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Visão geral dos fatores de risco estabelecidos para
doenças cardiovasculares
Autor: Dr. Peter WF Wilson
Editores de seção: , Joann G Elmore, MD, MPH , Christopher P Cannon, MD
Editores Adjuntos: , Jane Givens, MD, MSCE , Nisha Parikh, MD, MPH
Todos os tópicos são atualizados à medida que novas evidências se tornam disponíveis e nosso processo de
revisão por pares está completo.
Revisão da literatura atual através de: Fev 2023. | Este tópico foi atualizado pela última vez: 11 de janeiro
de 2023.
INTRODUÇÃO
A doença cardiovascular (DCV) é comum na população em geral em todo o mundo, afetando
a maioria dos adultos após os 60 anos de idade. Em 2012 e 2013, estimou-se que as DCV
resultassem em 17,3 milhões de mortes em todo o mundo em uma base anual [1-3]. A
atualização de 2019 Heart Disease and Stroke Statistics da American Heart Association (AHA)
relatou que 48% das pessoas ≥20 anos de idade nos Estados Unidos têm DCV (que inclui
doença cardíaca coronária [CHD] [4], insuficiência cardíaca, acidente vascular cerebral e
hipertensão) [4]. A prevalência relatada aumenta com a idade para homens e mulheres.
Como categoria diagnóstica, as DCV incluem quatro áreas principais:
Uma visão geral dos fatores de risco estabelecidos para DCV é apresentada aqui. Uma visão
geral dos possíveis fatores de risco emergentes para DCV, dados que apoiam a importância
dos fatores de risco individuais (por exemplo, hiperlipidemia, hipertensão, tabagismo),
fatores de risco coronariano de particular importância em mulheres e em pacientes jovens e
estimativa do risco coronariano em um paciente individual são discutidos em outro lugar.
(Ver "Visão geral dos possíveis fatores de risco para doenças cardiovasculares" e "Terapia
®
DCC, manifestada por infarto do miocárdio (IM), angina de peito e morte coronariana●
Doença cerebrovascular, manifestada por acidente vascular cerebral e ataque
isquêmico transitório
●
Doença arterial periférica, manifestada por claudicação intermitente●
Aterosclerose aórtica e aneurisma da aorta torácica ou abdominal●
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redutora de colesterol de lipoproteína de baixa densidade na prevenção primária de
doenças cardiovasculares" e "Visão geral da hipertensão em adultos", seção sobre
"Tratamento" e "Visão geral dos fatores de risco cardiovascular ateroscleróticos em
mulheres" e "Doença arterial coronariana e infarto do miocárdio em jovens" e "Avaliação do
risco de doença cardiovascular aterosclerótica para prevenção primária em adultos: nossa
abordagem" e "Avaliação de risco de doença cardiovascular para prevenção primária:
calculadoras de risco".)
EPIDEMIOLOGIA
O risco ao longo da vida de doença cardiovascular geral (DCV) se aproxima de 50% para
pessoas com 30 anos de idade sem DCV conhecida [5]. A doença coronariana (DCC) é
responsável por aproximadamente um terço a metade do total de casos de DCV, sendo a
doença isquêmica do coração a causa número um de morte em adultos de países de baixa,
média e alta renda [4,6]. O risco de DCC ao longo da vida foi ilustrado em um estudo de 7733
participantes, com idades entre 40 e 94 anos, no Framingham Heart Study que estavam
inicialmente livres de DCC [7]. O risco ao longo da vida para indivíduos aos 40 anos foi de
49% nos homens e 32% nas mulheres. Mesmo aqueles que estavam livres de DCC aos 70
anos tinham um risco não trivial ao longo da vida de desenvolver DCC (35 e 24 por cento em
homens e mulheres, respectivamente). Achados semelhantes foram relatados em uma
metanálise de 18 coortes envolvendo mais de 250.000 adultos [8]. (Ver "Avaliação do risco de
doença cardiovascular aterosclerótica para prevenção primária em adultos: nossa
abordagem", seção sobre "Risco ao longo da vida".)
Dados de autópsia documentaram o início precoce da aterosclerose, começando na
segunda e terceira décadas de vida, embora a prevalência de DCC anatômica tenha
diminuído ao longo do tempo. Em uma análise de 3832 autópsias realizadas em militares
dos Estados Unidos (98% do sexo masculino, idade média de 26 anos) que morreram de
combate ou lesões não intencionais entre outubro de 2001 e agosto de 2011, a prevalência
de qualquer aterosclerose coronariana foi de 8,5% [9]. Isso representa um declínio
acentuado na prevalência de DCC documentada por autópsia em comparação com as taxas
observadas durante a Guerra da Coreia na década de 1950 (77%) e a Guerra do Vietnã na
década de 1960 (45%) [9].
Apesar do aumento da longevidade e da diminuição das taxas de mortalidade específicas
por idade por DCV, DCC e acidente vascular cerebral desde 1975, as DCV e suas
complicações relacionadas permanecem altamente prevalentes e caras de tratar [4,10-14].
Em uma coorte de mais de 1,9 milhão de pessoas com 30 anos ou mais, livres de DCV basal
conhecida, que foram acompanhadas por uma mediana de seis anos, a maioria das
apresentações iniciais de DCV não foi infarto do miocárdio (IM) nem acidente vascular
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cerebral [15]. Essas apresentações, que incluíram angina ( tabela 1), insuficiência cardíaca,
doença arterial periférica, ataque isquêmico transitório e aneurisma da aorta abdominal,
juntamente com algumas manifestações menos comuns, representaram 66% das
apresentações iniciais de DCV.
Embora as DCV continuem a ser a principal causa de morte na maioria dos países
desenvolvidos, a mortalidade por IAM agudo parece ter diminuído em até 50% nas décadas
de 1990 e 2000. Entre os 49 países da Europa e do norte da Ásia, mais de quatro milhões de
pessoas morrem anualmente de DCC [16]. Nos Estados Unidos, aproximadamente 1,5
milhão de pessoas sofrem um ataque cardíaco ou acidente vascular cerebral anualmente,
resultando em mais de 250.000 mortes [17,18].
