Fawzy, Ameenathul M

Lip, Gregory Y H

English

PubMed

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    Aalborg UniversitetCardiovascular disease preventionRisk factor modification at the heart of the matterFawzy, Ameenathul M; Lip, Gregory Y HPublished in:The Lancet regional health. Western PacificDOI (link to publication from Publisher):10.1016/j.lanwpc.2021.100291Creative Commons LicenseCC BY-NC-ND 4.0Publication date:2021Document VersionPublisher's PDF, also known as Version of recordLink to publication from Aalborg UniversityCitation for published version (APA):Fawzy, A. M., & Lip, G. Y. H. (2021). Cardiovascular disease prevention: Risk factor modification at the heart ofthe matter. The Lancet regional health. Western Pacific, 17, [100291].https://doi.org/10.1016/j.lanwpc.2021.100291General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            - Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            - You may not further distribute the material or use it for any profit-making activity or commercial gain            - You may freely distribute the URL identifying the publication in the public portal -Take down policyIf you believe that this document breaches copyright please contact us at vbn@aub.aau.dk providing details, and we will remove access tothe work immediately and investigate your claim.Downloaded from vbn.aau.dk on: November 19, 2022The Lancet Regional Health - Western Pacific 17 (2021) 100291 Contents lists available at ScienceDirect The Lancet Regional Health - Western Pacific journal homepage: www.elsevier.com/locate/lanwpc Commentary Cardiovascular disease prevention: Risk factor modification at the heart of the matter ✩ Ameenathul M. Fawzy 1 , Gregory Y.H. Lip 1 , 2 , ∗1 Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom 2 Department of Clinical Medicine, Aalborg University, Aalborg, Denmark a r t i c l e i n f o Article history: Received 15 September 2021 Accepted 15 September 2021 Available online 20 October 2021 armr  rs[enaoptop  potpnowtdrCSltaspwewmfrtgrwa4CtTahWh2(Cardiovascular disease (CVD) stubbornly retains its reputation s a leading cause of morbidity and mortality. Deaths from CVD emain alarmingly high and are projected to be an astounding 23 illion worldwide in 2030, although overall mortality rates have educed over recent decades [ 1 , 2 ]. Nonetheless, the burden of CVDemains unchanged, owing to an increasing number of patients urviving into older age with debilitating cardiovascular problems 3] . Perhaps this is the more pressing issue, courtesy of the adverse ffects on patient quality of life and the tremendous health eco- omic impact. Hence, there is growing emphasis on CVD risk man- gement and prevention, to reduce disease burden [4] . After all, an unce of prevention is worth a pound of cure. Given that many atients with CVD have associated comorbidities and lifestyle fac- ors that should be addressed, this has also led to the evolution f more holistic or integrated multidisciplinary management ap- roaches to improve patient care [ 5 , 6 ]. Adherence to such an ap-roach has been associated with significant reductions in adverse utcomes, for example, in patients with atrial fibrillation [ 7 , 8 ]. In this issue, Wang and colleagues [9] discuss findings from heir prospective study aimed at characterising age-specific risk rofiles for CVD and mortality, with the notion that one size does ot fit all when it comes to cardiovascular risk modification. Data n modifiable cardiometabolic, lifestyle and socio-economic factors as collected, and 119,455 and 139,925 patients were included in he CVD and mortality analysis respectively. Over a mean follow-up uration of 3.8 years, 2975 CVD events and 2154 mortalities were ecorded. ✩ Disclosures: None related to this work ∗ Corresponding Author: Prof Gregory Y H Lip, University of Liverpool, Liverpool entre for Cardiovascular Science, William Henry Duncan Building, 6 West Derby treet, Liverpool, L7 8TX, United Kingdom, Tel: 0151 7949020 E-mail address: gregory.lip@liverpool.ac.uk (G.Y.H. Lip). ctttp((ttps://doi.org/10.1016/j.lanwpc.2021.100291 