presentation of heart disease

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• About Stroke
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• The term "heart disease" refers to several types of heart conditions.
• Know your risk for heart disease so you can prevent it.
• High blood pressure, high blood cholesterol, and smoking are key risk factors.
• About 1 in 5 people in the United States died from heart disease in 2022.

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What is heart disease?

The term "heart disease" refers to several types of heart conditions. The most common type of heart disease in the United States is coronary artery disease (CAD). CAD affects the blood flow to the heart. Decreased blood flow can cause a heart attack.

Sometimes heart disease may be "silent" and not diagnosed until a person experiences signs or symptoms of a heart attack, heart failure, or an arrhythmia. When these events happen, symptoms may include: 1

• Heart attack : Chest pain or discomfort, upper back or neck pain, heartburn, nausea or vomiting, extreme fatigue, dizziness, and shortness of breath.
• Arrhythmia : Fluttering feelings in the chest (palpitations).
• Heart failure : Shortness of breath, fatigue, or swelling of the feet, ankles, legs, abdomen, or neck veins.

Risk factors

High blood pressure , high blood cholesterol , and smoking are key risk factors for heart disease. About half of people in the United States (47%) have at least one of these three risk factors. 2 Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including

• Overweight and obesity
• Unhealthy diet
• Physical inactivity
• Excessive alcohol use

Learn how heart disease and mental health disorders are related .

Learn the Facts About Heart Disease‎

Treatment and recovery, what is cardiac rehabilitation.

Cardiac rehabilitation is an important program for anyone recovering from a heart attack. This can also include heart failure, or some types of heart surgery. Cardiac rehabilitation is a supervised program that includes

• Physical activity.
• Education about healthy eating.
• Taking medicine as prescribed.
• Ways to help you quit smoking.
• Counseling to find ways to relieve stress and improve mental health.

A team of people may help you through cardiac rehabilitation. This may include

• Your health care team.
• Exercise and nutrition specialists.
• Physical therapists.
• Counselors or mental health professionals.

What CDC is doing

• Million Hearts ®
• National Heart, Lung, and Blood Institute
• National Center for Health Statistics. Multiple Cause of Death 2018–2022 on CDC WONDER Database . Accessed May 3, 2024.
• Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics—2023 Update: a report from the American Heart Association . Circulation. 2023;147:e93–e621.

Heart Disease

Heart disease is the leading cause of death in the United States.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Cardiovascular disease.

Edgardo Olvera Lopez ; Brian D. Ballard ; Arif Jan .

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Last Update: August 22, 2023 .

• Continuing Education Activity

The cardiovascular system consists of the heart and its blood vessels. A wide array of problems can arise within the cardiovascular system, a few of which include endocarditis, rheumatic heart disease, and conduction system abnormalities. Cardiovascular disease, also known as heart disease, refers to the following 4 entities: coronary artery disease (CAD) which is also referred to as coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease (PAD), and aortic atherosclerosis. CAD results from decreased myocardial perfusion that causes angina due to ischemia and can result in myocardial infarction (MI), and/or heart failure. It accounts for one-third to one-half of all cases of cardiovascular disease. Cerebrovascular disease is the entity associated with strokes, also termed cerebrovascular accidents, and transient ischemic attacks (TIAs). Peripheral arterial disease (PAD) is arterial disease predominantly involving the limbs that may result in claudication. Aortic atherosclerosis is the entity associated with thoracic and abdominal aneurysms. This activity reviews the evaluation and treatment of cardiovascular disease and the role of the medical team in evaluating and treating these conditions.

• Review the cause of coronary artery disease.
• Describe the pathophysiology of atherosclerosis.
• Summarize the treatment options for heart disease.
• Outline the evaluation and treatment of cardiovascular disease and the role of the medical team in evaluating and treating this condition.
• Introduction

The cardiovascular system consists of the heart and blood vessels. [1]  There is a wide array of problems that may arise within the cardiovascular system, for example, endocarditis, rheumatic heart disease, abnormalities in the conduction system, among others, cardiovascular disease (CVD) or heart disease refer to the following 4 entities that are the focus of this article [2] :

• Coronary artery disease (CAD): Sometimes referred to as Coronary Heart Disease (CHD), results from decreased myocardial perfusion that causes angina, myocardial infarction (MI), and/or heart failure. It accounts for one-third to one-half of the cases of CVD.
• Cerebrovascular disease (CVD): Including stroke and transient ischemic attack (TIA)
• Peripheral artery disease (PAD): Particularly arterial disease involving the limbs that may result in claudication
• Aortic atherosclerosis:  Including thoracic and abdominal aneurysms

Although CVD may directly arise from different etiologies such as emboli in a patient with atrial fibrillation resulting in ischemic stroke, rheumatic fever causing valvular heart disease, among others, addressing risks factors associated to the development of atherosclerosis is most important because it is a common denominator in the pathophysiology of CVD.

