Reasons for Increased Absolute Cardiovascular Risk (ACR)
Absolute Cardiovascular Risk is increased by multiple modifiable and non-modifiable risk factors that contribute to the development of cardiovascular disease, with hypertension, diabetes mellitus, dyslipidemia, and smoking being the most significant contributors.
Traditional Modifiable Risk Factors
Hypertension: A major risk factor that accelerates atherosclerosis, causes vascular remodeling, and contributes to left ventricular hypertrophy, significantly increasing the risk of poor outcomes in cardiovascular disease 1
Dyslipidemia/Hypercholesterolemia: Elevated LDL cholesterol and low HDL cholesterol contribute to endothelial dysfunction and atherosclerosis, with approximately 63.2% of adults with hypertension also having hypercholesterolemia 1, 2
Diabetes Mellitus: Associated with a 2.37-fold increased risk of myocardial infarction and significantly higher mortality rates in patients with acute coronary syndrome 1, 3
Current Cigarette Smoking: Causes endothelial dysfunction, promotes atherosclerosis, increases platelet aggregation, and induces coronary vasospasm, with a population attributable risk of 35.7% for myocardial infarction 1, 4, 3
Obesity/Abdominal Obesity: Particularly abdominal obesity increases cardiovascular risk with a population attributable risk of 20.1% for myocardial infarction 1, 3
Physical Inactivity/Low Fitness: Lack of regular physical activity increases cardiovascular risk with a population attributable risk of 12.2% 1, 3
Unhealthy Diet: Poor dietary patterns, particularly lack of daily fruit and vegetable consumption, contribute to increased cardiovascular risk with a population attributable risk of 13.7% 1, 3
Secondhand Smoking: Exposure to environmental tobacco smoke increases cardiovascular risk 1
Non-Modifiable Risk Factors
Increased Age: A strong independent risk factor for cardiovascular disease, with risk increasing substantially after age 65 1
Male Sex: Men have higher cardiovascular risk compared to pre-menopausal women of the same age 1
Family History of Premature CAD: Particularly sibling history of premature coronary artery disease carries stronger risk than parental history 1
Chronic Kidney Disease: Associated with increased cardiovascular risk and often co-exists with hypertension 1
Low Socioeconomic/Educational Status: Associated with higher cardiovascular risk through multiple pathways 1
Additional Risk Modifiers
Psychosocial Stress: Associated with a 2.67-fold increased risk of myocardial infarction with a population attributable risk of 32.5% 1, 3
Obstructive Sleep Apnea: Contributes to cardiovascular risk through multiple mechanisms including intermittent hypoxia and sympathetic activation 1
Auto-immune Inflammatory Diseases: Conditions such as rheumatoid arthritis, systemic lupus erythematosus, and psoriasis increase cardiovascular risk 1
Severe Mental Illness: Major depressive disorder, bipolar disorder, and schizophrenia are associated with increased cardiovascular risk 1
HIV Infection: Associated with increased cardiovascular risk through multiple mechanisms 1
High-risk Ethnicity: Certain ethnic groups (e.g., South Asian) have higher cardiovascular risk independent of traditional risk factors 1
Pregnancy Complications: History of gestational hypertension, pre-eclampsia, gestational diabetes, pre-term delivery, stillbirth, or recurrent miscarriage increases long-term cardiovascular risk in women 1
Emerging Risk Factors
Elevated Coronary Artery Calcium Score: A CAC score >100 Agatston units or ≥75th percentile for age, sex, and ethnicity indicates increased cardiovascular risk 1
Arterial Stiffness: Increased pulse wave velocity (>10 m/s carotid-femoral or >14 m/s brachial-ankle) is associated with increased cardiovascular risk 1
Carotid or Femoral Artery Plaque: Presence of plaque in these arteries improves cardiovascular risk prediction 1
Substance Abuse: Cocaine and methamphetamine use can precipitate acute coronary events through vasospasm, thrombosis, and direct cardiac toxicity 1, 4
Clinical Implications
Multiple risk factors frequently occur in combination, with ≥3 risk factors present in 17% of patients, substantially increasing overall cardiovascular risk 1
The presence of multiple cardiovascular risk factors results in high absolute risks for coronary heart disease and stroke, with 41.7% of US adults with hypertension having a 10-year CHD risk >20% 1
Risk assessment tools like SCORE2/SCORE2-OP or TIMI risk score can help quantify cardiovascular risk and guide management decisions 1
An absolute risk-based approach is superior to individual risk factor management when identifying patients who would benefit most from preventive interventions 5
Pitfalls and Caveats
The "smoker's paradox" (lower short-term mortality in smokers with acute coronary syndrome) should not diminish aggressive smoking cessation efforts, as this paradox is primarily due to smokers being younger with less severe underlying coronary artery disease 1
Similarly, the "obesity paradox" (lower short-term risk in overweight/obese individuals with acute coronary syndrome) masks the higher long-term mortality risk in these patients 1
Traditional risk factors for coronary artery disease (hypertension, hypercholesterolemia, smoking) are only weakly predictive of the likelihood of acute ischemia and are less important than symptoms, ECG findings, and cardiac biomarkers in the acute setting 1
The predictive ability of commonly used risk assessment scores for nonfatal coronary heart disease risk is only moderate, with age, sex, and race capturing 63-80% of the prognostic performance of cardiovascular risk models 1, 6