Risk Factors for Development of Cardiovascular Disease

Pradeep Kumar Ray,  Engineering Research Center on Digital Medicine and Clinical Translation (DMCT), Shanghai Jiao Tong University

KATM EhsanulHuq,  Graduate School of Biomedical & Health Sciences, Hiroshima University

Michiko Moriyama,  Graduate School of Biomedical & Health Sciences, Hiroshima University

Susumu Nakayama,  Graduate School of Biomedical & Health Sciences, Hiroshima University

Md Moshiur Rahman,  Graduate School of Biomedical & Health Sciences, Hiroshima University

The largest proportion of global mortality is attributed to Cardiovascular Disease (CVD), withmore than three-fourths of CVD relateddeaths occur in low-and-middle incomecountries. The primaryrisk factors of CVD are strongly correlated with health behaviours and overall physical condition. CVD can be effectively prevented by controlling the associated risk factors and proper medications management.

Cardiovascular Disease (CVD) is the number one killer in the world. Globally, about 17.5 million people die every year due to CVD. More than three-fourths of the deaths occur in developing countries. Sustainable Development Goals (SDGs) target 3 is to reduce premature mortality through prevention and treatment of non-communicable diseases by 2030. In the World Congress of Cardiology and Cardiovascular Health in Mexico in June 2016, the World Heart Foundation declared 25 per cent reduction of premature CVD related death by 2025. In September 22, 2016, World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), World Heart Federation, World Stroke Organization, International Society of Hypertension, World Hypertension League and other partner organisations took the ‘Global Hearts Initiative’ to prevent and control the CVD.

CVD consists of heart and its circulation. It includes coronary heart disease, angina, heart attack, heart failure, congenital heart disease (CHD), valvular disease, cardiomyopathy, atrial fibrillation, arrhythmia, stroke, rheumatic heart disease, venous disease and peripheral arterial disease.

CVD occurs when arteries become narrowed by a gradual build-up of fatty materials (atheroma) within the walls. When atheroma breaks away from the arteries, after clotting it can block coronary and obstruct the oxygen-rich blood supply to the heart muscles. Then heart muscles become permanently damaged and cause heart attack. When the blood clot blocks the arteries of the brain, then it causes stroke. Eighty per cent of the CVD patients died due to heart attack and strokes. Narrow arteries can’t carry enough oxygen-rich blood to the heart, that can cause pain and discomfort in the chest called angina.

The risk factors for CVD include unhealthy behaviours; e.g smoking, less physical activities, salt containing diet and overweight, and health factors including cholesterol, Blood Pressure (BP) and glucose. High BP is the highest risk factor to develop CVD. BP related with several genetic factors and environment also influence to contribute. Genetic factors influence about 30-50 per cent and environmental factors about 50 per cent for developing BP. The factors including enzymes, receptors and channels that regulate BP. About 50 per cent of the hypertensive patients develop stroke and ischemic heart disease. Next is smoking, the most important preventable cause of death for CVD. It causes about 10 per cent of CVD. Globally, over 1.1 billion people smoke tobacco as of 2015, and about 6 million people die and it will increase to more than 8 million in 2030. It makes fatty substance in the arteries and causes coronary heart diseases that leads to heart attack. Patients with diabetes are also at high risk to develop cardiovascular disease. CVD is the leading cause of diabetes related morbidity and mortality. Obese people are prone to diabetes due to less physical activities that increase the risk of CVD.

Congenital Heart Diseases (CHD) are associated with genetic syndromes and about 30 per cent of the congenital heart diseases are related to genetic illnesses. Environmental factors including rubella infection, significant alcohol intake, insulin-dependent diabetes and obesity of the mother are also contributing to develop CHD.

The genetic risk factor includes the family history influences for CVD. If both father and mother suffer from heart disease before the age of 55, the risk of getting heart disease rise to 50 per cent compared to other people. There are also increased chances of a stroke, if there is any family history.