The industrialization of the economy with a resultant shift from physically demanding to sedentary jobs, along with the current consumerism and technology-driven culture that is related to longer work hours, longer commutes, and less leisure time for recreational activities, may explain the significant and steady increase in the rates of CVD during the last few decades. Specifically, physical inactivity, intake of a high-calorie diet, saturated fats, and sugars are associated with the development of atherosclerosis and other metabolic disturbances like metabolic syndrome, diabetes mellitus, and hypertension that are highly prevalent in people with CVD. [3] [2] [4] [5]

According to the INTERHEART study that included subjects from 52 countries, including high, middle, and low-income countries, 9 modifiable risks factors accounted for 90% of the risk of having a first MI: smoking, dyslipidemia, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, regular alcohol consumption, and physical inactivity. It is important to mention that in this study 36% of the population-attributable risk of MI was accounted to smoking. [6]

Other large cohort studies like the Framingham Heart Study [7] and the Third National Health and Nutrition Examination Survey (NHANES III) [5] have also found a strong association and predictive value of dyslipidemia, high blood pressure, smoking, and glucose intolerance. Sixty percent to 90% of CHD events occurred in subjects with at least one risk factor.

These findings have been translated into health promotion programs by the American Heart Association with emphasis on seven recommendations to decrease the risk of CVD: avoiding smoking, being physically active, eating healthy, and keeping normal blood pressure, body weight, glucose, and cholesterol levels. [8] [9]

On the other hand, non-modifiable factors as family history, age, and gender have different implications. [4] [7] Family history, particularly premature atherosclerotic disease defined as CVD or death from CVD in a first-degree relative before 55 years (in males) or 65 years (in females) is considered an independent risk factor. [10] There is also suggestive evidence that the presence of CVD risk factors may differently influence gender. [4] [7]  For instance, diabetes and smoking more than 20 cigarettes per day had increased CVD risk in women compared to men. [11] Prevalence of CVD increases significantly with each decade of life. [12]  

The presence of HIV (human immunodeficiency virus), [13]  history of mediastinal or chest wall radiation, [14]  microalbuminuria, [15] , increased inflammatory markers [16] [17]  have also been associated with an increased rate and incidence of CVD. 

Pointing out specific diet factors like meat consumption, fiber, and coffee and their relation to CVD remains controversial due to significant bias and residual confounding encountered in epidemiological studies. [18] [19]

• Epidemiology

Cardiovascular diseases (CVD) remain among the 2 leading causes of death in the United States since 1975 with 633,842 deaths or 1 in every 4 deaths, heart disease occupied the leading cause of death in 2015 followed by 595,930 deaths related to cancer. [2]  CVD is also the number 1 cause of death globally with an estimated 17.7 million deaths in 2015, according to the World Health Organization (WHO). The burden of CVD further extends as it is considered the most costly disease even ahead of Alzheimer disease and diabetes with calculated indirect costs of $237 billion dollars per year and a projected increased to $368 billion by 2035. [20]

Although the age-adjusted rate and acute mortality from MI have been declining over time, reflecting the progress in diagnosis and treatment during the last couple of decades, the risk of heart disease remains high with a calculated 50% risk by age 45 in the general population. [7] [21]  The incidence significantly increases with age with some variations between genders as the incidence is higher in men at younger ages. [2]  The difference in incidence narrows progressively in the post-menopausal state. [2]

• Pathophysiology

Atherosclerosis is the pathogenic process in the arteries and the aorta that can potentially cause disease as a consequence of decreased or absent blood flow from stenosis of the blood vessels. [22]

It involves multiple factors dyslipidemia, immunologic phenomena, inflammation, and endothelial dysfunction. These factors are believed to trigger the formation of fatty streak, which is the hallmark in the development of the atherosclerotic plaque [23] ; a progressive process that may occur as early as in the childhood. [24]  This process comprises intimal thickening with subsequent accumulation of lipid-laden macrophages (foam cells) and extracellular matrix, followed by aggregation and proliferation of smooth muscle cells constituting the formation of the atheroma plaque. [25]  As this lesions continue to expand, apoptosis of the deep layers can occur, precipitating further macrophage recruitment that can become calcified and transition to atherosclerotic plaques. [26]

