YEAR IN REVIEW CVD PREVENTION IN 2014

Advances in the prevention of cardiovascular disease Nizal Sarrafzadegan and Carolyn Gotay

Prevention of cardiovascular diseases (CVDs), particularly atherosclerosis, remains a priority on the global health agenda. A healthy lifestyle at both individual and population levels, combined with pharmacological treatment of CVD risk factors, is recommended. In this Year in Review article, we discuss the major advances in CVD prevention in 2014. Sarrafzadegan, N. & Gotay, C. Nat. Rev. Cardiol. advance online publication 23 December 2014; doi:10.1038/nrcardio.2014.209

Lipid-lowering therapy is one of the most effective strategies to decrease the burden of cardiovascular diseases (CVDs), and clinical guidelines have been developed for preventing coronary and cerebrovascular disease.1 However, the extent to which these guidelines are followed in real-world practice is uncertain. Saposnik and colleagues examined medical records of >900,000 highrisk patients who were admitted to hospital with an acute ischaemic stroke or transient ischaemic attack; these patients had previously experienced a stroke, transient ischaemic attack, coronary artery disease, or other CVD.2 The findings were alarming: only 41.8% of all patients were receiving lipidlowering agents when the stroke occurred, and only 25% had achieved the recommended LDL-cholesterol level of 669,000 participants who selfreported on aspects such as tobacco smoking, workplace exposure to PM2.5, weight, height, nutrition, demographic, health history, and use of medications. Additional estimates of PM2.5 exposure were computed using geo­ coding of the individuals’ home addresses, and cause of death was derived from death certificates. Over the 22‑year follow-up, high levels of PM2.5 were associated with increased CVD mortality in individuals with or without a history of cardiometabolic disorders, specifi­cally hypertension, diabetes, and obesity (HR 1.12, 95% CI 1.10–1.15 per

10 μg/m3 of PM2.5).3 Ischaemic and hypertensive diseases had the highest associations with mortality, and hypertension and diabetes were developed or exacerbated after long-term exposure to PM2.5. Despite the limitations of this study—mainly the reliance on cohort enrolment questionnaires completed by a non­randomized sample and death certificates—the data highlight the important effect that air quality has on CVDrelated deaths. The results demonstrate that not all modifiable risk factors are within the realm of individual control, and that a broad, societal perspective is needed to prevent and control CVD. Adherence to healthy lifestyle practices is the cornerstone of CVD prevention. 4 Prevention can be achieved by inhibiting the initiation of risk-associated behaviour, and maintaining healthy behaviour throughout life.4,5 A population-based, prospective cohort of >20,000 healthy Swedish men was used to investigate the effect of low-risk diet and other lifestyle behavioural changes on the prevention of myocardial infarction (MI).6 The study linked self-reported and medical-record data over an 11‑year period. The five aspects of lifestyle were healthy diet; moderate alcohol consumption (10–30 g per day); no tobacco smoking; ≥40 min of physical activity daily and ≥1 h of exercise weekly; and abdominal adiposity control with a waist circumference 12,000 people to explore whether coronary artery calcium (CAC) scores, a well-known method to assess subclinical atherosclerosis, could be used to predict who would benefit from the polypill. The researchers compared CVD event rates in the four cohorts and calculated the 5‑year number needed to treat