666-6065/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article http://creativecommons.org/licenses/by-nc-nd/4.0/ ) Overall, hypertension was the strongest risk factor for CVD, fol- owed by chronic kidney disease (CKD) and diabetes, while the top hree risk factors for mortality were CKD, low education, and in- ppropriate sleep duration. Interestingly, dyslipidaemia and obe- ity were not associated with increased mortality and the ‘obesity aradox’ was regarded a possible explanation. In contrast, the study by Yusuf et al. indicated that hypertension as the predominant risk factor for both CVD and mortality, with levated cholesterol levels and body mass index – measured using aist to hip ratio - also showing a positive correlation [10] . This ulti-national study had a comparable sample size but a longer ollow-up duration of 9.5 years. These findings also call for further esearch to investigate the plausibility of the obesity paradox in he setting of CVD. Wang and colleagues [9] also stratified risk according to age roups, with focus on individuals aged ≥75 years. Notably, CVD isk associated with metabolic factors such as diabetes and CKD as seen to diminish with age, with HR 2.04 95% CI (1.69-2.46) nd HR 3.89 95% CI (2.28-6.63) respectively for those between 0-54 years, and HR 1.44 95% CI (1.12 – 1.86) and HR 1.11 95% I (0.80 – 1.55) respectively for those ≥75 years. In this group, he strongest risk factor for CVD was inappropriate sleep duration. his reflects existing evidence associating habitual sleep loss with  heightened risk of CVD and metabolic problems such as obesity, ypertension and diabetes mellitus. Population attributable risk percentages (PAR%) were used by ang and colleagues [9] as measures to estimate the proportion of ases attributable to a particular risk factor. For the overall popula- ion, hypertension (PAR% 30.7% 95% CI (26.7-34.7%) and low educa- ion (PAR% 22% 95% CI (16.0%-27.7%)) were the biggest contributors o CVD and mortality respectively. In individuals ≥75 years, inap- ropriate sleep duration was the biggest influencer of both CVD PAR 30.5% 95% CI (17.9%-42%)) and mortality (PAR 34.7% 95% CI 24.5%-44.1%)). Lifestyle factors primarily accounted for mortality under the CC BY-NC-ND license A.M. Fawzy and G.Y.H. Lip The Lancet Regional Health - Western Pacific 17 (2021) 100291 Figure 1. depicts the biopsychosocial model for modifying cardiovascular risk and the wider multi-disciplinary components essential for this CVD – Cardiovascular disease, GPs – General practitioners, OTs – Occupational therapists, BP – blood pressure, CKD – chronic kidney disease, BMI – Body mass inde ipifcgpibstbtaiwstalsmttpvcc(tepbetvDR n the overall population as well as CVD and mortality in partici- ants ≥75 years, while metabolic factors mostly accounted for CVD n the overall population. This work by Wang and colleagues [9] is commendable, also or focusing on the concept of individualised risk-profiling to fa- ilitate personalised risk management. The study’s findings sug- est that stringent blood pressure control, dietary modifications, ublic health awareness and healthcare accessibility, particularly n lower socio-economic regions, can significantly alleviate CVD urden in the overall population, with individuals ≥75 requiring pecific measures to address sleep disturbance and lifestyle fac- ors such as smoking. Indeed, adjustment of these risk factors is ound to achieve positive outcomes, but one must remember that he study only provides a snapshot and does not account for risk ccumulation over time. Risk cannot be interpreted in silos as it s an interconnected, ever evolving entity. Given that participants ere recruited through home visits, there may be an element of ampling and selection bias which may partly explain why 66.1% of he study population was female. The study is also prone to gender nd recall bias, and effects from unaccounted confounders. Further, ong-term CVD or mortality risk cannot be determined due to the hort follow-up period. One striking observation is the