The State of the Art in Cardiovascular Risk Reduction

Kim Allan Williams, Sr., MD, MACC; Sarah Alexander, MD; Hena N. Patel, MD


March 05, 2018

Editorial Collaboration

Medscape &


High cholesterol, present in nearly 1 in 3 US adults, is a major risk factor for CVD. In 2011 to 2012, the targets for total cholesterol were met in 75.7% of children (< 170 mg/dL) and 46.6% of adults (< 200 mg/dL).[4] Declining cholesterol levels in recent years are attributable to greater use of cholesterol-lowering drugs rather than dietary changes.[4] These gains are due primarily to the use of statins. Recently, a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor, a new class of drug to lower lipids, produced striking reductions in LDL cholesterol that, in the long term, reduced the incidence of subsequent coronary events in people with existing coronary disease. Still, adding lifestyle components that incorporate dietary changes and physical activity, even when cholesterol is controlled with medications, promotes lifestyle changes that also contribute to long term-health, longevity, and well-being. The Million Hearts Program recommends limiting saturated and trans fats and increasing fiber in the diet, getting regular physical activity, maintaining a healthy weight, and smoking cessation.[6]


One in 10 US adults has diabetes and 90%-95% of cases are type 2 diabetes. Type 2 diabetes disproportionately affects minorities and is increasingly common among children and adolescents.[4] Diabetes is associated with a two- to three-fold increased risk for CVD, which is more likely to be the cause of hospitalization in patients with diabetes than are diabetes-related factors. Experts recommend prevention of cardiovascular events as the goal of diabetes treatment.

Two new classes of drugs, sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, have been shown to reduce cardiovascular events beyond their glucose-lowering benefit. The American Diabetes Association recommends lifestyle management in addition to medications for the management of diabetes and cardiovascular risk factors, including nutrition therapy, physical activity, and smoking cessation.[7]

Poor diet is the leading risk factor for death and disability in the United States and was responsible for 678,000 deaths from all causes in 2010. Insufficient intake of fruits, vegetables, nuts and seeds, whole grains, and seafood, as well as excess sodium intake, are considered major contributors.[4] In fact, the best improvements in heart health through risk factor reduction have been seen with a predominantly plant-based diet that emphasizes green, leafy vegetables, whole grains, legumes, and fruit. Limitation of dietary cholesterol is also recommended.