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Cardiovascular disease
Specialty	Cardiology

Cardiovascular disease (also called heart disease) is a class of diseases that involve the heart or blood vessels (arteries, capillaries and veins).

Cardiovascular disease refers to any disease that affects the cardiovascular system, principally cardiac disease, vascular diseases of the brain and kidney, and peripheral arterial disease. The causes of cardiovascular disease are diverse but atherosclerosis and/or hypertension are the most common. Additionally, with aging come a number of physiological and morphological changes that alter cardiovascular function and lead to subsequently increased risk of cardiovascular disease, even in healthy asymptomatic individuals.

Cardiovascular disease is the leading cause of deaths worldwide, though since the 1970s, cardiovascular mortality rates have declined in many high-income countries. At the same time, cardiovascular deaths and disease have increased at a fast rate in low- and middle-income countries. Although cardiovascular disease usually affects older adults, the antecedents of cardiovascular disease, notably atherosclerosis, begin in early life, making primary prevention efforts necessary from childhood. There is therefore increased emphasis on preventing atherosclerosis by modifying risk factors, such as healthy eating, exercise, and avoidance of smoking.

Types

• Coronary heart disease (also ischaemic heart disease or coronary artery disease)
• Cardiomyopathy - diseases of cardiac muscle
• Hypertensive heart disease - diseases of the heart secondary to high blood pressure
• Heart failure
• Cor pulmonale - a failure of the right side of the heart
• Cardiac dysrhythmias - abnormalities of heart rhythm
• Inflammatory heart disease
  • Endocarditis – inflammation of the inner layer of the heart, the endocardium. The structures most commonly involved are the heart valves.
  • Inflammatory cardiomegaly
  • Myocarditis – inflammation of the myocardium, the muscular part of the heart.
• Valvular heart disease
• Cerebrovascular disease - disease of blood vessels that supplies to the brain such as stroke
• Peripheral arterial disease - disease of blood vessels that supplies to the arms and legs
• Congenital heart disease - heart structure malformations existing at birth
• Rheumatic heart disease - heart muscles and valves damage due to rheumatic fever caused by streptococcal bacteria infections

Risk factors

Epidemiology suggests a number of risk factors for heart disease: age, gender, high blood pressure, high serum cholesterol levels, tobacco smoking, excessive alcohol consumption, family history, obesity, lack of physical activity, psychosocial factors, diabetes mellitus, air pollution. While the individual contribution of each risk factor varies between different communities or ethnic groups the consistency of the overall contribution of these risk factors to epidemiological studies is remarkably strong. Some of these risk factors, such as age, gender or family history, are immutable; however, many important cardiovascular risk factors are modifiable by lifestyle change, drug treatment or social change.

Age

Age is an important risk factor in developing cardiovascular diseases. It is estimated that 87 percent of people who die of coronary heart disease are 60 and older. At the same time, the risk of stroke doubles every decade after age 55.

Multiple explanations have been proposed to explain why age increases the risk of cardiovascular diseases. One of them is related to serum cholesterol level. In most populations, the serum total cholesterol level increases as age increases. In men, this increase levels off around age 45 to 50 years. In women, the increase continues sharply until age 60 to 65 years.

Aging is also associated with changes in the mechanical and structural properties of the vascular wall, which leads to the loss of arterial elasticity and reduced arterial compliance and may subsequently lead to coronary artery disease.

Sex

Men are at greater risk of heart disease than pre-menopausal women. However, once past menopause, a woman's risk is similar to a man's.

Among middle-aged people, coronary heart disease is 2 to 5 times more common in men than in women. In a study done by the World Health Organization, sex contributes to approximately 40% of the variation in the sex ratios of coronary heart disease mortality. Another study reports similar results that gender difference explains nearly half of the risk associated with cardiovascular diseases One of the proposed explanations for the gender difference in cardiovascular disease is hormonal difference. Among women, estrogen is the predominant sex hormone. Estrogen may have protective effects through glucose metabolism and hemostatic system, and it may have a direct effect on improving endothelial cell function. The production of estrogen decreases after menopause, and may change the female lipid metabolism toward a more atherogenic form by decreasing the HDL cholesterol level and by increasing LDL and total cholesterol levels. Women who have experienced early menopause, either naturally or because they have had a hysterectomy, are twice as likely to develop heart disease as women of the same age group who have not yet gone through menopause.