decrease in the impact of etabolic factors with age. Selective survival was offered as a po- ential explanation though age-related increases were observed in he prevalence of these factors. Inappropriate sleep duration ap- eared to be the single most important risk factor in older indi- iduals but whether this is due to sleep loss being reported in- reasingly with age or a true association is unclear. What are the implications? CVD is an unmatched public health risis, and a holistic approach is imperative to reduce its burden  figure 1 ). This cannot be achieved unless its prevention is priori- ised, with personalised risk factor modification at the heart of ev- ry stage. Indeed, risk factors tend to cluster, for example, a hy- ertensive patient may have associated risk factors such as dia- etes and sleep apnoea, as well as adverse lifestyle factors, such as 2 xcessive drinking and smoking and sedentary behaviours. Hence, he urgent need for an integrated or holistic approach to CVD pre- ention discussed above. Things can only get better. eclaration of Competing Interest The authors declare no conflict of interest. eferences [1] Bhatnagar P, Wickramasinghe K, Wilkins E, Townsend N. Trends in the epi- demiology of cardiovascular disease in the UK. Heart 2016;102(24):1945–52. doi: 10.1136/HEARTJNL- 2016- 309573 . [2] Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis forthe Global Burden of Disease Study 2010. The Lancet 2012;380(9859):2095–128. doi: 10.1016/S0140- 6736(12)61728- 0 . [3] Amini M, Zayeri F, Salehi M. Trend analysis of cardiovascular disease mor- tality, incidence, and mortality-to-incidence ratio: results from global bur- den of disease study 2017. BMC Public Health 2021 21:1 2021;21(1):1–12. doi: 10.1186/S12889- 021- 10429- 0 . [4] Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovas- cular disease prevention in clinical practiceDeveloped by the Task Force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies With the special contribution of the European Association of Preventive Cardiology (EAPC). European Heart Journal 2021;42(34):3227–337. doi: 10.1093/EURHEARTJ/ EHAB484 . [5] Lip G, Ntaios G. Integrated Care for Stroke Management: Easy as ABC. Throm- bosis and haemostasis September 2, 2021 Published online. doi: 10.1055/ A- 1632- 1777 . [6] Field M, Kuduvalli M, Torella F, McKay V, Khalatbari A, Lip G. Integrated Care Pathways and The Aortovascular Hub. Thrombosis and Haemostasis August 18, 2021 Published online. doi: 10.1055/A-1591-8033 . [7] Yoon M, Yang P, Jang E, et al. Improved Population-Based Clinical Outcomes of Patients with Atrial Fibrillation by Compliance with the Simple ABC (Atrial Fibrillation Better Care) Pathway for Integrated Care Management: A Na- tionwide Cohort Study. Thrombosis and haemostasis 2019;119(10):1695–703. doi: 10.1055/S- 0039- 1693516 . [8] Romiti G, Pastori D, Rivera-Caravaca J, et al. Adherence to the “Atrial Fibrilla- tion Better Care” Pathway in Patients with Atrial Fibrillation: Impact on Clinical Outcomes-A Systematic Review and Meta-Analysis of 285,0 0 0 Patients. Throm- bosis and haemostasis 2021 Published online. doi: 10.1055/A-1515-9630 . A.M. Fawzy and G.Y.H. Lip The Lancet Regional Health - Western Pacific 17 (2021) 100291  [[9] Wang T, Zhao Z, Yu X, et al. Age-specific modifiable risk factor profiles for car-diovascular disease and all-cause mortality: a nationwide, population-based, prospective cohort study. The Lancet Regional Health - Western Pacific. Pub- lished online 2021. doi:10.1016/j.lanwpc.2021.100277 3 10] Yusuf PS, Joseph P, Rangarajan S, et al. Modifiable risk factors, cardiovascular disease and mortality in 155,722 individuals from 21 high-, middle-, and low- income countries. Lancet (London, England) 2020;395(10226):795. doi: 10.1016/ S0140- 6736(19)32008- 2 . 

Cardiovascular disease prevention:Risk factor modification at the heart of the matter

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Cardiovascular disease prevention:Risk factor modification at the heart of the matter

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