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Latest revision as of 18:48, 17 February 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels.^[1] Cardiovascular disease includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack).^[1] Other CVDs include stroke, heart failure, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, heart arrhythmia, congenital heart disease, valvular heart disease, carditis, aortic aneurysms, peripheral artery disease, thromboembolic disease, and venous thrombosis.^[1]^[2]

The underlying mechanisms vary depending on the disease in question.^[1] Coronary artery disease, stroke, and peripheral artery disease involve atherosclerosis.^[1] This may be caused by high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol consumption, among others.^[1] High blood pressure results in 13% of CVD deaths, while tobacco results in 9%, diabetes 6%, lack of exercise 6% and obesity 5%.^[1] Rheumatic heart disease may follow untreated strep throat.^[1]

It is estimated that 90% of CVD is preventable.^[3] Prevention of atherosclerosis involves improving risk factors through: healthy eating, exercise, avoidance of tobacco smoke and limiting alcohol intake.^[1] Treating risk factors, such as high blood pressure, blood lipids and diabetes is also beneficial.^[1] Treating people who have strep throat with antibiotics can decrease the risk of rheumatic heart disease.^[4] The effect of the use of aspirin in people who are otherwise healthy is of unclear benefit.^[5]^[6]

Cardiovascular diseases are the leading cause of death globally.^[1] This is true in all areas of the world except Africa.^[1] Together they resulted in 17.9 million deaths (32.1%) in 2015, up from 12.3 million (25.8%) in 1990.^[7]^[2] Deaths, at a given age, from CVD are more common and have been increasing in much of the developing world, while rates have declined in most of the developed world since the 1970s.^[8]^[9] Coronary artery disease and stroke account for 80% of CVD deaths in males and 75% of CVD deaths in females.^[1] Most cardiovascular disease affects older adults. In the United States 11% of people between 20 and 40 have CVD, while 37% between 40 and 60, 71% of people between 60 and 80, and 85% of people over 80 have CVD.^[10] The average age of death from coronary artery disease in the developed world is around 80 while it is around 68 in the developing world.^[8] Disease onset is typically seven to ten years earlier in men as compared to women.^[11]

Types

File:Inflammatory heart diseases world map - DALY - WHO2004.svg

Disability-adjusted life year for inflammatory heart diseases per 100,000 inhabitants in 2004^[12]

no data

less than 70

70–140

140–210

210–280

280–350

350–420

420–490

490–560

560–630

630–700

700–770

more than 770

There are many cardiovascular diseases involving the blood vessels. They are known as vascular diseases.

Coronary artery disease (also known as coronary heart disease and ischemic heart disease)
Peripheral arterial disease – disease of blood vessels that supply blood to the arms and legs
Cerebrovascular disease – disease of blood vessels that supply blood to the brain (includes stroke)
Renal artery stenosis
Aortic aneurysm

There are also many cardiovascular diseases that involve the heart.

Cardiomyopathy – diseases of cardiac muscle
Hypertensive heart disease – diseases of the heart secondary to high blood pressure or hypertension
Heart failure - a clinical syndrome caused by the inability of the heart to supply sufficient blood to the tissues to meet their metabolic requirements
Pulmonary heart disease – a failure at the right side of the heart with respiratory system involvement
Cardiac dysrhythmias – abnormalities of heart rhythm
Inflammatory heart disease
- Endocarditis – inflammation of the inner layer of the heart, the endocardium. The structures most commonly involved are the heart valves.
- Inflammatory cardiomegaly
- Myocarditis – inflammation of the myocardium, the muscular part of the heart.
Valvular heart disease
Congenital heart disease – heart structure malformations existing at birth
Rheumatic heart disease – heart muscles and valves damage due to rheumatic fever caused by Streptococcus pyogenes a group A streptococcal infection.

Risk factors

There are many risk factors for heart diseases: age, gender, tobacco use, physical inactivity, excessive alcohol consumption, unhealthy diet, obesity, genetic predisposition and family history of cardiovascular disease, raised blood pressure (hypertension), raised blood sugar (diabetes mellitus), raised blood cholesterol (hyperlipidemia), psychosocial factors, poverty and low educational status, and air pollution.^[13]^[14]^[15]^[16] While the individual contribution of each risk factor varies between different communities or ethnic groups the overall contribution of these risk factors is very consistent.^[17] Some of these risk factors, such as age, gender or family history/genetic predisposition, are immutable; however, many important cardiovascular risk factors are modifiable by lifestyle change, social change, drug treatment (for example prevention of hypertension, hyperlipidemia, and diabetes).^[18] People with obesity are at increased risk of atherosclerosis of the coronary arteries.^[19]

Genetics

Genetic factors influence the development of cardiovascular disease in men who are less than 55 years-old and in women who are less than 65 years old.^[18] Cardiovascular disease in a person's parents increases their risk by 3 fold.^[20] Multiple single nucleotide polymorphisms (SNP) have been found to be associated with cardiovascular disease in genetic association studies,^[21]^[22] but usually their individual influence is small, and genetic contributions to cardiovascular disease are poorly understood.^[22]

Age

File:Calcified Heart.jpg

Calcified heart of an older woman with cardiomegaly

Age is by far the most important risk factor in developing cardiovascular or heart diseases, with approximately a tripling of risk with each decade of life.^[23] Coronary fatty streaks can begin to form in adolescence.^[24] It is estimated that 82 percent of people who die of coronary heart disease are 65 and older.^[25] At the same time, the risk of stroke doubles every decade after age 55.^[26]

Multiple explanations have been proposed to explain why age increases the risk of cardiovascular/heart diseases. One of them is related to serum cholesterol level.^[27] In most populations, the serum total cholesterol level increases as age increases. In men, this increase levels off around age 45 to 50 years. In women, the increase continues sharply until age 60 to 65 years.^[27]

Aging is also associated with changes in the mechanical and structural properties of the vascular wall, which leads to the loss of arterial elasticity and reduced arterial compliance and may subsequently lead to coronary artery disease.^[28]

Sex

Men are at greater risk of heart disease than pre-menopausal women.^[23]^[29] Once past menopause, it has been argued that a woman's risk is similar to a man's^[29] although more recent data from the WHO and UN disputes this.^[23] If a female has diabetes, she is more likely to develop heart disease than a male with diabetes.^[30]

Coronary heart diseases are 2 to 5 times more common among middle-aged men than women.^[27] In a study done by the World Health Organization, sex contributes to approximately 40% of the variation in sex ratios of coronary heart disease mortality.^[31] Another study reports similar results finding that gender differences explain nearly half the risk associated with cardiovascular diseases^[27] One of the proposed explanations for gender differences in cardiovascular diseases is hormonal difference.^[27] Among women, estrogen is the predominant sex hormone. Estrogen may have protective effects on glucose metabolism and hemostatic system, and may have a direct effect in improving endothelial cell function.^[27] The production of estrogen decreases after menopause, and this may change the female lipid metabolism toward a more atherogenic form by decreasing the HDL cholesterol level while increasing LDL and total cholesterol levels.^[27]

Among men and women, there are notable differences in body weight, height, body fat distribution, heart rate, stroke volume, and arterial compliance.^[28] In the very elderly, age-related large artery pulsatility and stiffness is more pronounced among women than men.^[28] This may be caused by the women's smaller body size and arterial dimensions which are independent of menopause.^[28]

There are data suggesting that female patients are less likely to receive treatment based on guidelines while they are hospitalized when compared to male patients.^[32]

One study demonstrated that female patients are less likely to receive treatments such as cardiac catheterization when compared to male patients with an exact clinical vignette.^[33]^[32]

Racial and Ethnic Groups

A higher prevalence of cardiovascular disease and related mortality have been reported in the following racial and ethnic groups:^[32]
- African-Amrican
- Hispanics
- South Asians
Access to care is one of the known factors that affect certain populations such as racial and ethnic groups and results in worse outcome.^[32]
Studies show that even after considering the access to care, there are other health disparities that can be the reason for the higher rate of cardiovascular disease among racial and ethnic groups. There are data suggesting that black patients are less likely to receive treatment based on guidelines while they are hospitalized when compared to white patients.^[32]
One study demonstrated that non-white patients are less likely to receive treatments such as cardiac catheterization when compared to white patients with an exact clinical vignette.^[33]^[32]

Tobacco

Cigarettes are the major form of smoked tobacco.^[1] Risks to health from tobacco use result not only from direct consumption of tobacco, but also from exposure to second-hand smoke.^[1] Approximately 10% of cardiovascular disease is attributed to smoking;^[1] however, people who quit smoking by age 30 have almost as low a risk of death as never smokers.^[34]

Physical inactivity

Insufficient physical activity (defined as less than 5 x 30 minutes of moderate activity per week, or less than 3 x 20 minutes of vigorous activity per week) is currently the fourth leading risk factor for mortality worldwide.^[1] In 2008, 31.3% of adults aged 15 or older (28.2% men and 34.4% women) were insufficiently physically active.^[1] The risk of ischemic heart disease and diabetes mellitus is reduced by almost a third in adults who participate in 150 minutes of moderate physical activity each week (or equivalent).^[35] In addition, physical activity assists weight loss and improves blood glucose control, blood pressure, lipid profile and insulin sensitivity. These effects may, at least in part, explain its cardiovascular benefits.^[1]

Diet

High dietary intakes of saturated fat, trans-fats and salt, and low intake of fruits, vegetables and fish are linked to cardiovascular risk, although whether all these associations are a cause is disputed. The World Health Organization attributes approximately 1.7 million deaths worldwide to low fruit and vegetable consumption.^[1] The amount of dietary salt consumed is also an important determinant of blood pressure levels and overall cardiovascular risk.^[1] Frequent consumption of high-energy foods, such as processed foods that are high in fats and sugars, promotes obesity and may increase cardiovascular risk.^[1] A Cochrane review found that replacing saturated fat with polyunsaturated fat (plant based oils) reduced cardiovascular disease risk. Cutting down on saturated fat reduced risk of cardiovascular disease by 17% including heart disease and stroke.^[36] High trans-fat intake has adverse effects on blood lipids and circulating inflammatory markers,^[37] and elimination of trans-fat from diets has been widely advocated.^[38] There is evidence that higher consumption of sugar is associated with higher blood pressure and unfavorable blood lipids,^[39] and sugar intake also increases the risk of diabetes mellitus.^[40] High consumption of processed meats is associated with an increased risk of cardiovascular disease, possibly in part due to increased dietary salt intake.^[41]

The relationship between alcohol consumption and cardiovascular disease is complex, and may depend on the amount of alcohol consumed. There is a direct relationship between high levels of alcohol consumption and risk of cardiovascular disease.^[1] Drinking at low levels without episodes of heavy drinking may be associated with a reduced risk of cardiovascular disease.^[42] Overall alcohol consumption at the population level is associated with multiple health risks that exceed any potential benefits.^[1]^[43]

Socioeconomic disadvantage

Cardiovascular disease affects low- and middle-income countries even more than high-income countries.^[44] There is relatively little information regarding social patterns of cardiovascular disease within low- and middle-income countries,^[44] but within high-income countries low income and low educational status are consistently associated with greater risk of cardiovascular disease.^[45] Policies that have resulted in increased socio-economic inequalities have been associated with greater subsequent socio-economic differences in cardiovascular disease^[44] implying a cause and effect relationship. Psychosocial factors, environmental exposures, health behaviours, and health-care access and quality contribute to socio-economic differentials in cardiovascular disease. ^[46] The Commission on Social Determinants of Health recommended that more equal distributions of power, wealth, education, housing, environmental factors, nutrition, and health care were needed to address inequalities in cardiovascular disease and non-communicable diseases.^[47]

Air pollution

Particulate matter has been studied for its short- and long-term exposure effects on cardiovascular disease. Currently, PM_2.5 is the major focus, in which gradients are used to determine CVD risk. For every 10 μg/m³ of PM_2.5 long-term exposure, there was an estimated 8–18% CVD mortality risk.^[48] Women had a higher relative risk (RR) (1.42) for PM_2.5 induced coronary artery disease than men (0.90) did.^[48] Overall, long-term PM exposure increased rate of atherosclerosis and inflammation. In regards to short-term exposure (2 hours), every 25 μg/m³ of PM_2.5 resulted in a 48% increase of CVD mortality risk.^[49] In addition, after only 5 days of exposure, a rise in systolic (2.8 mmHg) and diastolic (2.7 mmHg) blood pressure occurred for every 10.5 μg/m³ of PM_2.5.^[49] Other research has implicated PM_2.5 in irregular heart rhythm, reduced heart rate variability (decreased vagal tone), and most notably heart failure.^[49]^[50] PM_2.5 is also linked to carotid artery thickening and increased risk of acute myocardial infarction.^[49]^[50]

Cardiovascular risk assessment

Existing cardiovascular disease or a previous cardiovascular event, such as a heart attack or stroke, is the strongest predictor of a future cardiovascular event.^[51] Age, sex, smoking, blood pressure, blood lipids and diabetes are important predictors of future cardiovascular disease in people who are not known to have cardiovascular disease.^[52] These measures, and sometimes others, may be combined into composite risk scores to estimate an individual's future risk of cardiovascular disease.^[51] Numerous risk scores exist although their respective merits are debated.^[53] Other diagnostic tests and biomarkers remain under evaluation but currently these lack clear-cut evidence to support their routine use. They include family history, coronary artery calcification score, high sensitivity C-reactive protein (hs-CRP), ankle–brachial pressure index, lipoprotein subclasses and particle concentration, lipoprotein(a), apolipoproteins A-I and B, fibrinogen, white blood cell count, homocysteine, N-terminal pro B-type natriuretic peptide (NT-proBNP), and markers of kidney function.^[54]^[55] High blood phosphorus is also linked to an increased risk.^[56]

Occupational exposure

Little is known about the relationship between work and cardiovascular disease, but links have been established between certain toxins, extreme heat and cold, exposure to tobacco smoke, and mental health concerns such as stress and depression.^[57]

Chemical risk factors

A 2015 SBU-report looking at non-chemical factors found an association for those:^[58]

with mentally stressful work with a lack of control over their working situation — with an effort-reward imbalance^[58]
who experience low social support at work; who experience injustice or experience insufficient opportunities for personal development; or those who experience job insecurity^[58]
those who work night schedules; or have long working weeks^[58]
those who are exposed to noise^[58]

Specifically the risk of stroke was also increased by exposure to ionizing radiation.^[58] Hypertension develops more often in those who experience job strain and who have shift-work.^[58] Differences between women and men in risk are small, however men risk suffering and dying of heart attacks or stroke twice as often as women during working life.^[58]

Non-chemical risk factors

A 2017 SBU report found evidence that workplace exposure to silica dust, engine exhaust or welding fumes is associated with heart disease.^[59] Associations also exist for exposure to arsenic, benzopyrenes, lead, dynamite, carbon disulphide, carbon monoxide, metalworking fluids and occupational exposure to tobacco smoke.^[59] Working with the electrolytic production of aluminium or the production of paper when the sulphate pulping process is used is associated with heart disease.^[59] An association was also found between heart disease and exposure to compounds which are no longer permitted in certain work environments, such as phenoxy acids containing TCDD(dioxin) or asbestos.^[59]

Workplace exposure to silica dust or asbestos is also associated with pulmonary heart disease. There is evidence that workplace exposure to lead, carbon disulfide, phenoxyacids containing TCDD, as well as working in an environment where aluminum is being electrolytically produced, is associated with stroke.^[59]

Somatic mutations

As of 2017, evidence suggests that certain leukemia-associated mutations in blood cells may also lead to increased risk of cardiovascular disease. Several large-scale research projects looking at human genetic data have found a robust link between the presence of these mutations, a condition known as clonal hematopoiesis, and cardiovascular disease-related incidents and mortality.^[60]

Pathophysiology

File:Cardiovascular calcification - Sergio Bertazzo.tif

Density-Dependent Colour Scanning Electron Micrograph SEM (DDC-SEM) of cardiovascular calcification, showing in orange calcium phosphate spherical particles (denser material) and, in green, the extracellular matrix (less dense material)^[61]

Population-based studies show that atherosclerosis, the major precursor of cardiovascular disease, begins in childhood. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study demonstrated that intimal lesions appear in all the aortas and more than half of the right coronary arteries of youths aged 7–9 years.^[62]

This is extremely important considering that 1 in 3 people die from complications attributable to atherosclerosis. In order to stem the tide, education and awareness that cardiovascular disease poses the greatest threat, and measures to prevent or reverse this disease must be taken.

Obesity and diabetes mellitus are often linked to cardiovascular disease,^[63] as are a history of chronic kidney disease and hypercholesterolaemia.^[64] In fact, cardiovascular disease is the most life-threatening of the diabetic complications and diabetics are two- to four-fold more likely to die of cardiovascular-related causes than nondiabetics.^[65]^[66]^[67]

Screening

Clinical practice guidelines by the United States Preventive Service Task Force in 2016 stated^[68]:

Providers should utilize the ACC/AHA Pooled Cohort Equations to estimate 10-year risk of CVD events. This calculation takes into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertensive medications, diabetic status, and smoking status.

The NIH recommends lipid testing in children beginning at the age of 2 if there is a family history of heart disease or lipid problems.^[69] It is hoped that early testing will improve lifestyle factors in those at risk such as diet and exercise.^[70]

Screening ECGs (either at rest or with exercise) are not recommended in those without symptoms who are at low risk.^[71] This includes those who are young without risk factors according to the American Heart Association and the American College of Cardiology.^[72] In those at higher risk the evidence for screening with ECGs is inconclusive.^[71] Echocardiography and stress testing (myocardial perfusion imaging orcardiac stress testing) are not recommended in those at low risk who do not have symptoms according to the American College of Physicians.^[73]

Evidence

Some biomarkers may add to conventional cardiovascular risk factors in predicting the risk of future cardiovascular disease; however, the clinical value of some biomarkers is questionable.^[74] Per this study, measured the incremental value of 10 contemporary biomarkers (C-reactive protein, B-type natriuretic peptide,N-terminal pro-atrial natriuretic peptide, aldosterone, renin, fibrinogen, D-dimer, plasminogen-activator inhibitor type 1, and homocysteine; and the urinary albumin-to-creatinine ratio). The C-statistic increased from 0.80 (with age, sex, and conventional risk factors as predictors) to 0.82 (with all predictors). The statistical significant of this increase was not reported.

Screening and selection for primary prevention interventions has traditionally been done through absolute risk using a variety of scores (ex. Framingham or Reynolds risk scores).^[75] This stratification has separated people who receive the lifestyle interventions (generally lower and intermediate risk) from the medication (higher risk). The number and variety of risk scores available for use has multiplied, but their efficacy according to a 2016 review was unclear due to lack of external validation or impact analysis.^[76] Risk stratification models often lack sensitivity for population groups and do not account for the large number of negative events among the intermediate and low risk groups.^[75] As a result, future preventative screening appears to shift toward applying prevention according to randomized trial results of each intervention rather than large-scale risk assessment.

