Major coronary risk factors include smoking, hyperlipidemia, hypertension, diabetes mellitus, age, obesity, a sedentary lifestyle, and a positive family history for premature manifestations of coronary artery disease such as an acute myocardial infarction. In recent years, several new risk factors have been identified. Some risk factors are quite unusual such as a history of premature birth. Recognizing the presence of one or more of these new risk factors should trigger attempts by the clinician to minimize more traditional major risk factors.
Diseases that increase systemic inflammation, the inflammasome
Diseases such as gout, inflammatory bowel disease, autoimmune collagen vascular diseases, and psoriasis are all associated with an increased tendency to develop coronary artery disease presumably because they increase the activity of the inflammasome.
1
, 2
, 3
Patients who had a recent gout flare had an augmented probability of developing an acute cardiovascular event such as a myocardial infarction or stroke.1
Studying a large VA database, The Veterans with Premature Atherosclerosis, Mahtta et al noted that patients diagnosed with rheumatoid arthritis and/or systemic lupus erythematosus had higher odds for concomitant premature and extremely premature coronary artery disease.2
And patients with inflammatory bowel disease, i.e., Crohn's disease and ulcerative colitis, also had an increased tendency to develop coronary artery disease.3
Psoriasis increases activation of several factors in the inflammatory milieu, e.g., tumor necrosis factor alpha, interferons, and cytokines. Patients with psoriasis are up to 50% more likely to develop cardiovascular disease.4
Maternal and childhood factors
Several maternal and childhood factors are associated with an increased risk for developing coronary artery disease: gestational diabetes, pre-eclampsia, delivering a child of low birth weight, preterm delivery, and premature or surgical menopause. The factor or factors increasing the risk for coronary artery disease associated with each of these conditions is not known but might be the result of increased cytokine and oxidative stress.
5
, 6
, 7
An unusual and yet unexplained association has been observed between migraine headaches with aura in women and incident cardiovascular disease.8
Also of interest is the association of early-life trauma and the risk of adverse cardiovascular outcomes in young and middle-aged individuals with a history of myocardial infarction.9
These investigators suggested that adverse childhood experiences could have contributed to cardiovascular risk through a pathway that involved inflammation possibly secondary to increased glucocorticoid signaling. Another gender related situation linked to augmented cardiovascular risk is seen in transgender patients who present for gender-affirming care. Here, the increase in coronary artery disease risk might possibly be related to high rates of anxiety and depression.10
Environmental factors
An increased incidence of coronary artery disease has been related to two environmental factors that might themselves be connected, i.e., low socio-economic status and air pollution.
11
, 12
, 13
Hamad et al suggested that increased psychosocial stressors, limited educational and economic opportunities, and lack of peer influence favoring healthier lifestyle choices might be causative elements leading to enhanced coronary artery disease in individuals with low socio-economic living conditions.11
Air pollution was estimated to have caused 9 million deaths worldwide in 2019 with 62% due to cardiovascular disease (coronary artery disease = 31.7% and stroke = 27.7%).12
Etiologic factors connected to air pollution include increased incidences of hypertension and diabetes, alterations in vascular tone, increased arterial intimal thickness and calcification, and insulin resistance. Severely polluted environmental aerosols also contain several toxic metals such as lead, mercury, arsenic, and cadmium.12
Chen et al reported that transient exposure to a variety of air pollutants might trigger the onset of an acute coronary syndrome.13
Lifestyle factors
Investigators have also reported several lifestyle risk factors for coronary artery disease other than poor diet and lack of exercise. Trudel et al observed that long working hours in patients with a first myocardial infarction increased the risk for a recurrent event possibly because of prolonged exposure to work stressors.
14
Rong et al noted that skipping breakfast was linked to increased cardiovascular and all cause mortality. Detrimental effects of skipping breakfast included general obesity, the metabolic syndrome, hypertension, higher fasting insulin, and lipid levels.15
And, long-term consumption of beverages containing sugar or artificial sweeteners was also associated with increased cardiovascular mortality probably related to the same entities as skipping breakfast, i.e., obesity, the metabolic syndrome, hypertension, and diabetes.16
As always, I am happy to hear from readers about this or any other commentary at [email protected] or [email protected]
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References
- Association between gout flare and subsequent cardiovascular events among patients with gout.JAMA. 2022; 328: 440-450
- Autoimmune rheumatic diseases and premature atherosclerotic cardiovascular disease: An analysis from the VITAL registry.Am J Med. 2020; 133: 1424-2432
- Premature atherosclerotic cardiovascular disease risk among patients with inflammatory bowel disease.Am J Med. 2021; 134: 1047-1051
- Cardiovascular risk in patients with psoriasis.J Am Coll Cardiol. 2021; 77: 1670-1680
- Significance of obstetrical history with future cardiovascular disease risk.Am J Med. 2019; 132: 567-571
- Association of premature natural and surgical menopause with incident cardiovascular disease.JAMA. 2019; 322: 2411-2421
- Prospective evaluation of cardiovascular risk 10 years after a hypertensive disorder of pregnancy.J Am Coll Cardiol. 2022; 79: 2401-2411
- Association of migraine with aura and other risk factors with incident cardiovascular disease.JAMA. 2020; 323: 2281-2289
- Association of early-life trauma and risk of adverse cardiovascular outcomes in young and middle-aged individuals with a history of myocardial infarction.JAMA Cardiol. 2021; 6: 336-340
- Assessment of cardiovascular risk in transgender patients presenting for gender-affirming care.Am J Med. 2021; 134: 1002-1008
- Association of low socio-economic status with premature coronary heart disease in US adults.JAMA Cardiol. 2020; 5: 899-908
- Pollution and the Heart.N Engl J Med. 2021; 385: 1881-1892
- Hourly air pollutants and acute coronary syndrome onset in 1.29 million patients.Circulation. 2022; 145: 1749-1760
- Long working hours and risk of recurrent events.J Am Coll Cardiol. 2021; 77: 1616-1625
- Association of skipping breakfast with cardiovascular and all-cause mortality.J Am Coll Cardiol. 2019; 73: 2025-2032
- Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortality in US adults.Circulation. 2019; 139: 2113-2125
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