Other mechanisms like arterial remodeling and intra-plaque hemorrhage play an important role in the delay and accelerated the progression of atherosclerotic CVD but are beyond the purpose of this article. [27]

• History and Physical

The clinical presentation of cardiovascular diseases can range from asymptomatic (e.g., silent ischemia, angiographic evidence of coronary artery disease without symptoms, among others) to classic presentations as when patients present with typical anginal chest pain consistent of myocardial infarction and/or those suffering from acute CVA presenting with focal neurological deficits of sudden onset. [28] [29] [28]

Historically, coronary artery disease typically presents with angina that is a pain of substernal location, described as a crushing or pressure in nature, that may radiate to the medial aspect of the left upper extremity, to the neck or the jaw and that can be associated with nausea, vomiting, palpitations, diaphoresis, syncope or even sudden death. [30]  Physicians and other health care providers should be aware of possible variations in symptom presentation for these patients and maintain a high index of suspicion despite an atypical presentation, for example, dizziness and nausea as the only presenting symptoms in patients having an acute MI [31] ), particularly in people with a known history of CAD/MI and for those with the presence of CVD risk factors. [32] [33] [34] [33] [32]  Additional chest pain features suggestive of ischemic etiology are the exacerbation with exercise and or activity and resolution with rest or nitroglycerin. [35]

Neurologic deficits are the hallmark of cerebrovascular disease including TIA and stroke where the key differentiating factor is the resolution of symptoms within 24 hours for patients with TIA. [36]  Although the specific symptoms depend on the affected area of the brain, the sudden onset of extremity weakness, dysarthria, and facial droop are among the most commonly reported symptoms that raise concern for a diagnosis of a stroke. [37] [38]  Ataxia, nystagmus and other subtle symptoms as dizziness, headache, syncope, nausea or vomiting are among the most reported symptoms with people with posterior circulation strokes challenging to correlate and that require highly suspicion in patients with risks factors. [39]

Patients with PAD may present with claudication of the limbs, described as a cramp-like muscle pain precipitated by increased blood flow demand during exercise that typically subsides with rest. [40] Severe PAD might present with color changes of the skin and changes in temperature. [41]  

Most patients with thoracic aortic aneurysm will be asymptomatic, but symptoms can develop as it progresses from subtle symptoms from compression to surrounding tissues causing cough, shortness of breath or dysphonia, to the acute presentation of sudden crushing chest or back pain due to acute rupture. [42]  The same is true for abdominal aortic aneurysms (AAA) that cause no symptoms in early stages to the acute presentation of sudden onset of abdominal pain or syncope from acute rupture. [43]

A thorough physical examination is paramount for the diagnosis of CVD. Starting with a general inspection to look for signs of distress as in patients with angina or with decompensated heart failure, or chronic skin changes from PAD. Carotid examination with the patient on supine position and the back at 30 degrees for the palpation and auscultation of carotid pulses, bruits and to evaluate for jugular venous pulsations on the neck is essential. Precordial examination starting with inspection, followed by palpation looking for chest wall tenderness, thrills, and identification of the point of maximal impulse should then be performed before auscultating the precordium. Heart sounds auscultation starts in the aortic area with the identification of the S1 and S2 sounds followed by characterization of murmurs if present. Paying attention to changes with inspirations and maneuvers to correctly characterize heart murmurs is encouraged. Palpating peripheral pulses with bilateral examination and comparison when applicable is an integral part of the CVD examination. [44]

Thorough clinical history and physical exam directed but not limited to the cardiovascular system are the hallmarks for the diagnosis of CVD. Specifically, a history compatible with obesity, angina, decreased exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, syncope or presyncope, and claudication should prompt the clinician to obtain a more detailed history and physical exam and, if pertinent, obtain ancillary diagnostic test according to the clinical scenario (e.g., electrocardiogram and cardiac enzymes for patients presenting with chest pain). 