Juntamente com as melhorias na mortalidade associadas ao evento inicial de DCV, a
prevalência de DCV também está aumentando rapidamente em países com recursos
limitados [19-21]. Entre 1990 e 2010, estima-se que a carga global de DCC aumentou 29%
devido ao aumento da terapia e da longevidade, juntamente com o crescimento da
população global [22]. Além disso, os dados de 2010 mostraram uma variação regional
significativa na mortalidade por DCC, com o maior número de mortes por DCC observadas
no sul da Ásia, mas as maiores taxas de mortalidade por DCC observadas na Europa Oriental
e Ásia Central [23]. Em um estudo com 156.424 pessoas de 17 países (3 de alta renda, 10 de
renda média, 4 de baixa renda), o escore de risco INTERHEART (para avaliar fatores de risco)
foi maior em países de alta renda e menor em países de baixa renda [24]. No entanto, os
eventos de DCV e a mortalidade apareceram inversamente relacionados ao escore
INTERHEART, com taxas significativamente mais baixas de eventos de DCV e mortalidade em
países de alta renda em comparação com países de renda média e baixa, um achado que é
supostamente devido à maior modificação dos fatores de risco em países de alta renda.
Muitos fatores de risco para DCV são modificáveis por medidas preventivas específicas. No
estudo mundial INTERHEART de pacientes de 52 países, nove fatores potencialmente
modificáveis representaram mais de 90% do risco atribuível à população de um primeiro
infarto do miocárdio. Tabagismo, dislipidemia, hipertensão, diabetes, obesidade abdominal
e fatores psicossociais foram associados a maior risco, e o consumo diário de frutas e
vegetais e o consumo regular de álcool foram associados a um menor risco [25].
DOENÇA ATEROSCLERÓTICA NÃO CORONÁRIA
Alguns pacientes sem doença coronariana (DCC) conhecida têm um risco de eventos
cardiovasculares subsequentes que é comparável ao de pacientes com DCC estabelecida
[26]. A doença arterial aterosclerótica não coronariana, uma condição difusa que envolve
toda a circulação arterial, inclui pacientes com doença arterial carotídea, doença arterial
periférica ou aneurisma da aorta abdominal. A presença de aterosclerose clínica em um
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território vascular geralmente indica uma maior probabilidade de que ela exista em outro
lugar, uma vez que os fatores de risco são geralmente os mesmos.
Fatores de risco concomitantes devem ser tratados agressivamente nesses pacientes. (Ver
"Manejo do aneurisma da aorta abdominal assintomático", seção sobre 'Introdução' e
"Tratamento da doença aterosclerótica carotídea extracraniana assintomática", seção sobre
'Terapia médica intensiva e acompanhamento' e 'Manejo da claudicação devido à doença
arterial periférica', seção sobre 'Risco de progressão e modificação do risco'.)
PREVALÊNCIA DE FATORES DE RISCO PARA DOENÇAS CARDIOVASCULARES
Muitos indivíduos na população em geral têm um ou mais fatores de risco para doença
coronariana (DCC), e mais de 90% dos eventos de DCC ocorrem em indivíduos com pelo
menos um fator de risco [25,27,28]. Estima-se que os cinco principais fatores de risco
modificáveis (hipercolesterolemia, diabetes, hipertensão, obesidade e tabagismo) sejam
responsáveis por mais da metade da mortalidade cardiovascular [29]. Por outro lado, a
ausência de fatores de risco importantes prediz um risco muito menor de DCC [28].
A frequência e o valor preditivo de cinco fatores de risco principais (pressão arterial,
lipoproteína de baixa densidade [LDL] e colesterol de lipoproteína de alta densidade [HDL],
intolerância à glicose e tabagismo) foram avaliados em indivíduos brancos não hispânicos
de 35 a 74 anos de idade sem DCC no Framingham Heart Study e no Third National Health
and Nutrition Examination Survey (NHANES III) ( tabela 2) [27 ]. A frequência de fatores de
risco "limítrofes" (definidos como pressão sistólica 120 a 139 mmHg, pressão diastólica 80 a
89 mmHg, colesterol LDL 100 a 159 mg/dL [2,6 a 4,1 mmol/L], colesterol HDL 40 a 59 mg/dL
[1,0 a 1,5 mmol/L], glicemia de jejum prejudicada sem diabetes evidente e história pregressa
de tabagismo) também foi avaliada nas mesmas coortes ( tabela 3) [27]. As seguintes
estimativas foram observadas:
Mais de 90% dos eventos de DCC ocorreram em indivíduoscom pelo menos um fator
de risco, e aproximadamente 8% ocorreram em indivíduos que tinham apenas níveis
limítrofes de múltiplos fatores de risco. Poucos eventos ocorreram em pacientes sem
fatores de risco elevados ou limítrofes. (Ver "Avaliação do risco de doença
cardiovascular aterosclerótica para prevenção primária em adultos: nossa abordagem",
seção sobre "Risco ao longo da vida".)
●
No NHANES III, aproximadamente 60% dos homens e 50% das mulheres tinham um a
dois fatores de risco elevados, e 26% dos homens e 41% das mulheres tinham pelo
menos um fator de risco limítrofe. A ausência completa de qualquer fator de risco
elevado ou limítrofe foi rara (0 a 0,4 por cento), exceto para mulheres entre as idades
de 35 a 44 (8,9 por cento) ou 45 a 54 (3,7 por cento).
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The increase in risk when multiple risk factors are present has been noted in several studies
in both Western and Asian populations [27,30-32]. As examples:
FATORES DE RISCO ESTABELECIDOS PARA DCV ATEROSCLERÓTICA
Princípios gerais – A aterosclerose é responsável por quase todos os casos de doença
cardíaca coronária (DCC). Este processo insidioso começa com estrias gordurosas que são
vistas pela primeira vez na adolescência; essas lesões progridem em placas no início da
idade adulta e culminam em oclusões trombóticas e eventos coronarianos na meia-idade e
mais tarde na vida. (Ver "Patogênese da aterosclerose".)
Uma variedade de fatores, muitas vezes agindo em conjunto, está associada a um risco
aumentado de placas ateroscleróticas nas artérias coronárias e outros leitos arteriais
( figura 1) [34]. A avaliação dos fatores de risco é útil em adultos para orientar a terapia
para dislipidemia, hipertensão e diabetes, e formulações multivariadas podem ser usadas
para ajudar a estimar o risco de eventos de doença coronariana [35,36]. (Ver "Avaliação do
risco de doença cardiovascular aterosclerótica para prevenção primária em adultos: nossa
abordagem".)
