Prevention of cardiovascular diseases
BMC Medicine volume 13, Article number: 261 (2015)
Cardiovascular disease (CVD) is the most important cause of premature death and disability globally. Much is known of the main aetiological risk factors, including elevated blood pressure, dyslipidaemia and smoking, with a raft of additional risks of increasing prevalence, such as obesity and diabetes. Furthermore, some of the most secure evidence-based management strategies in healthcare relate to interventions that modify risk. Yet major gaps remain in the implementation of such evidence, summarized in international guideline recommendations. Some of this gap relates to knowledge deficits amongst clinicians, but also to continued uncertainties over interpretation of the evidence base and areas where data are less available. This article collection in BMC Medicine seeks to offer reflections in each of these areas of uncertainty, spanning issues of better diagnosis, areas of controversy and glimpses of potentially potent future interventions in the prevention of CVD.
Cardiovascular disease (CVD) remains the leading cause of global morbidity and mortality . The risk factors of abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, poor diet and irregular physical exercise account for more than 90 % of the CVD risk in epidemiological studies .
The commonest risk factor is hypertension, with a global prevalence estimated at 26.4 % (972 million adults) in 2000 and a predicted rise of 60 % to a total of 1.56 billion adults (29.2 %) by 2025 . A major predictor for coronary heart disease (CHD) and stroke [4, 5], international guidelines highlight the management of hypertension [6, 7] based on huge clinical outcome trial datasets , which show that a net blood pressure (BP) reduction of 10–12 mmHg systolic BP and 5–6 mmHg diastolic BP reduces stroke incidence by 38 % and CHD by 16 % . In absolute terms, treating 1000 patients in four 5-year CVD risk groups observed in the placebo arms of trials (5-year risks of <11 %, 11–15 %, 15–21 % and >21 %) with BP-lowering treatment for 5 years would prevent 14 (95 % CI: 8–21), 20 (95 % CI: 8–31), 24 (95 % CI: 8–40) and 38 (95 % CI: 16–61) cardiovascular events, respectively (P = 0.04 for trend) .
Interventions that lower low-density lipoprotein cholesterol (LDL-C) concentrations are also proven to significantly reduce the incidence of CHD and other major vascular events in a wide range of individuals. A meta-analysis of 14 statin trials showed that for every 40 mg/dL (1 mmol/L) decrease in LDL-C, it led to a 21 % decrease in CHD risk after 1 year of treatment . These data were incorporated into clinical guidance, such as the American College of Cardiology/American Heart Association (ACC/AHA)  and National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines  in the US; the Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice guidelines in Europe ; and the National Institute for Health and Care Excellence (NICE) in the UK, which all recognise the importance of dyslipidaemia, as well as hypertension and smoking, as the main risk factors for CVD. They also provide practical tools (Framingham, Systematic Coronary Risk Evaluation (SCORE) and QRISK 10-year CVD risk algorithms, respectively) to assist short-term risk estimation in individuals without prior CVD, although there remain many barriers to guideline implementation in routine clinical practice .
However, despite this huge evidence base on the aetiology of CVDs and their treatment options, many questions still remain unanswered. Some of these are considered in this special article collection in BMC Medicine, including critical reviews on diagnosing hypertension , the potential of PCSK9 antibodies , an entirely new class of LDL-C modifiers developed from basic concept to phase III trials in less than a decade, and the evidence for smoking reduction interventions .
In the near future, there will also be an upcoming forum debate on the relative impact of statins on vascular disease — over 20 years after their introduction and now one of the most prescribed drugs in the world, there remains much debate on these agents. The article collection will also present the updated guidance on stroke prevention in atrial fibrillation (SPAF) which, alongside detection and management of hypertension, is the most important strategy to prevent stroke. Atrial fibrillation (AF) is the commonest cardiac arrhythmia, with about 1–2 % of the general population estimated to be affected . It is a particularly common disorder in older people, with over 5 % over the age of 65 years suffering from AF and around 10 % of people over the age of 75 years [19, 20], with the prevalence predicted to rise [21, 22]. Patients with AF are at an almost five-fold higher risk of stroke compared to age-matched individuals with normal sinus rhythm , as well as at a twice as high risk of all-cause mortality and heart failure. About 20 % of all ischaemic strokes are attributable to embolism as a result of AF . Not only do patients with AF have more strokes, they also develop more recurrent strokes, more severe strokes, regardless of age , and are more likely to be left with long-term disability and require long-term care . It is a very important topic for patients and for healthcare system payers.