Besides a diagnosis prompted by clinical suspicion, most of the efforts should be oriented for primary prevention by targeting people with the presence of risk factors and treat modifiable risk factors by all available means. All patient starting at age 20 should be engaged in the discussion of CVD risk factors and lipid measurement. [9]  Several calculators that use LDL-cholesterol and HDL-cholesterol levels and the presence of other risk factors calculate a 10-year or 30-year CVD score to determine if additional therapies like the use of statins and aspirin are indicated for primary prevention, generally indicated if such risk is more than ten percent. [10]  Like other risk assessment tools, the use of this calculators have some limitations, and it is recommended to exert precaution when assessing patients with diabetes and familial hypercholesterolemia as their risk can be underestimated. Another limitation to their use is that people older than 79 were usually excluded from the cohorts where these calculators were formulated, and individualized approach for these populations is recommended by discussing risk and benefits of adjunctive therapies and particular consideration of life expectancy. Some experts recommend a reassessment of CVD risk every 4 to 6 years. [9]

Preventative measures like following healthy food habits, avoiding overweight and following an active lifestyle are pertinent in all patients, particularly for people with non-modifiable risk factors such as family history of premature CHD or post-menopause. [9] [8]

The use of inflammatory markers and other risk assessment methods as coronary artery calcification score (CAC) are under research and have limited applications that their use should not replace the identification of people with known risk factors, nonetheless these resources remain as promising tools in the future of primary prevention by detecting people with subclinical atherosclerosis at risk for CVD. [45]

• Treatment / Management

Management of CVD is very extensive depending on the clinical situation (catheter-directed thrombolysis for acute ischemic stroke, angioplasty for peripheral vascular disease, coronary stenting for CHD); however, patients with known CVD should be strongly educated on the need for secondary prevention by risk factor and lifestyle modification. [9] [46]

• Differential Diagnosis
• Acute pericarditis
• Angina pectoris
• Artherosclerosis
• Coronary artery vasospasm
• Dilated cardiomyopathy
• Giant cell arteritis
• Hypertension
• Hypertensive heart disease
• Kawasaki disease
• Myocarditis

The prognosis and burden of CVD have been discussed in other sections.

• Complications

The most feared complication from CVD is death and, as explained above, despite multiple discoveries in the last decades CVD remains in the top leading causes of death all over the world owing to the alarming prevalence of CVD in the population. [2]  Other complications as the need for longer hospitalizations, physical disability and increased costs of care are significant and are the focus for health-care policymakers as it is believed they will continue to increase in the coming decades. [20]

For people with heart failure with reduced ejection fraction (HFreEF) of less than 35%, as the risk of life-threatening arrhythmias is exceedingly high in these patients, current guidelines recommend the implantation of an implantable-cardioverter defibrillator (ICD) for those with symptoms equivalent to a New York Heart Association (NYHA) Class II-IV despite maximal tolerated medical therapy. [47]

Strokes can leave people with severe disabling sequelae like dysarthria or aphasia, dysphagia, focal or generalized muscle weakness or paresis that can be temporal or cause permanent physical disability that may lead to a complete bedbound state due to hemiplegia with added complications secondary to immobility as is the higher risk of developing urinary tract infections and/or risk for thromboembolic events. [48] [49]

There is an increased risk of all-cause death for people with PAD compared to those without evidence of peripheral disease. [50]  Chronic wounds, physical limitation, and limb ischemia are among other complications from PAD. [51]

• Consultations

An interprofessional approach that involves primary care doctors, nurses, dietitians, cardiologists, neurologists, and other specialists is likely to improve outcomes. This has been shown to be beneficial in patients with heart failure, [52]  coronary disease, [53]  and current investigations to assess the impact on other forms of CVD are under planning and promise encouraging results.

• Deterrence and Patient Education

Efforts should be directed toward primary prevention by leading a healthy lifestyle, and an appropriate diet starting as early as possible with the goal of delay or avoid the initiation of atherosclerosis as it relates to the future risk of CVD. The AHA developed the concept of "ideal cardiovascular health" defined by the presence of [8] :

• Ideal health behaviors: Nonsmoking, body mass index less than 25 kg/m2, physical activity at goal levels, and the pursuit of a diet consistent with current guideline recommendations
• Ideal health factors: Untreated total cholesterol less than 200 mg/dL, untreated blood pressure less than 120/80 mm Hg, and fasting blood glucose less than 100 mg/dL) with the goal to improve the health of all Americans with an expected decrease in deaths from CVD by 20%

Specific attention should be made to people at higher risk for CVD as are people with diabetes, hypertension, hyperlipidemia, smokers, and obese patients. Risk factors modification by controlling their medical conditions, avoiding smoking, taking appropriate measures to lose weight and maintaining an active lifestyle is of extreme importance. [8] [9] [10] The recommendations on the use of statins and low-dose aspirin for primary and secondary prevention has been discussed in other sections.

• Pearls and Other Issues

Cardiovascular disease generally refers to 4 general entities: CAD, CVD, PVD, and aortic atherosclerosis. 