Prevention

Up to 90% of cardiovascular disease may be preventable if established risk factors are avoided.^[77]^[78] Currently practiced measures to prevent cardiovascular disease include:

Tobacco cessation and avoidance of second-hand smoke.^[79] Smoking cessation reduces risk by about 35%.^[80]
A low-fat, low-sugar, high-fiber diet including whole grains and fruit and vegetables.^[79]^[81]^[82] Dietary interventions are effective in reducing cardiovascular risk factors over a year, but the longer term effects of such interventions and their impact on cardiovascular disease events is uncertain.^[83]
At least 150 minutes (2 hours and 30 minutes) of moderate exercise per week.^[84]^[85] Exercise-based cardiac rehabilitation reduces risk of subsequent cardiovascular events by 26%,^[86] but there have been few high quality studies of the benefits of exercise training in people with increased cardiovascular risk but no history of cardiovascular disease.^[87]
Limit alcohol consumption to the recommended daily limits;^[79] People who moderately consume alcoholic drinks have a 25–30% lower risk of cardiovascular disease.^[88]^[89] However, people who are genetically predisposed to consume less alcohol have lower rates of cardiovascular disease^[90] suggesting that alcohol itself may not be protective. Excessive alcohol intake increases the risk of cardiovascular disease^[91]^[89] and consumption of alcohol is associated with increased risk of a cardiovascular event in the day following consumption.^[89]
Lower blood pressure, if elevated. A 10 mmHg reduction in blood pressure reduces risk by about 20%.^[92]
Decrease non-HDL cholesterol.^[93]^[94] Statin treament reduces cardiovascular mortality by about 31%.^[95]
Decrease body fat if overweight or obese.^[96] The effect of weight loss is often difficult to distinguish from dietary change, and evidence on weight reducing diets is limited.^[97] In observational studies of people with severe obesity, weight loss following bariatric surgery is associated with a 46% reduction in cardiovascular risk.^[98]
Decrease psychosocial stress.^[99] This measure may be complicated by imprecise definitions of what constitute psychosocial interventions.^[100] Mental stress–induced myocardial ischemia is associated with an increased risk of heart problems in those with previous heart disease.^[101] Severe emotional and physical stress leads to a form of heart dysfunction known as Takotsubo syndrome in some people.^[102] Stress, however, plays a relatively minor role in hypertension.^[103] Specific relaxation therapies are of unclear benefit.^[104]^[105]

Most guidelines recommend combining preventive strategies. A 2015 Cochrane Review found some evidence that interventions aiming to reduce more than one cardiovascular risk factor may have favourable effects on blood pressure, body mass index and waist circumference; however, evidence was limited and the authors were unable to draw firm conclusions on the effects on cardiovascular events and mortality.^[106] For adults without a known diagnosis of hypertension, diabetes, hyperlipidemia, or cardiovascular disease, routine counseling to advise them to improve their diet and increase their physical activity has not been found to significantly alter behavior, and thus is not recommended.^[107] Another Cochrane review suggested that simply providing people with a cardiovascular disease risk score may reduce cardiovascular disease risk factors by a small amount compared to usual care.^[108] However, there was some uncertainty as to whether providing these scores had any effect on cardiovascular disease events. It is unclear whether or not dental care in those with periodontitis affects their risk of cardiovascular disease.^[109]

Diet

A diet high in fruits and vegetables decreases the risk of cardiovascular disease and death.^[110] Evidence suggests that the Mediterranean diet may improve cardiovascular outcomes.^[111] There is also evidence that a Mediterranean diet may be more effective than a low-fat diet in bringing about long-term changes to cardiovascular risk factors (e.g., lower cholesterol level and blood pressure).^[112] The DASH diet (high in nuts, fish, fruits and vegetables, and low in sweets, red meat and fat) has been shown to reduce blood pressure,^[113] lower total and low density lipoprotein cholesterol^[114] and improve metabolic syndrome;^[115] but the long-term benefits outside the context of a clinical trial have been questioned.^[116] A high fiber diet appears to lower the risk.^[117]

Total fat intake does not appear to be an important risk factor.^[118]^[119] A diet high in trans fatty acids, however, does increase rates of cardiovascular disease.^[119]^[120] Worldwide, dietary guidelines recommend a reduction in saturated fat.^[121] However, there are some questions around the effect of saturated fat on cardiovascular disease in the medical literature.^[120]^[122] Reviews from 2014 and 2015 did not find evidence of harm from saturated fats.^[120]^[122] A 2012 Cochrane review found suggestive evidence of a small benefit from replacing dietary saturated fat by unsaturated fat.^[123] A 2013 meta analysis concludes that substitution with omega 6 linoleic acid (a type of unsaturated fat) may increase cardiovascular risk.^[121] Replacement of saturated fats with carbohydrates does not change or may increase risk.^[124]^[125] Benefits from replacement with polyunsaturated fat appears greatest;^[119]^[126] however, supplementation with omega-3 fatty acids (a type of polysaturated fat) does not appear to have an effect.^[127]

The effect of a low-salt diet is unclear. A Cochrane review concluded that any benefit in people with high or normal blood pressure is small if present.^[128] In addition, the review suggested that a low-salt diet may be harmful in those with congestive heart failure.^[128] However, the review was criticized in particular for not excluding a trial in heart failure where people had low-salt and -water levels due to diuretics.^[129] When this study is left out, the rest of the trials show a trend to benefit.^[129]^[130] Another review of dietary salt concluded that there is strong evidence that high dietary salt intake increases blood pressure and worsens hypertension, and that it increases the number of cardiovascular disease events; both as a result of the increased blood pressure and, quite likely, through other mechanisms.^[131]^[132] Moderate evidence was found that high salt intake increases cardiovascular mortality; and some evidence was found for an increase in overall mortality, strokes, and left ventricular hypertrophy.^[131]

Medication

Blood pressure medication reduces cardiovascular disease in people at risk,^[92] irrespective of age,^[133] the baseline level of cardiovascular risk,^[134] or baseline blood pressure.^[135] The commonly-used drug regimens have similar efficacy in reducing the risk of all major cardiovascular events, although there may be differences between drugs in their ability to prevent specific outcomes.^[136] Larger reductions in blood pressure produce larger reductions in risk,^[136] and most people with high blood pressure require more than one drug to achieve adequate reduction in blood pressure.^[137]

Statins are effective in preventing further cardiovascular disease in people with a history of cardiovascular disease.^[138] As the event rate is higher in men than in women, the decrease in events is more easily seen in men than women.^[138] In those at risk, but without a history of cardiovascular disease (primary prevention), statins decrease the risk of death and combined fatal and non-fatal cardiovascular disease.^[139] A United States guideline recommends statins in those who have a 12% or greater risk of cardiovascular disease over the next ten years.^[140] Niacin, fibrates and CETP Inhibitors, while they may increase HDL cholesterol do not affect the risk of cardiovascular disease in those who are already on statins.^[141]

Anti-diabetic medication may reduce cardiovascular risk in people with Type 2 Diabetes, although evidence is not conclusive.^[142] A meta-analysis in 2009 including 27,049 participants and 2,370 major vascular events showed a 15% relative risk reduction in cardiovascular disease with more-intensive glucose lowering over an average follow-up period of 4.4 years, but an increased risk of major hypoglycemia.^[143]

Aspirin has been found to be of only modest benefit in those at low risk of heart disease as the risk of serious bleeding is almost equal to the benefit with respect to cardiovascular problems.^[144] In those at very low risk it is not recommended.^[145] The United States Preventive Services Task Force recommends against use of aspirin for prevention in women less than 55 and men less than 45 years old; however, in those who are older it is recommends in some individuals.^[146]

The use of vasoactive agents for people with pulmonary hypertension with left heart disease or hypoxemic lung diseases may cause harm and unnecessary expense.^[147]

Physical activity

A systematic review estimated that inactivity is responsible for 6% of the burden of disease from coronary heart disease worldwide.^[148] The authors estimated that 121,000 deaths from coronary heart disease could have been averted in Europe in 2008, if physical inactivity had been removed. A Cochrane review found some evidence that yoga has favourable effects on blood pressure and cholesterol, but studies included in this review were of low quality.^[149]

Dietary supplements

While a healthy diet is beneficial, the effect of antioxidant supplementation (vitamin E, vitamin C, etc.) or vitamins has not been shown to protect against cardiovascular disease and in some cases may possibly result in harm.^[150]^[151] Mineral supplements have also not been found to be useful.^[152] Niacin, a type of vitamin B3, may be an exception with a modest decrease in the risk of cardiovascular events in those at high risk.^[153]^[154] Magnesium supplementation lowers high blood pressure in a dose dependent manner.^[155] Magnesium therapy is recommended for people with ventricular arrhythmia associated with torsades de pointes who present with long QT syndrome as well as for the treatment of people with digoxin intoxication-induced arrhythmias.^[156] There is no evidence to support omega-3 fatty acid supplementation.^[157]

Management

Cardiovascular disease is treatable with initial treatment primarily focused on diet and lifestyle interventions.^[1] Influenza may make heart attacks and strokes more likely and therefore influenza vaccination may decrease the chance of cardiovascular events and death in people with heart disease.^[158]

Proper CVD management necessitates a focus on MI and stroke cases due to their combined high mortality rate, keeping in mind the cost-effectiveness of any intervention, especially in developing countries with low or middle income levels.^[75] Regarding MI, strategies using aspirin, atenolol, streptokinase or tissue plasminogen activator have been compared for quality-adjusted life-year (QALY) in regions of low and middle income. The costs for a single QALY for aspirin, atenolol, streptokinase, and t-PA were $25, $630–$730, and $16,000, respectively. Aspirin, ACE inhibitors, beta blockers, and statins used together for secondary CVD prevention in the same regions showed single QALY costs of $300–400.

Epidemiology

File:Cardiovascular diseases world map-Deaths per million persons-WHO2012.svg

Cardiovascular diseases deaths per million persons in 2012

318–925

926–1,148

1,149–1,294

1,295–1,449

1,450–1,802

1,803–2,098

2,099–2,624

2,625–3,203

3,204–5,271

5,272–10233

File:Cardiovascular diseases world map - DALY - WHO2004.svg

Disability-adjusted life year for cardiovascular diseases per 100,000 inhabitants in 2004^[12]

no data

<900

900–1650

1650–2300

2300–3000

3000–3700

3700–4400

4400–5100

5100–5800

5800–6500

6500–7200

7200–7900

>7900

Cardiovascular diseases are the leading cause of death worldwide and in all regions except Africa.^[159] In 2008, 30% of all global death was attributed to cardiovascular diseases. Death caused by cardiovascular diseases are also higher in low- and middle-income countries as over 80% of all global deaths caused by cardiovascular diseases occurred in those countries. It is also estimated that by 2030, over 23 million people will die from cardiovascular diseases each year.

It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the Indian Heart Association are working with the World Heart Federation to raise awareness about this issue.^[160]

Research

There is evidence that cardiovascular disease existed in pre-history,^[161] and research into cardiovascular disease dates from at least the 18th century.^[162] The causes, prevention, and/or treatment of all forms of cardiovascular disease remain active fields of biomedical research, with hundreds of scientific studies being published on a weekly basis.

Recent areas of research include the link between inflammation and atherosclerosis^[163] the potential for novel therapeutic interventions,^[164] and the genetics of coronary heart disease.^[165]

References

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External links

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European Guidelines on cardiovascular disease prevention in clinical practice (version 2012)
Heart Disease MedicineNet Slides, photos, descriptions

Template:Vascular diseases Template:Certain conditions originating in the perinatal period

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v t e Symptoms and signs: circulatory (R00–R03, 785)
Cardiovascular	Template:Navbox subgroup
Myeloid/blood	Template:Navbox subgroup

v t e Eponymous medical signs for circulatory system
Heart disease	Template:Navbox subgroup
Vascular disease	Template:Navbox subgroup
Template:Navbox with columns Template:Navbox with columns

