Coronary heart disease, cerebral hemorrhage and cerebral thrombosis are the most common cardiovascular and cerebrovascular diseases in clinical practice, with high mortality and disability rates. Epidemiological data show that deaths caused by cardiovascular and cerebrovascular diseases account for one-third of all-cause human deaths, which means that one out of every three people will be killed by cardiovascular and cerebrovascular diseases.
China’s cardiovascular and cerebrovascular diseases present three major characteristics.
1, the incidence rate is increasing year by year: In the past, the incidence rate of cardiovascular and cerebrovascular diseases in China was much lower than that in Western countries, but recently, due to the implementation of a series of intervention measures in Western countries, the incidence of cardiovascular and cerebrovascular diseases in China is showing a rapid growth momentum while the trend is decreasing.
2, cardiovascular disease is young trend: In the past, cardiovascular disease is the patent of the elderly, but today, young people in their 30s and even early 20s have joined the ranks of cardiovascular disease; patients aged 60-70 have become the “main force” of cardiovascular disease.
3. For most individuals with cardiovascular diseases, the exact cause and pathogenesis of cardiovascular diseases are not yet fully understood, and we do not yet know exactly what causes and through what mechanism cardiovascular diseases are caused. Therefore, we are currently unable to prevent CVD at its root or reverse existing CVD. Existing treatments (stents, bypasses) do not cure coronary heart disease and have a high recurrence rate.
Early screening of cardiovascular disease is of great significance
Cardiovascular disease is certainly scary, but we are not helpless in the face of the disease. In summary, to reduce the harm of cardiovascular and cerebrovascular diseases, we should start from the following three levels.
1.Preventing and controlling the occurrence and development of risk factors of cardiovascular and cerebrovascular diseases.
2.Preventing the development of existing cardiovascular and cerebrovascular diseases.
3.Reducing the hazards of complications of cardiovascular and cerebrovascular diseases. Since cardiovascular diseases are characterized by insidious onset, sudden onset and lack of aura, and have a high mortality and disability rate, early screening is of great significance.
Large population studies have found that cardiovascular disease is a consequence of multiple risk factors, and if we can systematically and scientifically apply the existing cardiovascular disease prevention and treatment tools, we can effectively reduce or control the occurrence and development of cardiovascular disease risk factors (such as hypertension, hyperlipidemia, diabetes and smoking) and reduce the occurrence of cardiovascular disease. On the contrary, if the risk factors of patients with cardiovascular diseases are not eliminated in time, the progress of their diseases will be difficult to control effectively, and the risk of cardiovascular diseases is significantly higher in people with multiple cardiovascular disease risk factors. It can be seen that the prevention of cardiovascular diseases should start from the prevention and control of their risk factors, and the successful experience of Europe and the United States and other developed countries in the field of prevention and treatment of cardiovascular diseases is worthy of our reference.
The academic community divides the prevention of cardiovascular diseases into three levels: level 0 prevention, level 1 prevention and level 2 prevention. level 0 prevention refers to the prevention of cardiovascular diseases in the healthy population by preventing the risk factors of cardiovascular diseases (so that healthy people do not suffer from hypertension, diabetes and tobacco exposure); level 1 prevention refers to the prevention of cardiovascular diseases when the risk factors of cardiovascular diseases already exist, but the diseases have not yet occurred, or the diseases are in the subclinical stage. Primary prevention refers to the active treatment of patients with cardiovascular disease to prevent the development of the disease and strive for its reversal.
Cardiovascular disease is actually a lifestyle disease, and by adopting a healthy lifestyle, we can fundamentally reduce cardiovascular morbidity and mortality. To reduce the rapid increase in the number of cardiovascular diseases, we should shift from a downstream clinical treatment focus to a disease upstream prevention focus, which means we should move the prevention front of cardiovascular diseases further forward, from primary and secondary prevention of cardiovascular diseases to level 0 prevention of cardiovascular diseases.
The development of cardiovascular disease is a long process, and asymptomatic atherosclerosis is present as early as childhood, often with a high risk of death and disability at the first onset. Early screening of people susceptible to cardiovascular diseases is expected to detect the risk factors of cardiovascular diseases and the pathological changes and/or clinical manifestations of existing cardiovascular diseases at an early stage, so that scientific prevention and treatment measures can be adopted as early as possible to prevent the occurrence and development of cardiovascular diseases starting from the prevention of risk factors of cardiovascular diseases. A series of early intervention studies of atherosclerosis in children and young adults and animal studies have confirmed that effective control of pathogenic risk factors in the early pathological stages before the onset of symptoms will delay or stop the development of asymptomatic atherosclerosis into clinical cardiovascular disease.