American College of Cardiology
American Heart Association
Adult Treatment Panel
Coronary heart disease
Low-density lipoprotein cholesterol
National Cholesterol Education Program
National Institute for Health and Care Excellence
Systematic Coronary Risk Evaluation
Stroke prevention in atrial fibrillation
GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–71.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937–52.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217–23.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;60:1903–13.
Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA. 1996;275:1571–6.
James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507–20.
Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31:1281–357.
Turnbull F, Neal B, Algert C, Chalmers J, Chapman N, Cutler J, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med. 2005;165:1410–9.
Blood Pressure Lowering Treatment Trialists’ Collaboration, Sundström J, Arima H, Woodward M, Jackson R, Karmali K, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384:591–8.
Cholesterol Treatment Trialists’ (CTT) Collaboration, Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. 2010;376:167–81.
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;63:2889–934.
Grundy SM, Cleeman JI, Merz CN, Brewer Jr HB, Clark LT, Hunninghake DB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004;44:720–32.
Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren WM, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Atherosclerosis. 2012;223:1–68.
Graham IM, Stewart M, Hertog MG, Cardiovascular Round Table Task Force. Factors impeding the implementation of cardiovascular prevention guidelines: findings from a survey conducted by the European Society of Cardiology. Eur J Cardiovasc Prev Rehabil. 2006;13:839–45.
Schwartz CL, McManus RJ. What is the evidence base for diagnosing hypertension and for subsequent blood pressure treatment targets in the prevention of cardiovascular disease? BMC Med. 2015. doi:10.1186/s12916-015-0502-5.
Stoekenbroek RM, Kastelein JJP, Huijgen R. PCSK9 inhibition: the way forward in the treatment of dyslipidemia. BMC Med. 2015. doi:10.1186/s12916-015-0503-4.
Begh R, Lindson-Hawley N, Aveyard P. Does reduced smoking if you can’t stop make any difference? BMC Med. 2015. doi:10.1186/s12916-015-0505-2.
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33:2719–47.
Hobbs FD, Fitzmaurice DA, Mant J, Murray E, Jowett S, Bryan S, et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess. 2005;9:1–74. iii–iv, ix–x.
Heeringa J, van der Kuip DA, Hofman A, Kors JA, van Herpen G, Stricker BH, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27:949–53.
Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of atrial fibrillation. Nat Rev Cardiol. 2014;11:639–54. doi:10.1038/nrcardio.2014.118.
Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011;123:e269–367.
Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983–8.
Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:483S–512S.
Jørgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS. Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke. 1996;27:1765–9.
Lin HJ, Wolf PA, Kelly-Hayes M, Beiser AS, Kase CS, Benjamin EJ, et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke. 1996;27:1760–4.
Zhang XL, Zhu QQ, Zhu L, Chen JZ, Chen QH, Li GN, et al. Safety and efficacy of anti-PCSK9 antibodies: a meta-analysis of 25 randomized, controlled trials. BMC Med. 2015;13:123. doi:10.1186/s12916-015-0358-8.
Liebetrau C, Weber M, Tzikas S, Palapies L, Möllmann H, Pioro G, et al. Identification of acute myocardial infarction in patients with atrial fibrillation and chest pain with a contemporary sensitive troponin I assay. BMC Med. 2015;13:169. doi:10.1186/s12916-015-0410-8.
Li Y, Ley SH, VanderWeele TJ, Curhan GC, Rich-Edwards JW, Willett WC, et al. Joint association between birth weight at term and later life adherence to a healthy lifestyle with risk of hypertension: a prospective cohort study. BMC Med. 2015;13:175. doi:10.1186/s12916-015-0409-1.
Banach M, Serban C, Sahebkar A, Mikhailidis DP, Ursoniu S, Ray KK, et al. Impact of statin therapy on coronary plaque composition: a systematic review and meta-analysis of virtual histology-intravascular ultrasound studies. BMC Med. 2015;13:229. doi:10.1186/s12916-015-0459-4.
FDRH has received occasional research funding, fees or expenses from a variety of pharmaceutical and biotechnology companies, including those active in vascular disease indications. However, there were no direct competing interests in relation to this Editorial.
FDRH is on the Editorial Board of BMC Medicine and is Guest Editor for the article collection, Prevention of cardiovascular diseases. FDRH is part-funded as Director of the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), Theme Leader of the NIHR Oxford Biomedical Research Centre (BRC), and Director of the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Oxford, UK. FDRH is also supported as a professorial Fellow by Harris Manchester College, Oxford, UK.
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Hobbs, F.D.R. Prevention of cardiovascular diseases. BMC Med 13, 261 (2015). https://doi.org/10.1186/s12916-015-0507-0
- Cardiovascular disease
- Risk factors