Management of Risk Factors in the General Population

Many cardiovascular deaths are potentially preventable if we can modify known risk factors. While some risk factors are fixed (such as age, gender and genetic background), many others are modifiable, as shown in the table below. Given that risk factors often occur together, all should be treated to gain the most benefit in terms of reducing cardiovascular disease.

Even greater attention should be paid to risk factors in people who have already developed cardiovascular disease. For instance smoking must be avoided and all people with coronary heart disease should be taking aspirin (unless a specific contraindication to its use is present). Meticulous attention to blood pressure and lipid control is also vital.

Diabetes and other high blood glucose conditions

Although high blood glucose levels constitute a cardiovascular risk factor in people with and without diabetes, there is at present no evidence that treatment of minor increases in blood glucose (which fall short of overt diabetes) decreases the subsequent development of cardiovascular disease. At the very least however, the finding of any rise in glucose levels should promote a careful search for and treatment of other cardiovascular risk factors.

Dyslipidaemia

There is strong evidence that reducing elevated levels of LDL cholesterol diminishes the risk of coronary heart disease. High levels of HDL cholesterol are also known to decrease the risk of coronary heart disease. Therefore raising HDL cholesterol in people with low HDL cholesterol levels may provide benefit. It is also likely that lowering high triglycerides has a similar effect. Reducing lipid levels may also be beneficial in the prevention of stroke and peripheral vascular disease.

The first line of treatment is lifestyle modification by improving diet, taking more physical exercise and losing excess body weight. If these measures fail then drug treatment can also be prescribed. A group of drugs called statinsA class of drug that lowers cholesterol. are particularly useful for lowering LDL cholesterol. Another group known as fibratesFibrates are cholesterol-lowering drugs that are primarily effective in lowering triglycerides and, to a lesser extent, in increasing high-density lipoprotein cholesterol levels. can be used to target triglycerides. Combinations of these can be used if required.

Hypertension

The lowering of elevated blood pressure substantially cuts the risk of stroke and coronary heart disease. If lifestyle measures including salt restriction are insufficient then antihypertensive drugs (e.g. angiotensin converting enzyme (ACE) inhibitorsA type of drug used for blood pressure control and heart failure. Studies indicate that it may also help prevent or slow the progression of kidney disease in people with diabetes., beta blockersDrugs that block the action of the hormone adrenaline that makes the heart beat faster and more vigorously, thereby relieving stress to the heart muscle. Beta blockers are often used to slow the heart rate, lower blood pressure, prevent angina attacks, prevent irregular heartbeats and reduce the risk of heart attacks in people who have already had one., calcium channel blockersA drug used to treat angina and to lower blood pressure., diureticsDiuretics increase the output of water and salt in the urine. They are used to treat heart failure and to lower blood pressure.) should also be administered. It is worth noting that many people will require more than one drug.

Insulin resistance

Insulin resistance is usually either caused or aggravated by obesity, particularly abdominal obesity. Hence diet to promote the loss of excess weight, together with exercise to improve muscle metabolism and aid weight loss can improve insulin sensitivity. When diabetes is present, tight glucose control can also enhance insulin sensitivity. Drugs which specifically target insulin resistance are now becoming available, but it is not yet known whether decreasing insulin resistance will in itself slow or prevent the development of macrovascular disease.

Obesity

Sustained weight loss in the overweight is of benefit for all cardiovascular diseases. It is also instrumental in decreasing other risk factors such as raised blood pressure and high fats.

Sedentary lifestyle

There is compelling evidence that aerobic physical activity reduces the risk of coronary heart disease. People who exercise regularly have less body fat, higher HDL cholesterol levels, lower LDL cholesterol and triglyceride levels, greater insulin sensitivity, lower blood glucose and blood pressure, and usually have an improved sense of well-being.

Smoking

Stopping smoking is of major benefit in the prevention of coronary heart disease, stroke and peripheral vascular disease, even in those who have smoked for a very long time.

Some risk factors cannot be easily measured and others may remain to be identified. For this reason, certain interventions may be found to be very effective even though they do not target a specific measured risk factor. A good example of this is aspirin, which has proved of major benefit in preventing coronary heart disease.

Even greater attention should be paid to risk factors in people who have already developed cardiovascular disease. For instance smoking must be avoided and all people with coronary heart disease should be taking aspirin (unless a specific contraindication to its use is present). Meticulous attention to blood pressure and lipid control is also vital.

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