Among men and women, there are differences in body weight, height, body fat distribution, heart rate, stroke volume, and arterial compliance. In the very elderly, age related large artery pulsatility and stiffness is more pronounced in women. This may be caused by the smaller body size and arterial dimensions independent of menopause.

Air pollution

Particulate matter has been studied for its short- and long-term exposure effects on cardiovascular disease. Currently, PM_2.5 is the major focus, in which gradients are used to determine CVD risk. For every 10 μg/m of PM_2.5 long-term exposure, there was an estimated 8-18% CVD mortality risk. Women had a higher relative risk (RR) (1.42) for PM_2.5 induced coronary artery disease than men (0.90) did. Overall, long-term PM exposure increased rate of atherosclerosis and inflammation. In regards to short-term exposure (2 hours), every 25 μg/m of PM_2.5 resulted in a 48% increase of CVD mortality risk. Additionally, after only 5 days of exposure, a rise in systolic (2.8 mmHg) and diastolic (2.7 mmHg) blood pressure occurred for every 10.5 μg/m of PM_2.5. Other research has implicated PM_2.5 in irregular heart rhythm, reduced heart rate variability (decreased vagal tone), and most notably heart failure. PM_2.5 is also linked to carotid artery thickening and increased risk of acute myocardial infarction.

Pathophysiology

Population based studies show that atherosclerosis the major precursor of cardiovascular disease begins in childhood. The Pathobiological Determinants of Atherosclerosis in Youth Study demonstrated that intimal lesions appear in all the aortas and more than half of the right coronary arteries of youths aged 7–9 years.

This is extremely important considering that 1 in 3 people will die from complications attributable to atherosclerosis. In order to stem the tide education and awareness that cardiovascular disease poses the greatest threat and measures to prevent or reverse this disease must be taken.

Obesity and diabetes mellitus are often linked to cardiovascular disease, as are a history of chronic kidney disease and hypercholesterolaemia. In fact, cardiovascular disease is the most life threatening of the diabetic complications and diabetics are two- to four-fold more likely to die of cardiovascular-related causes than nondiabetics.

Screening

Screening ECGs (either at rest or with exercise) are not recommended in those without symptoms who are at low risk. In those at higher risk the evidence for screening with ECGs is inconclusive.

Some biomarkers may add to conventional cardiovascular risk factors in predicting the risk of future cardiovascular disease; however, the clinical value of some biomarkers is still questionable. Currently, biomarkers which may reflect a higher risk of cardiovascular disease include:

• Coronary artery calcification
• Carotid intima-media thickness
• Carotid total plaque area
• Higher fibrinogen and PAI-1 blood concentrations
• Elevated homocysteine
• Elevated blood levels of asymmetric dimethylarginine
• Inflammation as measured by C-reactive protein
• Elevated blood levels of brain natriuretic peptide (also known as B-type) (BNP)

Prevention

Currently practiced measures to prevent cardiovascular disease include:

• A low-fat, high-fiber diet including whole grains and plenty of fresh fruit and vegetables (at least five portions a day)
• Tobacco cessation and avoidance of second-hand smoke;
• Limit alcohol consumption to the recommended daily limits; consumption of 1-2 standard alcoholic drinks per day may reduce risk by 30% However excessive alcohol intake increases the risk of cardiovascular disease.
• Lower blood pressures, if elevated, through the use of antihypertensive medications;
• Decrease body fat (BMI) if overweight or obese;
• Increase daily activity to 30 minutes of vigorous exercise per day at least five times per week;
• Decrease psychosocial stress. Stress however plays a relatively minor role in hypertension. Specific relaxation therapies are not supported by the evidence.

Routine counselling of adults to advise them to improve their diet and increase their physical activity has not been found to significantly alter behaviour, and thus is not recommended.