CVD is the main cause of death globally.

Measures aimed to prevent the progression of atherosclerosis are the hallmark for primary prevention of CVD.

Risk factor and lifestyle modification are paramount in the prevention of CVD.

• Enhancing Healthcare Team Outcomes

An interprofessional and patient-oriented approach can help to improve outcomes for people with cardiovascular disease as shown in patients with heart failure (HF) who had better outcomes when the interprofessional involvement of nurses, dietitians, pharmacists, and other health professionals was used (Class 1A). [52]

Similarly, positive results were obtained in people in an intervention group who were followed by an interprofessional team comprised of pharmacists, nurses and a team of different physicians. This group had a reduction in all-cause mortality associated with CAD by 76% compared to the control group. [53]  Healthcare workers should educate the public on lifestyle changes and reduce the modifiable risk factors for heart disease to a minimum.

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Atherosclerosis as a result of coronary heart disease. Contributed by National Heart, Lung and Blood Institute (NIH)

Coronary Artery Disease Pathophysiology. Coronary artery disease is usually caused by an atherosclerotic plaque that blocks the lumen of a coronary artery, typically the left anterior descending artery. Contributed by S Bhimji, MD

Disclosure: Edgardo Olvera Lopez declares no relevant financial relationships with ineligible companies.

Disclosure: Brian Ballard declares no relevant financial relationships with ineligible companies.

Disclosure: Arif Jan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Olvera Lopez E, Ballard BD, Jan A. Cardiovascular Disease. [Updated 2023 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Shared and non-shared familial susceptibility of coronary heart disease, ischemic stroke, peripheral artery disease and aortic disease. [Int J Cardiol. 2013] Shared and non-shared familial susceptibility of coronary heart disease, ischemic stroke, peripheral artery disease and aortic disease. Calling S, Ji J, Sundquist J, Sundquist K, Zöller B. Int J Cardiol. 2013 Oct 3; 168(3):2844-50. Epub 2013 Apr 30.
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Cardiovascular diseases (CVDs)

• Cardiovascular diseases (CVDs) are the leading cause of death globally.
• An estimated 17.9 million people died from CVDs in 2019, representing 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke.
• Over three quarters of CVD deaths take place in low- and middle-income countries.
• Out of the 17 million premature deaths (under the age of 70) due to noncommunicable diseases in 2019, 38% were caused by CVDs.
• Most cardiovascular diseases can be prevented by addressing behavioural and environmental risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, harmful use of alcohol and air pollution.
• It is important to detect cardiovascular disease as early as possible so that management with counselling and medicines can begin.

Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels. They include:

• coronary heart disease – a disease of the blood vessels supplying the heart muscle;
• cerebrovascular disease – a disease of the blood vessels supplying the brain;
• peripheral arterial disease – a disease of blood vessels supplying the arms and legs;
• rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
• congenital heart disease – birth defects that affect the normal development and functioning of the heart caused by malformations of the heart structure from birth; and
• deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. Strokes can be caused by bleeding from a blood vessel in the brain or from blood clots.

What are the risk factors for cardiovascular disease?

The most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. Amongst environmental risk factors, air pollution is an important factor. The effects of behavioural risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risks factors” can be measured in primary care facilities and indicate an increased risk of heart attack, stroke, heart failure and other complications.

Cessation of tobacco use, reduction of salt in the diet, eating more fruit and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of cardiovascular disease. Health policies that create conducive environments for making healthy choices affordable and available, as well as improving air quality and reducing pollution, are essential for motivating people to adopt and sustain healthy behaviours.

There are also a number of underlying determinants of CVDs. These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization and population ageing. Other determinants of CVDs include poverty, stress and hereditary factors.

In addition, drug treatment of hypertension, diabetes and high blood lipids are necessary to reduce cardiovascular risk and prevent heart attacks and strokes among people with these conditions. 

What are common symptoms of cardiovascular diseases?

Symptoms of heart attacks and strokes.

Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or stroke may be the first sign of underlying disease. Symptoms of a heart attack include:

• pain or discomfort in the centre of the chest; and/or
• pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.

In addition the person may experience difficulty in breathing or shortness of breath; nausea or vomiting; light-headedness or faintness; a cold sweat; and turning pale. Women are more likely than men to have shortness of breath, nausea, vomiting, and back or jaw pain.

The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often on one side of the body. Other symptoms include sudden onset of:

• numbness of the face, arm, or leg, especially on one side of the body;
• confusion, difficulty speaking or understanding speech;
• difficulty seeing with one or both eyes;
• difficulty walking, dizziness and/or loss of balance or coordination;
• severe headache with no known cause; and/or
• fainting or unconsciousness.