Como exemplo, um acompanhamento de 12 anos de 14.786 homens e mulheres
finlandeses, com idades entre 25 e 64 anos, descobriu que a incidência de DCC era três vezes
maior em homens do que em mulheres e a mortalidade era cinco vezes maior [37]. A
diferença relativa no risco de DCC entre os sexos foi maior entre os indivíduos mais jovens
(25 a 49 anos), mas a diferença absoluta foi maior na faixa etária mais avançada, devido a
In a cohort study of 20,000 adults in Chicago with 22 years of follow-up, when two or all
three major risk factors (serum cholesterol ≥200 mg/dL [≥5.2 mmol/L], elevated systolic
and diastolic blood pressure [≥120/80 mmHg], and cigarette smoking) were present,
both males and females had a marked increase in the relative risk of CHD (5.5 and 5.7,
respectively), cardiovascular disease (CVD; 4.1 and 4.5), and all-cause mortality (3.2 and
2.3) [31].
●
In a cohort study of 380,000 individuals from Asia, Australia, and New Zealand, patients
in the higher categories of both total cholesterol (≥240 mg/dL [6.25 mmol/L]) and
systolic pressure (≥160 mmHg) had a sevenfold increase in CHD and an eightfold
increase in stroke compared with patients in the lowest category of both total
cholesterol (less than 183 mg/dL [4.75 mmol/L]) and systolic pressure (less than 130
mmHg) [32]. Estimates of CVD risk factors across Asia in the early 21 century have
generally shown decreases in systolic blood pressure and blood cholesterol in high-
income countries but increases in other countries, while there has also been a
significant increase in the prevalence of diabetes in most Asian countries [33].
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uma maior prevalência (60 a 64 anos). Quase metade da diferença no risco de DCC entre
homens e mulheres foi associada às diferenças entre os sexos nos fatores de risco
cardiovascular, particularmente a relação lipoproteína de alta densidade (HDL)/colesterol
total e o tabagismo. Diferenças no colesterol total sérico, pressão arterial, índice de massa
corporal e prevalência de diabetes representaram aproximadamente um terço do aumento
relacionado à idade na prevalência de DCC em homens e 50 a 60 por cento em mulheres.
Com base nos riscos absolutos, relativos e atribuíveis impostos pelos vários fatores de risco,
os conceitos de "normal" evoluíram de valores usuais ou médios para valores mais ótimos
associados à ausência de doença a longo prazo. Como resultado, os valores ideais de
pressão arterial, glicose no sangue e lipídios foram revisados para baixo nos últimos 20 anos
[38-40].
Alguns autores afirmaram que aproximadamente metade de todos os pacientes que sofrem
uma manifestação de DCC não têm fatores de risco estabelecidos além da idade e do sexo,
uma alegação que contribuiu para os esforços para identificar outros marcadores de risco
cardiovascular [41,42]. No entanto, a precisão dessa afirmação tem sido desafiadapelos
resultados de várias análises que sugerem que a prevalência dos principais fatores de risco
em pacientes com DCC é superior a 75% [43-45]:
Em um estudo observacional do Registro Nacional de Infarto do Miocárdio que incluiu
mais de 540.000 pacientes entre 1994 e 2006 que apresentaram um primeiro infarto do
miocárdio (IM) sem doença cardiovascular prévia, 86% tinham um dos cinco principais
fatores de risco (hipertensão, tabagismo, dislipidemia, diabetes mellitus ou história
familiar de doença coronariana) [45 ]. Entre os quase 51.000 pacientes que morreram
antes da alta hospitalar, houve uma relação inversa significativa entre o risco de morte
e o número de principais fatores de risco presentes, com os pacientes tendo 0 a 2
fatores de risco significativamente mais propensos a morrer em comparação com
pessoas com todos os cinco fatores de risco (razão de chances ajustada [OR] de morte
para fatores de risco zero 1,54, IC 95% 1,23-1,94).
●
Um relatório baseado em dados de três estudos observacionais (o Framingham Heart
Study, o Multiple Risk Factor Intervention Trial [MRFIT] e o Chicago Heart Association
Detection Project in Industry) incluiu mais de 380.000 indivíduos, 21.000 dos quais
morreram de doença coronariana [43]. Os principais fatores de risco para DCC foram
definidos como colesterol total ≥240 mg/dL (≥6,22 mmol/L), pressão arterial sistólica
≥140 mmHg, pressão arterial diastólica ≥90 mmHg, tabagismo e diabetes. Os sujeitos
do estudo foram estratificados por idade e sexo. Entre os indivíduos que morreram de
DCC, a exposição a pelo menos um fator de risco variou de 87% (para homens de 40 a
59 anos no estudo MRFIT) a 100% (para mulheres de 18 a 39 anos no Framingham
Heart Study).
●
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/38-40
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/41,42
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/43-45
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/45
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/43
Várias métricas para fatores de risco têm sido associadas a um maior risco de doença
cardiovascular (DCV): níveis médios, níveis médios, tempo gasto em um alto nível de fator de
risco e aumento da variabilidade em uma métrica específica ao longo do tempo. Isso tem
sido relatado para os fatores de risco pressão arterial, níveis de colesterol e peso corporal,
entre outros [46-50]. Os pacientes que não são muito aderentes com seus tratamentos
geralmente têm maior variabilidade nas medidas dos fatores de risco, e o erro de medição é
muitas vezes muito maior em valores altos. Agravando a questão para a doença cardíaca é
que as pessoas de muito baixo peso podem experimentar maior risco de doença cardíaca
recorrente.
Prevalência de fatores de risco – Uma estimativa exata da prevalência de fatores de risco
para DCV permanece indescritível, mas a prevalência de fatores de risco identificados
mudou ao longo do tempo com o aumento da conscientização e mudanças na dieta e estilo
de vida. Uma comparação de resultados de relatórios sequenciais do National Health and
Nutrition Examination Survey (NHANES) mostrou que a prevalência de obesidade (índice de
massa corporal [IMC] ≥30 kg/m2) aumentou dramaticamente nos Estados Unidos entre 1960
e 2000 (15 a 30 por cento) [51]. Não surpreendentemente, houve um aumento associado no
diabetes diagnosticado (1,8 a 5,0 por cento) que foi mais proeminente em indivíduos obesos
(2,9 a 10,1 por cento). (Veja "Obesidade" abaixo.)
Por outro lado, uma série de outros fatores de risco cardiovascular importantes diminuiu
substancialmente entre 1960 e 2000 [51]:
Essas alterações ocorreram em todos os grupos de peso, incluindo indivíduos obesos, e
foram associadas ao aumento do uso de hipolipemiantes e anti-hipertensivos. (Ver
"Sobrepeso e obesidade em adultos: consequências para a saúde", seção sobre "Tendências
em fatores de risco cardiovascular".)
