Cardiovascular Disease Prevention: Training Opportunities,the Challenges,and Future Directions

Purpose

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide, necessitating major efforts in prevention. This review summarizes the currently available training opportunities in CVD prevention for fellows-in-training (FITs) and residents. We also highlight the challenges and future directions for CVD prevention as a field and propose a structure for an inclusive CVD prevention training program.

Recent Findings

At present, there is a lack of centralized training resources for FITs and residents interested in pursuing a career in CVD prevention. Training in CVD prevention is not an accredited subspecialty fellowship by the American Council of Graduate Medical Education (ACGME). Although there are several independent training programs under the broad umbrella of CVD prevention focusing on different aspects of prevention, there is no unified curriculum or training.

Summary

More collaborative efforts are needed to identify CVD prevention as an ACGME-accredited subspecialty fellowship. Providing more resources can encourage and produce more leaders in this essential field.

     

Cardiovascular Disease Prevention During the COVID-19 Pandemic: Lessons Learned and Future Opportunities

The coronavirus disease 2019 (COVID-19) pandemic has been the defining healthcare issue since its outbreak, consuming healthcare systems and disrupting all aspects of human life throughout 2020 and continuing through 2021. When reviewing cardiovascular disease (CVD) prevention throughout the COVID-19 pandemic, the first tendency may be to focus on the negative disruption. Months of quarantine, isolation, and missed healthcare visits or delayed care may have exacerbated the epidemic of CVD in the United States. Looking back, however, perhaps it wasn’t a lost year as much as a health crisis that better prepared us for the battle to improve cardiovascular health. The pandemic brought new platforms for interacting with patients eager to engage, presenting a unique opportunity to reset how we approach preventive care.In this review, we discuss what the pandemic has taught us about caring for those vulnerable patients who were most afflicted—older adults, persons of color, and people facing adverse socioeconomic circumstances—and who continue to be impacted by CVD. We also identify opportunities for enhanced CVD prevention now boosted by the overnight adoption of telemedicine and other innovative cardiac care models. Lastly, we discuss how the COVID-19 pandemic has motivated physicians and patients alike to prioritize our health above all else, if only transiently, and how we can leverage this increased health awareness and investment into long-term, meaningful disease prevention.     

Nuts and Cardiovascular Disease Prevention

Purpose of Review

We review recent epidemiological and clinical studies investigating the consumption of tree nuts and peanuts and cardiovascular disease (CVD) mortality as well as CVD risk factors.

Recent Findings

A greater consumption of tree nuts and peanuts is associated with a reduced risk of CVD mortality, as well as lower CVD events. Furthermore, risk factors associated with the development of CVD such as dyslipidemia, impaired vascular function, and hypertension are improved with regular tree nut and peanut consumption through a range of mechanism associated with their nutrient-rich profiles. There is weak inconsistent evidence for an effect of nut consumption on inflammation. There is emerging evidence that consuming tree nuts reduces the incidence of non-alcoholic fatty liver disease (NAFLD) and promotes diversity of gut microbiota, which in turn may improve CVD outcomes.

Summary

Evidence for CVD prevention is strong for some varieties of tree nuts, particularly walnuts, and length of supplementation and dose are important factors for consideration with recommendations.

     

Cardiorespiratory Fitness and Cardiovascular Disease Prevention: an Update

Purpose of Review

Cardiovascular diseases account for nearly one third of all deaths globally. Improving exercise capacity and cardiorespiratory fitness (CRF) has been an important target to reduce cardiovascular events. In addition, the American Heart Association defined decreased physical activity as the fourth risk factor for coronary artery disease. Multiple large cohort studies have evaluated the impact of CRF on outcomes. In this review, we will discuss the role of CRF in reducing cardiovascular morbidity and mortality.

Recent Findings

Recent data suggest that CRF has an important role in reducing not only cardiovascular and all-cause mortality, but also incident myocardial infarction, hypertension, diabetes, atrial fibrillation, heart failure, and stroke. Most recently, its role in cancer prevention started to emerge. CRF protective effects have also been seen in patients with prior comorbidities like prior coronary artery disease, heart failure, depression, end-stage renal disease, and stroke.

