Changes in the Risk Profile of Heart Disease Over the Past Decade
The risk profile for coronary heart disease has undergone significant shifts over the past decade, with the most notable changes being a declining overall impact of traditional risk factors (particularly hypertension and dyslipidemia) in older adults, but concerning stagnation or worsening trends in younger populations driven by rising obesity and diabetes, alongside persistent and widening sex, racial, and ethnic disparities. 1, 2
Overall Temporal Trends in Risk Factor Impact
The population attributable fraction (PAF) of six modifiable risk factors combined for cardiovascular disease decreased from 57% in the 1990s to 39% by the 2010s, indicating that traditional risk factors explain a smaller proportion of total CVD burden than previously 1. However, this decline masks important age-specific and demographic variations that require careful consideration.
Key Shifts in Individual Risk Factors
Hypertension's contribution to CVD has declined substantially over time, dropping from a PAF of 0.37 in the 1990s to becoming non-significant in some CVD subtypes by the 2010s, likely reflecting improved detection and treatment 1. Despite this progress, hypertension remains highly prevalent, affecting 66.3% of Black women compared to 41.7% of White women 2.
Smoking has emerged as the largest single contributor to CVD risk in the most recent decade (PAF 0.20 in 2010s), particularly for stroke, even as overall smoking rates have declined 1. The gender gap persists, with current smoking rates of 18.7% in men versus 15.0% in women in the UK by 2017 2.
Dyslipidemia's impact has changed considerably, with its contribution to coronary heart disease varying significantly across time periods 1. Globally, mean plasma cholesterol showed little change between 1980 and 2008, with declines in high-income regions offset by increases in East and Southeast Asia 2.
Alarming Trends in Younger Adults
A sentinel event has occurred: CHD mortality rates among men aged 35-44 increased for the first time in over two decades in 2002, and mortality declines have slowed in both men and women aged 45-54 3. This contrasts sharply with continued steady decreases in older adults 3.
The most plausible explanation for flattening mortality in younger adults is the burgeoning epidemic of obesity and diabetes, as deteriorations in medical management appear implausible 3. Between the 1990s and 2010s, obesity and diabetes have shown ominous increases specifically among young adults 3, 4.
Rising Prevalence of Metabolic Risk Factors
Diabetes prevalence has increased dramatically, particularly affecting women and racial minorities 2. Black women show diabetes prevalence of 31% compared to 14.6% in White women 2. Among patients presenting with acute coronary syndrome, diabetes rates range from 28-58% depending on geographic region 2.
Obesity has reached epidemic proportions with stark racial disparities: non-Hispanic Black women show 56.1% prevalence, Hispanic women 48.4%, White women 38.8%, and Asian women 13.6% 2. Puerto Rican women demonstrate the highest obesity prevalence at 51.4% among Hispanic subgroups 2.
Sex-Specific Changes in Risk Profile
Myocardial infarction prevalence and incidence have increased dramatically in younger women (age <55 years) while decreasing in similarly aged men over the past four decades 2. This represents a fundamental shift in the epidemiology of acute coronary syndromes.
Novel Risk Factors Disproportionately Affecting Women
Women face unique risk factors that have gained recognition over the past decade 2:
- Pregnancy-related factors including preeclampsia, gestational diabetes, and pregnancy-associated hypertension significantly increase lifetime CVD risk 2
- Systemic inflammatory disorders (such as rheumatoid arthritis, systemic lupus erythematosus) confer higher CVD risk in women 2
- Spontaneous coronary artery dissection (SCAD) accounts for a substantial proportion of MI in younger women 2
- Psychosocial stress and socioeconomic factors have stronger associations with CVD in women 2
Traditional risk factors show differential impact by sex: diabetes confers 5-fold higher risk in women versus 3-fold in men, and HDL cholesterol and triglycerides have greater impact on CHD risk in women compared to men 2, 5.
Racial and Ethnic Disparities
Black and Hispanic women are significantly less likely to achieve ideal cardiovascular health compared to White women 2. Using seven ideal health metrics (blood pressure, glucose, cholesterol, smoking, BMI, physical activity, diet), Black women showed an adjusted odds ratio of 0.54 for ideal cardiovascular health even after controlling for sociodemographic factors 2.
The burden of traditional risk factors explains much of the racial disparity in ACS incidence: after adjustment for baseline risk factors, the hazard ratio for incident ACS events became similar between Black and White women, highlighting that the excess risk is mediated through higher prevalence of modifiable factors 2.
Geographic Variations in Risk Factor Prevalence
In low- and middle-income countries, women present with severe aggregation of risk factors and extreme delays in care 2:
- In Arabian Gulf countries, women with ACS show hypertension rates of 59-74%, diabetes 48-57%, but lower smoking rates (3-25%) compared to men 2
- In Sub-Saharan Africa, women present with mean delays of 54 hours before receiving medical care 2
- In Tunisia, ACS mortality rates increased more rapidly in women (23.8%) than men (11.8%) between 1997-2003, attributed to westernization and lifestyle changes 2
Persistent High Burden Despite Improvements
Ninety percent of patients with coronary heart disease have at least one atherosclerotic risk factor, and 92% of men and 98% of women who died from CHD had at least one of the three major risk factors (hypertension, elevated cholesterol, smoking) 2, 6. This contradicts the misconception that many CHD victims lack traditional risk factors 6.
In the EUROASPIRE III survey (2006-2007), fewer than half of patients with established CHD reached therapeutic targets for risk factor management, and the proportion of smokers did not decrease between EUROASPIRE I (1996) and EUROASPIRE III 2. This represents a critical implementation gap between guidelines and clinical practice.
Clinical Implications for Risk Assessment
The declining PAF of traditional risk factors does not diminish their importance but rather reflects improved population-level control in some demographics while highlighting emerging challenges in others 1. The key clinical takeaway is that risk assessment must now account for:
- Age-specific trends: younger adults require more aggressive screening and intervention for obesity and diabetes 3
- Sex-specific pathophysiology: women are twice as likely to present with MINOCA and require evaluation for novel risk factors including pregnancy history and inflammatory disorders 2
- Racial and ethnic disparities: Black and Hispanic women require intensified risk factor modification given their higher baseline burden 2
- Multiple risk factor interactions: persons with multiple major risk factors face exponentially higher risk than those with single factors 2, 7
Early detection strategies including breast arterial calcification and coronary calcium scoring should be considered for subclinical atherosclerosis detection, particularly in women with novel risk factors, to enable early treatment and prevent clinical disease 2.