Guidelines for cardiovascular prevention: prevention through lifestyle
Cardiovascular disease is the leading cause of death in the westernised world. Myocardial infarction, and more specifically ischemic heart disease, most often affects individuals at the peak of their psycho-physical, reproductive and working efficiency
The incidence of atherosclerotic disease and mortality from cardiovascular causes is falling in all westernised countries, but it is still the main cause of illness and death.
The main cause of its occurrence is multiple cardiovascular risk factors while a healthy lifestyle prevents or slows down its onset.
Cardiovascular prevention guidelines
The guidelines on cardiovascular prevention were updated in 2021.
The main points of these guidelines underline the importance of being very decisive, almost aggressive, towards the multiple cardiovascular risk factors and to be so for the whole population, therefore for all age groups and all risk levels because it is very important to prevent the onset of atherosclerotic disease.
The cardiovascular risk factors for both sexes are age, family history and sex (non-modifiable factors); smoking, high blood pressure, diabetes, dyslipidaemia and overweight, on the other hand, can be modified by lifestyle.
In the latest guidelines of 2021, prevention was extended to the elderly population, the over-70s, who have a life expectancy of more than 10 years.
To count individual cardiovascular risk, risk SCOREs are used. These are cards that calculate the probability of a major cardiovascular event occurring; a true calculator that takes into account each patient’s gender, age, smoking habits, blood pressure and cholesterol values.
In this way, the individual’s risk of developing heart disease can be calculated, enabling the doctor and specialist to establish a targeted, individualised therapy to reduce the risk.
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Cardiovascular prevention is aimed at people who do not suffer from heart disease
It is mainly based on lifestyle correction, including good eating habits, adequate physical activity, without forgetting good sleep hygiene and the reduction of stressful factors.
In the latest guidelines attention has been given to the practicability of prevention with measures not only aimed at the individual but also involving health authorities with Health Plans that allow all individuals to get closer to cardiovascular prevention.
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Heart: the differences between men and women
Cardiovascular risk factors must be differentiated in the two sexes, stressing that in women there is a natural watershed constituted by the menopause with the known hormonal changes that follow it.
In addition, women have not reduced their smoking habits in recent years, and over the age of 45, 52% suffer from high blood pressure and 40% have high cholesterol levels (U.S. National Center for Health Statistics).
The possible primary cardiovascular preventive role of hormone replacement therapy in symptomatic postmenopausal women is still debated.
If the later onset of the disease and the appearance of different symptoms may appear as positive aspects, they actually only make a successful preventive and therapeutic course more complex.
In addition, the female heart tends to be more susceptible to adrenalin rushes caused by strong emotions, leading, in the acute phase, to Tako Tsubo syndrome, a name derived from a basket used in Japan for fishing, since the heart, stressed by a strong discharge of neurotransmitters, assumes its shape deforming and losing contractile force.
In addition to the risk factors in the strict sense of the word, there is another, no less important one, represented by the different perception that women have of their health and, consequently, of their state of illness.
In fact, women have a profoundly different conception of cardiovascular disease from men, who have always been taught to consider themselves exempt from this type of pathology, which is almost exclusively a matter for men.
Hence also the lack of attention to primary prevention on the part of most women themselves.
This attitude of neglect translates, in many cases, into avoidable delays in treatment, admissions to hospital when symptoms do not appear, with treatments involving drugs mostly designed for the male organism which therefore penalise the treatment pathway for women.
Prevention of cardiovascular disease and diet: the Mediterranean diet
From a dietary point of view, the Mediterranean diet seems to promote heart health more than any other, as highlighted by the PREDIMED study published in the New England Journal of Medicine in 2013.
This randomised study, which lasted almost ten years, involved 4774 patients aged between 50 and 80, without previous cardiovascular disease but at high risk due to the presence of at least three traditional risk factors, divided into three groups with different diets:
- Mediterranean diet with extra virgin olive oil (1 litre of oil per week);
- Mediterranean diet with the addition of nuts (walnuts, almonds and hazelnuts, 30 grams a day);
- standard control diet.
The results showed that following a Mediterranean diet (with extra virgin olive oil or nuts rich in unsaturated fats, i.e. good fats) has a considerable benefit, significantly reducing the incidence of cardiovascular events.
