Multifactorial Risk Factor Modification and Control
Multifactorial risk factor modification and control, especially interventions designed to reduce total cholesterol, systolic blood pressure, smoking prevalence, overweight/obesity, diabetes mellitus, and physical inactivity, can have a profound and favorable impact on decreasing the incidence of initial and recurrent cardiovascular events. In addition, along with cardio-protective medications, the roles of lifestyle interventions, psychological factors, air pollution, dietary patterns, physical inactivity, low cardio-respiratory fitness, obesity, cardiac rehabilitation, and inflammation have been better elucidated as modulators of CVD and as targets for education, behavioral interventions, and policy approaches to improving health. There are no randomized trials showing that alcohol consumption improves health, and the overall harms are well known: addiction, social dysfunction, and motor vehicle accidents. One large-scale study showed that low to moderate alcohol consumption may be associated with an increased risk of cancer in women.
Cigarette smokers die approximately 10 years younger than nonsmokers. For someone who has smoked since adulthood, cessation at age 50 years halved the hazard, and cessation at age 30 years avoided almost all of it. Quitting smoking at age 60 or 40 years increased life expectancy by 3 and 9 years, respectively. Even a very short period of passive smoke exposure has persistent vascular consequences, such as the mobilization of dysfunctional endothelial progenitor cells with blocked nitric oxide production. Secondhand smoke is responsible for an estimated 603 000 deaths worldwide each year, and more than half of the deaths (379 000) are due toCVD
Considerable data now strongly support the role of lifestyle intervention to improve glucose and insulin homeostasis. a lifestyle intervention (reducing body weight by _5%; decreasing fat and saturated fat intake to _30% and _10% of energy intake, respectively; increasing fiber intake to _15 g/1000 kcal; and an increase in exercise to _30 min/d) resulted in a 58% reduction in the development of diabetes mellitus in high-risk overweight subjects with impaired glucose tolerance.
Factors such as depressive symptoms, anxiety, and vital exhaustion may worsen or exacerbate the development of
CVD through associated unhealthy behaviors and physiological responses that may lead to clinical consequences, including myocardial ischemia, threatening ventricular arrhythmias, vulnerable plaque, and increased thrombosis potential and inflammation. Patients with clinical depression are at least 3 times more likely to die during the first year after AMI than are patients without depression. patients with depression after AMI are less likely to take prescribed medications and adhere to recommended behavior and lifestyle changes intended to reduce the risk of recurrent cardiovascular events. Nurses’ Health Study II, adherence to 6 lifestyle factors—normal body mass index (_25 kg/m2); a low-sodium diet high in fruits, vegetables, and low-fat dairy products; a daily average of 30 minutes of vigorous exercise; modest alcohol intake (up to 10 g/d); infrequent use of nonnarcotic analgesics (less than once per week); and folic acid supplementation (_400 _g/d)—was associated with a significantly lower incidence of self-reported hypertension. Men who adhered to _4 of 6 healthy lifestyle habits (normal body weight, not smoking, regular exercise, moderate alcohol intake, consumption of breakfast cereals, and a diet high in fruits and vegetables) had a 10% risk of developing heart failure. Men who did not adhere to any of these factors had a 21% risk ofdeveloping heart failure.
Numerous epidemiological studies have demonstrated consistent associations between short-term elevations in particulate matter (air pollution) and increases in nonfatal and fatal cardiovascular events, including myocardial ischemia and infarction, ventricular arrhythmia, heart failure exacerbation, and stroke. The pathways linking air pollution exposure to the onset of acute cardiovascular events may be explained by the direct effects from agents that cross the pulmonary epithelium into the circulation, including gases and the soluble constituents of particles (eg, transition metals).
One systematicreview found strong evidence of a causal relationship for cardioprotective dietary practices, including vegetables, nuts, and Mediterranean eating patterns, as well as associations for harmful factors, including intake of trans fatty acids and foods with a high glycemic index or load, and CHD. Modest reductions in dietary salt may also substantially reduce cardiovascular events and associated medical costs.57 Epidemiological and controlled interventional studies have consistently demonstrated the beneficial effects of omega-3 fatty acid consumption, especially the longer-chain fatty acids (_20 carbons) from marine sources, on cardiovascular endpoints.Moreover, a 2-year study of weight loss diets, using either low-fat, Mediterranean, or low-carbohydrate strategies, reported a significant regression of carotid atherosclerosis, irrespective of the dietary intervention
In healthy men and women, each 1-metabolic equivalent increase in exercise capacity confers a 13% and 15% reduction in all-cause mortality and cardiovascular events, respectively. Participants with an aerobic capacity _7.9 metabolic equivalents had the most favorable health outcomes.
A disproportionate number of acute cardiovascular events occur in habitually sedentary individuals with known or occult CHD performing unaccustomed vigorous physical activity. Collectively, these data suggest that the least active, least fit, “high-risk” patient cohort may especially benefit from structured exercise, increased lifestyle activity, or both to improve survival
Underweight and obesity, particularly high levels of obesity, were associated with increased mortality relative to the normal weight category. On the other hand, overweight (body mass index 25 to _30 kg/m2) was not associated with increased mortality, a finding recently echoed in patients with CHD. A normal or desirable body mass index is classified between 19.0 and 24.9 kg/m2; however, this is primarily because body mass indexes _25 kg/m2 are associated with increased morbidity.
The Behavioral Risk Factor Surveillance System reported in 2000 that only 3% of 153 805 adults had 4 of 4 healthy lifestyle characteristics of current nonsmoking, body mass index 18.5 to 24.9 kg/m2, consumption of 5 fruits and vegetables per day, and regular physical activity.