Very High Prevalence of Nonoptimally Controlled Traditional Risk Factors at the Onset of Cardiovascular Disease

Recent studies suggest that coronary heart disease (CHD) may frequently occur in the absence of traditional cardiovascular disease (CVD) risk factors. However, it is unclear whether this could reflect missed clinical diagnoses or subthreshold nonoptimal risk factor exposure preceding CHD, and whether similar patterns are observed for heart failure (HF) or stroke.

The purpose of this study was to determine the antecedent occurrence of nonoptimal levels of 4 traditional risk factors (blood pressure [BP], cholesterol, glucose, and tobacco smoking) before first CHD, HF, or stroke.

We analyzed 2 population-based prospective cohorts: KNHIS (Korean National Health Insurance Service) (n = 9,341,100; baseline age ≥20 years; follow-up, 2009-2022) and MESA (Multi-Ethnic Study of Atherosclerosis) (n = 6,803; baseline age 45-84 years; follow-up, 2000-2019). Among individuals who developed incident CHD, HF, or stroke during follow-up, we determined the prevalence of ≥1 traditional risk factor above optimal level-systolic BP ≥120 mm Hg or diastolic BP ≥80 mm Hg or BP-lowering treatment; total cholesterol ≥200 mg/dL or lipid-lowering treatment; fasting glucose ≥100 mg/dL or diagnosis of diabetes or glucose-lowering treatment; or past or current smoking-at any visit before CVD.

Analyses were based on 601,025 and 1,188 CVD events in KNHIS and MESA, respectively. Prevalence of ≥1 nonoptimal risk factor was high (99.7% and 99.6%) before CHD, with similar patterns before HF (99.4% and 99.5%) and stroke (99.3% and 99.5%) in both KNHIS and MESA, respectively. Prevalence of ≥1 risk factor before CVD was consistently high (>99%) across age groups in both men and women, with the lowest proportion observed for HF and stroke (>95%) when occurring at ages <60 years in women. Prevalence of ≥2 risk factors was also common (93.2% to 97.2%) before CVD events.

In this binational study of 2 prospective cohorts, the presence of nonoptimal levels of ≥1 traditional risk factor was nearly universal before CVD. These results not only challenge claims that CHD events frequently occur without antecedent major risk factors but also demonstrate that other CVD events, including HF or stroke, rarely occur in the absence of nonoptimal traditional risk factors, highlighting the importance of primordial prevention efforts.