Hypertension, high lipid profile and type 2 diabetes also have the genetic component to develop CVD. It means, if father or brother develops CVD under the age of 55 and mother or sister under the age of 65 diagnose with CVD, then screening is recommended after the age of 40 years for CVD.

CVD also varies in different ethnic groups. CVD burden is the highest in the South Asian population. It is the most alarming that younger age groups in South Asia develop CVD more compared to other continents. With the conventional risk factors, congenital, adult metabolic, environmental pollutions, social, and psychological factors also act as risk factors for developing CVD. In South Asian people, the risk of getting coronary heart disease, stroke and diabetes are higher compared to other UK populations. Compared to women, men are more prone to develop CVD at an early age. With age, the chances of getting CVD also increase. Stress, alcohol consumption, and type of work further influence the development of CVD.

WHO has developed evidence-based guidelines for the prevention of CVD. People need primary prevention who have the risk for developing CVD and secondary prevention to avert recurrence of the CVD. The people who are at risk need to maintain risk prediction chart for specific preventive actions and the degree of intensity they need. However, CVD risk is higher in contrast of the risk prediction chart for those who are on antihypertensive therapy, obese, have family history, maintain sedentary lifestyle, elevated triglyceride, C-reactive protein, fibrinogen, homocysteine, apolipoprotein B or Lipoprotein(a), fasting glycaemia, impaired glucose tolerance, microalbuminuria, low HDL cholesterol, increase pulse rate, socioeconomic deprivation, and premature menopause in case of female. For the secondary prevention, intensive lifestyle interventions and appropriate drug therapy are empirical.

For prevention and early detection of CVD, exploring the risk factors is crucial. Unstructured clinical narrative health records data can be extracted and calculated to get the risk scores for developing CVD. Data from electronic health record (EHR) systems are a major source for identification of risk factors and assessment of the prognosis of heart diseases.  Information extraction (IE) system has been used to take out unstructured data from EHRs and risk factors were successfully evaluated by assigning indicators and time attributes.

Researchers and institutes have developed different CVD risk assessment calculator based on the scoring system. These systems can help the patients to predict the risk and control the risk factors to prevent CVD. Framingham CVD risk calculator includes age, sex, present smoking status, total cholesterol, high density lipoprotein cholesterol (HDL-C), systolic blood pressure and drug history for blood pressure control. The estimation was calculated for CVD within 10 years. The scoring systems didn’t include the diet and level of smoking as a risk factor. Reynolds risk scoring system wasdeveloped for men and women separately and includes family history and C-reactive protein with the Framingham’s variables.Some other scoring systems included height, weight, race, diabetes, history of heart attack, family history, physical activities and diet. The American Heart Association (AHA) developed a Health Campaign especially for the young and adult people to avoid smoking and smokeless tobacco products, be active by engaging daily physical activities, eat healthy diets, maintain healthy weight and control blood pressure, cholesterol and glucose. A meta-analysis of prospective cohort studies found that ideal cardiovascular health metrics significantly reduced CVD, cardiovascular mortality and overall all cause of death. Improved cardiovascular health metrics can reduce death related to coronary heart diseases between 2010 and 2020 by 30 per cent. Interventions were recommended to complete cessation of smoking and stop environmental exposure. Asking patients to stop smoking refers to smoking cessation programme. Patients should control blood pressure <140>

Diabetic patients should check blood glucose and maintain lifestyle modifications and treatment. Patients should take antiplatelet and antihypertensive therapy when necessary. CVD patients should have influenza vaccine annually. Depressive illness patients should be evaluated and treated, and cardiac rehabilitation programme should be implemented. Evidence approves that inclusive risk factor management can improve survival, reduce recurrence rate, and improve quality of life. Healthcare provider’s support to the patients, is also essential for the wellbeing of the patients.