@@ Line 1: / Line 1: @@
 __NOTOC__
-{{Infobox_Disease |
+{{SI}}
-  Name           = {{PAGENAME}} |
+{{CMG}}
-  Image          = |
-  Caption        = |
+== Overview ==
-  DiseasesDB     = 28808 |
+<!-- Definition and symptoms -->
-  ICD10          = {{ICD10|I|51|6|i|30}} |
+'''Cardiovascular disease''' ('''CVD''') is a class of diseases that involve the [[heart]] or [[blood vessel]]s.<ref name="WHO2011">{{cite book|author1=Shanthi Mendis|author2=Pekka Puska|author3=Bo Norrving|author4=World Health Organization|title=Global Atlas on Cardiovascular Disease Prevention and Control|url=http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf?ua=1|year=2011|publisher=World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization|pages=3–18|isbn=978-92-4-156437-3|deadurl=no|archiveurl=https://web.archive.org/web/20140817123106/http://whqlibdoc.who.int/publications/2011/9789241564373_eng.pdf?ua=1|archivedate=2014-08-17|df=}}</ref> Cardiovascular disease includes [[coronary artery disease]]s (CAD) such as [[angina pectoris|angina]] and [[myocardial infarction]] (commonly known as a heart attack).<ref name=WHO2011/> Other CVDs include [[stroke]], [[heart failure]], [[hypertensive heart disease]], [[rheumatic heart disease]], [[cardiomyopathy]], [[heart arrhythmia]], [[congenital heart disease]], [[valvular heart disease]], [[carditis]], [[aortic aneurysm]]s, [[peripheral artery disease]], [[Thrombosis|thromboembolic disease]], and [[venous thrombosis]].<ref name=WHO2011/><ref name=GDB2013/>
-  ICD9           = {{ICD9|429.2}} |
-  ICDO           = |
+<!-- Types -->
-  OMIM           = |
+The underlying mechanisms vary depending on the disease in question.<ref name=WHO2011/> Coronary artery disease, stroke, and peripheral artery disease involve [[atherosclerosis]].<ref name=WHO2011/> This may be caused by [[hypertension|high blood pressure]], [[tobacco smoking|smoking]], [[diabetes mellitus|diabetes]], lack of [[physical exercise|exercise]], [[obesity]], [[hypercholesterolaemia|high blood cholesterol]], poor diet, and excessive [[alcoholic beverage|alcohol]] consumption, among others.<ref name=WHO2011/> High blood pressure results in 13% of CVD deaths, while tobacco results in 9%, diabetes 6%, lack of exercise 6% and obesity 5%.<ref name=WHO2011/> Rheumatic heart disease may follow untreated [[streptococcal pharyngitis|strep throat]].<ref name=WHO2011/>
-  MedlinePlus    = |
-  MeshID         = D002318 |
+<!-- Prevention and treatment -->
-}}
+It is estimated that 90% of CVD is preventable.<ref name=McGill2008>{{cite journal |vauthors=McGill HC, McMahan CA, Gidding SS |title=Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study |journal=Circulation |volume=117 |issue=9 |pages=1216–27 |date=March 2008 |pmid=18316498 |doi=10.1161/CIRCULATIONAHA.107.717033 |url=}}</ref> Prevention of atherosclerosis involves improving risk factors through: [[healthy eating]], exercise, avoidance of tobacco smoke and limiting alcohol intake.<ref name=WHO2011/> Treating risk factors, such as high blood pressure, blood lipids and diabetes is also beneficial.<ref name=WHO2011/> Treating people who have strep throat with [[antibiotic]]s can decrease the risk of rheumatic heart disease.<ref>{{cite journal|last1=Spinks|first1=A|last2=Glasziou|first2=PP|last3=Del Mar|first3=CB|title=Antibiotics for sore throat.|journal=The Cochrane Database of Systematic Reviews|date=5 November 2013|volume=11|pages=CD000023|pmid=24190439|doi=10.1002/14651858.CD000023.pub4}}</ref> The effect of the use of [[aspirin]] in people who are otherwise healthy is of unclear benefit.<ref>{{cite journal|last1=Sutcliffe|first1=P|last2=Connock|first2=M|last3=Gurung|first3=T|last4=Freeman|first4=K|last5=Johnson|first5=S|last6=Ngianga-Bakwin|first6=K|last7=Grove|first7=A|last8=Gurung|first8=B|last9=Morrow|first9=S|last10=Stranges|first10=S|last11=Clarke|first11=A|title=Aspirin in primary prevention of cardiovascular disease and cancer: a systematic review of the balance of evidence from reviews of randomized trials.|journal=PLOS ONE|date=2013|volume=8|issue=12|pages=e81970|pmid=24339983|doi=10.1371/journal.pone.0081970|pmc=3855368}}</ref><ref>{{cite journal|last1=Sutcliffe|first1=P|last2=Connock|first2=M|last3=Gurung|first3=T|last4=Freeman|first4=K|last5=Johnson|first5=S|last6=Kandala|first6=NB|last7=Grove|first7=A|last8=Gurung|first8=B|last9=Morrow|first9=S|last10=Clarke|first10=A|title=Aspirin for prophylactic use in the primary prevention of cardiovascular disease and cancer: a systematic review and overview of reviews.|journal=Health Technology Assessment |date=September 2013|volume=17|issue=43|pages=1–253|pmid=24074752|doi=10.3310/hta17430|pmc=4781046}}</ref>
+<!-- Epidemiology -->
+Cardiovascular diseases are the leading cause of death globally.<ref name=WHO2011/> This is true in all areas of the world except Africa.<ref name=WHO2011/> Together they resulted in 17.9 million deaths (32.1%) in 2015, up from 12.3 million (25.8%) in 1990.<ref name=GBD2015De/><ref name=GDB2013>{{cite journal|last1=GBD 2013 Mortality and Causes of Death|first1=Collaborators|title=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.|journal=Lancet|date=17 December 2014|pmid=25530442|doi=10.1016/S0140-6736(14)61682-2|volume=385|issue=9963|pages=117–71|pmc=4340604}}</ref> [[Age standardized deaths|Deaths, at a given age]], from CVD are more common and have been increasing in much of the [[developing world]], while rates have declined in most of the [[developed world]] since the 1970s.<ref name=IOM2010>{{cite book|title=Promoting cardiovascular health in the developing world : a critical challenge to achieve global health|year=2010|publisher=National Academies Press|location=Washington, D.C.|isbn=978-0-309-14774-3|pages=Chapter 2|url=https://www.ncbi.nlm.nih.gov/books/NBK45688/|author=Fuster, Board on Global Health|author2=Valentin|author3=Academies, Bridget B. Kelly|editors=Institute of Medicine of the National|deadurl=no|archiveurl=https://web.archive.org/web/20170908144309/https://www.ncbi.nlm.nih.gov/books/NBK45688/|archivedate=2017-09-08|df=}}</ref><ref>{{cite journal|last1=Moran|first1=AE|last2=Forouzanfar|first2=MH|last3=Roth|first3=GA|last4=Mensah|first4=GA|last5=Ezzati|first5=M|last6=Murray|first6=CJ|last7=Naghavi|first7=M|title=Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the Global Burden of Disease 2010 study.|journal=Circulation|date=8 April 2014|volume=129|issue=14|pages=1483–92|pmid=24573352|doi=10.1161/circulationaha.113.004042|pmc=4181359}}</ref> Coronary artery disease and stroke account for 80% of CVD deaths in males and 75% of CVD deaths in females.<ref name=WHO2011/> Most cardiovascular disease affects older adults. In the United States 11% of people between 20 and 40 have CVD, while 37% between 40 and 60, 71% of people between 60 and 80, and 85% of people over 80 have CVD.<ref name=Go2013>{{cite journal|last1=Go|first1=AS|last2=Mozaffarian|first2=D|last3=Roger|first3=VL|last4=Benjamin|first4=EJ|last5=Berry|first5=JD|last6=Borden|first6=WB|last7=Bravata|first7=DM|last8=Dai|first8=S|last9=Ford|first9=ES|last10=Fox|first10=CS|last11=Franco|first11=S|last12=Fullerton|first12=HJ|last13=Gillespie|first13=C|last14=Hailpern|first14=SM|last15=Heit|first15=JA|last16=Howard|first16=VJ|last17=Huffman|first17=MD|last18=Kissela|first18=BM|last19=Kittner|first19=SJ|last20=Lackland|first20=DT|last21=Lichtman|first21=JH|last22=Lisabeth|first22=LD|last23=Magid|first23=D|last24=Marcus|first24=GM|last25=Marelli|first25=A|last26=Matchar|first26=DB|last27=McGuire|first27=DK|last28=Mohler|first28=ER|last29=Moy|first29=CS|last30=Mussolino|first30=ME|last31=Nichol|first31=G|last32=Paynter|first32=NP|last33=Schreiner|first33=PJ|last34=Sorlie|first34=PD|last35=Stein|first35=J|last36=Turan|first36=TN|last37=Virani|first37=SS|last38=Wong|first38=ND|last39=Woo|first39=D|last40=Turner|first40=MB|last41=American Heart Association Statistics Committee and Stroke Statistics|first41=Subcommittee|title=Heart disease and stroke statistics--2013 update: a report from the American Heart Association.|journal=Circulation|date=1 January 2013|volume=127|issue=1|pages=e6-e245|pmid=23239837|doi=10.1161/cir.0b013e31828124ad}}</ref> The average age of death from coronary artery disease in the developed world is around 80 while it is around 68 in the developing world.<ref name=IOM2010/> Disease onset is typically seven to ten years earlier in men as compared to women.<ref name=WHO2011pg48>{{cite book|last1=Mendis|first1=Shanthi|last2=Puska,|first2=Pekka|last3=Norrving|first3=Bo|title=Global atlas on cardiovascular disease prevention and control|date=2011|publisher=World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization|location=Geneva|isbn=9789241564373|pages=48|edition=1}}</ref>
+==Types==
+[[File:Inflammatory heart diseases world map - DALY - WHO2004.svg|thumb|[[Disability-adjusted life year]] for inflammatory heart diseases per 100,000&nbsp;inhabitants in 2004<ref name="World Health Organization">{{cite web |url=http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html |title=WHO Disease and injury country estimates |year=2009 |work=World Health Organization |accessdate=Nov 11, 2009 |deadurl=no |archiveurl=https://web.archive.org/web/20091111101009/http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html |archivedate=2009-11-11 |df= }}</ref>{{refbegin|2}}
+{{legend|#b3b3b3|no data}}
+{{legend|#ffff65|less than 70}}
+{{legend|#fff200|70–140}}
+{{legend|#ffdc00|140–210}}
+{{legend|#ffc600|210–280}}
+{{legend|#ffb000|280–350}}
+{{legend|#ff9a00|350–420}}
+{{legend|#ff8400|420–490}}
+{{legend|#ff6e00|490–560}}
+{{legend|#ff5800|560–630}}
+{{legend|#ff4200|630–700}}
+{{legend|#ff2c00|700–770}}
+{{legend|#cb0000|more than 770}}
+{{refend}}]]
+There are many cardiovascular diseases involving the blood vessels. They are known as [[vascular disease]]s.
+*[[Coronary artery disease]] (also known as coronary heart disease and ischemic heart disease)
+*[[Peripheral arterial disease]] – disease of blood vessels that supply blood to the arms and legs
+*[[Cerebrovascular disease]] – disease of blood vessels that supply blood to the brain (includes [[stroke]])
+*[[Renal artery stenosis]]
+*[[Aortic aneurysm]]
+There are also many cardiovascular diseases that involve the heart.
+*[[Cardiomyopathy]] – diseases of cardiac muscle
+*[[Hypertensive heart disease]] – diseases of the heart secondary to high [[blood pressure]] or [[hypertension]]
+* [[Heart failure]] - a clinical syndrome caused by the inability of the heart to supply sufficient blood to the tissues to meet their metabolic requirements
+* [[Pulmonary heart disease]] – a failure at the right side of the heart with respiratory system involvement
+* [[Cardiac dysrhythmias]] – abnormalities of heart rhythm
+*Inflammatory heart disease
+** [[Endocarditis]] – [[inflammation]] of the inner layer of the heart, the [[endocardium]]. The structures most commonly involved are the [[heart valve]]s.
+** Inflammatory [[cardiomegaly]]
+** [[Myocarditis]] – inflammation of the [[myocardium]], the muscular part of the heart.
+*[[Valvular heart disease]]
+*[[Congenital heart disease]] – heart structure malformations existing at birth
+*[[Rheumatic heart disease]] – heart muscles and valves damage due to [[rheumatic fever]] caused by  ''[[Streptococcus pyogenes]]'' a [[group A streptococcal infection]].
+==Risk factors==
+There are many risk factors for heart diseases: age, gender, tobacco use, physical inactivity, excessive [[alcohol]] consumption, unhealthy diet, obesity, genetic predisposition and family history of cardiovascular disease, raised blood pressure ([[hypertension]]), raised blood sugar ([[diabetes mellitus]]), raised blood cholesterol ([[hyperlipidemia]]), psychosocial factors, poverty and low educational status, and [[air pollution]].<ref name = Fuster>{{cite book |author=Bridget B. Kelly |author2=Institute of Medicine |author3=Fuster, Valentin |title=Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health |publisher=National Academies Press |location=Washington, D.C |year=2010 |pages= |isbn=0-309-14774-3 |oclc= |doi= }}</ref><ref>{{cite journal|last=Finks|first=SW|author2=Airee, A |author3=Chow, SL |author4=Macaulay, TE |author5=Moranville, MP |author6=Rogers, KC |author7= Trujillo, TC |title=Key articles of dietary interventions that influence cardiovascular mortality.|journal=Pharmacotherapy|date=April 2012|volume=32|issue=4|pages=e54-87|pmid=22392596|doi=10.1002/j.1875-9114.2011.01087.x}}</ref><ref>{{cite journal|last1=Micha|first1=R|last2=Michas|first2=G|last3=Mozaffarian|first3=D|title=Unprocessed red and processed meats and risk of coronary artery disease and type 2 diabetes—an updated review of the evidence.|journal=Current Atherosclerosis Reports|date=Dec 2012|volume=14|issue=6|pages=515–24|pmid=23001745|doi=10.1007/s11883-012-0282-8|pmc=3483430}}</ref><ref name="MendisPuska2011">{{cite book|author1=Shanthi Mendis|author2=Pekka Puska|author3=Bo Norrving|title=Global Atlas on Cardiovascular Disease Prevention and Control|url=https://books.google.com/books?id=ZRbKygAACAAJ|year=2011|publisher=World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization|isbn=978-92-4-156437-3|deadurl=no|archiveurl=https://web.archive.org/web/20160506235630/https://books.google.com/books?id=ZRbKygAACAAJ|archivedate=2016-05-06|df=}}</ref> While the individual contribution of each risk factor varies between different communities or ethnic groups the overall contribution of these risk factors is very consistent.<ref name = interheart>{{cite journal |vauthors=Yusuf S, Hawken S, Ounpuu S |title=Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study |journal=Lancet |volume=364 |issue=9438 |pages=937–52 |year=2004 |pmid=15364185 |doi=10.1016/S0140-6736(04)17018-9 |url=|display-authors=etal}}</ref> Some of these risk factors, such as age, gender or family history/genetic predisposition, are immutable; however, many important cardiovascular risk factors are modifiable by lifestyle change, social change, drug treatment (for example prevention of hypertension, hyperlipidemia, and diabetes).<ref name = McPhee2012>{{cite book | last = McPhee | first = Stephen | title = Current medical diagnosis & treatment 2012 | publisher = McGraw-Hill Medical | location = New York | year = 2012 | isbn = 9780071763721 | page = 430 }}</ref> People with obesity are at increased risk of [[atherosclerosis]] of the [[coronary arteries]].<ref>{{Cite web|url=http://circ.ahajournals.org/content/96/9/3248|title=Obesity and Heart Disease:  A Statement for Healthcare Professionals From the Nutrition Committee, American Heart Association|last=Eckel|first=Robert H.|date=November 4, 1997|website=ahajournals.org|archive-url=https://web.archive.org/web/20170701095943/http://circ.ahajournals.org/content/96/9/3248|archive-date=2017-07-01|dead-url=no|access-date=|df=}}</ref>
+===Genetics===
+Genetic factors influence the development of cardiovascular disease in men who are less than 55 years-old and in women who are less than 65 years old.<ref name = McPhee2012/> Cardiovascular disease in a person's parents increases their risk by 3 fold.<ref>{{cite journal|last1=Kathiresan|first1=S|last2=Srivastava|first2=D|title=Genetics of human cardiovascular disease.|journal=Cell|date=16 March 2012|volume=148|issue=6|pages=1242–57|pmid=22424232|doi=10.1016/j.cell.2012.03.001|pmc=3319439}}</ref> Multiple [[Single-nucleotide polymorphism|single nucleotide polymorphisms]] (SNP) have been found to be associated with cardiovascular disease in genetic association studies,<ref>{{Cite journal|last=Nikpay|first=Majid|last2=Goel|first2=Anuj|last3=Won|first3=Hong-Hee|last4=Hall|first4=Leanne M|last5=Willenborg|first5=Christina|last6=Kanoni|first6=Stavroula|last7=Saleheen|first7=Danish|last8=Kyriakou|first8=Theodosios|last9=Nelson|first9=Christopher P|title=A comprehensive 1000 Genomes–based genome-wide association meta-analysis of coronary artery disease|url=http://www.nature.com/doifinder/10.1038/ng.3396|journal=Nature Genetics|volume=47|issue=10|pages=1121–1130|doi=10.1038/ng.3396|pmc=4589895|pmid=26343387}}</ref><ref name="MacRae 2634–2639">{{Cite journal|last=MacRae|first=Calum A.|last2=Vasan|first2=Ramachandran S.|date=2016-06-21|title=The Future of Genetics and Genomics: Closing the Phenotype Gap in Precision Medicine|journal=Circulation|volume=133|issue=25|pages=2634–2639|doi=10.1161/CIRCULATIONAHA.116.022547|issn=1524-4539|pmid=27324359}}</ref> but usually their individual influence is small, and genetic contributions to cardiovascular disease are poorly understood.<ref name="MacRae 2634–2639"/>
+===Age===
+[[File: Calcified Heart.jpg|thumb|Calcified heart of an older woman with cardiomegaly]]
+Age is by far the most important risk factor in developing cardiovascular or heart diseases, with approximately a tripling of risk with each decade of life.<ref name=Finegold>{{cite journal|last=Finegold|first=JA|author2=Asaria, P |author3=Francis, DP |title=Mortality from ischaemic heart disease by country, region, and age: Statistics from World Health Organisation and United Nations.|journal=International Journal of Cardiology|date=Dec 4, 2012|pmid=23218570|doi=10.1016/j.ijcard.2012.10.046|volume=168|issue=2|pages=934–945|pmc=3819990}}</ref>  Coronary fatty streaks can begin to form in adolescence.<ref>{{cite journal|last1=D'Adamo|first1=E|last2=Guardamagna|first2=O|last3=Chiarelli|first3=F|last4=Bartuli|first4=A|last5=Liccardo|first5=D|last6=Ferrari|first6=F|last7=Nobili|first7=V|title=Atherogenic dyslipidemia and cardiovascular risk factors in obese children.|journal=International Journal of Endocrinology|date=2015|volume=2015|pages=912047|pmid=25663838|doi=10.1155/2015/912047|pmc=4309297}}</ref> It is estimated that 82 percent of people who die of coronary heart disease are 65 and older.<ref>"Understand Your Risk of Heart Attack". American Heart Association.http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp#</ref> At the same time, the risk of stroke doubles every decade after age 55.<ref>Mackay, Mensah, Mendis, et al. The Atlas of Heart Disease and Stroke. World Health Organization. January 2004.</ref>
+Multiple explanations have been proposed to explain why age increases the risk of cardiovascular/heart diseases. One of them is related to serum cholesterol level.<ref name=Jou99>{{cite journal |author1=Jousilahti Vartiainen |author2=Tuomilehto Puska | year = 1999 | title = Sex, Age, Cardiovascular Risk Factors, and coronary heart disease | url = | journal = Circulation | volume = 99 | issue = 9| pages = 1165–1172 | doi=10.1161/01.cir.99.9.1165}}</ref> In most populations, the serum total cholesterol level increases as age increases. In men, this increase levels off around age 45 to 50 years. In women, the increase continues sharply until age 60 to 65 years.<ref name=Jou99/>
+Aging is also associated with changes in the mechanical and structural properties of the vascular wall, which leads to the loss of arterial elasticity and reduced arterial compliance and may subsequently lead to coronary artery disease.<ref name="autogenerated357">{{cite journal |vauthors=Jani B, Rajkumar C | year = 2006 | title = Ageing and vascular ageing | url = | journal = Postgrad Med J | volume = 82 | issue = 968| pages = 357–362 | doi=10.1136/pgmj.2005.036053}}</ref>
+===Sex===
+Men are at greater risk of heart disease than pre-menopausal women.<ref name=Finegold/><ref name=WHF>{{cite web |url=http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors |title=Archived copy |accessdate=2012-05-03 |deadurl=no |archiveurl=https://web.archive.org/web/20120510135600/http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/ |archivedate=2012-05-10 |df= }}</ref> Once past [[menopause]], it has been argued that a woman's risk is similar to a man's<ref name=WHF/> although more recent data from the WHO and UN disputes this.<ref name=Finegold/> If a female has diabetes, she is more likely to develop heart disease than a male with diabetes.<ref>{{cite web|url=http://www.npr.org/blogs/health/2014/05/22/314869923/diabetes-raises-womens-risk-of-heart-disease-more-than-for-men|title=Diabetes raises women's risk of heart disease more than for men|work=NPR.org|date=May 22, 2014|accessdate=May 23, 2014|deadurl=no|archiveurl=https://web.archive.org/web/20140523093525/http://www.npr.org/blogs/health/2014/05/22/314869923/diabetes-raises-womens-risk-of-heart-disease-more-than-for-men|archivedate=May 23, 2014|df=}}</ref>