Summary

The prognostic value of CRF has been demonstrated in various patient populations and cardiovascular conditions. Higher CRF is associated with improved survival and decreased incidence of cardiovascular diseases (CVD) and other comorbidities including hypertension, diabetes, heart failure, and atrial fibrillation.

     

Women and Cardiovascular Disease—Prevention of Heart Disease

The specific characteristics of cardiovascular (CV) disease in women are discussed, emphasizing that coronary heart disease (CHD) is the major health problem in women but, overall, women are still less likely to die of CHD than men. This is clarified by the fact that women under age 75 are more likely to die from a myocardial infarction when one occurs and that CHD, when it is present, is especially malignant in women under the age of 50. Separate from risk are the issues of prevention and treatment. The latest in prevention with aggressive treatment of cholesterol especially is emphasized and discussed. Regardless of gender, the guidelines for low-density lipoprotein (LDL) cholesterol lowering have become more and more intensive with benefit accruing to the patient with high CV risk of either sex at levels of LDL cholesterol below 70 mg/dl. Inflammatory risk factors as well as homocysteine and lipoprotein (a) have been shown to make a difference and their control has assumed increased importance. There are now multiple therapeutic options for attaining blood lipid goals and the major therapeutic options are discussed. Statins are still primary in controlling LDL cholesterol but numerous other medications contribute secondary additional benefits or are primary because of specific metabolic problems such as the metabolic syndrome and hypertriglyceridemia. When CHD is established or the risk for CHD is high, it is essential to treat aggressively all major risk factors: hypercholesterolemia, hypertension, cigarette smoking, diabetes mellitus, and metabolic syndrome. Such management delays development of clinical CHD and saves lives.     

Multifactorial Prevention of Cardiovascular Disease in Patients with Hypertension: the Cardiovascular Polypill

Hypertension is a major, if not the most important, contributor to the disease burden and premature death globally which is largely related to cardiovascular disease. In both the primary and the secondary preventions of cardiovascular disease, blood pressure (BP) targets are often not achieved which is similar to achievement of cholesterol goals. Combining aspirin, cholesterol and blood pressure-lowering agents into a fixed-dose combination pill called the cardiovascular polypill has been proposed as complementary care in the prevention of cardiovascular diseases in both the primary and secondary preventions of cardiovascular disease. This review article focuses on the potential role of fixed-dose combination therapy in the treatment of hypertension, outlines the pros and cons of combination therapy and emphasizes the rationale for trialling their use. Current and planned future cardiovascular polypill trials are summarized, and the prerequisites for implementation of the polypill strategy are described.     

饮食对心血管疾病的预防和保护

心血管疾病作为目前危害人类健康和生命的常见病与多发病,受到广泛关注。长期暴露于具有某种危险因素的饮食模式,会加大心血管疾病的发生概率。合理的饮食习惯对保护心血管的健康、预防心血管的发病及阻止病程进展都有帮助。现结合当前文献,综述饮食对心血管疾病的预防和保护,对各种有利于心血管疾病防治的饮食进行阐述。     

Dyslipidemias in the Prevention of Cardiovascular Disease: Risks and Causality

Atherosclerotic cardiovascular disease is now the major global cause of death, despite reductions in CVD deaths in developed societies. Dyslipidemias are a major contributor, but the mass occurrence of CVD relates to the combined effects of hyperlipidemia, hypertension, and smoking. Total blood cholesterol and LDL-cholesterol relate to CVD risk in an independent and graded manner and fulfill the criteria for causality. Therapeutic reduction of these lipid fractions is associated with improved outcomes. There is good evidence that HDL-cholesterol, triglycerides, and Lp(a) relate to CVD although the evidence for a causal relationship is weaker. The HDL association with CVD is largely independent of other risk factors whereas triglycerides may be more important as signaling a need to look intensively for other measures of risk such as central obesity, hypertension, low HDL-cholesterol, and glucose intolerance. Lp(a) is an inherited risk marker. The benefit of lowering it is uncertain, but it may be that its impact on risk is attenuated if LDL-cholesterol is low.     