People experiencing these symptoms should seek medical care immediately.

What is rheumatic heart disease?

Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by an abnormal response of the body to infection with streptococcal bacteria, which usually begins as a sore throat or tonsillitis in children.

Rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Globally, about 2% of deaths from cardiovascular diseases are related to rheumatic heart disease.

Symptoms of rheumatic heart disease

Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heartbeats, chest pain and fainting.

Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach cramps and vomiting.

Why are cardiovascular diseases a development issue in low- and middle-income countries?

At least three-quarters of the world's deaths from CVDs occur in low- and middle-income countries. People living in low- and middle-income countries often do not have the benefit of primary health care programmes for early detection and treatment of people with risk factors for CVDs. People in low- and middle-income countries who suffer from CVDs and other noncommunicable diseases have less access to effective and equitable health care services which respond to their needs. As a result, for many people in these countries detection is often late in the course of the disease and people die at a younger age from CVDs and other noncommunicable diseases, often in their most productive years.

The poorest people in low- and middle-income countries are most affected. At the household level, evidence is emerging that CVDs and other noncommunicable diseases contribute to poverty due to catastrophic health spending and high out-of-pocket expenditure. At the macro-economic level, CVDs place a heavy burden on the economies of low- and middle-income countries.

How can the burden of cardiovascular diseases be reduced?

The key to cardiovascular disease reduction lies in the inclusion of cardiovascular disease management interventions in universal health coverage packages, although in a high number of countries health systems require significant investment and reorientation to effectively manage CVDs.

Evidence from 18 countries has shown that hypertension programmes can be implemented efficiently and cost-effectively at the primary care level which will ultimately result in reduced coronary heart disease and stroke. Patients with cardiovascular disease should have access to appropriate technology and medication. Basic medicines that should be available include:

• beta-blockers;
• angiotensin-converting enzyme inhibitors; and

An acute event such as a heart attack or stroke should be promptly managed.

Sometimes, surgical operations are required to treat CVDs. They include:

• coronary artery bypass;
• balloon angioplasty (where a small balloon-like device is threaded through an artery to open the blockage);
• valve repair and replacement;
• heart transplantation; and
• artificial heart operations.

Medical devices are required to treat some CVDs. Such devices include pacemakers, prosthetic valves, and patches for closing holes in the heart.

WHO response

In 2013, WHO Member States agreed on global mechanisms to reduce the avoidable NCD burden including a "Global action plan for the prevention and control of NCDs 2013-2020". This Plan aims to reduce the number of premature deaths from NCDs by 25% by 2025 through nine voluntary global targets. Two of the targets directly focus on preventing and controlling CVDs.

Target 6: Reduce global prevalence of raised blood pressure by 25% between 2010 and 2025.

Target 8: At least 50% of eligible people should receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes by 2025.

In addition, target 9 states that there should be 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities.

Achieving these targets will require significant investment in and strengthening of health systems.

WHO is currently working on increasing the normative guidance available for the management of acute coronary syndrome and stroke which will provide guidance in these important areas.

Related links

• Global action plan for the prevention and control of NCDs 2013-2020
• Health topic: cardiovascular diseases

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Slide Set | 2020 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

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See Also: Guideline Hub | Valvular Heart Disease

Date: December 17, 2020    

Keywords: Anticoagulants, Fibrinolytic Agents, Platelet Aggregation Inhibitors, Aortic Valve Insufficiency, Aortic Valve Stenosis, Aortic Valve, Aortic Diseases, Perioperative Period, Cardiac Catheterization, Cardiac Imaging Techniques, Magnetic Resonance Imaging, Cardiovascular Surgical Procedures, Diagnostic Techniques, Cardiovascular, Drug Therapy, Echocardiography, Endocarditis, Exercise Test, Diagnostic Imaging, Angiography, Hemodynamics, Mitral Valve Stenosis, Mitral Valve Insufficiency, Heart Murmurs, Mitral Valve, Pregnancy, Heart Valve Prosthesis, Decision Making, Heart Valve Diseases, Heart Defects, Congenital, Patient Care Team, Thromboembolism, Thrombosis, Transcatheter Aortic Valve Replacement, Heart Valve Prosthesis Implantation, Catheters, Echocardiography, Transesophageal, Tricuspid Valve

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MHRA approves GLP –1 receptor agonist semaglutide to reduce risk of serious heart problems in obese or overweight adults

Semaglutide is the first weight loss drug approved in the UK as a preventative treatment for those with established cardiovascular disease

The Medicines and Healthcare products Regulatory Agency (MHRA) has today, 23 July 2024, approved a new indication for semaglutide (Wegovy) to reduce the risk of overweight and obese adults suffering serious heart problems or strokes.