Outro relatório, baseado em 14 ensaios clínicos randomizados de DCC, incluiu mais de
120.000 indivíduos com IAM com supradesnivelamento do segmento ST, síndrome
coronariana aguda sem supradesnivelamento do segmento ST ou intervenção
coronária percutânea [44]. Os fatores de risco foram definidos por informações
coletadas no momento da inclusão no estudo, incluindo tabagismo, diabetes,
hipertensão e hiperlipidemia. Pelo menos um desses quatro fatores de risco estava
presente em 85% das mulheres e 81% dos homens. Quando estratificada por idade, a
menor prevalência de pelo menos um fator de risco foi observada entre indivíduos >75
anos (77% das mulheres e 65% dos homens).
●
Colesterol total sérico ≥240 mg / dL (6,2 mmol / L) – 34 a 17 por cento●
Hipertensão (pressão arterial ≥140/≥90 mmHg) – 31 a 15 por cento●
Tabagismo – 39 a 26 por cento●
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/46-50
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/51
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/51
https://www.uptodate.com/contents/overweight-and-obesity-in-adults-health-consequences?sectionName=Trends+in+cardiovascular+risk+factors&search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&anchor=H5&source=see_link#H5
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/44
A presença de fatores de risco estabelecidos está associada às DCV, e a conquista e
manutenção da boa saúde está sendo enfatizada em programas da American Heart
Association (AHA) que promovem sete métricas ideais de saúde cardiovascular ("Life's Simple
7"), incluindo [52]:
Numerosos estudos mostraram consistentemente benefícios de morbidade e mortalidade
por DCV de alcançar um maior número de métricas ideais de saúde cardiovascular, com
reduções de risco relativo se aproximando de 75% em pessoas que alcançam todas as sete
métricas [53-60]. Em uma revisão sistêmica e meta-análise de 2018, que incluiu 210.443
pessoas de 12 estudos de coorte, as pessoas que alcançaram entre cinco e sete métricas
ideais de saúde cardiovascular tiveram a maior redução nas DCV incidentes (taxa de risco
[HR] 0,28 em comparação com pessoas que alcançaram entre zero e duas métricas; IC 95%
0,23-0,33), enquanto as pessoas que alcançaram três e quatro métricas também obtiveram
um benefício menor, mas significativo (HR 0,53 em comparação com pessoas que
alcançaram entre zero e duas métricas; IC 95% 0,47-0,59) [61].
A prevalência de fatores de risco em países em desenvolvimento tem sido desconhecida
e/ou sub-representada na literatura. Entre 46.239 adultos chineses com 20 anos ou mais
(40% do sexo masculino) recrutados em 2007 e 2008 como uma coorte nacionalmente
representativa, a prevalência geral de DCV foi baixa (1,8 e 1,1% em homens e mulheres,
respectivamente) [62]. A prevalência de fatores de risco tradicionais para DCV foi muito
maior:
Após o ajuste para idade e sexo, as chances de DCV aumentaram com o número de fatores
de risco presentes (OR 2,4, 4,2, 4,9 e 7,2 para 1, 2, 3 e 4 ou mais fatores de risco,
respectivamente, em comparação com nenhum fator de risco) [62]. Esses dados sugerem
que, na ausência de estilo de vida eficaz e intervenções médicas, é provável que haja um
aumento significativo na incidência e prevalência de DCV na China no futuro.
Não fumadores●
Ser fisicamente ativo●
Ter uma pressão arterial normal●
Ter um nível normal de glicose no sangue●
Ter um nível normal de colesterol total●
Ser peso normal●
Comer uma dieta saudável●
Sobrepeso ou obesidade – 36,7 e 29,8 por cento em homens e mulheres,
respectivamente
●
Hipertensão – 30,1 e 24,8 por cento em homens e mulheres, respectivamente●
Dislipidemia– 64 e 67,4 por cento em homens e mulheres, respectivamente●
Hiperglicemia – 26,7 e 23,6 por cento em homens e mulheres, respectivamente●
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/52
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/53-60
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/61
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/62
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/62
Fatores de risco na infância – Os fatores de risco cardiovascular são identificáveis na
infância e podem ser preditivos do desenvolvimento subsequente de DCC [63-65]. A
identificação de crianças com fatores de risco para DCV e o desenvolvimento de
aterosclerose em crianças são discutidos em detalhes separadamente. (Ver "Prevenção
pediátrica de doenças cardiovasculares em adultos: Promovendo um estilo de vida saudável
e identificando crianças em risco" e "Visão geral dos fatores de risco para o desenvolvimento
de aterosclerose e doença cardiovascular precoce na infância".)
Idade e sexo – Os fatores de risco cardiovascular promovem DCV em ambos os sexos
biológicos em todas as idades, mas com importância relativa diferente.
O diabetes e a baixa relação HDL-colesterol/colesterol total operam com maior poder
em mulheres [66,67]. (Ver "Prevalência e fatores de risco para doença coronariana em
pacientes com diabetes mellitus".)
●
A incidência de um IAM é aumentada seis vezes em mulheres e três vezes em homens
que fumam pelo menos 20 cigarros por dia em comparação com indivíduos que nunca
fumaram [68,69]. (Veja "Risco cardiovascular de fumar e benefícios da cessação do
tabagismo".)
●
A pressão arterial sistólica e a hipertensão sistólica isolada são os principais fatores de
risco para DCC em homens e mulheres em todas as idades [40]. O estudo de
Framingham descobriu que a importância relativa da pressão sistólica, diastólica e de
pulso (a diferença entre as pressões arterial sistólica e diastólica) muda com a idade
[70]. Em pacientes com <50 anos de idade, a pressão arterial diastólica foi o mais forte
preditor de risco de DCC; naqueles de 50 a 59 anos de idade, todos os três índices de
pressão arterial foram preditores comparáveis de risco de DCC, enquanto naqueles ≥60
anos de idade, a pressão de pulso foi o preditor mais forte. (Veja 'Hipertensão' abaixo e
"Riscos cardiovasculares de hipertensão".)
●
Alguns fatores de risco, como dislipidemia, tolerância à glicose prejudicada e
fibrinogênio elevado, têm um impacto diminuído com o avanço da idade, mas um
menor risco relativo é compensado pelo alto risco absoluto em adultos mais velhos
[71,72]. Assim, todos os principais fatores de risco continuam a ser relevantes em
pessoas idosas.