Dairy products can also be beneficial to heart health: a study published in the journal Lancet, for example, showed that consuming more than two daily portions of milk and low-fat dairy products, compared with no consumption, was associated with a lower risk of all-cause mortality, cardiovascular disease and stroke.
A study published in Circulation highlights the role of breakfast: men who do not eat breakfast have an increased risk of heart attack and coronary heart disease.
However, the study found that men who skipped breakfast smoked more, worked full-time, were often unmarried, exercised less and consumed more alcohol.
Neglecting breakfast, therefore, was associated with risk factors that may have played a role as a contributory cause of cardiac events, if not the cause itself, thus underlining the importance of our lifestyle.
Regular physical activity to prevent cardiovascular disease
Regular physical activity is an important aspect of primary cardiovascular prevention.
In particular, aerobic activity – commensurate with age and health status – plays a preventive role.
For example, a brisk 45-minute walk three times a week is recommended for older people, while younger people can engage in more intense activities such as swimming, running or gymnastics.
The important thing is to get your heart used to working properly and consistently week after week. It is therefore better to engage in daily physical activity, even a brisk walk for a relatively short period of time, gradually increasing the intensity of aerobic work.
It is important not to overdo it, especially at the beginning when you are not trained, and in general it can be useful to rely on a personal trainer or even on the advice of a doctor for a tailor-made and safe physical activity programme.
The benefits of physical activity for the heart
Sedentariness is an important and well-known cardiovascular risk factor: leading a sedentary life, in fact, predisposes to the development of atherosclerosis and therefore of eventual coronary disease, while regular physical exercise brings benefits comparable to those given by the administration of a drug and is recommended for healthy and unhealthy individuals.
Good news: there are no age limits when it comes to physical activity.
Even after spending half of your life sedentary, once you reach middle age, it is possible and beneficial to start exercising (subject to your condition and capabilities, of course, and evaluated by your doctor or cardiologist).
Practising aerobic activity (e.g. brisk walking, running) promotes the formation of nitrous oxide, both in the heart muscle and at systemic level, throughout the cardiovascular system (arteries, veins, capillaries), which is an important vasodilator, i.e. it stimulates the dilation of blood vessels, particularly arteries, thereby lowering blood pressure and promoting mainly arterial circulation.
Regular physical activity also leads to:
- Decreased resting heart rate, which causes a drop in myocardial oxygen consumption and systemic blood pressure;
- Increased cardiac output (the amount of blood expelled by the heart in one minute);
- Increased myocardial contraction force, so the heart pumps more efficiently.
Finally, exercise, as well as helping to keep blood pressure levels under control, helps to reduce the level of fat in the blood, keep metabolic balance and body weight under control.
Recommended for everyone, especially those with hypertension, dyslipidaemia and overweight people.
Checks before starting physical activity in healthy people
Before starting a new exercise/physical activity routine, it is advisable to have a medical examination.
This is always a useful tool for primary prevention, as it allows you to check blood pressure and, through blood tests, blood sugar, cholesterol and triglycerides.
If aspects requiring further investigation emerge, a cardiological examination with electrocardiogram may be requested.
In general, from the age of 40, it is advisable to have your blood pressure and blood tests checked regularly.
If there is a family history of heart disease, these regular check-ups should be carried out from the age of 30 and could include an exercise test.
If blood pressure and blood tests are normal, the first cardiological examination can be after the age of 50.
However, it should be done even earlier if there are alarm bells, such as suspected chest pain, which occurs with physical activity and disappears when it is stopped.
Physical activity and cardiovascular disease
Regular aerobic exercise is recommended for healthy individuals, but also for those who have been diagnosed with heart disease, heart attack, cardiac surgery, coronary angioplasty or heart failure: it is a non-pharmacological therapy that helps in the management of the disease with a reduction of the consequences of the disease with effective resumption of daily activities.
The aim of cardiorespiratory rehabilitation is to reduce the functional limitations associated with the pathology with a reduction in the burden of disability associated with the acute event.
During the rehabilitation period, the patient has to be taught a change of lifestyle in addition to optimising the drug therapy.
In this way, the quality of life after the acute event improves significantly.
Patients who engage in physical activity – of course in accordance with the appropriate, personalised medical indications – benefit from better follow-up; if the disease is stabilised, the risk of instability is reduced and the results achieved are safeguarded, preventing possible future adverse events.
