Cardiovascular Disease Prevention Disease Background

Last updated: 07 July 2025

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Introduction

Content on this page:

Introduction

Introduction

Atherosclerotic cardiovascular disease (ASCVD) risk assessment is essential for primary prevention. Cardiovascular disease (CVD) includes coronary heart disease (CHD), heart failure, peripheral artery disease, and stroke. For patients aged 20 to 39 years, traditional ASCVD risk factors may be assessed at least every 4 to 6 years, while patients aged 40 years and older should be evaluated for the absolute risk of CVD at every routine physician visit. Additionally, patients aged 20 to 39 years and those between 40 to 59 years old with a low 10-year ASCVD risk (less than 7.5%) may be assessed for long-term or lifetime risk.

Epidemiology

Cardiovascular diseases are the leading cause of death globally and a major cause of global morbidity. In 2019 alone, an estimated 17.9 million people died from CVDs in 2019 alone, representing 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke. It is also notable that roughly 75% of deaths due to CVD occur in low- and middle-income countries. In the United States (US), CVD is one of the leading causes of deaths as well, responsible for 1 in every 4 deaths.  

Cardiovascular disease is also the leading cause of death in Asia, causing as many as 10 million deaths, 35% of total deaths in Asia. Indeed, Asia had the highest age-standardized CVD mortality rate. CVD deaths in Asia were mostly due to ischemic heart disease (IHD) (47%) or stroke (40%). In Malaysia, CVD is the leading cause of mortality and morbidity for more than a decade.

Pathophysiology

Cardiovascular diseases are the result of the complex interplay of various factors such as genetics, immunologic phenomena, dyslipidemia, and endothelial dysfunction.

Risk Factors

Risk Stratification  

ASCVD risk estimation identifies patients who may benefit from an intensive risk factor reduction.  

Major Risk Factors

  • Age (men ≥45 years; women ≥55 years)
  • Cigarette smoking
  • Apolipoprotein-B-containing lipoproteins (most abundant of which is low-density lipoprotein cholesterol [LDL])
    • Primary hypercholesterolemia (LDL-C 160-189mg/dL [4.1-4.8 mmol/L]; non-HDL-C 190-219 mg/dL [4.9-5.6 mmol/L])
  • Increased serum total cholesterol
  • Chronic kidney disease (CKD)
  • Diabetes mellitus (DM)
    • For individuals with high high-density lipoprotein cholesterol (HDL-C) (>60 mg/dL), subtract one risk factor from the total
    • History of gestational diabetes in women
  • Hypertension (elevated BP or on anti-hypertensive medication)
    • History of preeclampsia or pregnancy-induced hypertension in women
  • Metabolic syndrome
  • Family history of premature ASCVD (male first-degree relative <55 years old; female first-degree relative <65 years old)

Additional Risk Factors

  • Dyslipidemic triad (hypertriglyceridemia, low HDL-C, and an excess of small, dense LDL-C)
  • Fasting or postpandrial hypertriglyceridemia
  • Family history of hyperlipidemia
  • Obesity, abdominal obesity
  • Elevated apo B
  • Elevated LDL particle number
  • Elevated small dense LDL-C
  • Polycystic ovarian syndrome (PCOS) in women
  • History of premature menopause
  • South Asian ancestry


Non-traditional Risk Factors

  • Elevated lipoprotein (a)
  • Elevated clotting factors
  • Elevated inflammatory markers (eg high-sensitivity CRP)
  • Chronic inflammatory conditions (eg HIV/AIDS, psoriasis, rheumatoid arthritis, lupus)
  • Elevated triglyceride-rich remnants
  • Elevated homocysteine levels
  • Apo E4 isoform
  • Elevated uric acid
  • Ankle-brachial index (ABI) <0.9


Conditions Considered as CHD Risk Equivalents

  • Type 2 DM
    • There was insufficient evidence to support type 1 DM as CHD risk equivalent, although type 1 DM with proteinuria may increase the risk for ischemic CVD
  • Patients with other forms of symptomatic atherosclerotic disease, such as peripheral arterial disease (PAD), abdominal aortic aneurysm, and symptomatic carotid artery disease
  • Large-vessel atherosclerotic ischemic stroke
  • Framingham Heart Score risk ≥20%


Noted that CVD risk may be higher than indicated in the coronary risk chart in the following:

  • Patients approaching the next age, BP or cholesterol category
  • Sedentary or obese patients
  • Those with family history of premature CHD or stroke in a first-degree relative (male <55 years; female <65 years)
  • Patients with low HDL-C or high triglyceride (TG)
  • Patients with DM or impaired glucose tolerance
  • Those already on antihypertensive therapy
  • Patients with evidence of preclinical atherosclerosis