Primary prevention of arteriosclerotic cardiovascular disease (ASCVD) is a desirable but challenging goal to attain. Several strategies to delay the onset of clinically meaningful ASCVD have been proposed, however, clinical application of these strategies is patchy at best.
What clinical counselling and advice could a clinician offer a young asymptomatic patient with a modest family history but no known cardiovascular disease? What evidence-based tests, if any, could inform their predicted risk of ASCVD? Furthermore, are there any actionable interventions to put in place as part of their management plan, to reduce their lifetime risk of clinically relevant ASCVD?
General interventions towards reducing the lifetime risk of cardiovascular events involve a combination of lifestyle modifications such as taking up a healthier diet, avoidance or quitting tobacco smoking and limiting the use of alcohol, and regular health check-ups to monitor markers of metabolic health such as blood pressure, glycaemic control, and cholesterol checks. Intimate knowledge of family history of cardiac disease is also an important motivation, to stay on the preventative front foot.
Cholesterol-years
The concept of low-density lipoprotein cholesterol-years, akin to pack years of smoking, is worth a highlight. Even with optimised lifestyle interventions, serum circulating low-density lipoprotein cholesterol (LDL-C) concentrations often exceed optimum levels, contributing to high cholesterol-years, which is associated with extravascular lipid deposition in tissues.
What’s more, some patients with normal cholesterol levels still harbour a high risk of cardiovascular-related events. To that end, there is merit in considering the atherogenicity of the LDL-C, which is an important risk factor for atherosclerosis. Routine assay of Lipoprotein A and Apolipoprotein B levels, to identity those with more atherogenic circulating LDL-C, could lead to early intervention in this cohort, possibly delaying the onset of clinically relevant ASCVD.
Optimising maximal oxygen intake
Clinicians should extol the evidence-based cardiovascular benefits of moderate intensity aerobic exercise, along with muscle strengthening activities. Exercise exerts favourable effects on cardiovascular function such as improving endothelial function and insulin sensitivity, lowering blood pressure and improving lipid indices, as well as reducing systemic inflammation.
Higher maximal oxygen uptake (VO2 max), a strong predictor of cardiorespiratory fitness, is associated with a reduced risk of coronary events. In clinical practice, routine testing of VO2 max is not routinely available to the well patient.
However, in the modern era, there are various commercially available smart gadgets which purport to measure VO2 max, the maximum amount of oxygen the body can utilise during intense exercise. There may be merit in educating the public about the utility of having a knowledge of one’s VO2 max, not least to act as motivation to undertake routine exercise to improve the VO2 max.
Visceral fat and insulin kinetics
There is a strong association between waist circumference, visceral fat and cardiovascular risk. Visceral fat is stored deep within the abdominal cavity and coats the internal organs. Metabolically active visceral fat promotes endothelial dysfunction and secretes pro-inflammatory cytokines and adipokines.
Consequently, patients with excess visceral fat are at risk of insulin resistance, dyslipidaemia, systemic hypertension and chronic systemic inflammation. Waist circumference is a simple measurement which is reproducible and can be individualised to a patient’s ideal body weight. It is a powerful tool to use for goal setting to contribute to future cardiovascular health.
The clinical thought process about the dynamics of insulin metabolism is often directed towards patients with abnormal glycaemic control. However, chronic dysregulation of insulin kinetics and hyperinsulinaemic states may be more common in the non-diabetic population, ultimately increasing the risk of ASCVD. To that end, clinical counselling about insulin sensitivity and glycaemic control could contribute to a steadier state metabolic profile, benefiting the well patient in the long run.
Key messages
- Atherogenic cholesterol contributes to developing early aggressive atherosclerosis
- Moderate intensity aerobic exercise reduces risk
- Waist circumference is a worthwhile tool and easily measured.
– References available on request
Author competing interests- nil