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 &


Numerous observational studies have demonstrated the benefit of a Mediterranean-style diet on cardiovascular risk reduction. The PREDIMED trial showed that a Mediterranean diet with increased mixed nuts or substitution of extra-virgin oil for regular olive oil reduced cardiovascular events by 30%.[7] While this is exemplary, it represents a 70% persistence of events, with residual risk reduction opportunities through further refinement of diet.[8]

A Mediterranean diet typically consists of:

  • Olive oil as the culinary fat;

  • Abundant fresh vegetables and fruits;

  • Grains;

  • Legumes;

  • Tree nuts;

  • Aromatic spices and herbs;

  • Frequent intake of fish and shellfish;

  • Moderate consumption of wine with meals; and

  • Low intake of meat, other animal products, and simple sugars.

Studies have found that the Dietary Approaches to Stop Hypertension (DASH) diet with sodium restriction has beneficial effects on cardiovascular risk factors.[9] Results from the DASH-Sodium trial showed that the combined effects of the low-sodium DASH diet versus the high-sodium control diet on systolic blood pressure ranged from –5.3 to –20.8 mm Hg.[9]

The DASH plan recommends:

  • Eating vegetables, fruits, and whole grains;

  • Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils;

  • Limiting foods high in saturated fats, such as fatty meats, full-fat dairy products, and tropical oils such as coconut and palm oils; and

  • Limiting sugar-sweetened candies and beverages.

It should be noted, however, that large, prospective datasets warn that consumption of any source of animal protein, including fish, as studied in DASH and PREDIMED, increases cardiovascular and overall mortality relative to vegetable protein sources in patients with at least one cardiac risk factor,[10] albeit with a large substitutionary benefit over red meat and processed red meat.[11]

Physical Activity

The benefits of physical activity in addition to a healthy diet for prevention of heart disease have long been recognized. Despite these benefits, 3 of 10 US adults report being inactive during their leisure time, and only half report aerobic exercise levels consistent with national guidelines.[12] The US Preventive Services Task Force recommends intensive behavioral counseling to promote physical activity for people with cardiovascular risk factors and those with CVD.[6]

The PURE study found that just 30 minutes of physical activity 5 days a week could prevent 1 in 12 deaths and 1 in 20 cases of CVD worldwide.[12] A higher reduction was seen in those who were highly active (750 minutes weekly). The PURE study also found that physical activity incorporated into daily life provided the same satisfaction as leisure activities. From the STABILITY trial, we learned that walking at a brisk pace for as little as 10 minutes a day or at a slower pace for 15-20 minutes can reduce all-cause mortality by 33% in patients with stable coronary heart disease.[13]

Although gains have been made, CVD reduction through lifestyle modification remains a challenge. Most Americans continue to lead an unhealthy lifestyle, and less than 1% of Americans meet ideal levels of seven key cardiovascular health metrics (blood pressure, physical activity, cholesterol, healthy diet, healthy weight, smoking status, blood glucose). Some obstacles to achieving healthy lifestyle patterns include limited healthcare provider training on healthy diets and the need for physical activity, lack of access to adequate healthcare, high cost of healthcare, prior authorization of medications, limited time with patients, and patient adherence to lifestyle modifications.

Better cardiovascular health will require an expanded focus on CVD prevention and promotion of healthy behaviors across the entire lifespan. Approaches that target lifestyle and treatment at the individual level are needed, along with healthcare system approaches that encourage, facilitate, and reward efforts by patients and providers to improve health behaviors and factors, as well as population-level approaches that target lifestyle and treatment in schools and workplaces, local communities, states, and the nation.

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