CVD causes an enormous burden in health and economy globally. Access to healthcare facilities and prevention of CVD intervention is inexpensive. To implement the universal health insurance system can reduce the risk of CVD; however, primary prevention is the key. In South Asia, one of the main risk factors is shifting in dietary behaviour for CVD. Low cost, local tailored intervention practice for changing the health risk behaviour can prevent CVD. To improve cardiovascular health, (1) changing the individual level lifestyle and treatment of the risk factor, (2) encouraging healthcare providers and patients to improve healthy behaviour, and (3) targeting schools, worship places, workplaces, local communities and, consequently the states and the whole nation, is important. It needs innovative research, advanced technologies and appropriate interventions to save lives. Moreover, along with the health professionals, governments, businesses and public partners need to be involved to achieve the goals.


01. World Health Organization. Available at http://www.who.int/cardiovascular_diseases/en/
02. United Nations. Available at http://www.un.org/sustainabledevelopment/health/
03. World Heart Federation. End of year review 2016. Highlights and achievements. Available at http://members.worldheart.org/downloads/WHF-End-of-Year-Review-2016.pdf
04. British Heart Foundation.  Available at https://www.bhf.org.uk/heart-health/conditions/cardiovascular-disease
05. American Heart Association (AHA) Available at  http://www.heart.org/HEARTORG/Support/What-is-Cardiovascular-Disease_UCM_301852_Article.jsp#.WUOdH4VOKAg
06. National Institutes of Health. Available at https://www.nhlbi.nih.gov/health/educational/hearttruth/lower-risk/what-is-heart-disease.htm
07. Heart disease and stroke statistics-2017 Update A report from the American Heart Association. Available at http://circ.ahajournals.org/content/early/2017/01/25/CIR.0000000000000485
08. Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet. 2008;371:1513–1518.
09. Merlin G. Butler. Genetics of hypertension, current status. J Med Liban. 2010 Jul-Sep;58(3):175-8. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5132177/
10. Jeanemaitre X, Gimenez-Roqueplo A, Disse-Nicodeme S, Corvol P. Molecular basis of human hypertension. Principles of Medical Genetics. 5th. Philadelphia: Churchill Livingston Elsevier; 2007. pp. 283–330.
11. American Heart Association (AHA). Available at  http://www.heart.org/HEARTORG/HealthyLiving/QuitSmoking/QuittingResources/Smoking-Cardiovascular-Disease_UCM_305187_Article.jsp#.WUQE2oVOKAg
12. Mendis S, Puska P, Norrving B editors. World Health Organization (in collaboration with the World Heart Federation and World Stroke Organization), Geneva 2011. Global Atlas on Cardiovascular Disease Prevention and Control.
13. WHO, Global Health Observatory (GHO) data.  Available at http://www.who.int/gho/tobacco/use/en/
14. American Heart Association 1999. Diabetes Mellitus: A major risk factor for cardiovascular disease. Circulation 100:1132-1133. Available at http://circ.ahajournals.org/content/100/10/1132
15. Jung Min Ko. Genetic Syndromes associated with Congenital Heart Disease. Korean Circulation Journal. 2015 Sep; 45(5): 357–361. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4580692/pdf/kcj-45-357.pdf
16. Eskedal LT, Hagemo PS, Eskild A, Frøslie KF, Seiler S, Thaulow E. A population-based study relevant to seasonal variations in causes of death in children undergoing surgery for congenital cardiac malformations. Cardiol Young 2007;17:423-31.
17. Bruce D. Gelb. History of Our Understanding of the Causes of Congenital Heart Disease. CircCardiovasc Genet. 2015 Jun; 8(3): 529–536
18. World Heart Federation. http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/family-history/
19. National Institutes of Health/National Heart, Lung, and Blood Institute’s Framingham Heart Study and Faculty of Medicine, Boston University, Boston. Ramachandran S. Vasan, MD, © 2010 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
20. Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, Pandey MR, Haque S, Mendis S, Rangarajan S, Yusuf S. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA 2007 Jan 17;297(3):286-94.
21. Nair M, Prabhakaran D. Why do South Asians have high risk for CAD? Global Heart 2012;7:307-14
22. World Health Organization (WHO). Prevention of cardiovascular disease (CVDs). Pocket guidelines for assessment and management of cardiovascular risk. Geveva2007. Available at http://www.who.int/cardiovascular_diseases/guidelines/Pocket_GL_information/en/
23. Jonnagaddala J, Liaw ST, Ray P, Kumar M, Chang NW, Dai HJ. Coronary artery disease risk assessment from unstructured electronic health records using text mining. J Biomed Inform. 2015 Dec;58 Suppl:S203-10.
24. Jitendra Jonnagaddala, Siaw-Teng Liaw, Pradeep Ray, Manish Kumar, Hong-Jie Dai, and Chien-YehHsu. Identification and progression of heart disease risk factors in diabetic patients from longitudinal electronic health records. BioMed Research International volume 2015, Article ID 636371, 10 pages
25. Harvard Health Publications, Harvard Medical School. Heart attack risk calculators. Published in June 2009. Available at http://www.health.harvard.edu/newsletter_article/Heart-attack-risk-calculators
26. Framingham Coronary Heart Disease Risk Score. Available at https://www.mdcalc.com/framingham-coronary-heart-disease-risk-score
27. Mayo Foundation. Available at http://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/heart-disease-risk/itt-20084942
28. ACC/AHA ASCVD Risk Calculator2013. ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Available at http://www.cvriskcalculator.com/
29. Sidney C Smith, Emelia J Benjamin, Robert O Bonow, Lynne T Braun, Mark A Creager, Barry A Franklin, Raymond J Gibbons, Scott M Grundy, Loren F Hiratzka, Daniel W Jones, Donald M Lloyd-Jones, Margo Minissian, Lori Mosca, Eric D Peterson, Ralph L Sacco, John Spertus, James H Stein, Kathryn A Taubert. AHA/ACCF Guideline. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 Available at http://circ.ahajournals.org/content/circulationaha/early/2011/11/01/CIR.0b013e318235eb4d.full.pdf
30. Andrew Moran, Rajesh Vedanthan. Cardiovascular disease prevention in South Asia, gathering the evidence. Glob Heart. 2013 Jun; 8(2): 139–140.
31. Turin TC, Shahana N, Wangchuk LZ, Specogna AV, AI Mamun M, Khan MA, Choudhury SR, Zaman MM, Rumana N. Burden of cardio-and cerebro-vascular diseases and the conventional risk factors in South Asian population. Glob Heart. 2013 Jun;8(2):121-30

