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Overview of primary prevention of coronary heart disease and stroke

Charles H Hennekens, MD, DrPH
Section Editors
Timothy O Lipman, MD
Freek Verheugt, MD, FACC, FESC
Deputy Editor
Daniel J Sullivan, MD, MPH


In the United States and most developed countries, despite remarkable declines in mortality, cardiovascular disease (CVD), which includes coronary heart disease, stroke, and peripheral artery disease, is and will remain, far and away, the leading cause of death in men and women [1].

An overview of the primary prevention of CVD is presented here, including a discussion of the additive benefits of risk factor reductions through therapeutic lifestyle changes and adjunctive drug therapies of proven benefit. Secondary prevention of CVD, emerging risk factors, and determining individual risk of a patient without known cardiovascular disease are discussed separately. (See "Prevention of cardiovascular disease events in those with established disease or at high risk" and "Overview of established risk factors for cardiovascular disease" and "Cardiovascular disease risk assessment for primary prevention: Our approach".)


In the United States (US), since 1975, cardiovascular disease (CVD) mortality has declined by 24 to 28 percent overall, among men and women, as well as black and whites, although men and blacks continue to experience far higher absolute mortality rates, especially at earlier ages, than their female and white counterparts. Further, the rate of decline has slowed since 1990 [2]. It has been estimated that nearly half of the decline is due to earlier diagnosis and more aggressive treatment, especially of lipids and blood pressure and, particularly with adjunctive drug therapies of life saving benefit, which include statins, aspirin, angiotensin converting enzyme inhibitors and beta blockers [3]. The remaining half of the decline in CVD mortality is attributable to favorable changes in therapeutic lifestyle changes, such as avoidance and cessation of cigarette smoking.

Despite these remarkable declines, however, CVD remains the leading cause of death in the US and has also become so worldwide. While continued improvement in diagnosis is desirable, modification of risk factor modification is a necessity. In descriptive data from a nationally representative survey, useful to formulate but not test hypotheses, five modifiable risk factors for CVD (elevated cholesterol, diabetes, hypertension, obesity, and smoking) accounted for one-half of CVD deaths in US adults aged 45 to 79 in 2009 to 2010 [4]. The preventable fraction of CVD mortality associated with these risk factors was 54 percent for men and 50 percent for women.

The majority of the risk factors for CVD and stroke are modifiable by preventive measures, including therapeutic lifestyle changes and adjunctive drug therapies of proven benefit [5]. In the descriptive INTERHEART study of patients from 52 countries, nine potentially modifiable factors accounted for over 90 percent of the population attributable risk of a first myocardial infarction (MI) [6]. These included cigarette smoking, dyslipidemia, hypertension, diabetes, abdominal obesity, and psychosocial factors. In addition, factors that were associated with lowered risks included regular physical activity, daily consumption of fruits and vegetables, and daily consumption of small amounts of alcohol, which is likely to be about one drink for women and two for men.

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Literature review current through: Nov 2017. | This topic last updated: Nov 20, 2017.
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