●
A obesidade ou o ganho de peso promove ou agrava a maioria dos fatores de risco
aterogênicos e a inatividade física piora alguns deles, predispondo indivíduos de todas
as idades a eventos de DCC [73-75]. (Veja "Sobrepeso e obesidade em adultos:
consequências para a saúde" e "Obesidade em adultos: Papel da atividade física e do
exercício".)
●
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/63-65
https://www.uptodate.com/contents/pediatric-prevention-of-adult-cardiovascular-disease-promoting-a-healthy-lifestyle-and-identifying-at-risk-children?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-risk-factors-for-development-of-atherosclerosis-and-early-cardiovascular-disease-in-childhood?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/66,67
https://www.uptodate.com/contents/prevalence-of-and-risk-factors-for-coronary-heart-disease-in-patients-with-diabetes-mellitus?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/68,69
https://www.uptodate.com/contents/cardiovascular-risk-of-smoking-and-benefits-of-smoking-cessation?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/40
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/70
https://www.uptodate.com/contents/cardiovascular-risks-of-hypertension?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/71,72
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/73-75
https://www.uptodate.com/contents/overweight-and-obesity-in-adults-health-consequences?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/obesity-in-adults-role-of-physical-activity-and-exercise?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
A idade por si só também parece contribuir para o desenvolvimento de DCV. Em uma coorte
de mais de 3,6 milhões de indivíduos com 40 anos ou mais de idade submetidos à triagem
autorreferida para DCV (índice braquial do tornozelo, ultrassonografia duplex carotídea e
ultrassonografia abdominal), a prevalência de qualquer doença vascular aumentou
significativamente a cada década de vida [76]:
After adjusting for traditional risk factors, each additional decade of life was associated with
an approximate doubling of the risk of vascular disease (ORs per decade of life were 2.14,
1.80, and 2.33 for peripheral arterial disease, carotid stenosis, and abdominal aortic
aneurysm, respectively).
Male sex alone may contribute to the risk of CHD, although the potential mechanisms for
such risk are not well understood. Several population studies have identified male sex as a
risk factor for higher rates of CHD and CHD-related mortality [77-79]. Among 31,000 patients
from the ONTARGET and TRANSCEND study populations (9378 females, 22,168 males) who
were followed for an average of 56 months, females had approximately 20 percent lower risk
than males for all major cardiovascular endpoints including cardiovascular death (adjusted
RR 0.83, 95% CI 0.75-0.92), MI (adjusted RR 0.78, 95% CI 0.68-0.89), and a combined endpoint
of death, MI, stroke, and heart failure hospitalization (adjusted RR 0.81, 95% CI 0.76-0.87)
[79]. In premenopausal women, serious manifestations of coronary disease, such as MI and
sudden death, are relatively rare. After menopause, the incidence and severity of coronary
disease increases abruptly, with rates three times those of women the same age who remain
premenopausal [80]. (See "Overview of atherosclerotic cardiovascular risk factors in
females".)
The risk of CHD in men has been associated with variations in the Y chromosome. Among
3233 biologically unrelated British men who underwent genotyping of their Y chromosome,
with 13 apparent ancient lineages (haplogroups) identified based on the genotype results,
those descendent from one particular haplogroup (haplogroup I, almost entirely unique to
Europeans) had significantly more CHD than men from other haplogroups (OR 1.56, 95% CI
1.24-1.97) [81]. These results suggest that differences in CHD risk within the male sex are
associated with inherited variations in sex chromosomes, which may contribute to the
importance of family history as a risk factor for CHD. (See 'Family history' below and
"Overview of possible risk factors for cardiovascular disease", section on 'Genetic markers'.)
2% em pessoas de 40 a 50 anos●
3,5% em pessoas de 51 a 60 anos●
7,1% em pessoas de 61a 70 anos●
13% em pessoas de 71 a 80 anos●
22,3% em pessoas de 81 a 90 anos●
32.5 percent in 91- to 100-year-olds●
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/76
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/77-79
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/79
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/80
https://www.uptodate.com/contents/overview-of-atherosclerotic-cardiovascular-risk-factors-in-females?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/81
https://www.uptodate.com/contents/overview-of-possible-risk-factors-for-cardiovascular-disease?sectionName=Genetic+markers&search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&anchor=H1267867&source=see_link#H1267867
Family history — Family history is an independent risk factor for CHD, particularly among
younger individuals with a family history of premature disease [82-88]. There is general
agreement that development of atherosclerotic CVD or death from CVD in a first-degree
relative (ie, biological parent or sibling) prior to age 55 (males) or 65 (females) denotes a
significant family history, although the definition of what constitutes a family history of
premature atherosclerosis has been somewhat variable across studies [89-91]. A wider
definition of a significant family history of CVD might also include CVD in a first-degree
relative of any age (ie, not necessarily premature) or other manifestations of atherosclerosis
beyond MI or CHD death, including stroke or transient ischemic attack, CHD requiring
revascularization in the absence of MI, peripheral artery disease, and abdominal aortic
aneurysm ( table 4) [91]. One study has suggested that compared with a family history of
premature CVD or a more detailed family history, asking a single question (does any first-
degree relative have CVD, at any age?) was as helpful in identifying an increased risk of CVD
[91]. (See "Coronary artery disease and myocardial infarction in young people".)
Using data from the 2011 to 2014 NHANES survey, the 2017 AHA heart disease and stroke
statistics reported that 12.2 percent of adults have a biological parent or sibling with heart
attack or angina before age 50 years [92]. The importance of family history has been shown
in several large cohort studies (Physician's Health Study, Women's Health Study, Reykjavik
Cohort Study, Framingham Offspring Study, INTERHEART Study, Cooper Center Longitudinal
Study, Danish national population database) that collectively followed over 163,000 patients,
and all showed that a positive family history is associated with greater risk of developing
CHD [82,83,85,86,93-96]. The risk of developing CHD in the presence of a positive family
history has ranged from 15 to 100 percent in various cohorts, with most cohorts showing a
30 to 60 percent increase [91].
The importance of a family history of premature CVD death appears to be magnified in
families with multiple premature deaths [97-99]. Using data from the Danish Family
Relations Database (3,985,301 persons born between 1950 and 2008 followed for nearly 90
million person-years), persons from families with two or more premature cardiovascular
deaths among first-degree relatives had a threefold greater risk of developing CVD before
age 50 (incidence risk ratio 3.30, 95% CI 2.77-3.94) [97]. Similar findings have been noted
among 185,810 cases of hospitalization or death due to CHD in the Swedish Multi-
Generation Registry, in which the risk of hospitalization or death due to CHD was increased
six- to sevenfold in persons with two or three siblings with CHD [98].