--Issue 37--

Author Bio

Pradeep Kumar Ray

Pradeep Ray is the Founder and Director of the WHO Collaborating Centre on eHealth at the University of New South Wales, Australia. He led to completion several global initiatives, such as the WHO Research on the Assessment of e-Health for Healthcare Delivery (eHCD) involving a number of countries in the Asia-Pacific region.

KATM EhsanulHuq

KATM EhsanulHuq is a doctoral student of Hiroshima University. He completed his masters from Uppsala University, Sweden, diploma from Swiss Tropical and Public Health Institute, Switzerland and medical graduation from Bangladesh. He worked at International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in different clinical researches specially vaccine trials, bioequivalence studies and drug development.

Michiko Moriyama

Michiko Moriyama is a Professor of Division of Nursing Science under the Institute of Biomedical& Health Sciences in Hiroshima University, Japan. She has been involved in various types of research activities such as Chronic Care and Disease Management, Family Nursing, and Population Sciences. She has multidisciplinary collaboration in different countries for sustainable development.

Susumu Nakayama

Susumu Nakayama is a doctoral student at Hiroshima University, Japan and completed masters graduation degree from Hiroshima University. He has engaged in construction of community cooperation system for heart failure patients in Hiroshima prefecture of Japan.

Md Moshiur Rahman

Moshiur Rahman is a Visiting Associate Professor at the Graduate School of Biomedical &Health Sciences in Hiroshima University, Japan. He has multidisciplinary experiences in clinical science, public health, and molecular research. Expertize in planning, implementing, monitoring and evaluation of public health programs & research in developing countries.