This medicine, a GLP-1 receptor agonist, was already approved for use in the treatment of obesity and for weight management, to be used alongside diet, physical activity and behavioural support.

The approval means that semaglutide is the first weight loss drug to be prescribed to prevent cardiovascular events, such as cardiovascular death, non-fatal heart attack and non-fatal stroke, in people with established cardiovascular disease and a Body Mass Index (BMI) higher or equal to 27 kg/m2.

Cardiovascular disease (CVD) is a general term for conditions affecting the heart or blood vessels. It is usually associated with a build-up of fatty deposits inside the arteries ( atherosclerosis ) and an increased risk of blood clots .

CVD is one of the main causes of death and disability in the UK, but it can often be prevented by leading a healthy lifestyle.

The approval is based on new data from a post-approval clinical study which demonstrated that semaglutide (2.4 mg once weekly by subcutaneous injection, for up to five years) lowers the incidence of major adverse cardiovascular events (MACE) vs placebo.

In a multi-national, multi-centre, placebo-controlled double-blind trial that randomly assigned over 17,600 participants to receive either Wegovy or a placebo, Wegovy significantly reduced the risk of major adverse cardiovascular events by 20%, such as cardiovascular death, heart attack and stroke, which occurred in 6.5% of participants who received Wegovy compared to 8% of participants who received placebo.

Shirley Hopper, MHRA Deputy Director of Innovative Medicines, said:

Our key priority  is enabling access to high quality, safe and effective medical products. We’re assured that the appropriate regulatory standards of safety, quality and effectiveness for the approval of this medicine have been met. This treatment option that prevents heart disease and strokes is an important step forward in tackling the serious health consequences of obesity. As with all medicines, we will keep its safety under close review.

Professor Bryan Williams, Chief Scientific and Medical Officer at the British Heart Foundation, said:

Nearly two thirds of adults in England are living with excess weight or obesity. Those that also have an established cardiovascular disease live with a very high risk that a serious event like a heart attack or stroke could happen. Several recent studies have shown us that semaglutide is an effective tool that can improve the quality of life for those with cardiovascular disease, including by lowering the risk of serious cardiac events. It is important that people using the drug to lose weight and improve their health are given the support they need from healthcare professionals to maintain these improvements long into the future. This means appropriate training and healthcare workforce development, along with policies to create a wider environment that supports everyone to stay as healthy as possible. Altogether, this can help save lives from the devastating impact of heart attacks and strokes.

The treatment is taken as a solution for injection in a pre-filled pen.

The active ingredient, semaglutide, is a GLP-1 receptor agonist. This mimics the action of the GLP-1 hormone, which is involved in regulating blood sugar levels. Semaglutide binds to GLP-1 receptors on pancreatic cells, enhancing the insulin secretion in response to meals, reducing glucagon release and slowing the gastric emptying process. This helps to promote weight loss.

The most common side effects of the medicine are gastrointestinal disorders including nausea, diarrhoea, constipation and vomiting.

As with any medicine, the MHRA keeps the safety and effectiveness of semaglutide under close review. Anyone who suspects they are having a side effect from this medicine is encouraged to talk to their doctor, pharmacist or nurse and report it directly to the Yellow Card scheme, either through the website or by searching the Google Play or Apple App stores for MHRA Yellow Card.

Notes to editors

• Authorisation for this new indication for semaglutide (Wegovy) was granted on 23 July 2024 to Novo Nordisk.
• The authorisation was granted as part of the International Recognition Procedure (IRP), via the reference regulator, the Food and Drug Administration in the USA. Launched in January this year, the IRP allows the MHRA to accelerate the assessment of new medicines by taking into account the expertise and decision-making of trusted regulatory partners in the authorisation process.
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Arteriosclerosis / atherosclerosis

Arteriosclerosis and atherosclerosis are sometimes used to mean the same thing, but there's a difference between the two terms.

Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body (arteries) become thick and stiff — sometimes restricting blood flow to the organs and tissues. Healthy arteries are flexible and elastic. But over time, the walls in the arteries can harden, a condition commonly called hardening of the arteries.

Atherosclerosis is a specific type of arteriosclerosis.