Exercise is a central element of rehabilitation cardiology programmes.
Risk stratification is based on clinical data.
An exercise test and echocardiogram are recommended for an exercise programme to document any residual ischaemia and to be aware of ventricular function.
Functional capacity should be assessed before and after completion of the exercise programme using valid and reliable methods.
For most patients, aerobic exercise of low to moderate intensity is recommended, adapted to each individual’s different level of physical capacity such as walking, swimming, gardening.
The intensity of exercise should be monitored and adjusted by the cardiac patient’s perception of effort using the Borg scale or through heart rate monitoring (patients can also self-adjust the intensity of effort).
Low to moderate risk cardiac patients may also undertake endurance training, which may precede aerobic training.
Screening for anxiety and depression should take place at the beginning of rehabilitation and at 6-12 months after the acute event.
Rehabilitation programmes should include both psychological and educational interventions as part of a comprehensive Rehabilitation with psychological and behavioural interventions targeted to the needs of individual patients.
Does stress affect heart health?
Stress has a strong impact on our physical and mental health, especially when chronic.
In fact, our level of stress affects our blood pressure and, if continuous, leads to an increase in blood pressure, thus increasing cardiovascular risk.
In addition, by inducing a whole series of hormonal stimuli, stress leads to changes in the cholesterol (or atherosclerotic) plaques in the coronary arteries, which can become unstable and rupture, with the risk of causing a heart attack or other ischaemic event.
Consulting a specialist (a neurologist or psychologist, for example) can help you assess your stress level.
Trying to eliminate sources of stress is certainly the first step.
If this is not enough, your doctor may consider specific changes in your lifestyle habits (eating and physical activity) and possibly specific drug therapy.
Sleep and cardiovascular risk
A good night’s sleep is invaluable for our psycho-physical health: sleeping poorly or not at all is a major strain on our bodies.
An American study looked at the relationship between quality and quantity of sleep and heart health and found that poor quality sleep and sleep lasting less than 6 hours a night increases cardiovascular risk.
Attention should also be paid to the possible presence of sleep apnoea, i.e. moments during sleep when breathing does not occur rhythmically and regularly but stops, pauses, lasting seconds.
The presence of apnoeas does not allow deep and restorative sleep and this leads to daytime sleepiness, possible bouts of sleepiness during the day even while driving, irritability and excessive tiredness.
Obesity undoubtedly predisposes to sleep apnoea, so weight control remains the first medicine.
The presence of apnoea should not be overlooked because it must be considered a real pathology and, if present, requires careful evaluation by your doctor, who must be informed.
Heart: signs not to be underestimated
Lastly, it is essential not to underestimate certain symptoms, the alarm bells, which should lead you to consult your cardiologist as soon as possible for further investigations:
Chest pain: an oppressive type of chest pain (chest tightness), which is heavy, stabbing or aching, may be located in the chest, shoulders or back, may radiate to the neck and teeth, lasts for a few minutes and is usually associated with exertion and intense sweating;
Palpitations (missing, irregular or fast beats). In general, sporadic palpitations are not a cause for concern and may be a natural reflex of the heart. However, if prolonged, unrelated to triggering events or if associated with significant dizziness or even loss of consciousness, they may be an indication of a significant arrhythmia.
Respiratory abnormalities, reported as sudden, new-onset breathing difficulty and fatigue during a usual activity that was previously well tolerated.
An important aid to diagnosis can be provided by the patient himself by his ability to tell the specialist about the symptoms and the conditions under which they occurred.
To ascertain their nature, depending on the disorder, the doctor may prescribe, among other examinations, a dynamic 24-hour Holter ECG, i.e. the recording of the electrocardiogram over the course of a whole day, during which the patient is asked to record in a kind of diary the activities carried out (work, rest, strong emotions, etc.), rest, strong emotions, etc.) and any symptoms, a stress test that may detect the appearance of heart pain during physical activity, and an echocardiogram, an ultrasound examination that assesses the size of the heart, the efficiency of contractile function and the appearance of the valve structures.
The cardiologist will then be able to assess the clinical picture more accurately and thoroughly; if heart disease is suspected, the specialist will proceed to request more in-depth level II examinations, such as a coronary CT scan or coronarography itself, which requires a short hospital stay.
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