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20.1 Prevention of Atherosclerotic Ischemic Heart Disease and Stroke

Table of Contents

Cardiovascular disease (CVD) prevention is a coordinated set of actions, at the population level or targeted at an individual at risk of developing cardiovascular disease, that are aimed at eliminating or minimizing the impact of CVDs and their related disabilities.

Diagnostic/screening Criteria

Major risk factors for ischaemic cardiovascular and cerebrovascular disease are:

  • Diabetes mellitus
  • Hypertension
  • Central obesity: waist circumference ≥ 94 cm (men) and ≥ 80 cm (women)
  • Dyslipidaemia (fasting levels): Total cholesterol > 5 mmol/L, or LDL> 3 mmol/L, or HDL< 1 mmol/L in men and < 1.2 mmol/L in women
  • Smoking
  • Age: Men > 50 years, Women > 60 years
  • Family history of early onset cardiovascular disease; Male relatives < 55 years and Female relatives < 65 year

Estimation of total cardiovascular risk is important for prevention of CVD in an individual, should be adapted to his or her total CV risk: the higher the risk, the more intense the management should be. See Table 20.1 Cardiovascular Disease Risk Classification and WHO risk estimate

Table 20.1: Cardiovascular Disease Risk Classification

Very High Risk Subjects with any of the following:

• Documented CVD, clinical or unequivocal on imaging: Documented clinical CVD includes previous AMI, ACS, coronary revascularization and other arterial revascularization procedures, stroke and TIA, aortic aneurysm and PAD. Unequivocally documented CVD on imaging includes plaque on coronary angiography or carotid ultrasound. It does NOT include some increase in continuous imaging parameters such as intima–media thickness of the carotid artery.

• DM with target organ damage such as proteinuria or with a major risk factor such as smoking or marked hypercholesterolaemia or marked hypertension.

• Severe CKD (GFR <30 mL/min/1.73 m²).

• A calculated CVD Risk Score ≥10%.

High Risk Subjects with:

• Markedly elevated single risk factors, in cholesterol >8 mmol/L (>310 mg/dL) (e.g. in familial hypercholesterolaemia) or BP ≥180/110 mmHg. • Most other people with DM (except for young people with type 1 DM and without major risk factors that may be at low or moderate risk).

• Moderate CKD (GFR 30–59 mL/min/1.73 m²).

• A calculated CVD Risk Score ≥5% and <10%.

Moderate

Risk

CVD Risk Score is ≥1% and <5% at 10 years. Many middle–aged subjects belong to this category
Low Risk CVD Risk Score < 1%

Non-Pharmacological Treatment

General measures (also refer to Table 6.1 below):

  • Lifestyle modification for all persons with risk factors for ischaemic heart disease should be encouraged (lifestyle changes as appropriate and summarized below on table 1.0)
  • Maintain ideal weight, i.e. BMI < 25 kg/m², Weight reduction in the overweight patient, i.e. BMI > 25 kg/m²,
  • Reduce alcohol intake to ≤ 2 standard drinks/day for men and ≤ 1 for women on no more than 5 out of 7 days per week (1 standard drink is equivalent to 25 mL of spirits, 125 mL of wine, 340 mL of beer or sorghum beer, or 60 mL of sherry),
  • Ideal healthy diet i.e. low fat, high fibre and unrefined carbohydrates, with adequate fresh fruit and vegetables.
  • Exercise; regular moderate aerobic exercise, e.g. 30 minutes brisk walking 3–5 times/week (150 minutes/week) and
  • Stop smoking.

Pharmacological Treatment

Individualized treatment targets are elaborated on Table 20.2 below, however for specific pharmacological treatment for hypertension, diabetes, dyslipidemia refer specific sections, respectively

Table 20.2: The summarized preventive measures to be individualized on targeted goals

Risk factor goals and target levels for important cardiovascular disease risk factor reduction
1 Smoking No exposure to tobacco in any form.
2 Diet. Low in saturated fat with a focus on wholegrain products, vegetables, fruit and fish.
3 Physical activity At least 150 minutes a week of moderate aerobic exercise (30 minutes for 5 days/week) or 75 minutes a week of vigorous aerobic exercise (15 minutes for 5 days/week) or a combination thereof
4 Body weight Body weight BMI 20–25 kg/m². Waist circumference <94 cm (men) or <80 cm (women)
5 Blood Pressure <140/90 mmHg
6 Lipids LDL–C is the

primary target

Very high–risk: <1.8 mmol/L (<70 mg/dL), or a reduction of at least 50% if the baseline is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL)

High–risk:<2.6mmol/L (<100 mg/dL), o r a reduction of at least 50% if the baseline is between 2.6 and 5.1 mmol/L (100

and 200 mg/dL)

Low to moderate risk:<3.0 mmol/L (<115 mg/dL)

HDL–C No target but >1.0 mmol/L (>40mg/dL) in men and >1.2 mmol/L (>45 mg/dL) in women indicate lower risk
Triglycerides No target but <1.7 mmol/L (<150 mg/dL) indicates lower risk and higher levels indicate a need to look for other risk factors.
7 Diabetes HbA1c <7%. (<5.3 mmol/l)

Recommended to repeat CV risk assessment every 5 years, and more often for individuals with risks close to thresholds mandating treatment3.

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