Despite multiple studies showing that family history of CHD in a first-degree relative
increases one's risk of developing CHD, the incremental predictive value of adding family
history to an established risk score appears to be small, ranging from 2 to 5 percent upward
reclassification of risk [87,100]. In the EPIC-Norfolk prospective cohort of 22,841 patients (45
percent male) aged 40 to 79 years who were followed for a mean of 10.9 years, a family
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/82-88
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/89-91
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https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/91
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/91
https://www.uptodate.com/contents/coronary-artery-disease-and-myocardial-infarction-in-young-people?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/92
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/82,83,85,86,93-96
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/91
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/97-99
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/97
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/98
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/87,100
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/87,100
history of CHD in a first-degree relative was associated with increased risk of future CHD
independent of the Framingham Risk Score (FRS) estimate (adjusted HR 1.74, 95% CI 1.56-
1.95) [87]. Despite this significantly increased risk, the addition of family history to the FRS
estimate resulted in minimal reclassification of patients into different risk groups (only 2
percent of patients deemed intermediate risk by FRS were reclassified to high risk because of
family history). (See "Cardiovascular disease risk assessment for primary prevention: Risk
calculators".)
Reliability of self-reported family history — The accuracy and reliability of a self-reported
family history may be difficult to ascertain. A 2009 report from the National Institutes of
Health reviewed the accuracy of self-reported family history of several common disease
states (asthma and allergies, diabetes mellitus, major depression and mood disorders,
stroke, CVD, and five common types of cancer) [89]. The probability that an unaffected family
member was correctly identified as disease-free was high (90 to 95 percent), but for family
members with one of the diseases, the probability that they were correctly identified as
having the disease was generally lower and far more variable (as low as 6 percent correct
identified as having a mood disorder, up to 95 percent correct for some types of cancer).
Generally, patients more accurately identified healthy family members as being healthy and
were less accurate in correctly identifying family members with specific diseases.
The reliability of a self-reported family history of CHD or of risk factors for CHD was explored
in an analysis from the Framingham Offspring Study [101]. A group of 1628 children of study
participants completed a questionnaire regarding parental medical history. The following
findings were noted:
These findings concerning validated and self-reported family history from Framingham
suggest that there is some value inobtaining family history information, but that self-
reported information might not be accurate. They also suggest that the additional
contribution of family history to CHD risk estimation after inclusion of other traditional risk
factors is relatively modest.
The predictive value of an affirmative statement was above 75 percent for family
histories of hypertension, diabetes, and hypercholesterolemia.
●
For cardiac death the positive predictive value was only 66 percent for fathers and 47
percent for mothers.
●
The predictive value of a negative statement was above 90 percent for family history of
cardiac death or for diabetes, but below 60 percent for family history of hypertension
or hypercholesterolemia.
●
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/87
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https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/87
https://www.uptodate.com/contents/cardiovascular-disease-risk-assessment-for-primary-prevention-risk-calculators?search=has+e+placas+ateroscler%C3%B3ticas&topicRef=1506&source=see_link
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/89
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Hypertension — Hypertension is a well-established risk factor for adverse cardiovascular
outcomes, including mortality from CHD and stroke [102,103]. The lifetime risk of developing
CVD is significantly higher among patients with hypertension ( table 5). In a cohort of over
1.25 million patients aged 30 years or older without baseline CVD, including 20 percent with
baseline treated hypertension, patients with baseline hypertension had a 63.3 percent
lifetime risk of developing CVD compared with a 46.1 percent risk for those with normal
baseline blood pressure [5]. In a separate study from the INTERHEART group, hypertension
accounted for 18 percent of the population-attributable risk of a first MI [25]. Greater
variations in blood pressure from one visit to the next may also be associated with greater
risk of CVD and mortality [104]. (See "Cardiovascular risks of hypertension".)
The determination of what blood pressure constitutes hypertension has long been the
subject of debate, with various committees and professional societies publishing statements
or guidelines attempting to define categories of hypertension [40,105]. An extensive
discussion of the definition of hypertension and treatment recommendations for various
patient groups is presented elsewhere. (See "Overview of hypertension in adults", section on
'Definitions' and "Goal blood pressure in adults with hypertension".)
Although blood pressure at the time of risk assessment (current blood pressure) is typically
used in most prediction algorithms, this does not accurately reflect an individual's past blood
pressure experience. Two analyses demonstrate the importance of inclusion of past blood
pressure into risk prediction models since the duration as well as the degree of hypertension
are both risk factors. This issue is discussed in detail elsewhere. (See "Cardiovascular risks of
hypertension", section on 'Current risk versus prior risk'.)
Ambulatory blood pressure measurements may be more predictive in patients with office or
white coat hypertension. (See "Out-of-office blood pressure measurement: Ambulatory and
self-measured blood pressure monitoring".)
A separate issue is the goal blood pressure in patients who already have or are at high risk
for CVD. This issue is discussed in great detail separately. (See "Cardiovascular risks of
hypertension" and "Goal blood pressure in adults with hypertension".)
Lipids and lipoproteins — Lipids, principally cholesterol and triglycerides, are the water
insoluble compounds that require larger protein-containing complexes called lipoproteins to
transport them in blood. The protein components of the lipoprotein are known as
apolipoproteins or apoproteins. (See "Lipoprotein classification, metabolism, and role in
atherosclerosis".)
The determination of what cholesterol level constitutes dyslipidemia has long been the
subject of debate, with professional societies publishing statements or guidelines
attempting to delineate risk levels and when to consider drug therapy for dyslipidemia [106].
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The prevalence of dyslipidemia is increased in patients with premature CHD, being as high as
75 to 85 percent compared with approximately 40 to 48 percent in age-matched controls
without CHD [84,107]. In the INTERHEART study, dyslipidemia (defined as a raised apo B to
apo A-1 ratio) accounted for 49 percent of the population-attributable risk of a first MI [25].
Disturbances in lipoprotein metabolism are often familial. As an example, 54 percent of all
patients and 70 percent of those with a lipid abnormality in one reported series had a
familial lipid disorder [107]. The most common familial disturbances were Lp(a) excess (alone
or with other dyslipidemia), hypertriglyceridemia with hypoalphalipoproteinemia, and
combined hyperlipidemia. Conversely, patients with favorable genetic profiles that result in
lifelong exposure to lower low-density lipoprotein (LDL) cholesterol levels have been shown
to be at decreased risk of MI, coronary revascularization, or death from CHD [108]. (See
"Inherited disorders of LDL-cholesterol metabolism other than familial
hypercholesterolemia".)