+Coronary heart diseases are 2 to 5 times more common among middle-aged men than women.<ref name=Jou99/>  In a study done by the [[World Health Organization]], sex contributes to approximately 40% of the variation in sex ratios of coronary heart disease mortality.<ref>Jackson R, Chambles L, Higgins M, Kuulasmaa K, Wijnberg L, Williams D (WHO MONICA Project, and ARIC Study.) Sex difference in ischaemic heart disease mortality and risk factors in 46 communities:  an ecologic analysis. Cardiovasc Risk Factors. 1999; 7:43–54.</ref> Another study reports similar results finding that gender differences explain nearly half the risk associated with cardiovascular diseases<ref name=Jou99/> One of the proposed explanations for gender differences in cardiovascular diseases is hormonal difference.<ref name=Jou99/>  Among women, estrogen is the predominant sex hormone. [[Estrogen]] may have protective effects on glucose metabolism and hemostatic system, and may have a direct effect in improving [[endothelial]] cell function.<ref name=Jou99/>  The production of estrogen decreases after menopause, and this may change the female lipid metabolism toward a more atherogenic form by decreasing the [[High-density lipoprotein|HDL]] cholesterol level while increasing LDL and total cholesterol levels.<ref name=Jou99/>
+Among men and women, there are notable differences in body weight, height, body fat distribution, heart rate, stroke volume, and arterial compliance.<ref name="autogenerated357"/> In the very elderly, age-related large artery pulsatility and stiffness is more pronounced among women than men.<ref name="autogenerated357"/> This may be caused by the women's smaller body size and arterial dimensions which are independent of menopause.<ref name="autogenerated357"/>
+There are data suggesting that [[female]] [[patients]] are less likely to receive [[treatment]] based on guidelines while they are [[hospital|hospitalized]] when compared to [[male]] [[patients]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+One study demonstrated that [[female]] [[patients]] are less likely to receive [[treatments]] such as [[cardiac catheterization]] when compared to [[male]] [[patients]] with an exact clinical vignette.<ref name="pmid10029647">{{cite journal| author=Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ | display-authors=etal| title=The effect of race and sex on physicians' recommendations for cardiac catheterization. | journal=N Engl J Med | year= 1999 | volume= 340 | issue= 8 | pages= 618-26 | pmid=10029647 | doi=10.1056/NEJM199902253400806 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10029647  }} </ref><ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+===Racial and Ethnic Groups===
+*A higher [[prevalence]] of [[cardiovascular disease]] and related [[mortality rate|mortality]] have been reported in the following racial and [[Ethnic group|ethnic groups]]:<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+**[[African people|African-Amrican]]
+**Hispanics
+**South Asians
+*[[Health disparities|Access to care]] is one of the known [[Risk factor|factors]] that affect certain populations such as racial and [[ethnic groups]] and results in worse outcome.<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*Studies show that even after considering the [[Health disparities|access to care]], there are other [[health disparities]] that can be the reason for the higher rate of [[cardiovascular disease]] among racial and [[Ethnic group|ethnic groups]]. There are data suggesting that black [[patients]] are less likely to receive [[treatment]] based on guidelines while they are [[hospital|hospitalized]] when compared to white [[patients]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*One study demonstrated that non-white [[patients]] are less likely to receive [[treatments]] such as [[cardiac catheterization]] when compared to white [[patients]] with an exact clinical vignette.<ref name="pmid10029647">{{cite journal| author=Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ | display-authors=etal| title=The effect of race and sex on physicians' recommendations for cardiac catheterization. | journal=N Engl J Med | year= 1999 | volume= 340 | issue= 8 | pages= 618-26 | pmid=10029647 | doi=10.1056/NEJM199902253400806 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10029647  }} </ref><ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+===Tobacco===
+Cigarettes are the major form of smoked tobacco.<ref name="WHO2011" /> Risks to health from tobacco use result not only from direct consumption of tobacco, but also from exposure to second-hand smoke.<ref name="WHO2011" /> Approximately 10% of cardiovascular disease is attributed to smoking;<ref name="WHO2011" /> however, people who quit smoking by age 30 have almost as low a risk of death as never smokers.<ref>{{Cite journal | author = [[Richard Doll]] |author2=[[Richard Peto]] |author3=Jillian Boreham |author4= Isabelle Sutherland |last-author-amp=yes | title = Mortality in relation to smoking: 50 years' observations on male British doctors | journal = [[The BMJ|BMJ]] | volume = 328 | issue = 7455 | page = 1519 |date=June 2004  | doi = 10.1136/bmj.38142.554479.AE | pmid = 15213107 | pmc=437139}}</ref>
+===Physical inactivity===
+Insufficient physical activity (defined as less than 5 x 30 minutes of moderate activity per week, or less than 3 x 20 minutes of vigorous activity per week) is currently the fourth leading risk factor for mortality worldwide.<ref name="WHO2011" />  In 2008, 31.3% of adults aged 15 or older (28.2% men and 34.4% women) were insufficiently physically active.<ref name="WHO2011" />
+The risk of ischemic heart disease and diabetes mellitus is reduced by almost a third in adults who participate in 150 minutes of moderate physical activity each week (or equivalent).<ref name="OrganizationUNAIDS2007">{{cite book|author1=World Health Organization|author2=UNAIDS|title=Prevention of Cardiovascular Disease|url=https://books.google.com/books?id=AS2RmtQVuLwC&pg=PT3|date=1 January 2007|publisher=World Health Organization|isbn=978-92-4-154726-0|pages=3–|deadurl=no|archiveurl=https://web.archive.org/web/20160427013804/https://books.google.com/books?id=AS2RmtQVuLwC&pg=PT3|archivedate=27 April 2016|df=}}</ref> In addition, physical activity assists weight loss and improves blood glucose control, blood pressure, lipid profile and insulin sensitivity. These effects may, at least in part, explain its cardiovascular benefits.<ref name="WHO2011" />
+===Diet===
+High dietary intakes of saturated fat, trans-fats and salt, and low intake of fruits, vegetables and fish are linked to cardiovascular risk, although whether all these associations are a cause is disputed. The World Health Organization attributes approximately 1.7 million deaths worldwide to low fruit and vegetable consumption.<ref name="WHO2011" /> The amount of dietary salt consumed is also an important determinant of blood pressure levels and overall cardiovascular risk.<ref name="WHO2011" /> Frequent consumption of high-energy foods, such as processed foods that are high in fats and sugars, promotes obesity and may increase cardiovascular risk.<ref name="WHO2011" />  A Cochrane review found that replacing saturated fat with polyunsaturated fat (plant based oils) reduced cardiovascular disease risk. Cutting down on saturated fat reduced risk of cardiovascular disease by 17% including heart disease and stroke.<ref>{{Cite journal|last=Hooper|first=Lee|last2=Martin|first2=Nicole|last3=Abdelhamid|first3=Asmaa|last4=Davey Smith|first4=George|date=2015-06-10|title=Reduction in saturated fat intake for cardiovascular disease|journal=The Cochrane Database of Systematic Reviews|volume=6|pages=CD011737|doi=10.1002/14651858.CD011737|issn=1469-493X|pmid=26068959}}</ref> High [[trans-fat]] intake has adverse effects on blood lipids and circulating inflammatory markers,<ref name="BookerMann2008">{{cite journal|last1=Booker|first1=C.S.|last2=Mann|first2=J.I.|title=Trans fatty acids and cardiovascular health: Translation of the evidence base|journal=Nutrition, Metabolism and Cardiovascular Diseases|volume=18|issue=6|year=2008|pages=448–456|issn=0939-4753|doi=10.1016/j.numecd.2008.02.005}}</ref> and elimination of trans-fat from diets has been widely advocated.<ref name="RemigFranklin2010">{{cite journal|last1=Remig|first1=Valentina|last2=Franklin|first2=Barry|last3=Margolis|first3=Simeon|last4=Kostas|first4=Georgia|last5=Nece|first5=Theresa|last6=Street|first6=James C.|title=Trans Fats in America: A Review of Their Use, Consumption, Health Implications, and Regulation|journal=Journal of the American Dietetic Association|volume=110|issue=4|year=2010|pages=585–592|issn=0002-8223|doi=10.1016/j.jada.2009.12.024}}</ref>
+There is evidence that higher consumption of sugar is associated with higher blood pressure and unfavorable blood lipids,<ref name="Te MorengaHowatson2014">{{cite journal|last1=Te Morenga|first1=L. A.|last2=Howatson|first2=A. J.|last3=Jones|first3=R. M.|last4=Mann|first4=J.|title=Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids|journal=American Journal of Clinical Nutrition|volume=100|issue=1|year=2014|pages=65–79|issn=0002-9165|doi=10.3945/ajcn.113.081521|pmid=24808490}}</ref> and sugar intake also increases the risk of diabetes mellitus.<ref>"Wylie-Rosett2002"</ref> High consumption of processed meats is associated with an increased risk of cardiovascular disease, possibly in part due to increased dietary salt intake.<ref name="MichaMichas2012">{{cite journal|last1=Micha|first1=Renata|last2=Michas|first2=Georgios|last3=Mozaffarian|first3=Dariush|title=Unprocessed Red and Processed Meats and Risk of Coronary Artery Disease and Type 2 Diabetes – An Updated Review of the Evidence|journal=Current Atherosclerosis Reports|volume=14|issue=6|year=2012|pages=515–524|issn=1523-3804|doi=10.1007/s11883-012-0282-8|pmid=23001745|pmc=3483430}}</ref>
+The relationship between alcohol consumption and cardiovascular disease is complex, and may depend on the amount of alcohol consumed. There is a direct relationship between high levels of alcohol consumption and risk of cardiovascular disease.<ref name="WHO2011" />  Drinking at low levels without episodes of heavy drinking may be associated with a reduced risk of cardiovascular disease.<ref name="MukamalChen2010">{{cite journal|last1=Mukamal|first1=Kenneth J.|last2=Chen|first2=Chiung M.|last3=Rao|first3=Sowmya R.|last4=Breslow|first4=Rosalind A.|title=Alcohol Consumption and Cardiovascular Mortality Among U.S. Adults, 1987 to 2002|journal=Journal of the American College of Cardiology|volume=55|issue=13|year=2010|pages=1328–1335|issn=0735-1097|doi=10.1016/j.jacc.2009.10.056|pmid=20338493|pmc=3865979}}</ref>
+Overall alcohol consumption at the population level is associated with multiple health risks that exceed any potential benefits.<ref name="WHO2011" /><ref name="Organization2011">{{cite book|author=World Health Organization|title=Global Status Report on Alcohol and Health|url=https://books.google.com/books?id=ktyfuAAACAAJ|year=2011|publisher=World Health Organization|isbn=978-92-4-156415-1|deadurl=no|archiveurl=https://web.archive.org/web/20160507000025/https://books.google.com/books?id=ktyfuAAACAAJ|archivedate=2016-05-07|df=}}</ref>
+===Socioeconomic disadvantage===
+Cardiovascular disease affects low- and middle-income countries even more than high-income countries.<ref name = "Di Cesare 2013">{{Cite journal |author1=Mariachiara Di Cesare |author2=Young-Ho Khang |author3=Perviz Asaria |author4=Tony Blakely |author5=Melanie J. Cowan |author6=Farshad Farzadfar |author7=Ramiro Guerrero |author8=Nayu Ikeda |author9=Catherine Kyobutungi |author10=Kelias P. Msyamboza |author11=Sophal Oum |author12=John W. Lynch |author13=Michael G. Marmot |author14=Majid Ezzati | title = Inequalities in non-communicable diseases and effective responses | journal = [[The Lancet|Lancet]] | volume = 381 | issue = 9866 | pages = 585–597 |date=February 2013
+ | doi = 10.1016/S0140-6736(12)61851-0 | pmid = 23410608}}</ref> There is relatively little information regarding social patterns of cardiovascular disease within low- and middle-income countries,<ref name = "Di Cesare 2013"/> but within high-income countries low income and low educational status are consistently associated with greater risk of cardiovascular disease.<ref>{{Cite journal |author1=J. P. Mackenbach |author2=A. E. Cavelaars |author3=A. E. Kunst |author4=F. Groenhof | title = Socioeconomic inequalities in cardiovascular disease mortality; an international study | journal = European Heart Journal | volume = 21 | issue = 14 | pages = 1141–1151 |date=July 2000
+ | doi = 10.1053/euhj.1999.1990 | pmid = 10924297}}</ref> Policies that have resulted in increased socio-economic inequalities have been associated with greater subsequent socio-economic differences in cardiovascular disease<ref name = "Di Cesare 2013"/> implying a cause and effect relationship. Psychosocial factors, environmental exposures, health behaviours, and health-care access and quality contribute to socio-economic differentials in cardiovascular disease.
+<ref name="Alexander 2009">{{Cite journal |author1=Alexander M. Clark |author2=Marie DesMeules |author3=Wei Luo |author4=Amanda S. Duncan |author5=Andy Wielgosz | title = Socioeconomic status and cardiovascular disease: risks and implications for care | journal = Nature Reviews Cardiology | volume = 6 | issue = 11 | pages = 712–722 |date=November 2009
+ | doi = 10.1038/nrcardio.2009.163 | pmid = 19770848}}</ref> The Commission on Social Determinants of Health recommended that more equal distributions of power, wealth, education, housing, environmental factors, nutrition, and health care were needed to address inequalities in cardiovascular disease and non-communicable diseases.<ref name="CSDoH2008">{{cite book|author=World Health Organization|title=Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health : Commission on Social Determinants of Health Final Report|url=https://books.google.com/books?id=zc_VfH7wfV8C&pg=PA26|year=2008|publisher=World Health Organization|isbn=978-92-4-156370-3|pages=26–|deadurl=no|archiveurl=https://web.archive.org/web/20160501062510/https://books.google.com/books?id=zc_VfH7wfV8C&pg=PA26|archivedate=2016-05-01|df=}}</ref>
+===Air pollution===
+[[Particulate matter]] has been studied for its short- and long-term exposure [[Particulate matter#Health effects|effects on cardiovascular disease]]. Currently, PM<sub>2.5</sub> is the major focus, in which gradients are used to determine CVD risk. For every 10 μg/m<sup>3</sup> of PM<sub>2.5</sub> long-term exposure, there was an estimated 8–18% CVD mortality risk.<ref name=Kha11>{{cite book|last=Khallaf|first=Mohamed|title=The Impact of Air Pollution on Health, Economy, Environment and Agricultural Sources|year=2011|publisher=InTech|isbn=978-953-307-528-0|pages=69–92|url=http://www.intechweb.org/books/show/title/the-impact-of-air-pollution-on-health-economy-environment-and-agricultural-sources}}</ref> Women had a higher relative risk (RR) (1.42) for PM<sub>2.5</sub> induced coronary artery disease than men (0.90) did.<ref name=Kha11/>  Overall, long-term PM exposure increased rate of atherosclerosis and inflammation. In regards to short-term exposure (2 hours), every 25 μg/m<sup>3</sup> of PM<sub>2.5</sub> resulted in a 48% increase of CVD mortality risk.<ref name="DOIthromres" /> In addition, after only 5 days of exposure, a rise in systolic (2.8 mmHg) and diastolic (2.7 mmHg) blood pressure occurred for every 10.5 μg/m<sup>3</sup> of PM<sub>2.5</sub>.<ref name="DOIthromres">{{cite journal | doi = 10.1016/j.thromres.2011.10.030 |vauthors=Franchini M, Mannucci PM | pmid =22113148 | title = Air pollution and cardiovascular disease | year = 2012 | journal = Thrombosis Research | volume = 129 | issue = 3 | pages = 230–4  }}</ref>  Other research has implicated PM<sub>2.5</sub> in irregular heart rhythm, reduced heart rate variability (decreased vagal tone), and most notably heart failure.<ref name="DOIthromres" /><ref name="Doicirculationaha">{{cite journal | doi = 10.1161/CIRCULATIONAHA.109.893461 | pmid =20585020 | title = Cardiovascular Effects of Ambient Particulate Air Pollution Exposure | year = 2010 | journal = Circulation | volume = 121 | issue = 25 | pages = 2755–65 | pmc = 2924678 |vauthors=Sun Q, Hong X, Wold LE }}</ref>  PM<sub>2.5</sub> is also linked to [[carotid artery]] thickening and increased risk of acute myocardial infarction.<ref name="DOIthromres" /><ref name="Doicirculationaha" />
+===Cardiovascular risk assessment===
+Existing cardiovascular disease or a previous cardiovascular event, such as a heart attack or stroke, is the strongest predictor of a future cardiovascular event.<ref name="Tunstall-Pedoe2011">{{cite journal|last1=Tunstall-Pedoe|first1=H.|title=Cardiovascular Risk and Risk Scores: ASSIGN, Framingham, QRISK and others: how to choose|journal=Heart|volume=97|issue=6|year=2011|pages=442–444|issn=1355-6037|doi=10.1136/hrt.2010.214858}}</ref> Age, sex, smoking, blood pressure, blood lipids and diabetes are important predictors of future cardiovascular disease in people who are not known to have cardiovascular disease.<ref name="Organization2007">{{cite book|author=World Health Organization|title=Prevention of Cardiovascular Disease: Guidelines for Assessment and Management of Cardiovascular Risk|url=https://books.google.com/books?id=oOfHQgAACAAJ|year=2007|publisher=World Health Organization|isbn=978-92-4-154717-8|deadurl=no|archiveurl=https://web.archive.org/web/20160506185216/https://books.google.com/books?id=oOfHQgAACAAJ|archivedate=2016-05-06|df=}}</ref> These measures, and sometimes others, may be combined into composite risk scores to estimate an individual's future risk of cardiovascular disease.<ref name="Tunstall-Pedoe2011"/> Numerous risk scores exist although their respective merits are debated.<ref name="Hernandezvan Staa2014">{{cite journal|last1=Hernandez|first1=Adrian V.|last2=van Staa|first2=Tjeerd-Pieter|last3=Gulliford|first3=Martin|last4=Ng|first4=Edmond S.-W.|last5=Goldacre|first5=Ben|last6=Smeeth|first6=Liam|title=Prediction of Cardiovascular Risk Using Framingham, ASSIGN and QRISK2: How Well Do They Predict Individual Rather than Population Risk?|journal=PLoS ONE|volume=9|issue=10|year=2014|pages=e106455|issn=1932-6203|doi=10.1371/journal.pone.0106455|pmid=25271417|pmc=4182667}} {{open access}}</ref> Other diagnostic tests and biomarkers remain under evaluation but currently these lack clear-cut evidence to support their routine use. They include family history, coronary artery [[calcification]] score, [[high sensitivity C-reactive protein]] (hs-CRP), [[ankle–brachial pressure index]],  lipoprotein subclasses and particle concentration, lipoprotein(a), apolipoproteins A-I and B, [[fibrinogen]], white blood cell count, [[homocysteine]], N-terminal pro B-type natriuretic peptide  (NT-proBNP), and markers of kidney function.<ref name="HlatkyGreenland2009">{{cite journal|last1=Hlatky|first1=M. A.|last2=Greenland|first2=P.|last3=Arnett|first3=D. K.|last4=Ballantyne|first4=C. M.|last5=Criqui|first5=M. H.|last6=Elkind|first6=M. S.V.|last7=Go|first7=A. S.|last8=Harrell|first8=F. E.|last9=Hong|first9=Y.|last10=Howard|first10=B. V.|last11=Howard|first11=V. J.|last12=Hsue|first12=P. Y.|last13=Kramer|first13=C. M.|last14=McConnell|first14=J. P.|last15=Normand|first15=S.-L. T.|last16=O'Donnell|first16=C. J.|last17=Smith|first17=S. C.|last18=Wilson|first18=P. W.F.|title=Criteria for Evaluation of Novel Markers of Cardiovascular Risk: A Scientific Statement From the American Heart Association|journal=Circulation|volume=119|issue=17|year=2009|pages=2408–2416|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.109.192278}}</ref><ref name="EckelCornier2014">{{cite journal|last1=Eckel|first1=Robert H|last2=Cornier|first2=Marc-Andre|title=Update on the NCEP ATP-III emerging cardiometabolic risk factors|journal=BMC Medicine|volume=12|issue=1|year=2014|pages=115|issn=1741-7015|doi=10.1186/1741-7015-12-115}} {{open access}}</ref> [[High blood phosphorus]] is also linked to an increased risk.<ref>{{cite journal|last1=Bai|first1=W|last2=Li|first2=J|last3=Liu|first3=J|title=Serum phosphorus, cardiovascular and all-cause mortality in the general population: A meta-analysis.|journal=Clinica Chimica Acta |date=1 October 2016|volume=461|pages=76–82|pmid=27475981|doi=10.1016/j.cca.2016.07.020}}</ref>