Worksite Wellness for the Primary and Secondary Prevention of Cardiovascular Disease in Japan: The Current Delivery System and Future Directions

In the Japanese workplace, employers are required to provide annual health checkups for workers in accordance with the “Industrial Safety and Health Law,” which also mandates that an occupational physician be assigned to companies employing at least 50 workers. The annual medical examination includes testing for the early detection of cardiovascular risk factors such as hypertension, dyslipidemia, diabetes, and the metabolic syndrome. This approach has successfully contributed to the extremely low incidence of coronary artery disease among Japanese workers. However, problems such as poor health and the low rate of participation in health checkups among small-scale companies still persist. Furthermore, although most wellness delivery systems in Japan employ strategies targeting high-risk individuals, instituting a strategy addressing the broader population irrespective of screening may be effective in reducing disease risk in the overall population. As a future direction, we should therefore develop practical methods for implementing a population strategy.     

Health Promotion and Cardiovascular Disease Prevention in Sub-Saharan Africa

Recent population studies demonstrate an increasing burden of cardiovascular disease (CVD) and related risk factors in sub-Saharan Africa (SSA). The mitigation or reversal of this trend calls for effective health promotion and preventive interventions. In this article, we review the core principles, challenges, and progress in promoting cardiovascular health with special emphasis on interventions to address physical inactivity, poor diet, tobacco use, and adverse cardiometabolic risk factor trends in SSA. We focus on the five essential strategies of the Ottawa Charter for Health Promotion. Successes highlighted include community-based interventions in Ghana, Nigeria, South Africa, and Mauritius and school-based programs in Kenya, Namibia, and Swaziland. We address the major challenge of developing integrated interventions, and showcase partnerships opportunities. We conclude by calling for intersectoral partnerships for effective and sustainable intervention strategies to advance cardiovascular health promotion and close the implementation gap in accordance with the 2009 Nairobi Call to Action on Health Promotion.     

Lifestyle and Primordial Prevention of Cardiovascular Disease: Challenges and Opportunities

The goal of primordial prevention is to prevent the risk factors which lead to disease. Successful implementation of primordial prevention in the context of chronic disease requires that healthy behaviors become normative. Cardiovascular disease (CVD) and its associated risk factors are generally preventable. Specifically, the attainment of ideal levels of four lifestyle factors (non-smoking, normal weight, physical activity, and healthy diet) results in lower CVD morbidity and mortality, as well as related biological risk factors (hypertension, elevated blood glucose, and hypercholesterolemia). Challenges to primordial prevention of CVD include recent adverse trends in lifestyle factors and persisting health disparities. Opportunities exist for public health policy and life course approaches to prevention. Changes in public health policy that successfully target these modifiable lifestyle factors have the potential to not only affect CVD, but other chronic diseases as well.     

Primary Prevention of Cardiovascular Disease in Older People

Abstract. Cardiovascular disease is the leading cause of death, morbidity and disability in older people. Strategies for cardiovascular disease prevention and intervention in older people are similar to those available for younger ages. The population strategy for primary prevention is broad ranging from food and tobacco policy legislation and media communication to simple and direct advice delivered by all health workers. High risk strategies for reducing elevated levels of the major cardiovascular risk factors such as hypertension and hypercholesterolemia in older populations indicate that gains in life expectancy are greatest where absolute risk is highest and the intervention is the cheapest available. Non-pharmacological treatment, in particular dietary therapy, is recommended as the first line of treatment for both raised blood pressure and blood cholesterol. Because of the high excess mortality associated with smoking, even a brief advice package associated with modest success is cost effective in older people. Health policy for older people should be directed towards the overall goal of maintenance of autonomy and should include prevention, treatment and rehabilitation of cardiovascular disease as part of a comprehensive program for the prevention and control of all diseases.