The debilitating and often fatal complications of cardiovascular disease (CVD) are usually seen in middle-aged or elderly men and women.
However, atherosclerosis – the main pathological process leading to coronary artery disease, cerebral artery disease and peripheral artery disease – begins early in life and progresses gradually through adolescence and early adulthood (15–17). It is usually asymptomatic for a long period.
The rate of progression of atherosclerosis is influenced by cardiovascular risk factors: tobacco use, an unhealthy diet and physical inactivity (which together result in obesity), elevated blood pressure (hypertension), abnormal blood lipids (dyslipidaemia) and elevated blood glucose (diabetes).
Continuing exposure to these risk factors leads to further progression of atherosclerosis, resulting in unstable atherosclerotic plaques, narrowing of blood vessels and obstruction of blood flow to vital organs, such as the heart and the brain. The clinical manifestations of these diseases include angina, myocardial infarction, transient cerebral ischaemic attacks and strokes.
Given this continuum of risk exposure and disease, the division of prevention of cardiovascular disease into primary, secondary and tertiary prevention is arbitrary, but may be useful for development of services by different parts of the health care system. The concept of a specific threshold for hypertension and hyperlipidaemia is also based on an arbitrary dichotomy.
The document provides evidence-based recommendations on how to assess and manage individuals with asymptomatic atherosclerosis, on the basis of their estimated total, or absolute, CVD risk. Total CVD risk is defined as the probability of an individual’s experiencing a CVD event (e.g. myocardial infarction or stroke) over a given period of time, for example 10 years.
Total CVD risk depends on the individual’s particular risk factor profile, sex and age; it will be higher for older men with several risk factors than for younger women with few risk factors. The total risk of developing cardiovascular disease is determined by the combined effect of cardiovascular risk factors, which commonly coexist and act multiplicatively.
An individual with several mildly raised risk factors may be at a higher total risk of CVD than someone with just one elevated risk factor.
Timely and sustained lifestyle interventions and, when needed, drug treatment will reduce the risk of CVD events, such as heart attacks and strokes, in people with a high total risk of CVD, and hence will reduce premature morbidity, mortality and disability.
Many people are unaware of their risk status; opportunistic and other forms of screening by health care providers are therefore a potentially useful means of detecting risk factors, such as raised blood pressure, abnormal blood lipids and blood glucose.
The predicted risk of an individual can be a useful guide for making clinical decisions on the intensity of preventive interventions: when dietary advice should be strict and specific, when suggestions for physical activity should be intensified and individualized, and when and which drugs should be prescribed to control risk factors.
Such a risk stratification approach is particularly suitable to settings with limited resources, where saving the greatest number of lives at lowest cost becomes imperative.
In patients with a systolic blood pressure above 150 mmHg, or a diastolic pressure above 90 mmHg, or a blood cholesterol level over 5.0 mmol/l, drug treatment reduces the relative risk of cardiovascular events by between one-quarter and one-third. Read Full PDF Here.