+=== Occupational exposure ===
+{{Main article|Occupational cardiovascular disease}}
+Little is known about the relationship between work and cardiovascular disease, but links have been established between certain toxins, extreme heat and cold, exposure to tobacco smoke, and mental health concerns such as stress and depression.<ref>{{Cite web|url=https://www.cdc.gov/niosh/programs/crcd/|title=CDC - NIOSH Program Portfolio : Cancer, Reproductive, and Cardiovascular Diseases : Program Description|website=www.cdc.gov|access-date=2016-06-07|deadurl=no|archiveurl=https://web.archive.org/web/20160515221455/http://www.cdc.gov/niosh/programs/crcd/|archivedate=2016-05-15|df=}}</ref>
+====Chemical risk factors====
+A 2015 SBU-report looking at non-chemical factors found an association for those:<ref name=":2" />
+*with mentally stressful work with a lack of control over their working situation — with an effort-reward imbalance<ref name=":2" />
+*who experience low social support at work; who experience injustice or experience insufficient opportunities for personal development; or those who experience job insecurity<ref name=":2" />
+*those who work night schedules; or have long working weeks<ref name=":2" />
+*those who are exposed to noise<ref name=":2" />
+Specifically the risk of [[stroke]] was also increased by exposure to ionizing radiation.<ref name=":2" /> Hypertension develops more often in those who experience job strain and who have shift-work.<ref name=":2" /> Differences between women and men in risk are small, however men risk suffering and dying of [[heart attack]]s or stroke twice as often as women during working life.<ref name=":2">{{Cite web|url=http://www.sbu.se/en/publications/sbu-assesses/occupational-exposures-and-cardiovascular-disease/|title=Occupational Exposures and Cardiovascular Disease|last=Services|first=Statens beredning för medicinsk och social utvärdering (SBU); Swedish Agency for Health Technology Assessment and Assessment of Social|website=www.sbu.se|language=en|access-date=2017-06-01|deadurl=no|archiveurl=https://web.archive.org/web/20170614063247/http://www.sbu.se/en/publications/sbu-assesses/occupational-exposures-and-cardiovascular-disease/|archivedate=2017-06-14|df=}}</ref>
+====Non-chemical risk factors====
+A 2017 SBU report found evidence that workplace exposure to [[silica dust]], [[engine exhaust]] or [[welding fumes]] is associated with heart disease.<ref name=SBU2017>{{Cite web|url=http://www.sbu.se/en/publications/sbu-assesses/occupational-health-and-safety--chemical-exposure/|title=Occupational health and safety – chemical exposure|last=Services|first=Statens beredning för medicinsk och social utvärdering (SBU); Swedish Agency for Health Technology Assessment and Assessment of Social|website=www.sbu.se|language=en|access-date=2017-06-01|deadurl=no|archiveurl=https://web.archive.org/web/20170606093333/http://www.sbu.se/en/publications/sbu-assesses/occupational-health-and-safety--chemical-exposure/|archivedate=2017-06-06|df=}}</ref> Associations also exist for exposure to [[arsenic]], [[Benzo(a)pyrene|benzopyrenes]], [[lead]], [[dynamite]], [[Carbon disulfide|carbon disulphide]], [[carbon monoxide]], [[Cutting fluid|metalworking fluids]] and occupational exposure to [[tobacco smoke]].<ref name="SBU2017" /> Working  with  the  [[electrolytic production]] of  aluminium  or  the  production  of  paper  when  the  [[sulphate pulping]]  process  is  used  is  associated with heart disease.<ref name="SBU2017" /> An association was also found  between  heart  disease  and  exposure  to  compounds  which  are  no  longer  permitted  in certain  work  environments,  such  as  [[phenoxy acid]]s containing [[2,3,7,8-Tetrachlorodibenzodioxin|TCDD]](dioxin) or [[asbestos]].<ref name="SBU2017" />
-{{SI}}
+Workplace exposure to silica dust or asbestos is also associated with [[pulmonary heart disease]]. There is evidence that workplace  exposure to lead, carbon disulfide, phenoxyacids containing  TCDD, as well as working in an environment where aluminum is being electrolytically produced, is associated with [[stroke]].<ref name="SBU2017" />
-{{WikiDoc Cardiology News}}
+=== Somatic mutations ===
+As of 2017, evidence suggests that certain [[leukemia]]-associated [[mutation]]s in [[blood cell]]s may also lead to increased risk of cardiovascular disease. Several large-scale research projects looking at human genetic data have found a robust link between the presence of these mutations, a condition known as [[clonal hematopoiesis]], and cardiovascular disease-related incidents and mortality.<ref>{{cite journal|last1=Jan|first1=M|last2=Ebert|first2=BL|last3=Jaiswal|first3=S|title=Clonal hematopoiesis.|journal=Seminars in hematology|date=January 2017|volume=54|issue=1|pages=43–50|doi=10.1053/j.seminhematol.2016.10.002|pmid=28088988}}</ref>
-{{CMG}}
+==Pathophysiology==
+[[File:Cardiovascular calcification - Sergio Bertazzo.tif|thumbnail|right|Density-Dependent Colour Scanning Electron Micrograph SEM (DDC-SEM) of cardiovascular calcification, showing in orange calcium phosphate spherical particles (denser material) and, in green, the extracellular matrix (less dense material)<ref name="Bertazzo">{{cite journal | author = Bertazzo S. ''et al.'' | year = 2013 | title = Nano-analytical electron microscopy reveals fundamental insights into human cardiovascular tissue calcification | url = | journal = Nature Materials | volume = 12 | issue = | pages = 576–583 | doi=10.1038/nmat3627 | pmid=23603848}}</ref>]]
+Population-based studies show that atherosclerosis, the major precursor of cardiovascular disease, begins in childhood. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study demonstrated that intimal lesions appear in all the aortas and more than half of the right coronary arteries of youths aged 7–9 years.<ref>{{cite journal |vauthors=Vanhecke TE, Miller WM, Franklin BA, Weber JE, McCullough PA |title=Awareness, knowledge, and perception of heart disease among adolescents |journal=Eur J Cardiovasc Prev Rehabil. |volume=13 |issue=5 |pages=718–23 |date=Oct 2006 |pmid=17001210 |doi=10.1097/01.hjr.0000214611.91490.5e |url=}}</ref>
-== Overview ==
+This is extremely important considering that 1 in 3 people die from complications attributable to atherosclerosis. In order to stem the tide, education and awareness that cardiovascular disease poses the greatest threat, and measures to prevent or reverse this disease must be taken.
-'''Cardiovascular disease''' refers to the class of diseases that involve the [[heart]] or [[blood vessel]]s ([[artery|arteries]] and [[vein]]s). While the term technically refers to any disease that affects the [[Circulatory system|cardiovascular system]], it is usually used to refer to those related to [[atherosclerosis]] (arterial disease). These conditions have similar causes, mechanisms, and treatments.  In practice, cardiovascular disease is treated by [[cardiology|cardiologists]], [[thoracic surgery|thoracic surgeons]], [[vascular surgery|vascular surgeons]], [[neurology|neurologists]], and [[interventional radiology|interventional radiologists]], depending on the organ system that is being treated.  There is considerable overlap in the specialties, and it is common for certain procedures to be performed by different types of specialists in the same hospital.
+Obesity and [[diabetes mellitus]] are often linked to cardiovascular disease,<ref>{{cite journal |vauthors=Highlander P, Shaw GP | year = 2010 | title = Current pharmacotherapeutic concepts for the treatment of cardiovascular disease in diabetics | url = | journal = Ther Adv Cardiovasc Dis | volume = 4 | issue = 1| pages = 43–54 | doi=10.1177/1753944709354305}}</ref> as are a history of chronic [[kidney disease]] and [[hypercholesterolaemia]].<ref name="nps01">{{cite web |title=NPS Prescribing Practice Review 53: Managing lipids |url=http://www.nps.org.au/health_professionals/publications/prescribing_practice_review/current/prescribing_practice_review_53 |author=NPS Medicinewise |accessdate=1 August 2011 |date=1 March 2011 |deadurl=yes |archiveurl=https://web.archive.org/web/20110319103522/http://www.nps.org.au/health_professionals/publications/prescribing_practice_review/current/prescribing_practice_review_53 |archivedate=19 March 2011 |df= }}</ref>  In fact, cardiovascular disease is the most life-threatening of the diabetic complications and diabetics are two- to four-fold more likely to die of cardiovascular-related causes than nondiabetics.<ref>{{cite journal |author1=Kvan E. |author2=Pettersen K.I. |author3=Sandvik L. |author4=Reikvam A. | year = 2007 | title = High mortality in diabetic patient with acute myocardial infarction: cardiovascular co-morbidities contribute most to the high risk | url = | journal = Int J Cardiol | volume = 121 | issue = 2| pages = 184–188 | doi=10.1016/j.ijcard.2006.11.003}}</ref><ref>{{cite journal |author1=Norhammar A. |author2=Malmberg K. |author3=Diderhol E. |author4=Lagerqvist B. |author5=Lindahl B., Ryde | year = 2004 | title = Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularization. J | url = | journal = Am Coll Cardiol | volume = 43 | issue = 4| pages = 585–591 | doi=10.1016/j.jacc.2003.08.050|display-authors=etal}}</ref><ref>{{cite journal | author = DECODE, European Diabetes Epidemiology Group | year = 1999 | title = Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria | url = | journal = Lancet | volume = 354 | issue = 9179| pages = 617–621 | doi=10.1016/S0140-6736(98)12131-1 | pmid=10466661}}</ref>
-Most Western countries face high and increasing rates of cardiovascular disease. Each year, [[heart disease]] kills more Americans than cancer.<ref>{{cite web
+==Screening==
-  | last = United States
-  | authorlink = Centers for Disease Control
-  | title = Chronic Disease Overview
-  | publisher = United States Government
-  | date = 1999
-  | url = http://www.cdc.gov/nccdphp/overview_text.htm
-  | accessdate =2007-02-07 }}</ref> Diseases of the heart alone caused 30% of all deaths, with other diseases of the cardiovascular system causing substantial further death and disability.
-Up until the year 2005, it was the number 1 cause of death and disability in the United States and most European countries. A large histological study (PDAY) showed vascular injury accumulates from adolescence, making primary prevention efforts necessary from childhood.<ref>Rainwater DL, McMahan CA, Malcom GT, Scheer WD, Roheim PS, McGill HC Jr, Strong JP. Lipid and apolipoprotein predictors of atherosclerosis in youth: apolipoprotein concentrations do not materially improve prediction of arterial lesions in PDAY subjects. The PDAY Research Group. Arterioscler Thromb Vasc Biol. 1999; 19: 753-61.</ref><ref>Mcgill, HC, Jr., Mcmahan, CA, Zieske, AW  et al. Associations of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth. The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Arterioscler. Thromb. Vasc. Biol. 2000; 20: 1998–2004.</ref>
-By the time that heart problems are detected, the underlying cause ([[atherosclerosis]]) is usually quite advanced, having progressed for decades. There is therefore increased emphasis on preventing atherosclerosis by modifying risk factors, such as [[Healthy diet|healthy eating]], [[Physical exercise|exercise]] and avoidance of [[tobacco smoking|smoking]].
+[[Clinical practice guideline]]s by the [[United States Preventive Service Task Force]] in 2016 stated<ref name="pmid27838723">{{cite journal| author=US Preventive Services Task Force. Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW et al.| title=Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. | journal=JAMA | year= 2016 | volume= 316 | issue= 19 | pages= 1997-2007 | pmid=27838723 | doi=10.1001/jama.2016.15450 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27838723  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28320000 Review in: Ann Intern Med. 2017 Mar 21;166(6):JC26] </ref>:
+* Providers should utilize the ACC/AHA Pooled Cohort Equations to estimate 10-year risk of CVD events. This calculation takes into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertensive medications, diabetic status, and smoking status.
-== Biomarkers ==
-Some [[Biomarker (medicine)|biomarkers]] are thought to offer a more detailed risk of cardiovascular disease. However, the clinical value of these biomarkers is questionable.<ref>{{cite journal |author=Wang TJ, Gona P, Larson MG, Tofler GH, Levy D, Newton-Cheh C, Jacques PF, Rifai N, Selhub J, Robins SJ, Benjamin EJ, D'Agostino RB, Vasan RS |title=Multiple biomarkers for the prediction of first major cardiovascular events and death |journal=N. Engl. J. Med. |volume=355 |issue=25 |pages=2631-9 |year=2006 |pmid=17182988}}</ref> Currently, biomarkers which may reflect a higher risk of cardiovascular disease include:
+The NIH recommends lipid testing in children beginning at the age of 2 if there is a family history of heart disease or lipid problems.<ref>{{Cite journal|last=Adolescents|first=Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children And|date=2011-12-01|title=Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report|url=http://pediatrics.aappublications.org/content/128/Supplement_5/S213|journal=Pediatrics|language=en|volume=128|issue=Supplement 5|pages=S213–S256|doi=10.1542/peds.2009-2107C|issn=0031-4005|pmc=4536582|pmid=22084329|deadurl=no|archiveurl=https://web.archive.org/web/20160716162851/http://pediatrics.aappublications.org/content/128/Supplement_5/S213|archivedate=2016-07-16|df=}}</ref> It is hoped that early testing will improve lifestyle factors in those at risk such as diet and exercise.<ref>{{Cite journal|last=Saenger|first=Amy K.|date=2012-08-01|title=Universal Lipid Screening in Children and Adolescents: A Baby Step toward Primordial Prevention?|url=http://www.clinchem.org/content/58/8/1179|journal=Clinical Chemistry|language=en|volume=58|issue=8|pages=1179–1181|doi=10.1373/clinchem.2012.182287|issn=0009-9147|pmid=22510399}}</ref>
-* Higher [[Fibrin|fibrinogen]] and [[Plasminogen activator inhibitor-1|PAI-1]] blood concentrations
-* Elevated [[homocysteine]], or even upper half of normal
-* Elevated blood levels of [[asymmetric dimethylarginine]]
-* High inflammation as measured by [[C-reactive protein]]
-* Elevated blood levels of [[B-type natriuretic peptide]] ([[BNP]]) <ref>{{cite journal |author=Ramachandran Vasan, et al |journal=N. Engl. J.}}</ref>
-== ACC/AHA Guidelines- Pocket Guideline: 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults (DO NOT EDIT) ==
+Screening [[ECG]]s (either at rest or with exercise) are not recommended in those without symptoms who are at low risk.<ref name=Annals2012>{{cite journal|last=Moyer|first=VA |author2=U.S. Preventive Services Task Force|title=Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement.|journal=Annals of Internal Medicine|date=Oct 2, 2012|volume=157|issue=7|pages=512–8|pmid=22847227|doi=10.7326/0003-4819-157-7-201210020-00514}}</ref> This includes those who are young without risk factors according to the American Heart Association and the American College of Cardiology.<ref>{{cite journal|last1=Maron|first1=B. J.|last2=Friedman|first2=R. A.|last3=Kligfield|first3=P.|last4=Levine|first4=B. D.|last5=Viskin|first5=S.|last6=Chaitman|first6=B. R.|last7=Okin|first7=P. M.|last8=Saul|first8=J. P.|last9=Salberg|first9=L.|last10=Van Hare|first10=G. F.|last11=Soliman|first11=E. Z.|last12=Chen|first12=J.|last13=Matherne|first13=G. P.|last14=Bolling|first14=S. F.|last15=Mitten|first15=M. J.|last16=Caplan|first16=A.|last17=Balady|first17=G. J.|last18=Thompson|first18=P. D.|title=Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology|journal=Circulation|date=15 September 2014|doi=10.1161/CIR.0000000000000025|volume=130|issue=15|pages=1303–1334|pmid=25223981}}</ref> In those at higher risk the evidence for screening with ECGs is inconclusive.<ref name=Annals2012/>
+[[Echocardiography]] and stress testing ([[myocardial perfusion imaging]] or[[cardiac stress test]]ing) are not recommended in those at low risk who do not have symptoms according to the American College of Physicians.<ref>{{cite journal|last1=Chou|first1=Roger|title=Cardiac Screening With Electrocardiography, Stress Echocardiography, or Myocardial Perfusion Imaging: Advice for High-Value Care From the American College of Physicians|journal=Annals of Internal Medicine|date=17 March 2015|volume=162|issue=6|pages=438|doi=10.7326/M14-1225}}</ref>
-{{cquote|
+===Evidence===
-Risk Stratification and Genomics
+Some [[Biomarker (medicine)|biomarkers]] may add to conventional cardiovascular risk factors in predicting the risk of future cardiovascular disease; however, the clinical value of some biomarkers is questionable.<ref name="pmid17182988">{{cite journal| author=Wang TJ, Gona P, Larson MG, Tofler GH, Levy D, Newton-Cheh C et al.| title=Multiple biomarkers for the prediction of first major cardiovascular events and death. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 25 | pages= 2631-9 | pmid=17182988 | doi=10.1056/NEJMoa055373 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17182988  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17607830 Review in: J Fam Pract. 2007 Mar;56(3):178] </ref> Per this study, measured the incremental value of 10 contemporary biomarkers (C-reactive protein, B-type natriuretic peptide,N-terminal pro-atrial natriuretic peptide, aldosterone, renin, fibrinogen, D-dimer, plasminogen-activator inhibitor type 1, and homocysteine; and the urinary albumin-to-creatinine ratio).  The [[C-statistic]] increased from 0.80 (with age, sex, and conventional risk factors as predictors) to 0.82 (with all predictors). The statistical significant of this increase was not reported.
-}}
-== Prevention ==
-Attempts to prevent cardiovascular disease are more effective when they remove and prevent causes, and they often take the form of modifying risk factors. Some factors, such as gender, age, and family history, cannot be modified. [[Smoking cessation]] (or abstinence) is one of the most effective and easily modifiable changes. Regular [[cardiovascular exercise]] ([[aerobic exercise]]) complements the healthful eating habits. According to the American Heart Association, build up of plaque on the arteries ([[atherosclerosis]]), partly as a result of high cholesterol and fat diet, is a leading cause for cardiovascular diseases. The combination of healthy diet and exercise is a means to improve serum [[cholesterol]] levels and reduce risks of cardiovascular diseases; if not, a physician may prescribe "cholesterol-lowering" drugs, such as the [[statin]]s. These medications have additional protective benefits aside from their lipoprotein profile improvement. [[Aspirin]] may also be prescribed, as it has been shown to decrease the [[Thrombus|clot]] formation that may lead to myocardial infarctions and strokes; it is routinely prescribed for patients with one or more cardiovascular risk factors.
+Screening and selection for primary prevention interventions has traditionally been done through absolute risk using a variety of scores (ex. Framingham or Reynolds risk scores).<ref name=":0">{{Cite book|url=https://www.worldcat.org/oclc/890409638|title=Braunwald's heart disease : a textbook of cardiovascular medicine|others=Mann, Douglas L.,, Zipes, Douglas P.,, Libby, Peter,, Bonow, Robert O.,, Braunwald, Eugene, 1929-|isbn=9781455751334|edition=Tenth|location=Philadelphia, PA|oclc=890409638}}</ref> This stratification has separated people who receive the lifestyle interventions (generally lower and intermediate risk) from the medication (higher risk). The number and variety of risk scores available for use has multiplied, but their efficacy according to a 2016 review was unclear due to lack of external validation or impact analysis.<ref>{{Cite journal|last=Damen|first=Johanna A. A. G.|last2=Hooft|first2=Lotty|last3=Schuit|first3=Ewoud|last4=Debray|first4=Thomas P. A.|last5=Collins|first5=Gary S.|last6=Tzoulaki|first6=Ioanna|last7=Lassale|first7=Camille M.|last8=Siontis|first8=George C. M.|last9=Chiocchia|first9=Virginia|date=2016-05-16|title=Prediction models for cardiovascular disease risk in the general population: systematic review|url=http://www.bmj.com/content/353/bmj.i2416|journal=BMJ|language=en|volume=353|pages=i2416|doi=10.1136/bmj.i2416|issn=1756-1833|pmc=4868251|pmid=27184143|deadurl=no|archiveurl=https://web.archive.org/web/20170829132646/http://www.bmj.com/content/353/bmj.i2416|archivedate=2017-08-29|df=}}</ref> Risk stratification models often lack sensitivity for population groups and do not account for the large number of negative events among the intermediate and low risk groups.<ref name=":0" /> As a result, future preventative screening appears to shift toward applying prevention according to randomized trial results of each intervention rather than large-scale risk assessment.