Evidence for the pathogenic importance of serum cholesterol has largely come from
randomized trials which showed that reductions in total and LDL cholesterol levels (almost
entirely with statins) reducecoronary events and mortality when given for primary and
secondary prevention [109-111]. Factors other than LDL cholesterol lowering also may
contribute to the observed benefit from statin therapy. (See "Mechanisms of benefit of lipid-
lowering drugs in patients with coronary heart disease" and "Low-density lipoprotein
cholesterol-lowering therapy in the primary prevention of cardiovascular disease".)
Recommendations for the treatment of hypercholesterolemia are discussed separately. (See
"Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of
cardiovascular disease" and "Management of low density lipoprotein cholesterol (LDL-C) in
the secondary prevention of cardiovascular disease".)
The following lipid and lipoprotein abnormalities are associated with increased CHD risk. The
supportive data are presented elsewhere as noted:
Elevated total cholesterol ( figure 2) and elevated LDL cholesterol (see "Screening for
lipid disorders in adults", section on 'Rationale for screening')
●
Low HDL cholesterol (see "HDL cholesterol: Clinical aspects of abnormal values",
section on 'Low HDL cholesterol as an ASCVD risk factor')
●
Hypertriglyceridemia (see "Hypertriglyceridemia in adults: Management")●
Increased non-HDL cholesterol (see "Screening for lipid disorders in adults", section on
'Choice of tests')
●
Increased Lp(a) (see "Lipoprotein(a)")●
Increased apolipoprotein C-III (see "Lipoprotein classification, metabolism, and role in
atherosclerosis")
●
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LDL levels in the normal range correlate with subclinical atherosclerosis in patients without
traditional CHD risk factors, suggesting a continuous relationship with no clear threshold
[112].
The abnormalities discussed above require measurement of lipids or lipoproteins. Proton
nuclear magnetic resonance (NMR) spectroscopy of lipoprotein particles has been proposed
as an alternative method for predicting CVD risk [113]. In a study of over 27,000 women, this
technique was comparable in predictive accuracy to, but not better than, standard
measurement of lipids or apolipoproteins [113].
Diabetes mellitus — Insulin resistance, hyperinsulinemia, and elevated blood glucose are
associated with atherosclerotic CVD [114-121]. In the INTERHEART study, diabetes accounted
for 10 percent of the population-attributable risk of a first MI [25]. The all-cause mortality
risk associated with diabetes has been compared with the all-cause mortality risk associated
with a prior MI [122].
In addition to the importance of diabetes as a risk factor, diabetics have a greater burden of
other atherogenic risk factors than nondiabetics, including hypertension, obesity, increased
total to HDL cholesterol ratio, hypertriglyceridemia, and elevated plasma fibrinogen. The
CHD risk in diabetics varies widely with the intensity of these risk factors.
Guidelines published by the National Cholesterol Education Program and the sixth Joint
National Committee have provided a framework to treat coronary risk factors aggressively in
diabetics [38,102]. There is compelling evidence of the value of aggressive therapy of serum
cholesterol and hypertension in patients with diabetes [123-125]. (See "Treatment of
hypertension in patients with diabetes mellitus" and "Management of low density
lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease".)
Hyperglycemia without overt diabetes mellitus — There is good evidence from
observational studies that higher levels of blood glucose and glycated hemoglobin correlate
with cardiovascular risk in patients with and without diabetes at baseline. Data on this are
discussed separately. (See "Prevalence of and risk factors for coronary heart disease in
patients with diabetes mellitus", section on 'CHD before diabetes' and "Prevalence of and
risk factors for coronary heart disease in patients with diabetes mellitus", section on
'Hyperglycemia'.)
Small, dense LDL particles (see "Inherited disorders of LDL-cholesterol metabolism
other than familial hypercholesterolemia", section on 'Small dense LDL (LDL phenotype
B)')
●
Different genotypes of apolipoprotein E (apoE) influence cholesterol and triglyceride
levels as well as the risk of CHD (see "Inherited disorders of LDL-cholesterol
metabolism other than familial hypercholesterolemia", section on 'Genetics')
●
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Chronic kidney disease — The increased CHD risk in patients with end-stage kidney disease
has been well described, but there is now clear evidence that mild to moderate kidney
dysfunction is also associated with a substantial increase in CHD risk [126]. Practice
guidelines from the National Kidney Foundation in 2002 and the American College of
Cardiology (ACC)/American Heart Association (AHA) task force in 2004 recommended that
chronic kidney disease (CKD) be considered a CHD risk equivalent [127,128].
Patients with CKD who undergo stress testing have worse outcomes, regardless of the
outcome, when compared with patients without CKD. In a study of 1652 patients who
underwent stress radionuclide myocardial perfusion imaging (rMPI), among whom CKD
(defined as estimated globular filtration rate <60 mL/minute/1.73 m ) was present in 36
percent of subjects, patients with CKD had significantly worse prognosis for similar rMPI
result compared with patients without CKD [129]. With CKD and a normal test, the annual
cardiac death rate was 2.7 percent; with no CKD and a normal test, the annual cardiac death
rate was significantly lower (0.8 percent). With CKD and ischemia, the annual cardiac death
rate was 11 percent; with no CKD and ischemia, the annual cardiac death rate was
significantly lower (4.5 percent).
The data supporting this conclusion are presented elsewhere. (See "Chronic kidney disease
and coronary heart disease".)
Lifestyle factors — A variety of lifestyle factors impact the risk of CVD:
Cigarette smoking — Cigarette smoking is an important and reversible risk factor for CHD.
In 2016, approximately 15.5 percent of United States adults age ≥18 years were smoking [4].
The incidence of a MI is increased sixfold in women and threefold in men who smoke at least
20 cigarettes per day compared with subjects who never smoked [68,69]. The risk of MI is
proportional to tobacco consumption in both males and females and is higher in inhalers
compared with non-inhalers [69]. In the INTERHEART study, smoking accounted for 36
percent of the population-attributable risk of a first MI [25].
Conversely, the risk of recurrent infarction in a study of smokers who had an MI fell by 50
percent within one year of smoking cessation and normalized to that of nonsmokers within
two years [130]. The benefits of smoking cessation are seen regardless of how long or how
much the patient has previously smoked. (See "Cardiovascular risk of smoking and benefits
of smoking cessation".)