after stratification based on the CAC score. To prevent one CVD event, the estimated 5‑year number needed to treat ranged from 81 to 130 for patients with a CAC score of 0, and from 18 to 20 for those with a CAC score >100.8 Although the separate cohorts differed in age, polypill formulation, and other characteristics, the findings were clear: a low CAC score was associated with a minimal benefit of receiving a polypill. This study might enable the widespread, but not universal, use of polypills, by providing a criterion to identify individuals who are unlikely to benefit. As the investigators note, the next steps should include a cost-effectiveness analysis to assess the utility of CAC screening compared with population-level intervention. According to the EUROASPIRE surveys,9 50% of smokers with coronary heart disease and 90% of smokers at high risk of CVD continue to smoke. Although most of these individuals receive advice to stop, only a minority receives pharmacological treatment. In the EUROACTION trial, a nurseled, multi­disciplinary preventive programme was associated with healthier lifestyles. However, encouraging participants to stop smoking was less successful, which led to the EUROACTION PLUS programme 10 involving individuals who were persistent, high-risk smokers. The aim was not only to achieve smoking cessation, but also to reduce overall CVD risk. A total of 696 men and women at high risk or who had experienced coronary events were randomly allocated to receive either usual care, or intensive, individual-based behavioural interventions for smoking cessation and optional varenicline (a nicotinic-receptor partial agonist). All participants were smokers who reported a willingness to quit. The results indicated a significant decrease in smoking at 16 weeks, with 51% not smoking in the intensivetherap­y group (91% used varenicline) compared with 19% of those who received usual care. 10 Good nutrition was better in the ­intensive-therapy group than in the usualcare group (52% versus 37%), as were physical activity (16% versus 7%) and blood-pressure control (52% versus 43%).10 This intervention provides a model for healthy lifestyle changes in high-risk groups, with a particularly strong effect on smoking cessation. The ultimate benefit will be seen in the long-term maintenance of smoking cessation and beneficial lifestyle change. In summary, traditional and novel risk factors, their role in predicting CVD, and preventive strategies that combine behavioural and pharmacological treatments were studied

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extensively in 2014. Following recommendations for a healthy lifestyle can prevent more than two-thirds of CVDs, but adherence is low. Given the growing global epidemic of CVDs, strategies to promote cardiovascular health should be the focus of future research. Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, PO Box 81465‑1148, Isfahan, Iran (N.S.). Canadian Cancer Society, School of Population & Public Health, University of British Columbia, Room 138–2206 East Mall, Vancouver, BC V6T 1Z3, Canada (C.G.). Correspondence to: N.S. [email protected] Acknowledgements N.S. is affiliated faculty at the School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada. Competing interests The authors declare no competing interests. 1.

Stone, N. J. et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol. 1, 2889–2934 (2014). 2. Saposnik, G. Guideline-directed low-density lipoprotein management in high-risk patients with ischemic stroke: findings from Get With The Guidelines—Stroke 2003 to 2012. Stroke 45, 3343–3351 (2014). 3. Pope, C. A. et al. Relationships between fine particulate air pollution, cardiometabolic disorders and cardiovascular mortality. Circ. Res. http://dx.doi.org/10.1161/ CIRCRESAHA.116.305060. 4. Wong, N. D. Epidemiological studies of CHD and the evolution of preventive cardiology. Nat. Rev. Cardiol. 11, 276–289 (2014). 5. Van Buren, D. J. & Tibbs, T. L. Lifestyle interventions to reduce diabetes and cardiovascular disease risk among children. Curr. Diab. Rep. 14, 557 (2014). 6. Akesson, A., Larsson, S. C., Discacciati, A. & Wolk, A. Low-risk diet and lifestyle habits in the primary prevention of myocardial infarction in men: a population-based prospective cohort study. J. Am. Coll. Cardiol. 64, 1299–1306 (2014). 7. Chrysant, S. G. & Chrysant, G. S. Future of polypill use for the prevention of cardiovascular disease and strokes. Am. J. Cardiol. 114, 641–645 (2014). 8. Bittencourt, M. S. et al. Polypill therapy, subclinical atherosclerosis, and cardiovascular events Implications for the use of preventive pharmacotherapy: MESA (Multi-Ethnic Study of Atherosclerosis). J. Am. Coll. Cardiol. 63, 434–443 (2014). 9. Kotseva, K. et al. EUROASPIRE III. Management of cardiovascular risk factors in asymptomatic high risk subjects in general practice: crosssectional survey in 12 European countries. Eur. J. Cardiovasc. Prev. Rehabil. 17, 530–540 (2010). 10. Jennings, C. et al. Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial. Eur. Heart J. 35, 1411–1420 (2014).

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CVD prevention in 2014: Advances in the prevention of cardiovascular disease.

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