-One possible way to decrease risk of cardiovascular disease is keep your total cholesterol below 150.  In the [[Framingham Heart Study]], those with total cholesterol below 150 only very rarely got coronary heart disease.
+==Prevention==
+Up to 90% of cardiovascular disease may be preventable if established risk factors are avoided.<ref name=":1">{{Cite journal|last=McGill|first=Henry C.|last2=McMahan|first2=C. Alex|last3=Gidding|first3=Samuel S.|date=2008-03-04|title=Preventing Heart Disease in the 21st Century|journal=Circulation|language=en|volume=117|issue=9|pages=1216–1227|doi=10.1161/CIRCULATIONAHA.107.717033|issn=0009-7322|pmid=18316498}}</ref><ref>{{Cite journal|last=McNeal|first=Catherine J.|last2=Dajani|first2=Tala|last3=Wilson|first3=Don|last4=Cassidy-Bushrow|first4=Andrea E.|last5=Dickerson|first5=Justin B.|last6=Ory|first6=Marcia|date=2010-01-01|title=Hypercholesterolemia in youth: opportunities and obstacles to prevent premature atherosclerotic cardiovascular disease|journal=Current Atherosclerosis Reports|volume=12|issue=1|pages=20–28|doi=10.1007/s11883-009-0072-0|issn=1534-6242|pmid=20425267}}</ref> Currently practiced measures to prevent cardiovascular disease include:
+* [[Tobacco]] cessation and avoidance of second-hand smoke.<ref name="NHS Direct" /> Smoking cessation reduces risk by about 35%.<ref>{{Cite journal|last=Critchley|first=J.|last2=Capewell|first2=S.|date=2004-01-01|title=Smoking cessation for the secondary prevention of coronary heart disease|journal=The Cochrane Database of Systematic Reviews|issue=1|pages=CD003041|doi=10.1002/14651858.CD003041.pub2|issn=1469-493X|pmid=14974003}}</ref>
+* A low-fat, low-sugar, high-fiber [[diet (nutrition)|diet]] including whole grains and fruit and vegetables.<ref name="NHS Direct">[http://www.nhs.uk/Conditions/Heart-attack/Pages/Prevention.aspx NHS Direct] {{webarchive|url=https://web.archive.org/web/20110906004112/http://www.nhs.uk/Conditions/Heart-attack/Pages/Prevention.aspx |date=2011-09-06 }}</ref><ref>{{cite journal|last=Ignarro|first=LJ |author2=Balestrieri, ML |author3=Napoli, C|title=Nutrition, physical activity, and cardiovascular disease: an update.|journal=Cardiovascular Research|date=Jan 15, 2007|volume=73|issue=2|pages=326–40|pmid=16945357|doi=10.1016/j.cardiores.2006.06.030}}</ref><ref>{{cite journal|last1=Levy|first1=L|last2=Tedstone|first2=A|title=UK Dietary Policy for the Prevention of Cardiovascular Disease.|journal=Healthcare|date=20 February 2017|volume=5|issue=1|pmid=28230719|url=http://www.mdpi.com/2227-9032/5/1/9/htm|doi=10.3390/healthcare5010009|page=9|deadurl=no|archiveurl=https://web.archive.org/web/20170313213655/http://www.mdpi.com/2227-9032/5/1/9/htm|archivedate=13 March 2017|df=}}</ref> Dietary interventions are effective in reducing cardiovascular risk factors over a year, but the longer term effects of such interventions and their impact on cardiovascular disease events is uncertain.<ref>{{Cite journal|last=Rees|first=Karen|last2=Dyakova|first2=Mariana|last3=Wilson|first3=Nicola|last4=Ward|first4=Kirsten|last5=Thorogood|first5=Margaret|last6=Brunner|first6=Eric|date=2013-12-06|title=Dietary advice for reducing cardiovascular risk|journal=The Cochrane Database of Systematic Reviews|issue=12|pages=CD002128|doi=10.1002/14651858.CD002128.pub5|issn=1469-493X|pmid=24318424}}</ref>
+* At least 150 minutes (2 hours and 30 minutes) of moderate exercise per week.<ref>{{Cite web|url=https://health.gov/paguidelines/guidelines/chapter4.aspx|title=Chapter 4: Active Adults|last=|first=|date=|website=health.gov|archive-url=https://web.archive.org/web/20170313131518/https://health.gov/paguidelines/guidelines/chapter4.aspx|archive-date=2017-03-13|dead-url=no|access-date=|df=}}</ref><ref>{{Cite web|url=http://www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-adults.aspx|title=Physical activity guidelines for adults|last=|first=|date=|website=NHS Choices|archive-url=https://web.archive.org/web/20170219235702/http://www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-for-adults.aspx|archive-date=2017-02-19|dead-url=no|access-date=|df=}}</ref> Exercise-based cardiac rehabilitation reduces risk of subsequent cardiovascular events by 26%,<ref>{{Cite journal|title=Exercise‐based cardiac rehabilitation for coronary heart disease|url=http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001800.pub2/full|doi=10.1002/14651858.cd001800.pub2|journal=Cochrane Database of Systematic Reviews|deadurl=no|archiveurl=https://web.archive.org/web/20170313130528/http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001800.pub2/full|archivedate=2017-03-13|df=}}</ref> but there have been few high quality studies of the benefits of exercise training in people with increased cardiovascular risk but no history of cardiovascular disease.<ref>{{Cite journal|last=Seron|first=Pamela|last2=Lanas|first2=Fernando|last3=Pardo Hernandez|first3=Hector|last4=Bonfill Cosp|first4=Xavier|date=2014-08-13|title=Exercise for people with high cardiovascular risk|journal=The Cochrane Database of Systematic Reviews|issue=8|pages=CD009387|doi=10.1002/14651858.CD009387.pub2|issn=1469-493X|pmid=25120097}}</ref>
+* Limit alcohol consumption to the recommended daily limits;<ref name="NHS Direct"/> People who moderately consume alcoholic drinks have a 25–30% lower risk of cardiovascular disease.<ref>{{Cite journal|last=Ronksley|first=Paul E.|last2=Brien|first2=Susan E.|last3=Turner|first3=Barbara J.|last4=Mukamal|first4=Kenneth J.|last5=Ghali|first5=William A.|date=2011-02-22|title=Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis|journal=BMJ |volume=342|pages=d671|doi=10.1136/bmj.d671|issn=1756-1833|pmc=3043109|pmid=21343207}}</ref><ref name="Mostofsky 979–987">{{Cite journal|last=Mostofsky|first=Elizabeth|last2=Chahal|first2=Harpreet S.|last3=Mukamal|first3=Kenneth J.|last4=Rimm|first4=Eric B.|last5=Mittleman|first5=Murray A.|date=2016-03-08|title=Alcohol and Immediate Risk of Cardiovascular Events: A Systematic Review and Dose-Response Meta-Analysis|journal=Circulation|volume=133|issue=10|pages=979–987|doi=10.1161/CIRCULATIONAHA.115.019743|issn=1524-4539|pmc=4783255|pmid=26936862}}</ref> However, people who are genetically predisposed to consume less alcohol have lower rates of cardiovascular disease<ref>{{Cite journal|last=Holmes|first=Michael V.|last2=Dale|first2=Caroline E.|last3=Zuccolo|first3=Luisa|last4=Silverwood|first4=Richard J.|last5=Guo|first5=Yiran|last6=Ye|first6=Zheng|last7=Prieto-Merino|first7=David|last8=Dehghan|first8=Abbas|last9=Trompet|first9=Stella|date=2014-07-10|title=Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data|journal=BMJ |volume=349|pages=g4164|doi=10.1136/bmj.g4164|issn=1756-1833|pmc=4091648|pmid=25011450}}</ref> suggesting that alcohol itself may not be protective. Excessive alcohol intake increases the risk of cardiovascular disease<ref>{{cite journal |author=Klatsky AL |title=Alcohol and cardiovascular diseases |journal=Expert Rev Cardiovasc Ther |volume=7 |issue=5 |pages=499–506 |date=May 2009 |pmid=19419257 |doi=10.1586/erc.09.22 |url=}}</ref><ref name="Mostofsky 979–987"/> and consumption of alcohol is associated with increased risk of a cardiovascular event in the day following consumption.<ref name="Mostofsky 979–987"/>
+* Lower blood pressure, if elevated. A 10&nbsp;mmHg reduction in blood pressure reduces risk by about 20%.<ref name="Ettehad 957–967">{{Cite journal|last=Ettehad|first=Dena|last2=Emdin|first2=Connor A.|last3=Kiran|first3=Amit|last4=Anderson|first4=Simon G.|last5=Callender|first5=Thomas|last6=Emberson|first6=Jonathan|last7=Chalmers|first7=John|last8=Rodgers|first8=Anthony|last9=Rahimi|first9=Kazem|date=2016-03-05|title=Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis|journal=Lancet |volume=387|issue=10022|pages=957–967|doi=10.1016/S0140-6736(15)01225-8|issn=1474-547X|pmid=26724178}}</ref>
+* Decrease non-[[High-density lipoprotein|HDL cholesterol]].<ref>{{Cite journal|title = Pathobiological determinants of atherosclerosis in youth risk scores are associated with early and advanced atherosclerosis|journal = Pediatrics|date = 2006-10-01|issn = 1098-4275|pmid = 17015535|pages = 1447–1455|volume = 118|issue = 4|doi = 10.1542/peds.2006-0970|first = C. Alex|last = McMahan|first2 = Samuel S.|last2 = Gidding|first3 = Gray T.|last3 = Malcom|first4 = Richard E.|last4 = Tracy|first5 = Jack P.|last5 = Strong|first6 = Henry C.|last6 = McGill}}</ref><ref>{{Cite journal|title = Endothelial function in healthy 11-year-old children after dietary intervention with onset in infancy: the Special Turku Coronary Risk Factor Intervention Project for children (STRIP)|journal = Circulation|date = 2005-12-13|issn = 1524-4539|pmid = 16330680|pages = 3786–3794|volume = 112|issue = 24|doi = 10.1161/CIRCULATIONAHA.105.583195|first = Olli T.|last = Raitakari|first2 = Tapani|last2 = Rönnemaa|first3 = Mikko J.|last3 = Järvisalo|first4 = Tuuli|last4 = Kaitosaari|first5 = Iina|last5 = Volanen|first6 = Katariina|last6 = Kallio|first7 = Hanna|last7 = Lagström|first8 = Eero|last8 = Jokinen|first9 = Harri|last9 = Niinikoski}}</ref> [[Statin]] treament reduces cardiovascular mortality by about 31%.<ref>{{Cite journal|last=Chou|first=Roger|last2=Dana|first2=Tracy|last3=Blazina|first3=Ian|last4=Daeges|first4=Monica|last5=Jeanne|first5=Thomas L.|date=2016-11-15|title=Statins for Prevention of Cardiovascular Disease in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force|journal=JAMA|volume=316|issue=19|pages=2008–2024|doi=10.1001/jama.2015.15629|issn=1538-3598|pmid=27838722}}</ref>
+* Decrease body fat if overweight or obese.<ref>{{cite journal |vauthors=McTigue KM, Hess R, Ziouras J |title=Obesity in older adults: a systematic review of the evidence for diagnosis and treatment |journal=Obesity |volume=14 |issue=9 |pages=1485–97 |date=September 2006 |pmid=17030958 |doi=10.1038/oby.2006.171 |url=}}</ref> The effect of weight loss is often difficult to distinguish from dietary change, and evidence on weight reducing diets is limited.<ref>{{Cite journal|last=Semlitsch|first=Thomas|last2=Jeitler|first2=Klaus|last3=Berghold|first3=Andrea|last4=Horvath|first4=Karl|last5=Posch|first5=Nicole|last6=Poggenburg|first6=Stephanie|last7=Siebenhofer|first7=Andrea|date=2016-03-02|title=Long-term effects of weight-reducing diets in people with hypertension|journal=The Cochrane Database of Systematic Reviews|volume=3|pages=CD008274|doi=10.1002/14651858.CD008274.pub3|issn=1469-493X|pmid=26934541}}</ref> In observational studies of people with severe obesity, weight loss following bariatric surgery  is associated with a 46% reduction in cardiovascular risk.<ref>{{Cite journal|last=Kwok|first=Chun Shing|last2=Pradhan|first2=Ashish|last3=Khan|first3=Muhammad A.|last4=Anderson|first4=Simon G.|last5=Keavney|first5=Bernard D.|last6=Myint|first6=Phyo Kyaw|last7=Mamas|first7=Mamas A.|last8=Loke|first8=Yoon K.|date=2014-04-15|title=Bariatric surgery and its impact on cardiovascular disease and mortality: a systematic review and meta-analysis|journal=International Journal of Cardiology|volume=173|issue=1|pages=20–28|doi=10.1016/j.ijcard.2014.02.026|issn=1874-1754|pmid=24636546}}</ref>
+* Decrease [[stress (psychological)|psychosocial stress]].<ref>{{cite journal |vauthors=Linden W, Stossel C, Maurice J |title=Psychosocial interventions for patients with coronary artery disease: a meta-analysis |journal=Arch. Intern. Med. |volume=156 |issue=7 |pages=745–52 |date=April 1996 |pmid=8615707 |doi= 10.1001/archinte.1996.00440070065008|url=}}</ref> This measure may be complicated by imprecise definitions of what constitute psychosocial interventions.<ref name="ThompsonSki2013">{{cite journal|last1=Thompson|first1=D. R.|last2=Ski|first2=C. F.|title=Psychosocial interventions in cardiovascular disease - what are they?|journal=European Journal of Preventive Cardiology|volume=20|issue=6|year=2013|pages=916–917|issn=2047-4873|doi=10.1177/2047487313494031}}</ref> Mental stress–induced [[myocardial ischemia]] is associated with an increased risk of heart problems in those with previous heart disease.<ref>{{cite journal|last1=Wei|first1=J|last2=Rooks|first2=C|last3=Ramadan|first3=R|last4=Shah|first4=AJ|last5=Bremner|first5=JD|last6=Quyyumi|first6=AA|last7=Kutner|first7=M|last8=Vaccarino|first8=V|title=Meta-analysis of mental stress-induced myocardial ischemia and subsequent cardiac events in patients with coronary artery disease.|journal=The American Journal of Cardiology|date=15 July 2014|volume=114|issue=2|pages=187–92|pmid=24856319|doi=10.1016/j.amjcard.2014.04.022|pmc=4126399}}</ref> Severe emotional and physical stress leads to a form of heart dysfunction known as [[Takotsubo syndrome]] in some people.<ref>{{cite journal|last1=Pelliccia|first1=F|last2=Greco|first2=C|last3=Vitale|first3=C|last4=Rosano|first4=G|last5=Gaudio|first5=C|last6=Kaski|first6=JC|title=Takotsubo syndrome (stress cardiomyopathy): an intriguing clinical condition in search of its identity.|journal=The American Journal of Medicine|date=August 2014|volume=127|issue=8|pages=699–704|pmid=24754972|doi=10.1016/j.amjmed.2014.04.004}}</ref> Stress, however, plays a relatively minor role in hypertension.<ref>{{cite journal|last=Marshall|first=IJ|author2=Wolfe, CD |author3=McKevitt, C |title=Lay perspectives on hypertension and drug adherence: systematic review of qualitative research.|journal=BMJ |date=Jul 9, 2012|volume=345|pages=e3953|pmid=22777025|pmc=3392078|doi=10.1136/bmj.e3953}}</ref> Specific relaxation therapies are of unclear benefit.<ref name=Relax2006>{{cite journal|last=Dickinson|first=HO|author2=Mason, JM |author3=Nicolson, DJ |author4=Campbell, F |author5=Beyer, FR |author6=Cook, JV |author7=Williams, B |author8= Ford, GA |title=Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials.|journal=Journal of Hypertension|date=February 2006|volume=24|issue=2|pages=215–33|pmid=16508562|doi=10.1097/01.hjh.0000199800.72563.26}}</ref><ref>{{cite journal|last1=Abbott|first1=RA|last2=Whear|first2=R|last3=Rodgers|first3=LR|last4=Bethel|first4=A|last5=Thompson Coon|first5=J|last6=Kuyken|first6=W|last7=Stein|first7=K|last8=Dickens|first8=C|title=Effectiveness of mindfulness-based stress reduction and mindfulness based cognitive therapy in vascular disease: A systematic review and meta-analysis of randomised controlled trials.|journal=Journal of Psychosomatic Research|date=May 2014|volume=76|issue=5|pages=341–51|pmid=24745774|doi=10.1016/j.jpsychores.2014.02.012}}</ref>
-A [[magnesium deficiency (medicine)|magnesium deficiency]], or lower levels of [[magnesium]], can contribute to heart disease and a [[healthy diet]] that contains adequate [[magnesium]] may prevent heart disease.<ref>[http://www.ars.usda.gov/is/AR/archive/may04/energy0504.htm Lack Energy? Maybe It's Your Magnesium Level]</ref>  [[Magnesium]] can be used to enhance long term treatment, so it may be effective in long term prevention.<ref name="Rosanoff">[http://www.jacn.org/cgi/reprint/23/5/501S.pdf Comparison of Mechanism and Functional Effects of Magnesium and Statin Pharmaceuticals] Andrea Rosanoff, PhD, Mildred S. Seelig, MD.  Journal of the American College of Nutrition, Vol. 23, No. 5, 501S–505S (2004)</ref>  Excess calcium may contribute to a buildup of calcium in the veins.  Excess calcium can cause a [[magnesium deficiency (medicine)|magnesium deficiency]], and [[magnesium]] can reduce excess calcium.
+Most guidelines recommend combining preventive strategies. A 2015 Cochrane Review found some evidence that interventions aiming to reduce more than one cardiovascular risk factor may have favourable effects on blood pressure, body mass index and waist circumference; however, evidence was limited and the authors were unable to draw firm conclusions on the effects on cardiovascular events and mortality.<ref>{{Cite journal|last=Uthman|first=Olalekan A.|last2=Hartley|first2=Louise|last3=Rees|first3=Karen|last4=Taylor|first4=Fiona|last5=Ebrahim|first5=Shah|last6=Clarke|first6=Aileen|date=2015-08-04|title=Multiple risk factor interventions for primary prevention of cardiovascular disease in low- and middle-income countries|journal=The Cochrane Database of Systematic Reviews|issue=8|pages=CD011163|doi=10.1002/14651858.CD011163.pub2|issn=1469-493X|pmid=26272648}}</ref> For adults without a known diagnosis of hypertension, diabetes, hyperlipidemia, or cardiovascular disease, routine counseling to advise them to improve their diet and increase their physical activity has not been found to significantly alter behavior, and thus is not recommended.<ref>{{cite journal|last=Moyer|first=VA |author2=U.S. Preventive Services Task Force|title=Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement.|journal=Annals of Internal Medicine|date=September 4, 2012|volume=157|issue=5|pages=36771|pmid=22733153|doi=10.7326/0003-4819-157-5-201209040-00486}}</ref> Another Cochrane review suggested that simply providing people with a cardiovascular disease risk score may reduce cardiovascular disease risk factors by a small amount compared to usual care.<ref>{{Cite journal|last=Karmali|first=Kunal N.|last2=Persell|first2=Stephen D.|last3=Perel|first3=Pablo|last4=Lloyd-Jones|first4=Donald M.|last5=Berendsen|first5=Mark A.|last6=Huffman|first6=Mark D.|date=2017-03-14|title=Risk scoring for the primary prevention of cardiovascular disease|journal=The Cochrane Database of Systematic Reviews|volume=3|pages=CD006887|doi=10.1002/14651858.CD006887.pub4|issn=1469-493X|pmid=28290160}}</ref> However, there was some uncertainty as to whether providing these scores had any effect on cardiovascular disease events. It is unclear whether or not dental care in those with [[periodontitis]] affects their risk of cardiovascular disease.<ref>{{cite journal|last1=Li|first1=C|last2=Lv|first2=Z|last3=Shi|first3=Z|last4=Zhu|first4=Y|last5=Wu|first5=Y|last6=Li|first6=L|last7=Iheozor-Ejiofor|first7=Z|title=Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis.|journal=The Cochrane Database of Systematic Reviews|date=Aug 15, 2014|volume=8|pages=CD009197|pmid=25123257|doi=10.1002/14651858.CD009197.pub2}}</ref>
-==== Foods for cardiovascular health ====
+===Diet===
+{{See also|Saturated fat and cardiovascular disease|Salt and cardiovascular disease}}
