By Dr Susan Kurvilla, Cardiologist, Nedlands
Cardiovascular disease remains the leading cause of mortality and is responsible for a significant number of death and disabilities that are largely preventable. It kills one in every four Australians.
Breakthrough therapies and advanced risk prediction tools offer remarkable possibilities of prevention, yet basic proven interventions often fail to reach many who need them most. Addressing the challenges we face in delivering proven preventive care is as crucial as identifying new treatments.
Achieving the promise of cardiovascular disease prevention requires solving the problem of translating what we know into tangible benefits for patients and populations.
Modifiable risk factors
High systolic blood pressure remains the leading modifiable risk factor globally for attributable premature cardiovascular deaths – 10.8 million cardiovascular deaths and 11.3 million deaths overall in 2021 – particularly linked to ischaemic heart disease and stroke-related death. Intensive blood pressure control is projected to extend life expectancy by up to three years when initiated in middle age.
Dietary risks accounted for 6.58 million cardiovascular deaths and 8 million deaths overall in 2021. This estimate included food types that are under consumed globally – fruits, vegetables, legumes, whole grains, nuts and seeds, milk, fibre calcium, omega-3 fatty acids from seafood, and polyunsaturated fatty acids – or overconsumed like red meat, processed meat, sugar-sweetened beverages, trans-fatty acids, and sodium.
Excess dietary sodium is a major driver of hypertension in many countries and modest dietary sodium restriction by 3g per day has been projected to avert cardiovascular events and reduce deaths in a cost-saving manner.
High LDL-C has persisted as a leading modifiable risk factor and is one of the most closely linked markers of atherosclerotic CVD. In 2021, 3.81 million cardiovascular deaths and 3.81 million deaths overall were attributed to elevated LDL-C levels.
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Exposure to lower cumulative LDL-C levels in young and middle-aged adults has been associated with reduced long-term cardiovascular risk.
Statins are the cornerstone of primary and secondary prevention of CVDs. Sequential advances have identified other effective classes of lipid-lowering therapies that lower LDL-C and positively affect cardiovascular health, for example ezetimibe, PCSK9 inhibitors and Inclisiran.
Leading causes of death
Air pollution in the form of ambient particulate matter with an aerodynamic diameter smaller than 2.5 μm and household air pollution from cooking fuels represents the leading environmental risk factor for premature CVD and mortality. In 2021, 4.75 million cardiovascular deaths and 8.54 million deaths overall were attributable to air pollution.
Tobacco is the fifth leading actual cause of cardiovascular death, with 3.01 million cardiovascular deaths and 7.61 million deaths overall attributable to tobacco use in 2021.
Obesity is closely associated with multiple health risks and directly contributes to the pathogenesis and progression of CVD. In 2021, 1.95 million cardiovascular deaths and 3.7 million deaths overall were attributable to elevated BMI.
Changing the trajectory
Community-based health promotion and intensive lifestyle management interventions may have durable impact on cardiometabolic health long-term. Early, comprehensive programs that can be embedded in schools have been demonstrated to influence childhood behaviours and cardiovascular health trajectories.
High fasting plasma glucose tracks closely with high burden of prediabetes, diabetes, and obesity worldwide. In 2021, 2.30 million cardiovascular deaths and 5.4 million deaths overall were attributable to elevated fasting plasma glucose.
Population strategies to improve glycaemic risk overlap substantially with approaches to other primary risk factors, including low physical activity and adverse dietary profiles.
Two therapeutic classes, SGLT-2 inhibitors and the glucagon-like peptide-1 receptor agonists, can prevent cardiovascular complications and kidney disease progression in patients with diabetes. Continuous glucose monitoring has been introduced to minimize glycaemic excursions and improve precision of glycaemic control.
In 2021, 1.87 million cardiovascular deaths and 3.47 million deaths overall were attributable to reduced kidney function. Patients who ultimately progress to end-stage kidney disease requiring dialysis face reduced health-related quality of life and heightened risk of death while contributing substantially to increased health system costs.
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Lead exposure remains a silent but major contributor to CVD mortality and health loss. Lead is an under recognised environmental factor linked with hypertension, stroke, coronary artery disease, peripheral artery disease, and other CVDs.
Low physical activity levels represent an important threat to cardiovascular health. In 2021, 0.397 million cardiovascular deaths and 0.686 million deaths overall were estimated as being attributable to inadequate physical activity.
Key messages
- Cardiovascular disease is the leading cause of mortality globally
- Attention to delivering proven preventive care is as crucial as development of new therapies.
There is clear evidence of substantial years of life lost and reduction in life expectancy with heavy alcohol use, especially as alcohol consumption exceeds 100g weekly. Cardiovascular risks associated with increased blood pressure and arrhythmias are seen with higher alcohol use.
The COVID-19 pandemic has had a profound impact on health worldwide. Patients with CVDs faced among the highest risks of mortality and complications when infected.
COVID-19 may trigger acute cardiovascular events, such as myocardial infarctions or strokes and the longer-term cardiovascular health implications of COVID-19 infection are increasingly recognised.
Author competing interests – nil
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