Diet

Worldwide, dietary guidelines recommend a reduction in saturated fat. A 2012 Cochrane review suggested lifestyle advice to all patients at risk for CVD, which should include a permanent reduction in dietary saturated fat but only partially replacing saturated fat with unsaturated fats, while remaining unclear on which unsaturated fats were beneficial. Other studies have shown detriment from unsaturated fats in preventing CVD. A 2013 meta analysis concludes that substitution of saturated fat with omega 6 linoleic acid (a type of unsaturated fat) may actually increase cardiovascular risk. Often overlooked are the patient's results based off what nutrient replaces dietary saturated fat. Replacing saturated fat with carbohydrates depends greatly on the type of carbohydrate. It is widely agreed that replacement of saturated fats with refined carbohydrates (sugars) does not change or may increase risk. The best outcomes are gained by replacing saturated fat with vegetables and polyunsaturated fats; which is best achieved through reducing red meat, and dairy products, and increasing intakes of nuts, fish, soy products, and non-hydrogenated vegetable oils. Benefits from replacing saturated fat with polyunsaturated fat appears greatest among dietary fatty acids. Clinical trials have showed that supplementation with omega-3 fatty acids (a type of polysaturated fat) does not appear to regularly produce desired outcomes. A diet high in trans fatty acids has also been shown to increase rates of cardiovascular disease.

Evidence suggests that the Mediterranean diet may improve cardiovascular outcomes. This may be by "about 30 percent" in those at high risk. In clinical trials the DASH diet (high in nuts, fish, fruits and vegetables, and low in sweets, red meat and fat) has been shown to reduce blood pressure, lower total and low density lipoprotein cholesterol and improve metabolic syndrome; however, recent clinical trials have showed that the DASH diet must be followed with high concordance among patients at higher risk, to ensure desired outcomes.

The effect of a low salt diet is unclear with any benefit in either hypertensive or normal tensive people being small if present. A low salt diet may be harmful in those with congestive heart failure.

Supplements

While a healthy diet is beneficial, the effect of antioxidant supplementation (vitamin E, vitamin C, etc.) or vitamins generally has not been shown to improve protection against cardiovascular disease and in some cases may possibly result in harm. Evidence to support omega-3 fatty acid supplementation is lacking.

Medication

Aspirin has not been found to be of benefit overall in those at low risk of heart disease as the risk of serious bleeding is equal to the benefit with respect to cardiovascular problems. Statins are effective in preventing further cardiovascular disease in those with a history of cardiovascular disease. A decreased risk of death and strokes however seems to only occur in men. In those without cardiovascular disease but risk factors statins appear to also be beneficial with a decrease in mortality and further heart disease.

Management

Cardiovascular disease is treatable with initial treatment primarily focused on diet and lifestyle interventions.

Epidemiology

Cardiovascular diseases are the leading cause of death. In 2008, 30% of all global death is attributed to cardiovascular diseases. Death caused by cardiovascular diseases are also higher in low and middle-income countries as over 80% of all global death caused by cardiovascular diseases occurred in those countries. It is also estimated that by 2030, over 23 million people will die from cardiovascular diseases annually.

Research

The first studies on cardiovascular health were performed in 1949 by Jerry Morris using occupational health data and were published in 1958. The causes, prevention, and/or treatment of all forms of cardiovascular disease remain active fields of biomedical research, with hundreds of scientific studies being published on a weekly basis. A trend has emerged, particularly in the early 2000s, in which numerous studies have revealed a link between fast food and an increase in heart disease. These studies include those conducted by the Ryan Mackey Memorial Research Institute, Harvard University and the Sydney Center for Cardiovascular Health. Many major fast food chains, particularly McDonald's, have protested the methods used in these studies and have responded with healthier menu options.

A fairly recent emphasis is on the link between low-grade inflammation that hallmarks atherosclerosis and its possible interventions. C-reactive protein (CRP) is a common inflammatory marker that has been found to be present in increased levels in patients at risk for cardiovascular disease. Also osteoprotegerin which involved with regulation of a key inflammatory transcription factor called NF-κB has been found to be a risk factor of cardiovascular disease and mortality.

Some areas currently being researched include possible links between infection with Chlamydophila pneumoniae (a major cause of pneumonia) and coronary artery disease. The Chlamydia link has become less plausible with the absence of improvement after antibiotic use.

Several research also investigated the benefits of melatonin on cardiovascular diseases prevention and cure. Melatonin is a pineal gland secretion and it is shown to be able to lower total cholesterol, very low density and low density lipoprotein cholesterol levels in the blood plasma of rats. Reduction of blood pressure is also observed when pharmacological doses are applied. Thus, it is deemed to be a plausible treatment for hypertension. However, further research needs to be conducted to investigate the side effects, optimal dosage and etc. before it can be licensed for use.

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External links

• Template:Dmoz
• European Guidelines on cardiovascular disease prevention in clinical practice (version 2012)

Template:Medical conditions

• Heart diseases