Cardiovascular disease is a major cause of disability and premature death throughout the world, and contributes substantially to the escalating costs of health care. The underlying pathology is atherosclerosis, which develops over many years and is usually advanced by the time symptoms occur, generally in middle age. Acute coronary and cerebrovascular events frequently occur suddenly, and are often fatal before medical care can be given. Modification of risk factors has been shown to reduce mortality and morbidity in people with diagnosed or undiagnosed cardiovascular disease.
Several forms of therapy can prevent coronary, cerebral and peripheral vascular events. Decisions about whether to initiate specific preventive action, and with what degree of intensity, should be guided by estimation of the risk of any such vascular event. The risk prediction charts that accompany these guidelines allow treatment to be targeted according to simple predictions of absolute cardiovascular risk.
The debilitating and often fatal complications of cardiovascular disease (CVD) are usually seen in middle-aged or elderly men and women. However, atherosclerosis – the main pathological process leading to coronary artery disease, cerebral artery disease and peripheral artery disease – begins early in life and progresses gradually through adolescence and early adulthood (15–17). It is usually asymptomatic for a long period.
The rate of progression of atherosclerosis is influenced by cardiovascular risk factors: tobacco use, an unhealthy diet and physical inactivity (which together result in obesity), elevated blood pressure (hypertension), abnormal blood lipids (dyslipidemia) and elevated blood glucose (diabetes). Continuing exposure to these risk factors leads to further progression of atherosclerosis, resulting in unstable atherosclerotic plaques, narrowing of blood vessels and obstruction of blood fl ow to vital organs, such as the heart and the brain. The clinical manifestations of these diseases include angina, myocardial infarction, transient cerebral ischemic attacks and strokes. Given this continuum of risk exposure and disease, the division of prevention of cardiovascular disease into primary, secondary and tertiary prevention is arbitrary, but may be useful for development of services by different parts of the health care system. The concept of a specific threshold for hypertension and hyperlipidemia is also based on an arbitrary dichotomy.
The purpose of applying the recommendations elaborated in these guidelines is to motivate and assist high-risk individuals to lower their cardiovascular risk by:
● quitting tobacco use, or reducing the amount smoked, or not starting the habit;
● making healthy food choices;
● being physically active; ● reducing body mass index (to less than 25 kg/m2) and waist–hip ratio (to less than 0.8 in women and 0.9 in men (these figures may be different for different ethnic groups) ;
● lowering blood pressure (to less than 140/90 mmHg);
● lowering blood cholesterol (to less than 5 mol/l or 190 mg/dl);
● lowering LDL-cholesterol (to less than 3.0 mol/l or 115 mg/dl);
● Controlling glycaemia, especially in those with impaired fasting glycaemia and impaired glucose tolerance or diabetes;
● taking aspirin (75 mg daily), once blood pressure has been controlled
Estimates of relative risk per unit increase in continuous risk factors, i.e. per mmHg for systolic blood pressure and per mol/l for total cholesterol, as well as for the presence of smoking were determined from the CRA project (largely from prospective cohort studies). These relative risk estimates were applied to the hypothetical cohort to determine the relative risk of each individual in the cohort.
Absolute risk of a cardiovascular event was determined by scaling individual relative risk to population incidence rates of cardiovascular disease (ischemic heart disease and stroke), estimated from the Global Burden of Disease Study. The probability of a cardiovascular event was extrapolated to a 10-year period. The mean absolute risk for various combinations of risk factor levels was then calculated and tabulated.
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