Cardiovascular prevention: components, levels, early origins, and metrics

This article presents core epidemiological studies that establish the basis for cardiovascular prevention strategies. The results of the classic INTERHEART and INTERSTROKE studies that delineated population-attributed risk for myocardial infarction and stroke are described. Differences in the levels or types of prevention-primordial, primary, and secondary-lead to the concept that risk occurs on a continuum throughout life with great variability, beginning in infancy. Any meaningful and sustained reduction in cardiovascular risk must begin in childhood, as habits formed early in life have an impact for decades. Although it is never too late to improve unhealthy habits, interventions early in life are more likely to be effective in preventing disease from developing, in delaying manifestations, or in reversing pathology through evidence-based therapies that are applied later. There is compelling evidence that coronary atherosclerosis, heart disease related to diabetes, and hypertension begin with endothelial activation. Oxidative stress and reduced nitric oxide availability are also among the earliest of events, from which a self-amplifying web of events proceed. The American Heart Association, even prior to its now-validated and classic definition of risk metrics, developed a strategic plan to improve health habits in the population and at the community level for promoting and monitoring behavior change and patients' self-reported health status. Other initiatives for improving cardiovascular health are in place as well. Despite improvements in treatment of risk factors, there has been minimal, if any, success in reversing the dual epidemics of obesity and diabetes. These 2 factors continue to drive the high burden of cardiovascular risk, and now lead current public health issues. Because treatment alone cannot fully address this tsunami of risk, it has been suggested that all physicians assume an unprecedented and aggressive role as advocates for behavior change to prevail against the foes of obesity and diabetes.