasing the sensitivity of cells to insulin. Examples include:
      • Sulfonylureas such as glipizide, glimepiride, glyburide
      • Biguanides such as metformin
      • Alpha-glucosidase inhibitors such as acarbose, miglitol
      • Thiazolidinediones such as pioglitazone, rosiglitazone
      • Meglitinides such as repaglinide, nateglinide
      • Dipeptidyl peptidase-4 inhibitors such as sitagliptin
      • If your pancreas no longer makes insulin at all, you will have to resort to insulin injections

 

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