+A diet high in fruits and vegetables decreases the risk of cardiovascular disease and [[death]].<ref name="ReferenceB">{{cite journal|last2=Ouyang|first2=Y|last3=Liu|first3=J|last4=Zhu|first4=M|last5=Zhao|first5=G|last6=Bao|first6=W|last7=Hu|first7=FB|date=Jul 29, 2014|title=Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies.|journal=BMJ |volume=349|pages=g4490|doi=10.1136/bmj.g4490|pmc=4115152|pmid=25073782|last1=Wang|first1=X}}</ref> Evidence suggests that the [[Mediterranean diet]] may improve cardiovascular outcomes.<ref>{{cite journal |vauthors=Walker C, Reamy BV |title=Diets for cardiovascular disease prevention: what is the evidence? |journal=Am Fam Physician |volume=79 |issue=7|pages=571–8 |date=April 2009 |pmid=19378874 |doi= |url=}}</ref> There is also evidence that a Mediterranean diet may be more effective than a [[low-fat diet]] in bringing about long-term changes to cardiovascular risk factors (e.g., lower [[cholesterol level]] and [[blood pressure]]).<ref>{{cite journal|last=Nordmann|first=AJ|author2=Suter-Zimmermann, K|author3=Bucher, HC|author4=Shai, I|author5=Tuttle, KR|author6=Estruch, R|author7=Briel, M|title=Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors.|journal=The American Journal of Medicine|date=September 2011|volume=124|issue=9|pages=841–51.e2|pmid=21854893|url=https://www.ncbi.nlm.nih.gov/pubmedhealth/featuredreviews/mediterraneandiet-2012/%20%20|doi=10.1016/j.amjmed.2011.04.024|deadurl=no|archiveurl=https://web.archive.org/web/20170908144309/https://www.ncbi.nlm.nih.gov/pubmedhealth/featuredreviews/mediterraneandiet-2012/%20%20|archivedate=2017-09-08|df=}}</ref> The [[DASH diet]] (high in nuts, fish, fruits and vegetables, and low in sweets, red meat and fat) has been shown to reduce blood pressure,<ref>{{cite journal |vauthors=Sacks FM, Svetkey LP, Vollmer WM |title=Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group |journal=N. Engl. J. Med. |volume=344 |issue=1 |pages=3–10 |date=January 2001 |pmid=11136953 |doi=10.1056/NEJM200101043440101 |url=|display-authors=etal}}</ref> lower total and low density lipoprotein cholesterol<ref>{{cite journal |vauthors=Obarzanek E, Sacks FM, Vollmer WM |title=Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial |journal=Am. J. Clin. Nutr. |volume=74 |issue=1 |pages=80–9 |date=July 2001 |pmid=11451721 |doi= |url=|display-authors=etal}}</ref>  and improve [[metabolic syndrome]];<ref>{{cite journal |vauthors=Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F |title=Beneficial effects of a Dietary Approaches to Stop Hypertension eating plan on features of the metabolic syndrome |journal=Diabetes Care |volume=28 |issue=12 |pages=2823–31 |date=December 2005 |pmid=16306540 |doi= 10.2337/diacare.28.12.2823|url=}}</ref> but the long-term benefits outside the context of a clinical trial have been questioned.<ref>{{cite journal |author=Logan AG |title=DASH Diet: time for a critical appraisal? |journal=Am. J. Hypertens. |volume=20 |issue=3 |pages=223–4 |date=March 2007 |pmid=17324730 |doi=10.1016/j.amjhyper.2006.10.006 |url=}}</ref> A [[high fiber diet]] appears to lower the risk.<ref>{{cite journal|last=Threapleton|first=D. E.|author2=Greenwood, D. C. |author3=Evans, C. E. L. |author4=Cleghorn, C. L. |author5=Nykjaer, C. |author6=Woodhead, C. |author7=Cade, J. E. |author8=Gale, C. P. |author9= Burley, V. J.  |title=Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis|journal=BMJ|date=19 December 2013|volume=347|issue=dec19 2|pages=f6879–f6879|doi=10.1136/bmj.f6879 |pmid=24355537 |pmc=3898422}}</ref>
-Research has shown that a diet that includes dark chocolate, almonds, fish, wine, fruits, vegetables, and garlic can increase life expectancy and decrease your risk for cardiovascular disease.<ref name= Franco >
+<!-- Fat -->
+Total fat intake does not appear to be an important risk factor.<ref>{{cite web|title=Fats and fatty acids in human nutrition Report of an expert consultation|url=http://www.who.int/nutrition/publications/nutrientrequirements/fatsandfattyacids_humannutrition/en/|website=World Health Organization|publisher=WHO/FAO|accessdate=20 December 2014|deadurl=no|archiveurl=https://web.archive.org/web/20141228005244/http://www.who.int/nutrition/publications/nutrientrequirements/fatsandfattyacids_humannutrition/en/|archivedate=28 December 2014|df=}}</ref><ref name=Will2012/> A diet high in [[trans fatty acids]], however, does increase rates of cardiovascular disease.<ref name=Will2012>{{cite journal|last=Willett|first=WC|title=Dietary fats and coronary heart disease.|journal=Journal of Internal Medicine|date=July 2012|volume=272|issue=1|pages=13–24|pmid=22583051|doi=10.1111/j.1365-2796.2012.02553.x}}</ref><ref name=Chow2014>{{cite journal|last=Chowdhury|first=Rajiv|author2=Warnakula, Samantha |author3=Kunutsor, Setor |author4=Crowe, Francesca |author5=Ward, Heather A. |author6=Johnson, Laura |author7=Franco, Oscar H. |author8=Butterworth, Adam S. |author9=Forouhi, Nita G. |author10=Thompson, Simon G. |author11=Khaw, Kay-Tee |author12=Mozaffarian, Dariush |author13=Danesh, John |author14=Di Angelantonio, Emanuele |title=Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk|journal=Annals of Internal Medicine|date=18 March 2014|volume=160|issue=6|pages=398–406|doi=10.7326/M13-1788|pmid=24723079}}</ref> Worldwide, dietary guidelines recommend a reduction in [[saturated fat]].<ref name=BMJ2013/> However, there are some [[Saturated fat and cardiovascular disease controversy|questions around the effect of saturated fat on cardiovascular disease]] in the medical literature.<ref name=Chow2014/><ref name=BMJ2015/> Reviews from 2014 and 2015 did not find evidence of harm from saturated fats.<ref name=Chow2014/><ref name=BMJ2015>{{cite journal|title=Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies|journal=BMJ|date=Aug 12, 2015|volume=351|issue=h3978|doi=10.1136/bmj.h3978|pmid=26268692|pmc=4532752 |vauthors=de Souza RJ, Mente A, Maroleanu A, Cozma AI, Ha V, Kishibe T, Uleryk E, Budylowski P, Schünemann H, Beyene J, Anand SS }}</ref> A 2012 [[Cochrane review]] found suggestive evidence of a small benefit from replacing dietary saturated fat by unsaturated fat.<ref>{{cite journal|last=Hooper|first=L|author2=Summerbell, CD |author3=Thompson, R |author4=Sills, D |author5=Roberts, FG |author6=Moore, HJ |author7= Davey Smith, G |title=Reduced or modified dietary fat for preventing cardiovascular disease.|journal=Cochrane Database of Systematic Reviews |date=May 16, 2012|volume=5|pages=CD002137|pmid=22592684|doi=10.1002/14651858.CD002137.pub3}}</ref> A 2013 meta analysis concludes that substitution with [[omega 6 linoleic acid]] (a type of unsaturated fat) may increase cardiovascular risk.<ref name=BMJ2013>{{cite journal|last=Ramsden|first=CE|author2=Zamora, D |author3=Leelarthaepin, B |author4=Majchrzak-Hong, SF |author5=Faurot, KR |author6=Suchindran, CM |author7=Ringel, A |author8=Davis, JM |author9= Hibbeln, JR  |title=Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study and updated meta-analysis.|journal=BMJ  |date=Feb 4, 2013|volume=346|pages=e8707|pmid=23386268|doi=10.1136/bmj.e8707 |pmc=4688426}}</ref> Replacement of saturated fats with [[carbohydrates]] does not change or may increase risk.<ref>{{cite journal |author1=Siri-Tarino Patty W |author2=Sun Qi |author3=Hu Frank B |author4=Krauss Ronald M | year = 2010 | title = Saturated fat, carbohydrate, and cardiovascular disease | url = | journal = American Journal of Clinical Nutrition | volume = 91 | issue = 3| pages = 502–509 | pmid=20089734 | doi=10.3945/ajcn.2008.26285 | pmc=2824150}}</ref><ref>{{cite journal|last=Micha|first=R|author2=Mozaffarian, D|title=Saturated fat and cardiometabolic risk factors, coronary heart disease, stroke, and diabetes: a fresh look at the evidence.|journal=Lipids|date=October 2010|volume=45|issue=10|pages=893–905|pmid=20354806|doi=10.1007/s11745-010-3393-4|pmc=2950931}}</ref> Benefits from replacement with [[polyunsaturated fat]] appears greatest;<ref name=Will2012/><ref>{{cite journal|last=Astrup|first=A|author2=Dyerberg, J |author3=Elwood, P |author4=Hermansen, K |author5=Hu, FB |author6=Jakobsen, MU |author7=Kok, FJ |author8=Krauss, RM |author9=Lecerf, JM |author10=LeGrand, P |author11=Nestel, P |author12=Risérus, U |author13=Sanders, T |author14=Sinclair, A |author15=Stender, S |author16=Tholstrup, T |author17=Willett, WC |title=The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010?|journal=The American Journal of Clinical Nutrition|date=April 2011|volume=93|issue=4|pages=684–8|pmid=21270379|doi=10.3945/ajcn.110.004622|pmc=3138219}}</ref> however, supplementation with [[omega-3 fatty acid]]s (a type of polysaturated fat) does not appear to have an effect.<ref>{{cite journal|last=Rizos|first=EC|author2=Ntzani, EE |author3=Bika, E |author4=Kostapanos, MS |author5= Elisaf, MS |title=Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis.|journal=JAMA |date=Sep 12, 2012|volume=308|issue=10|pages=1024–33|pmid=22968891|doi=10.1001/2012.jama.11374}}</ref>
-{{cite journal
+<!-- Salt -->
-| author= Franco, O, Bonneux, L, de Laet. C, Steyerberg, E, Mackenbach, J | title= Franco, O, Bonneux, L, de Laet. C, Steyerberg, E, Mackenbach, J | journal=BMJ. | year=2004 | pages= 1447–1450 | volume=329|
+The effect of a [[low-salt diet]] is unclear. A [[Cochrane review]] concluded that any benefit in people with high or normal blood pressure is small if present.<ref name=Taylor2011>{{cite journal|last=Taylor|first=RS|author2=Ashton, KE |author3=Moxham, T |author4=Hooper, L |author5= Ebrahim, S |title=Reduced dietary salt for the prevention of cardiovascular disease.|journal=Cochrane Database of Systematic Reviews |date=Jul 6, 2011|issue=7|pages=CD009217|pmid=21735439|doi=10.1002/14651858.CD009217}}</ref> In addition, the review suggested that a low-salt diet may be harmful in those with congestive heart failure.<ref name=Taylor2011/> However, the review was criticized in particular for not excluding a trial in heart failure where people had low-salt and -water levels due to diuretics.<ref name=He2011/> When this study is left out, the rest of the trials show a trend to benefit.<ref name=He2011>{{cite journal|last=He|first=F J|author2=MacGregor G A|title=Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials|journal=[[The Lancet]]|year=2011|volume=378|pages=380–382|url=http://www.actiononsalt.org.uk/news/Salt%20in%20the%20news/2011/58301.pdf|pmid=21803192|doi=10.1016/S0140-6736(11)61174-4|issue=9789|deadurl=no|archiveurl=https://web.archive.org/web/20131220235208/http://www.actiononsalt.org.uk/news/Salt%20in%20the%20news/2011/58301.pdf|archivedate=2013-12-20|df=}}</ref><ref name=Paterna2008>{{cite journal|last=Paterna|first=S|author2=Gaspare P|author3=Fasullo S|author4=Sarullo FM|author5=Di Pasquale P|title=Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend?|journal=[[Clinical Science (journal)|Clinical Science]]|year=2008|volume=114|pages=221–230|url=http://www.clinsci.org/cs/114/0221/cs1140221.htm|pmid=17688420|doi=10.1042/CS20070193|issue=3|deadurl=no|archiveurl=https://web.archive.org/web/20131208171407/http://www.clinsci.org/cs/114/0221/cs1140221.htm|archivedate=2013-12-08|df=}}</ref> Another review of dietary salt concluded that there is strong evidence that high dietary salt intake increases blood pressure and worsens hypertension, and that it increases the number of cardiovascular disease events; both as a result of the increased blood pressure ''and'', quite likely, through other mechanisms.<ref name=Bochud2011>{{cite journal|last=Bochud|first=M|author2=Marques-Vidal, P|author3=Burnier, M|author4=Paccaud, F|title=Dietary Salt Intake and Cardiovascular Disease: Summarizing the Evidence|journal=Public Health Reviews|year=2012|volume=33|pages=530–552|url=http://www.publichealthreviews.eu/show/f/85|deadurl=no|archiveurl=https://web.archive.org/web/20131221091620/http://www.publichealthreviews.eu/show/f/85|archivedate=2013-12-21|df=}}</ref><ref name=Cook2007>{{cite journal|last=Cook|first=N R|title=Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP)|journal=[[BMJ]]|year=2007|pages=885–8|url=http://www.bmj.com/content/334/7599/885|pmid=17449506|doi=10.1136/bmj.39147.604896.55|volume=334|issue=7599|pmc=1857760|display-authors=etal|deadurl=no|archiveurl=https://web.archive.org/web/20130803155958/http://www.bmj.com/content/334/7599/885|archivedate=2013-08-03|df=}}</ref> Moderate evidence was found that high salt intake increases cardiovascular mortality; and some evidence was found for an increase in overall mortality, strokes, and [[left ventricular hypertrophy]].<ref name=Bochud2011/>
-}}</ref>
-Eating [[oily fish]] at least twice a week may help reduce the risk of sudden death and arrhythmias. A 2005 review of 97 clinical trials by Studer et al. noted that omega-3 fats gave lower risk ratios than did statins.<ref>Studer M, Briel M, Liemenstoll B, Blass TR, Bucher HC. "Effect of different antilipidemic agents and diets on mortality: a systematic review." Arch. Intern. Med. 2005; 165(7): 725-730.</ref> [[Olive oil]] is said to have benefits.  Studies of individual heart cells showed that fatty acids blocked excessive [[sodium]] and [[calcium]] currents in the [[heart]], which could otherwise cause dangerous, unpredictable changes in its rhythm.
+===Medication===
+Blood pressure medication reduces cardiovascular disease in people at risk,<ref name="Ettehad 957–967"/> irrespective of age,<ref>{{Cite journal|last=Blood Pressure Lowering Treatment Trialists' Collaboration|last2=Turnbull|first2=F.|last3=Neal|first3=B.|last4=Ninomiya|first4=T.|last5=Algert|first5=C.|last6=Arima|first6=H.|last7=Barzi|first7=F.|last8=Bulpitt|first8=C.|last9=Chalmers|first9=J.|date=2008-05-17|title=Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials|journal=BMJ |volume=336|issue=7653|pages=1121–1123|doi=10.1136/bmj.39548.738368.BE|issn=1756-1833|pmc=2386598|pmid=18480116}}</ref> the baseline level of cardiovascular risk,<ref>{{Cite journal|last=Blood Pressure Lowering Treatment Trialists' Collaboration|last2=Sundström|first2=Johan|last3=Arima|first3=Hisatomi|last4=Woodward|first4=Mark|last5=Jackson|first5=Rod|last6=Karmali|first6=Kunal|last7=Lloyd-Jones|first7=Donald|last8=Baigent|first8=Colin|last9=Emberson|first9=Jonathan|date=2014-08-16|title=Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data|journal=Lancet |volume=384|issue=9943|pages=591–598|doi=10.1016/S0140-6736(14)61212-5|issn=1474-547X|pmid=25131978}}</ref> or baseline blood pressure.<ref>{{Cite journal|last=Czernichow|first=Sébastien|last2=Zanchetti|first2=Alberto|last3=Turnbull|first3=Fiona|last4=Barzi|first4=Federica|last5=Ninomiya|first5=Toshiaru|last6=Kengne|first6=André-Pascal|last7=Lambers Heerspink|first7=Hiddo J.|last8=Perkovic|first8=Vlado|last9=Huxley|first9=Rachel|date=2011-01-01|title=The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials|journal=Journal of Hypertension|volume=29|issue=1|pages=4–16|doi=10.1097/HJH.0b013e32834000be|issn=1473-5598|pmid=20881867}}</ref> The commonly-used drug regimens have similar efficacy in reducing the risk of all major cardiovascular events, although there may be differences between drugs in their ability to prevent specific outcomes.<ref name=":02">{{Cite journal|last=Turnbull|first=Fiona|last2=Blood Pressure Lowering Treatment Trialists' Collaboration|date=2003-11-08|title=Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials|journal=Lancet |volume=362|issue=9395|pages=1527–1535|issn=1474-547X|pmid=14615107|doi=10.1016/s0140-6736(03)14739-3}}</ref> Larger reductions in blood pressure produce larger reductions in risk,<ref name=":02" />  and most people with high blood pressure require more than one drug to achieve adequate reduction in blood pressure.<ref>{{Cite journal|last=Go|first=Alan S.|last2=Bauman|first2=Mary Ann|last3=Coleman King|first3=Sallyann M.|last4=Fonarow|first4=Gregg C.|last5=Lawrence|first5=Willie|last6=Williams|first6=Kim A.|last7=Sanchez|first7=Eduardo|last8=American Heart Association|last9=American College of Cardiology|date=2014-04-01|title=An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention|journal=Hypertension |volume=63|issue=4|pages=878–885|doi=10.1161/HYP.0000000000000003|issn=1524-4563|pmid=24243703}}</ref>
-=== Cardiovascular disease and salt ===
+[[Statins]] are effective in preventing further cardiovascular disease in people with a history of cardiovascular disease.<ref name="Statins20122">{{cite journal|last=Gutierrez|first=J|date=Jun 25, 2012|title=Statin Therapy in the Prevention of Recurrent Cardiovascular Events: A Sex-Based Meta-analysisStatin Therapy to Prevent Recurrent CV Events.|journal=Archives of Internal Medicine|volume=172|issue=12|pages=909–19|doi=10.1001/archinternmed.2012.2145|pmid=22732744|author2=Ramirez, G|author3=Rundek, T|author4=Sacco, RL}}</ref> As the event rate is higher in men than in women, the decrease in events is more easily seen in men than women.<ref name="Statins20122" /> In those at risk, but without a history of cardiovascular disease (primary prevention), statins decrease the risk of death and combined fatal and non-fatal cardiovascular disease.<ref>{{cite journal|last=Taylor|first=F|date=Jan 31, 2013|title=Statins for the primary prevention of cardiovascular disease.|journal=Cochrane Database of Systematic Reviews |volume=1|pages=CD004816|doi=10.1002/14651858.CD004816.pub5|pmid=23440795|author2=Huffman, MD|author3=Macedo, AF|author4=Moore, TH|author5=Burke, M|author6=Davey Smith, G|author7=Ward, K|author8=Ebrahim, S}}</ref> A United States guideline recommends statins in those who have a 12% or greater risk of cardiovascular disease over the next ten years.<ref>{{cite journal|last2=O'Malley|first2=PG|date=18 August 2015|title=Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline.|journal=Annals of Internal Medicine|volume=163|issue=4|pages=291–7|doi=10.7326/m15-0840|pmid=26099117|last1=Downs|first1=JR}}</ref>  [[Niacin]], [[fibrates]] and [[CETP Inhibitors]], while they may increase [[HDL cholesterol]] do not affect the risk of cardiovascular disease in those who are already on statins.<ref>{{cite journal|last2=Price|first2=C|last3=Shun-Shin|first3=MJ|last4=Francis|first4=DP|date=Jul 18, 2014|title=Effect on cardiovascular risk of high density lipoprotein targeted drug treatments niacin, fibrates, and CETP inhibitors: meta-analysis of randomised controlled trials including 117,411 patients.|journal=BMJ |volume=349|pages=g4379|doi=10.1136/bmj.g4379|pmc=4103514|pmid=25038074|last1=Keene|first1=D}}</ref>
-There is evidence from one large unblinded randomised controlled trial of more than 3000 patients that reducing the amount of sodium in the diet reduced the risk of cardiovascular events by more than 25%.<ref name="TOHP2007">{{cite journal | title=Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP) | author=Cook NR, Cutler JA, Obarzanek E, ''et al.'' | journal=Br Med J | year=2007 | doi=10.1136/bmj.39147.604896.55 }}</ref>  This re-affirms evidence from the [[Intersalt study]] published in 1988, that high levels of dietary salt are harmful;<ref>{{cite journal | author=Elliott P, Stamler J, Nichols R, ''et al.'' | title=Intersalt revisited: further analyses of 24 hour sodium excretion and blood pressure within and across populations. Intersalt Cooperative Research Group | journal=Br Med J | year=1996 | volume=312 | issue=7041 | pages=1249&ndash;53 | id=PMID 8634612 }}</ref> these results were at the time heavily disputed by the [[Salt Institute]] (the salt producers' trade organisation).<ref>{{cite journal | author=Godlee F | title=Editor's Choice: Time to talk salt | journal=Br Med J | year=2007 | volume=334 | issue=7599 | doi=10.1136/bmj.39196.679537.47 }}</ref>
+[[Anti-diabetic medication]] may reduce cardiovascular risk in people with Type 2 Diabetes, although evidence is not conclusive.<ref>{{Cite journal|last=Holman|first=Rury R|last2=Sourij|first2=Harald|last3=Califf|first3=Robert M|title=Cardiovascular outcome trials of glucose-lowering drugs or strategies in type 2 diabetes|url=https://dx.doi.org/10.1016/S0140-6736(14)60794-7|journal=The Lancet|volume=383|issue=9933|pages=2008–2017|doi=10.1016/s0140-6736(14)60794-7}}</ref> A meta-analysis in 2009 including 27,049 participants and 2,370 major vascular events showed a 15% [[relative risk reduction]] in cardiovascular disease with more-intensive glucose lowering over an average follow-up period of 4.4 years, but an increased risk of major [[hypoglycemia]].<ref>{{Cite journal|last=Control Group|last2=Turnbull|first2=F. M.|last3=Abraira|first3=C.|last4=Anderson|first4=R. J.|last5=Byington|first5=R. P.|last6=Chalmers|first6=J. P.|last7=Duckworth|first7=W. C.|last8=Evans|first8=G. W.|last9=Gerstein|first9=H. C.|date=2009-11-01|title=Intensive glucose control and macrovascular outcomes in type 2 diabetes|journal=Diabetologia|volume=52|issue=11|pages=2288–2298|doi=10.1007/s00125-009-1470-0|issn=1432-0428|pmid=19655124}}</ref>
-== Awareness ==
+[[Aspirin]] has been found to be of only modest benefit in those at low risk of heart disease as the risk of serious bleeding is almost equal to the benefit with respect to cardiovascular problems.<ref>{{cite journal|last=Berger|first=JS|date=July 2011|title=Aspirin for the prevention of cardiovascular events in patients without clinical cardiovascular disease: a meta-analysis of randomized trials.|journal=American Heart Journal|volume=162|issue=1|pages=115–24.e2|doi=10.1016/j.ahj.2011.04.006|pmid=21742097|author2=Lala, A|author3=Krantz, MJ|author4=Baker, GS|author5=Hiatt, WR}}</ref> In those at very low risk it is not recommended.<ref>{{cite web|url=http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-for-the-prevention-of-cardiovascular-disease-preventive-medication|title=Final Recommendation Statement Aspirin for the Prevention of Cardiovascular Disease: Preventive Medication|date=March 2009|accessdate=15 January 2015|deadurl=no|archiveurl=https://web.archive.org/web/20150110041518/http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-for-the-prevention-of-cardiovascular-disease-preventive-medication|archivedate=10 January 2015|df=}}</ref> The [[United States Preventive Services Task Force]] recommends against use of aspirin for prevention in women less than 55 and men less than 45 years old; however, in those who are older it is recommends in some individuals.<ref>{{cite journal|date=17 March 2009|title=Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement.|journal=Annals of Internal Medicine|volume=150|issue=6|pages=396–404|doi=10.7326/0003-4819-150-6-200903170-00008|pmid=19293072|last1=US Preventive Services Task|first1=Force}}</ref>
