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Aging, Systemic Disease and Oral Health: Implications for Women Worldwide (Part I)

Course Number: 302

Risk Factors, Prevention, and Treatment (Cardiovascular Disease)

Heart attack and stroke share many similar risk factors such as elevated blood pressure, smoking, elevated cholesterol, diabetes, obesity, and physical inactivity (Figure 5). A family history of heart disease co-existing with diabetes can contribute to even greater risk.16 According to the WHO, tobacco use worldwide will contribute to the single greatest cause of death and disability with a projected 7 million deaths yearly by 2030.17 Smoking the equivalent of one cigarette per day carries a risk of developing coronary heart disease and stroke much greater than expected, that is, around half that for people who smoke 20 per day.18 Smoking e-cigarettes daily doubles risk of heart attacks, and when combined with daily cigarette use, heart attack risk rises five-fold.19 Obesity is another risk factor for several chronic conditions. Older women are heavier now than they were a decade ago. Approximately 62% of American women 20 years of age and older are reported overweight and 33% of the women are identified as extremely overweight.

Image: Cardiovascular Disease – Risk Factors, Treatments and Connections to Oral Health.

Figure 5. Cardiovascular Disease – Risk Factors, Treatments and Connections to Oral Health.

Fortunately, there are preventive treatment and lifestyle recommendations that can significantly reduce risk. Research indicates when smoking, obesity, stress, and physical inactivity are altered with lifestyle changes, positive health benefits are realized.20

In 2019, the ACC/AHA issued a “Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.”21 The most important way to prevent cardiovascular disease is to promote a healthy lifestyle throughout life. The guidelines are helpful in assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals, such as coronary artery calcium scanning, as well as treatments pharmacological therapy. A healthy diet healthy that focuses on consumption of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages is encouraged.22 Maintaining a healthy weight and exercising are part of the regimen, and tobacco use in any form should be stopped completely.

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Figure 6. Flow Diagram of the Development of CVD and Possible Prevention by a Healthy Diet22

Image: Spotlight on a Finnish Study.

Figure 7. Spotlight on a Finnish Study.

When lifestyle changes are inadequate, medications are often used to reduce risk, such as:

  • Calcium channel blockers(Calan®, Procardia®, Cardizem®) to dilate coronary arteries that in turn increase blood flow to the heart

  • Angiotensin-converting enzyme (ACE) inhibitors (Vasotec®, Prinivil®, and Zestril®) that aid in lowering blood pressure by inhibiting the formation of angiotensin II

  • Statins (Zocor®, Lipitor®) that block the enzyme (HMG-CoA) necessary for cholesterol production

Medications such as anti-hypertensives are frequently used to lower blood pressure.24 In addition to these preventive and pharmaceutical approaches, new scientific breakthroughs are on the horizon. The Atlas of Heart Disease and Stroke is a data publication from the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) that presents the latest global data related to heart disease and stroke in an accessible format.25 For example, research is being conducted on stem cell applications that actually repair the damaged heart muscle and improve cardiac function. According to the National Institute of Health, stem cells can create new blood vessels to supply the necessary oxygen to the heart.26,27 Researchers in a 2020 study found that human cardiopoietic cells focus on damaged proteins to reverse complex changes caused by a heart attack.27 Cardiopoietic cells are derived from adult stem cell sources of bone marrow. These medical advances may lead to significant reductions in cardiovascular disease for future generations.

New Research

Reproductive history represents many possible sex-specific risk-enhancing factors for CVD. A thorough reproductive history offers an opportunity for early prevention of risk factors and primary prevention. This includes the timing of menarche, menopause and any pregnancy complications, all of which could reveal short and long-term cardiometabolic and cardiovascular risk curves.28 Factors increasing CVD risk in women are: early and late menarche; polycystic ovary syndrome; menstrual irregularity; infertility; adverse pregnancy outcomes, such as hypertensive disorders of pregnancy; and absence of breastfeeding.

Hypertensive disorders of pregnancy are not rare conditions and are the second leading cause of maternal death after maternal hemorrhage. They are a significant cause of short and long-term maternal and newborn morbidity worldwide, and 15% of U.S. childbearing women experience these during at least one pregnancy.29 Prior research indicates hypertension develops faster among women who experienced hypertensive disorders of pregnancy, up to 10 years earlier, compared with women with normal blood pressure during pregnancies.

A statement by the American Heart Association (AHA)states that high blood pressure during pregnancy remains a major cause of maternal and fetal pregnancy-related complications and death, and it increases women’s short and long-term risks for cardiovascular disease.30 The statement highlights that hypertension treatment in pregnancy is safe and effective, and lessens maternal heart risks. The paper was based on data from clinical trials and observational research which support the benefits and safety of blood pressure treatment during pregnancy. The statement advises multidisciplinary, team-based personalized care where clinicians partner with the patient to determine preferred treatment and consider the risks for hypertension-related adverse outcomes.

In addition to the current risk factors for CVD, as mentioned above, AHA)has added another risk factor of concern. In addition to high blood pressure, high LDL cholesterol, diabetes, smoking and secondhand smoke exposure, obesity, unbalanced diet and physical inactivity, the AHA has added chronic kidney disease to the list of risks.31 Cardiovascular-Kidney-Metabolic Syndrome (CKM) is “a systemic disorder characterized by pathophysiologic interactions among metabolic risk factors, chronic kidney disease, and the cardiovascular system, leading to multi-organ dysfunction and a high rate of adverse cardiovascular outcomes”.31 According to the AHA, cardiovascular-kidney-metabolic health reflects the interaction among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has serious impacts on morbidity and mortality. The advisory imparts guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent goal for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.32

The AHA recommends its Life’s Essential 8 as a framework for people to use to prevent disease. The areas it focuses on include health behaviors: eating a balanced diet, being more active, quitting tobacco and getting healthy sleep and individual health factors such as managing a healthy weight, cholesterol, blood sugar and blood pressure.32