Atherosclerosis is the buildup of fats, cholesterol and other substances in and on the artery walls. This buildup is called plaque. The plaque can cause arteries to narrow, blocking blood flow. The plaque can also burst, leading to a blood clot.

Although atherosclerosis is often considered a heart problem, it can affect arteries anywhere in the body. Atherosclerosis can be treated. Healthy lifestyle habits can help prevent atherosclerosis.

Mild atherosclerosis usually doesn't have any symptoms.

Atherosclerosis symptoms usually don't happen until an artery is so narrowed or clogged that it can't supply enough blood to organs and tissues. Sometimes a blood clot completely blocks blood flow. The clot may break apart and can trigger a heart attack or stroke.

Symptoms of moderate to severe atherosclerosis depend on which arteries are affected. For example:

• If you have atherosclerosis in your heart arteries, you may have chest pain or pressure (angina).
• If you have atherosclerosis in the arteries leading to your brain, you may have sudden numbness or weakness in your arms or legs, difficulty speaking or slurred speech, temporary loss of vision in one eye, or drooping muscles in your face. These signal a transient ischemic attack (TIA). Untreated, a TIA can lead to a stroke.
• If you have atherosclerosis in the arteries in your arms and legs, you may have symptoms of peripheral artery disease, such as leg pain when walking (claudication) or decreased blood pressure in an affected limb.
• If you have atherosclerosis in the arteries leading to your kidneys, you may develop high blood pressure or kidney failure.

When to see a doctor

If you think you have atherosclerosis, talk to your health care provider. Also pay attention to early symptoms caused by a lack of blood flow, such as chest pain (angina), leg pain or numbness.

Early diagnosis and treatment can stop atherosclerosis from worsening and prevent a heart attack, stroke or another medical emergency.

Atherosclerosis is a slowly worsening disease that may begin as early as childhood. The exact cause is unknown. It may start with damage or injury to the inner layer of an artery. The damage may be caused by:

• High blood pressure
• High cholesterol
• High triglycerides, a type of fat (lipid) in the blood
• Smoking or chewing tobacco
• Insulin resistance
• Inflammation from an unknown cause or from diseases such as arthritis, lupus, psoriasis or inflammatory bowel disease

Once the inner wall of an artery is damaged, blood cells and other substances may gather at the injury site and build up in the inner lining of the artery.

Over time, fats, cholesterols and other substances also collect on the inner walls of the heart arteries. This buildup is called plaque. Plaque can cause the arteries to narrow, blocking blood flow. The plaque can also burst, leading to a blood clot.

Risk factors

Hardening of the arteries occurs over time. Aging is a risk factor for atherosclerosis. Other things that may increase the risk of atherosclerosis include:

• A family history of early heart disease
• An unhealthy diet
• High levels of C-reactive protein (CRP), a marker of inflammation
• Lack of exercise
• Sleep apnea
• Smoking and other tobacco use

Complications

The complications of atherosclerosis depend on which arteries are narrowed or blocked. For example:

• Coronary artery disease. When atherosclerosis narrows the arteries close to your heart, you may develop coronary artery disease, which can cause chest pain (angina), a heart attack or heart failure.
• Carotid artery disease. When atherosclerosis narrows the arteries close to your brain, you may develop carotid artery disease. This can cause a transient ischemic attack (TIA) or stroke.
• Peripheral artery disease. When atherosclerosis narrows the arteries in your arms or legs, you may develop blood flow problems in your arms and legs called peripheral artery disease. This can make you less sensitive to heat and cold, increasing your risk of burns or frostbite. Rarely, a lack of blood flow to the arms or legs can cause tissue death (gangrene).
• Aneurysms. Atherosclerosis can also cause aneurysms, a serious complication that can occur anywhere in the body. Most people with aneurysms have no symptoms. Pain and throbbing in the area of an aneurysm may occur and is a medical emergency. If an aneurysm bursts, it can cause life-threatening bleeding inside the body.
• Chronic kidney disease. Atherosclerosis can cause the arteries leading to the kidneys to narrow. Narrowing of these arteries prevents enough oxygen-rich blood from reaching the kidneys. The kidneys need enough blood flow to help filter waste products and remove excess fluids.

The same healthy lifestyle changes recommended to treat atherosclerosis also help prevent it. These lifestyle changes can help keep the arteries healthy:

• Quitting smoking
• Eating healthy foods
• Exercising regularly
• Maintaining a healthy weight
• Checking and maintaining a healthy blood pressure
• Checking and maintaining healthy cholesterol and blood sugar levels

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