Cardiovascular disease (CVD) consists of a group of disorders that affect the heart and blood vessels. Among these disorders are heart disease, heart attack, stroke, heart failure, arrhythmia, and heart valve problems.¹ These diseases are the leading cause of death worldwide. In 2019, CVD resulted in an estimated 17.9 million deaths, which is equivalent to 32% of all deaths globally. Of all CVD-related deaths, heart attack and stroke account for 85%.² While most CVD deaths occur in low- and middle-income countries, nearly half of all adults in the United States have at least one form of heart disease.^2,3 Fortunately, modifying adverse behavior risk factors, such as tobacco use, diet and obesity, physical inactivity, and alcohol use, can prevent most cases of CVD. Early detection is critical to begin management with counseling and medications, and to prevent potential cardiovascular surgical treatments.²

Cardiovascular disease can have various causes, like emboli in a patient with atrial fibrillation leading to ischemic stroke or rheumatic fever causing valvular heart disease. However, many risk factors are associated with the development of atherosclerosis, a common underlying factor in the pathophysiology of CVD.⁴ Unhealthy behaviors like poor diet, lack of exercise, smoking, and excessive alcohol use cause heart disease and stroke. These lead to high blood pressure and cholesterol levels, as well as overweight and obesity. Other factors like poverty, stress, hereditary traits, globalization, urbanization, and population aging may also contribute to CVD.²

According to the INTERHART study, which assessed potentially modifiable risk factors associated with myocardial infarction in 52 countries, abnormal lipid levels, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity account for 90% or more of the risk of myocardial infarction worldwide.⁵ These results included both sexes and all ages in all regions.

The Framingham heart study examined the lifetime risk of CVD among individuals with and without obesity and diabetes over a 30-year study period. The lifetime risk of CVD among women with diabetes was 54.8% for women with weight within normal limits and 78.8% for women with obesity. Among men with weight within normal limits and diabetes, the lifetime risk of CVD was 78.6%, whereas it was 86.9% among men with diabetes and obesity. The study concluded that the lifetime risk of CVD among individuals with diabetes is high, and is exacerbated by higher adiposity.⁶

When the 10-year coronary heart disease event rates from the Framingham Study were applied to risk factor levels measured in the third National Health and Nutrition Examination Survey (NHANES III), 26% of men and 41% of women aged 35 to 74 years had at least one borderline risk factor. Only one-tenth of the projected coronary heart disease events were associated with borderline levels, and most were due to elevated risk factors. Among men, almost 1 in 6 events occurred before age 55 years.⁷

There are multiple tests that can be used to diagnose CVD. These can include blood tests, chest X-ray, electrocardiogram, holter monitoring, echocardiogram, exercise tests or stress tests, cardiac catheterization, cardiac computed tomography scan, and cardiac magnetic resonance imaging.⁸

Diagnosis is typically prompted by clinical suspicion. Health care practitioners should focus on primary prevention in individuals with risk factors and treating modifiable risk factors.⁴ The 2019 American College of Cardiology and American Heart Association guideline on the primary prevention of CVD suggests that the most effective way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to maintain a healthy lifestyle. The guidelines highlight the importance of a team-based care approach in preventing CVD. Clinicians must consider the social determinants of health that impact individuals to make informed treatment decisions.⁹

For individuals aged 40 to 75 years who are being evaluated for CVD prevention, it is recommended that they undergo a 10-year atherosclerotic CVD risk estimation and have a clinician-patient risk discussion before starting on pharmacological therapy, like antihypertensive therapy, a statin, or aspirin. Furthermore, assessing for other risk-enhancing factors is also important to guide decisions about preventive interventions in some patients.⁹ Assessing traditional cardiovascular risk factors in adults aged 20 to 39 years is recommended every 4 to 6 years. For adults who are at borderline risk, considering additional risk-enhancing factors can be reasonable when making decisions about preventive interventions. For adults at intermediate risk or some adults at borderline risk, measuring coronary artery calcium can be reasonable in cases of uncertainty about risk-based decisions for preventative interventions. This can guide discussions between the clinician and patient regarding the risks involved.⁹

All adults need to maintain a healthy diet that prioritizes the consumption of vegetables, fruits, legumes, nuts, whole grains, lean vegetable or animal protein, and fish to decrease the risk for CVD. Limiting the intake of foods such as trans fats, red meat, processed red meats, refined carbohydrates, and sweetened beverages can also reduce the risk of CVD. A diet containing reduced amounts of cholesterol and sodium may also be beneficial. For adults with overweight or obesity, it is recommended to seek counseling and follow a calorie-restricted diet to achieve and maintain weight loss. Adults should aim for at least 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity to maintain good health.⁹

Lifestyle changes, such improving dietary habits and achieving exercise recommendations, are especially important for adults diagnosed with type 2 diabetes mellitus. At every health care visit, all adults should be evaluated for tobacco use. Those who use tobacco should be strongly advised to quit and provided with assistance to do so.⁹

Treatment and management for CVD is extensive and depends on the clinical situation. Some people with CVD may need surgery, depending on the type of heart disease and the amount of damage to the heart. These include commonly performed surgical procedures like coronary artery bypass grafting (CABG), non-surgical procedures like percutaneous coronary intervention (PCI), or minimally invasive procedures like catheter ablation, among many others.³