-[[Atherosclerosis]] is a process that develops over decades and is often silent until an acute event (heart attack) develops in later life.   Population based studies in the youth show that the precursors of heart disease start in adolescence. The process of atherosclerosis evolves over decades, and begins as early as childhood. The Pathobiological Determinants of Atherosclerosis in Youth Study demonstrated that intimal lesions appear in all the aortas and more than half of the right coronary arteries of youths aged 15–19 years.  However, most adolescents are more concerned about other risks such as HIV, accidents, and cancer than cardiovascular disease.<ref>Vanhecke TE, Miller WM, Franklin BA, Weber JE, McCullough PA.  Awareness, knowledge, and perception of heart disease among adolescents.  European Journal of Cardiovascular Prevention and Rehabilitation.  October, 2006; 13(5): 718-723.  ISSN 1741-8267</ref>  This is extremely important considering that 1 in 3 people will die from complications attributable to atherosclerosis. In order to stem the tide of cardiovascular disease, primary prevention is needed.  Primary prevention starts with education and awareness that cardiovascular disease poses the greatest threat and measures to prevent or reverse this disease must be taken.
+The use of [[vasoactive]] agents for people with pulmonary hypertension with left heart disease or hypoxemic lung diseases may cause harm and unnecessary expense.<ref name="ACCPandATSfive2">{{Citation|title=Five Things Physicians and Patients Should Question|date=September 2013|url=http://www.choosingwisely.org/doctor-patient-lists/american-college-of-chest-physicians-and-american-thoracic-society/|author1=American College of Chest Physicians|author2=American Thoracic Society|author1-link=American College of Chest Physicians|author2-link=American Thoracic Society|work=[[Choosing Wisely]]: an initiative of the [[ABIM Foundation]]|page=|publisher=American College of Chest Physicians and American Thoracic Society|accessdate=6 January 2013|deadurl=no|archiveurl=https://web.archive.org/web/20131103063427/http://www.choosingwisely.org/doctor-patient-lists/american-college-of-chest-physicians-and-american-thoracic-society/|archivedate=3 November 2013|df=}}</ref>
-== Treatment ==
+=== Physical activity ===
+A systematic review estimated that inactivity is responsible for 6% of the burden of disease from coronary heart disease worldwide.<ref>{{Cite journal|last=Lee|first=I.-Min|last2=Shiroma|first2=Eric J.|last3=Lobelo|first3=Felipe|last4=Puska|first4=Pekka|last5=Blair|first5=Steven N.|last6=Katzmarzyk|first6=Peter T.|last7=Lancet Physical Activity Series Working Group|date=2012-07-21|title=Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy|journal=Lancet |volume=380|issue=9838|pages=219–229|doi=10.1016/S0140-6736(12)61031-9|issn=1474-547X|pmc=3645500|pmid=22818936}}</ref> The authors estimated that 121,000 deaths from coronary heart disease could have been averted in Europe in 2008, if physical inactivity had been removed. A Cochrane review found some evidence that yoga has favourable effects on blood pressure and cholesterol, but studies included in this review were of low quality.<ref>{{Cite journal|last=Hartley|first=Louise|last2=Dyakova|first2=Mariana|last3=Holmes|first3=Jennifer|last4=Clarke|first4=Aileen|last5=Lee|first5=Myeong Soo|last6=Ernst|first6=Edzard|last7=Rees|first7=Karen|date=2014-05-13|title=Yoga for the primary prevention of cardiovascular disease|journal=The Cochrane Database of Systematic Reviews|issue=5|pages=CD010072|doi=10.1002/14651858.CD010072.pub2|issn=1469-493X|pmid=24825181}}</ref>
-Treatment of cardiovascular disease depends on the specific form of the disease in each patient, but effective treatment always includes preventive lifestyle changes discussed above.  Medications, such as [[antihypertensive|blood pressure reducing medications]], aspirin and the statin cholesterol-lowering drugs may be helpful.  In some circumstances, [[Coronary artery bypass surgery|surgery]] or [[angioplasty]] may be warranted to reopen, repair, or replace damaged blood vessels.
+===Dietary supplements===
+While a [[healthy diet]] is beneficial, the effect of [[antioxidant]] supplementation ([[vitamin E]], [[vitamin C]], etc.) or vitamins has not been shown to protect against cardiovascular disease and in some cases may possibly result in harm.<ref>{{cite journal|last=Bhupathiraju|first=SN|date=Aug 17, 2011|title=Coronary heart disease prevention: nutrients, foods, and dietary patterns.|journal=Clinica Chimica Acta |volume=412|issue=17–18|pages=1493–514|doi=10.1016/j.cca.2011.04.038|pmid=21575619|author2=Tucker, KL}}</ref><ref>{{cite journal|last=Myung|first=SK|date=Jan 18, 2013|title=Efficacy of vitamin and antioxidant supplements in prevention of cardiovascular disease: systematic review and meta-analysis of randomised controlled trials.|journal=BMJ |volume=346|pages=f10|doi=10.1136/bmj.f10|pmc=3548618|pmid=23335472|author2=Ju, W|author3=Cho, B|author4=Oh, SW|author5=Park, SM|author6=Koo, BK|author7=Park, BJ|author8=for the Korean Meta-Analysis (KORMA) Study, Group}}</ref> Mineral supplements have also not been found to be useful.<ref>{{cite journal|last=Fortmann|first=SP|date=Nov 12, 2013|title=Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force.|journal=Annals of Internal Medicine|volume=159|issue=12|pages=824–34|doi=10.7326/0003-4819-159-12-201312170-00729|pmid=24217421|author2=Burda, BU|author3=Senger, CA|author4=Lin, JS|author5=Whitlock, EP}}</ref> [[Niacin]], a type of vitamin B3, may be an exception with a modest decrease in the risk of cardiovascular events in those at high risk.<ref>{{cite journal|last=Bruckert|first=E|date=June 2010|title=Meta-analysis of the effect of nicotinic acid alone or in combination on cardiovascular events and atherosclerosis|journal=Atherosclerosis|volume=210|issue=2|pages=353–61|doi=10.1016/j.atherosclerosis.2009.12.023|pmid=20079494|author2=Labreuche, J|author3=Amarenco, P}}</ref><ref>{{cite journal|last=Lavigne|first=PM|date=Jan 29, 2013|title=The current state of niacin in cardiovascular disease prevention: a systematic review and meta-regression.|journal=Journal of the American College of Cardiology|volume=61|issue=4|pages=440–6|doi=10.1016/j.jacc.2012.10.030|pmid=23265337|author2=Karas, RH}}</ref> [[Magnesium]] supplementation lowers high blood pressure in a dose dependent manner.<ref name="Jee2002">{{cite journal|year=2002|title=The effect of magnesium supplementation on blood pressure: a meta-analysis of randomized clinical trials|journal=Am J Hypertens|volume=15|issue=8|pages=691–696|doi=10.1016/S0895-7061(02)02964-3|pmid=12160191|vauthors=Jee SH, Miller ER, Guallar E|display-authors=etal}}</ref> Magnesium therapy is recommended for people with ventricular [[arrhythmia]] associated with [[torsades de pointes]] who present with [[long QT syndrome]] as well as for the treatment of people with digoxin intoxication-induced arrhythmias.<ref name="Zipes2006">{{cite journal|year=2012|title=ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society|journal=Circulation|volume=114|issue=10|pages=e385–e484|doi=10.1161/CIRCULATIONAHA.106.178233|pmid=16935995|vauthors=Zipes DP, Camm AJ, Borggrefe M|display-authors=etal}}</ref> There is no evidence to support [[omega-3 fatty acid]] supplementation.<ref>{{cite journal|last=Kwak|first=SM|date=Apr 9, 2012|title=Efficacy of Omega-3 Fatty Acid Supplements (Eicosapentaenoic Acid and Docosahexaenoic Acid) in the Secondary Prevention of Cardiovascular Disease: A Meta-analysis of Randomized, Double-blind, Placebo-Controlled Trials.|journal=Archives of Internal Medicine|volume=172|issue=9|pages=686|doi=10.1001/archinternmed.2012.262|pmid=22493407|author2=Myung, SK|author3=Lee, YJ|author4=Seo, HG|author5=for the Korean Meta-analysis Study, Group}}</ref>
-== Types of Cardiovascular Diseases ==
+==Management==
+Cardiovascular disease is treatable with initial treatment primarily focused on diet and lifestyle interventions.<ref name=WHO2011/> [[Influenza]] may make heart attacks and strokes more likely and therefore [[influenza vaccination]] may decrease the chance of cardiovascular events and death in people with heart disease.<ref>{{Cite journal|last=Clar|first=Christine|last2=Oseni|first2=Zainab|last3=Flowers|first3=Nadine|last4=Keshtkar-Jahromi|first4=Maryam|last5=Rees|first5=Karen|date=2015-05-05|title=Influenza vaccines for preventing cardiovascular disease|journal=The Cochrane Database of Systematic Reviews|issue=5|pages=CD005050|doi=10.1002/14651858.CD005050.pub3|issn=1469-493X|pmid=25940444}}</ref>
-* [[Aneurysm]]
+Proper CVD management necessitates a focus on MI and stroke cases due to their combined high mortality rate, keeping in mind the cost-effectiveness of any intervention, especially in developing countries with low or middle income levels.<ref name=":0" /> Regarding MI, strategies using aspirin, atenolol, streptokinase or tissue plasminogen activator have been compared for quality-adjusted life-year (QALY) in regions of low and middle income. The costs for a single QALY for aspirin, atenolol, streptokinase, and t-PA were $25, $630–$730, and $16,000, respectively. Aspirin, ACE inhibitors, beta blockers, and statins used together for secondary CVD prevention in the same regions showed single QALY costs of $300–400.
-* [[Angina pectoris|Angina]]
-* [[Cardiac arrhythmia|Arrhythmia]]
-* [[Atherosclerosis]]
-* [[Cardiomyopathy]]
-* [[Cerebrovascular accident]] ([[Stroke]])
-* [[Cerebrovascular disease]]
-* [[Congenital heart disease]]
-* [[Heart failure|Congestive Heart Failure]]
-* [[Myocarditis]]
-* [[Valvular heart disease|Valve Disease]]
-* [[Coronary heart disease|Coronary Artery Disease]]
-* [[Dilated cardiomyopathy]]
-* [[Diastolic dysfunction]]
-* [[Endocarditis]]
-* [[Hypertension|High Blood Pressure (Hypertension)]]
-* [[Hypertrophic cardiomyopathy]]
-* [[Mitral valve prolapse]]
-* [[Myocardial infarction]] ([[Heart Attack]])
-* [[vein|Venous]] [[Thrombosis|Thromboembolism]]
-== Research ==
+==Epidemiology==
+[[File:Cardiovascular diseases world map-Deaths per million persons-WHO2012.svg|thumb|upright=1.3|Cardiovascular diseases  deaths per million persons in 2012 {{refbegin|3}}{{legend|#ffff20|318–925}}{{legend|#ffe820|926–1,148}}{{legend|#ffd820|1,149–1,294}}{{legend|#ffc020|1,295–1,449}}{{legend|#ffa020|1,450–1,802}}{{legend|#ff9a20|1,803–2,098}}{{legend|#f08015|2,099–2,624}}{{legend|#e06815|2,625–3,203}}{{legend|#d85010|3,204–5,271}}{{legend|#d02010|5,272–10233}}{{refend}}]]
+[[File:Cardiovascular diseases world map - DALY - WHO2004.svg|thumb|upright=1.3|Disability-adjusted life year for cardiovascular diseases per 100,000&nbsp;inhabitants in 2004<ref name="World Health Organization"/>{{refbegin|2}}
+{{legend|#b3b3b3|no data}}
+{{legend|#ffff65|<900}}
+{{legend|#fff200|900–1650}}
+{{legend|#ffdc00|1650–2300}}
+{{legend|#ffc600|2300–3000}}
+{{legend|#ffb000|3000–3700}}
+{{legend|#ff9a00|3700–4400}}
+{{legend|#ff8400|4400–5100}}
+{{legend|#ff6e00|5100–5800}}
+{{legend|#ff5800|5800–6500}}
+{{legend|#ff4200|6500–7200}}
+{{legend|#ff2c00|7200–7900}}
+{{legend|#cb0000|>7900}}
+{{refend}}]]
-The causes, prevention, and/or treatment of all forms of cardiovascular disease are active fields of [[biomedical research]], with hundreds of scientific studies being published on a weekly basis.
+Cardiovascular diseases are the leading cause of death worldwide and in all regions except Africa.<ref>{{Cite book|url=https://www.worldcat.org/oclc/796362754|title=Global atlas on cardiovascular disease prevention and control|last=Shanthi|first=Mendis,|last2=Pekka|first2=Puska,|last3=Bo|first3=Norrving,|date=2011-01-01|publisher=World Health Organization|isbn=9789241564373|oclc=796362754}}</ref> In 2008, 30% of all global death was attributed to cardiovascular diseases. Death caused by cardiovascular diseases are also higher in low- and middle-income countries as over 80% of all global deaths caused by cardiovascular diseases occurred in those countries. It is also estimated that by 2030, over 23 million people will die from cardiovascular diseases each year.
-A fairly recent emphasis is on the link between low-grade [[inflammation]] that hallmarks atherosclerosis and its possible interventions. [[C-reactive protein]] (CRP) is an inflammatory marker that may be present in increased levels in the blood in patients at risk for cardiovascular disease. Its exact role in predicting disease is the subject of debate.
+It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the [[Indian Heart Association]] are working with the [[World Heart Federation]] to raise awareness about this issue.<ref name="Indian Heart">Indian Heart Association Why South Asians Facts Web. 29 April 2015. <{{cite web |url=http://indianheartassociation.org/why-indians-why-south-asians/overview/ |title=Archived copy |accessdate=2015-05-08 |deadurl=no |archiveurl=https://web.archive.org/web/20150518111218/http://indianheartassociation.org/why-indians-why-south-asians/overview/ |archivedate=2015-05-18 |df= }}></ref>
-Some areas currently being researched include possible links between [[infection]] with ''[[Chlamydophila pneumoniae]]'' and coronary artery disease. The ''Chlamydia'' link has become less plausible with the absence of improvement after antibiotic use.<ref>Andraws R, Berger JS, Brown DL. ''Effects of antibiotic therapy on outcomes of patients with coronary artery disease''. [[Journal of the American Medical Association|JAMA]] 2005;293:2641-7. PMID 15928286.</ref>
+==Research==
+{{See also|Timeline of cardiovascular disease}}
+There is evidence that cardiovascular disease existed in pre-history,<ref>{{Cite journal|last=Thompson|first=Randall C|last2=Allam|first2=Adel H|last3=Lombardi|first3=Guido P|last4=Wann|first4=L Samuel|last5=Sutherland|first5=M Linda|last6=Sutherland|first6=James D|last7=Soliman|first7=Muhammad Al-Tohamy|last8=Frohlich|first8=Bruno|last9=Mininberg|first9=David T|title=Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations|url=https://dx.doi.org/10.1016/S0140-6736(13)60598-X|journal=The Lancet|volume=381|issue=9873|pages=1211–1222|doi=10.1016/s0140-6736(13)60598-x}}</ref> and research into cardiovascular disease dates from at least the 18th century.<ref>{{Cite journal|last=Alberti|first=Fay Bound|date=2013-05-01|title=John Hunter's Heart|url=http://publishing.rcseng.ac.uk/doi/10.1308/003588413X13643054409261|journal=The Bulletin of the Royal College of Surgeons of England|volume=95|issue=5|pages=168–169|doi=10.1308/003588413X13643054409261|issn=1473-6357}}</ref>  The causes, prevention, and/or treatment of all forms of cardiovascular disease remain active fields of [[biomedical research]], with hundreds of scientific studies being published on a weekly basis.
-== References ==
+Recent areas of research include the link between inflammation and atherosclerosis<ref>{{Cite journal|last=Ruparelia|first=Neil|last2=Chai|first2=Joshua T.|last3=Fisher|first3=Edward A.|last4=Choudhury|first4=Robin P.|title=Inflammatory processes in cardiovascular disease: a route to targeted therapies|url=http://www.nature.com/doifinder/10.1038/nrcardio.2016.185|journal=Nature Reviews Cardiology|volume=14|issue=3|pages=133–144|doi=10.1038/nrcardio.2016.185}}</ref>  the potential for novel therapeutic interventions,<ref>{{Cite journal|last=Tang|first=W. H. Wilson|last2=Hazen|first2=Stanley L.|date=2017-01-17|title=Atherosclerosis in 2016: Advances in new therapeutic targets for atherosclerosis|journal=Nature Reviews Cardiology|volume=14|issue=2|pages=71–72|doi=10.1038/nrcardio.2016.216|issn=1759-5010|pmid=28094270}}</ref> and the genetics of coronary heart disease.<ref>{{Cite journal|last=Swerdlow|first=Daniel I.|last2=Humphries|first2=Steve E.|date=2017-02-01|title=Genetics of CHD in 2016: Common and rare genetic variants and risk of CHD|journal=Nature Reviews Cardiology|volume=14|issue=2|pages=73–74|doi=10.1038/nrcardio.2016.209|issn=1759-5010|pmid=28054577}}</ref>
-{{reflist|2}}
+{{-}}
-== External links ==
+==References==
+{{Reflist}}
-* [[American Heart Association]] "Heart Disease and Stroke Statistics-2006 Update".  http://www.americanheart.org/downloadable/heart/1140534985281Statsupdate06book.pdf
+==External links==
-* [http://www.cvdf.org Cardiovascular Disease Foundation] Your connection to prevention, research, and education.
+{{Medical condition classification and resources
-* [http://www.sistertosister.org Sister to Sister] Information about Women's Heart Disease
+| DiseasesDB     = 28808
-* [http://www.nature.com/ncpcardio/index.html NCP Cardiovascular Medicine] A Journal Covering Clinical Cardiovascular Medicine
+| ICD10          = {{ICD10|I|51|6|i|30}}
-* [http://www.dietaryfiberfood.com/cholesterol-high-avoid.php Cholesterol Content in Food]
+| ICD9           = {{ICD9|429.2}}
-* [http://www.americanheart.org/presenter.jhtml?identifier=3039313 The lacking awareness of cardiovascular disease by youth] A study by Dr Thomas E. Vanhecke, MD.
+| ICDO           =
-* [http://www.americanheart.org/presenter.jhtml?identifier=3000333 American Heart Association]
+| OMIM           =
-* [http://www.who.int/cardiovascular_diseases/en/ World Health Organization cardiovascular disease site]
+| MedlinePlus    =
-* [http://news.bbc.co.uk/1/hi/health/4764891.stm Heart disease 'costing UK £29bn'] at BBC News, 14 May 2006
+| eMedicineSubj  =
-* [http://www.who.int/nutrition/topics/dietnutrition_and_chronicdiseases/en/ Diet, Nutrition and the prevention of chronic diseases] (including cardiovascular diseases) by a Joint [[WHO]]/[[FAO]] Expert consultation (2003)
+| eMedicineTopic =
-* [http://www.lipidsonline.org/slides/slide01.cfm?q=cholesterol+distribut&dpg=1 Total Cholesterol Distribution vs. CHD deaths]
+| MeshID         = D002318
-* [http://www.ohsu.edu/drugeffectiveness/reports/documents/BB_final_report_update%203.pdf Drug Class Review on Beta Adrenergic Blockers Sep 2007]
+}}
+* {{dmoz|Health/Conditions_and_Diseases/Cardiovascular_Disorders/Heart_Disease}}
+* [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-CVD-prevention.pdf European Guidelines on cardiovascular disease prevention in clinical practice (version 2012)]
+* [http://www.medicinenet.com/heart_disease_coronary_artery_disease/article.htm Heart Disease] [[MedicineNet]] Slides, photos, descriptions
 {{Circulatory system pathology}}
+{{Vascular diseases}}
+{{Certain conditions originating in the perinatal period}}
+{{Cardiovascular system symptoms and signs}}
+{{Eponymous medical signs for cardiovascular system}}
-[[Category:Cardiology]]
+{{Authority control}}
-[[Category:Medical conditions related to obesity]]
-[[de:Herz-Kreislauf-Erkrankung]]
-[[fr:Maladie cardio-vasculaire]]
-[[lv:sirds slimības]]
-[[no:Hjerte- og karsykdommer]]
-[[pl:Choroby układu krążenia]]
-[[pt:Doença cardiovascular]]
-[[sl:Bolezni srca in ožilja]]
-[[sv:Hjärt- och kärlsjukdomar]]
-[[zh:心血管疾病]]
-{{WH}}
+{{DEFAULTSORT:Cardiovascular Disease}}
-{{WS}}
+[[Category:Heart diseases| ]]
-{{jb1}}
+[[Category:RTT]]
+[[Category:RTTEM]]

Cardiovascular disease: Difference between revisions

Latest revision as of 18:48, 17 February 2022

Overview

Types

Risk factors

Genetics

Age

Sex

Racial and Ethnic Groups

Tobacco

Physical inactivity

Diet

Socioeconomic disadvantage

Air pollution

Cardiovascular risk assessment

Occupational exposure

Chemical risk factors

Non-chemical risk factors

Somatic mutations

Pathophysiology

Screening

Evidence

Prevention

Diet

Medication

Physical activity

Dietary supplements

Management

Epidemiology

Research

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External links

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