Diet — Aspects of diet that have been evaluated for CHD risk include the glycemic index
(GI), fruits and vegetables, meat, trans fatty acids, fiber, coffee, and low-cholesterol diets.
2
Dietary factors that may increase risk●
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Exercise — Exercise of even moderate degree has a protective effect against CHD and all-
cause mortality [25,75,132-135]. Exercise may have a variety of beneficial effects including an
elevation in serum HDL cholesterol, a reduction in blood pressure, less insulin resistance,
and weight loss. In addition to the amount of exercise performed, the degree of
cardiovascular fitness (a measure of physical activity), as determined by duration of exercise
and maximal oxygen uptake on a treadmill, is also associated with a reduction in CHD risk
and overall cardiovascular mortality [136-146].
High glycemic index – Diets containing foods with a high GI or glycemic load (GL)
may contribute to the risk of CHD ( table 6).
•
Low consumption of fruits and vegetables – There is growing evidence that
greater fruit and vegetable consumption is inversely related to the risk of CVD.
•
High serum concentrations of enterolactone, a putative biomarker of a diet high in
fiber and vegetables, have been inversely correlated with the risk of acute coronary
events and with CHD mortality. (See "Healthy diet in adults" and "Overview of
primary prevention of cardiovascular disease", section on 'Healthy diet'.)
High consumption of red meat – Greater intake of red meat has been associated
with higher risks of CVD.
•
High consumption of trans fatty acids – Several observational studies have linked
the consumption of trans fatty acids, or foods that contain them, with adverse
cardiovascular outcomes ( table 7). (See "Dietary fat", section on 'Trans fatty
acids'.)
•
Low consumption of Fiber – Low fiber intake is inversely related to risk of CHD. It is
also associated with development of cardiovascular risk factors including
hypertension, diabetes mellitus, and elevated lipid levels. ( table 8)
•
Dietary factors of uncertain effect●
Coffee – Coffee consumption, both caffeinated and non-caffeinated, appears to
have a neutral effect on the development of CVD. (See "Benefits and risks of caffeine
and caffeinated beverages" and "Cardiovascular effects of caffeine and caffeinated
beverages".)
•
Low-cholesterol diet – The relationship between dietary cholesterol and
development of CVD is unclear due to observational studies with mixed results.
However, the 2020 Dietary Guidelines for Americans suggest maintaining an overall
healthy eating pattern and consuming as little dietary cholesterol as possible [131].
•
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Resistance training appears to have a beneficial impact on several risk factors for
cardiovascular disease. These include lowering blood pressure, reducing fasting serum
glucose concentrations, improving insulin sensitivity and dyslipidemia, decreasing waist
circumference, and improving body composition [147-154]. (See "Strength training for health
in adults: Terminology, principles, benefits, and risks".)
The AHA prepared a listing of the most effective strategies to promote exercise, as well as a
healthy diet, based on a systematic review of studies published in English between 1999 and
2009 ( table 9). (See "Exercise and fitness in the prevention of atherosclerotic
cardiovascular disease" and "The benefits and risks of aerobic exercise".)
In 2018, the US Department of Health and Human Services published guidelines for physical
activity in children and adults [155]. (See "Exercise prescription and guidance for adults",
section on 'Prescribing an exercise program'.)
Alcohol — Epidemiologic data indicate that moderate alcohol intake has a protective effect
on CHD. (See "Cardiovascular benefits and risks of moderate alcohol consumption".)
Obesity — Obesity, defined as a BMI greater than 30, is a highly prevalent condition,
particularly in developed countries, with estimates that 35 percent of the population of the
United States in 2011 to 2012 was obese [156]. Obesity is associated with a number of risk
Men who engaged in moderately vigorous sports activity have been reported to have a
23 percent lower risk of death than those who were less active [132]. Persons with mild
to moderate levels of physical activity as part of their occupation appear to have lower
risk of MI compared with sedentary workers [143].
●
In the INTERHEART study, lack of regular physical activity accounted for 12 percent of
the population-attributable risk of a first MI [25].
●
Cardiovascular fitness has been assessed in several studies [140,141,144-146]. In a
prospective study of 6213 men referred for exercise testing who were followed for a
mean of 6.2 years [140], peak exercise capacity, measured in metabolic equivalents
(METs), was a stronger predictor of mortality than other established cardiovascular risk
factors among men with and without CVD. In a separate study of 11,190 persons
deemed "low-risk" by FRS and without diabetes mellitus who underwent treadmill
exercise testing and were followed for an average of 27 years, all-cause mortality was
significantly higher among individuals in the lowest quintile of exercise capacity at
baseline (15 versus 6 percent mortality in the highest quintile) [141]. In a study of
cardiorespiratory fitness in 5107 man (mean age 48.8 years) without known CVD who
were followed for 46 years, high cardiorespiratory fitness in the fifth decade of life was
associated with mortality benefits extending for over four decades [145].
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https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/156
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/132
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/143
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/25
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/140,141,144-146
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/140
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/141
https://www.uptodate.com/contents/overview-of-established-risk-factors-for-cardiovascular-disease/abstract/145
factors for atherosclerosis, CVD, and cardiovascular mortality, including hypertension, insulin
resistance and glucose intolerance, hypertriglyceridemia, reduced HDL cholesterol, and low
levels of adiponectin [157-160]. However, in an analysis of data from 4780 adults in the
Framingham Offspring Study, obesity as measured by BMI significantly and independently
predicted the occurrence of CHD and cerebrovascular disease after adjusting for traditional
risk factors [161]. Additionally, there is a continuous linear relationship between higher BMI
and greater risk of CVD [162,163]. These relationships are discussed in detail elsewhere. (See
"Obesity: Association with cardiovascular disease" and "Overweight and obesity in adults:
Health consequences" and "Obesity in adults: Dietary therapy".)
In addition to the risk associated with obesity, patients with more significant fluctuations in
body weight (ie, cycles of weight gain and weight loss) appear to have an increased risk of
future CVD events. Among 9509 patients with established CVD and LDL cholesterol below
130 mg/dL (3.4 mmol/L) who participated in the randomized Treating to New Targets trial
(randomized to 10 mg or 80 mg of daily atorvastatin), post hoc analysis was performed to
assess the impact of fluctuations in body weight on the composite outcome of any CHD
event (combination of death from CHD, nonfatal MI, resuscitated sudden cardiac arrest,
revascularization, and angina) [50]. For each standard deviation increase in body weight
fluctuation (approximately 1.5 to 1.9 kg deviation from baseline), there was a significant