Coronary artery bypass grafting (also known as bypass surgery) is the most common heart operation performed by cardiac surgeons, with almost 400,000 procedures completed in the United States each year to treat coronary artery disease.^10,11 While remaining the most common major surgical procedure, the total number of operations performed has decreased in recent years, as alternative, minimally invasive treatment approaches such as PCI have increased.¹² Unlike CABG, which is traditionally an open-heart surgical procedure where coronary artery blockages are bypassed with harvested venous or arterial conduits, PCI is a non-surgical procedure where the clinician uses a catheter to place a stent with the goal of opening blood vessels in the heart that were previously narrowed by atherosclerosis.^12,13 The primary indications for PCI are angina pectoris, myocardial ischemia, and acute myocardial infarction.¹³ About 80% of PCIs are performed with stents, although some procedures are performed without stenting.¹³

Catheter ablation for atrial fibrillation is a minimally invasive surgical procedure that involves either burning or freezing a small area of the heart. This causes some scarring on the inside of the heart to help break up the electrical signals that were creating an irregular heartbeat.¹⁴ Although atrial fibrillation affects patients with a prevalence greater than 10% after 80 years of age, it can occur in relatively younger patients as well. A recent study found that patients younger than 50 years of age who underwent catheter ablation had a lower risk of readmission for atrial fibrillation or any cause at 1 year compared with those who were not treated with catheter ablation.¹⁵

Cardiovascular surgery is common not only with patients who have heart disease or other cardiovascular risk factors, but also those at high-risk for developing these problems. To lessen one’s risk for heart surgery, clinicians should communicate the need for secondary prevention through the modification of risk factors and lifestyle for patients with known CVD. Patient-centered approaches to comprehensive cardiovascular risk prevention should include team-based care and shared decision-making. Clinicians’ advice should consider the patients' socioeconomic and educational status, as well as cultural, work, and home environments.⁹

Team-based care is an approach that involves a variety of health care professionals working together to improve the quality of care and maintenance of CVD prevention. This multifaceted approach supports clinical decision-making using treatment algorithms, encourages collaboration among clinicians, and involves patients and their family members to facilitate treatment goals. Additionally, collaboration between clinicians and patients is crucial when deciding primary prevention.⁹

In young adults aged between 20 and 39 years with high blood cholesterol, estimating their lifetime risk and adopting a healthy lifestyle is recommended. In most cases, medication therapy is only recommended for those with moderately high LDL-C (≥ 160 mg/dL) or those with very high LDL-C (≥ 190 mg/dL). For adults aged between 40 and 75 years, the decision to prescribe statin treatment should be based on their 10-year atherosclerotic CVD risk. The higher the estimated risk, the more likely the patient will benefit from statin treatment. For patients over 75 years of age, it is essential to assess their risk status and discuss risk with the patient when deciding whether to initiate or continue statin treatment.⁹ Statin treatments include atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin calcium, and simvastatin. Other cholesterol-lowering therapies include ezetimibe, bile acid sequestrants, PCSK9 inhibitors, adenosine triphosphate-citrate lyase inhibitors, fibrates, niacin, omega-3 fatty acid ethyl esters, and marine-derived omega-3 polyunsaturated fatty acids.¹⁶

Nonpharmacological interventions are recommended for adults with elevated blood pressure or hypertension, including those requiring antihypertensive medications. These interventions include weight loss, a healthy diet, sodium reduction, potassium supplementation, a structured exercise program, and limited alcohol intake. Blood pressure-lowering medications are recommended in adults with an estimated 10-year CVD risk of 10% or higher, an average systolic blood pressure of 130 mm Hg or higher, or an average diastolic blood pressure of 80 mm Hg or higher.⁹ Diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha-blockers, alpha-2 receptor agonists, combined alpha and beta-blockers, and vasodilators are all classes of blood pressure medications.¹⁷

The FDA approved the first anti-inflammatory medication for CVD in June of 2023.¹⁸ Research shows that colchicine 0.5 mg reduces the risk of cardiac events in adults with established atherosclerotic CVD by an additional 31% compared with the standard of care alone.¹⁹ Additionally, sotagliflozin, a sodium-glucose cotransporter 1 and 2 inhibitor, was approved in May of 2023 by the FDA for reducing the risk for cardiovascular death, hospitalization for heart failure, and for preventing death and hospitalization in patients with type 2 diabetes, chronic kidney disease, and other cardiovascular risk factors.²⁰

As CVD involves many components, a multidisciplinary approach to care is typically holistic and patient-centered. The composition of a multidisciplinary team can vary depending on patient needs. It may involve a cardiologist, cardiac surgeon, vascular surgeon, primary care physician, cardiovascular nurse, pharmacist, dietitian, rehabilitation specialist, and social worker. Managing CVD through a multidisciplinary team improves patient outcomes and is a critical component for the successful delivery of cardiovascular care.²¹

CVD is a widespread health condition that affects millions of people worldwide. Fortunately, some types of CVD can be prevented by adopting healthy habits. People at risk for CVD should regularly seek care from health care providers for routine visits and testing. Early diagnosis and treatment can help reduce the risk of complications.

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