Common risk factors for cardiovascular disease include age, gender, blood pressure, total cholesterol levels, overweight and obesity, diabetes, smoking, lack of exercise, lack of vegetables and fruits in the diet, and excessive psychological stress, among others. Among the common risk factors for cardiovascular diseases, except for those that we cannot change such as age, gender, family and genetic variation (we call them untreatable risk factors), most of the risk factors can be treated through health education, lifestyle improvement and proper medical interventions to effectively improve the prognosis of patients, which we call them treatable risk factors. For example, smoking, obesity, hypertension, hyperglycemia, hyperlipidemia, respiratory sleep disorders and other risk factors can be treated by the above means. Control of risk factors can reduce morbidity and improve prognosis.
Recommendations for early screening of cardiovascular and cerebrovascular diseases
Based on the existing research results, academic institutions at home and abroad have made the following recommendations for cardiovascular disease risk assessment and primary prevention of cardiovascular disease in asymptomatic adults.
1. For all asymptomatic adults it is recommended that
The first cardiovascular risk assessment should be performed at the age of 20 years, and individuals over the age of 40 years should undergo risk assessment at least once every 5 years. Individuals with more than 2 risk factors should have an annual risk assessment.
Blood pressure should be monitored at least once every 2 years for adults over 18 years of age and at least once every year for adults over 35 years of age, and at least twice daily during adjustment of treatment and twice weekly after stabilization of blood pressure in patients with hypertension. Encourage home self-testing of blood pressure.
Health checkups for the general population should include lipid testing; people under 40 with normal lipids should have their lipids tested every 2 to 5 years; people over 40 should have their lipids tested at least once a year. People at high risk of cardiovascular disease should have their blood lipids tested every 6 months
Fasting blood sugar check once a year starting at age 40 Healthy people should have their blood glucose tested regularly starting at age 45 or if they are overweight, and once every 3 years if they are normal. Patients with hypertension or coronary artery disease should be routinely tested with an OGTT (glucose tolerance test) once every 3 years if normal.
Advise all smokers to quit smoking.
2. For all asymptomatic adults and those with previously undiagnosed coronary artery disease:
Traditional risk factors for CVD (age, sex, blood pressure, overweight and obesity, total cholesterol levels, smoking, and diabetes) should be assessed using risk assessment tools such as the Framingham Risk Assessment Tool or the 10-Year Risk Assessment Scale for Ischemic Cardiovascular Disease in the Chinese Population. “Risk assessment tools such as the Framingham Risk Assessment Tool or the 10-Year Risk Assessment Scale for Ischemic Cardiovascular Disease in Chinese can be used to quantitatively assess the risk of cardiovascular disease in asymptomatic individuals and obtain an overall risk assessment.
Based on the overall risk assessment results, subjects can be classified as: low risk (10-year risk of developing ischemic cardiovascular disease <10%), moderate risk (10-year risk of developing ischemic cardiovascular disease 10%-20%) and high risk (10-year risk of developing ischemic cardiovascular disease >20%). For those at low risk, lifestyle changes are the first step; for those at intermediate risk, further testing is needed to assess risk and determine if intervention is needed; for those at high risk, further risk factor interventions and medications are needed.
Family
Family history is an independent risk factor for cardiovascular disease. Family history can help in the new risk stratification of individuals, especially those with moderate risk of CVD. All asymptomatic adults should be assessed for cardiovascular disease risk with a detailed family history of cardiovascular disease, particularly coronary heart disease and stroke, and advised to improve lifestyle and correct risk factors if they have a family history of cardiovascular disease.
If necessary, glycated hemoglobin (HbA1C) can be tested.
If necessary, resting 12-lead electrocardiogram can be performed.
C-reactive protein (CRP) levels are measured in those who meet the following criteria: men ≥ 50 years of age or women ≥ 60 years of age with low-density lipoprotein cholesterol (LDL-C) less than 130
mg/dL (3.36 mml/L); who are not receiving lipid-lowering, hormone replacement or immunosuppressive therapy; and who do not have diabetes, chronic kidney disease or severe inflammatory conditions.
Oral glucose tolerance test (OGTT): those aged <45 years with the following risk factors: obesity (BMI ≥28 kg/m2); first-degree relative of a person with type 2 diabetes; history of delivery of a large child (birth weight ≥4
kg) or gestational diabetes; hypertension (blood pressure ≥140/90 mmHg), HDL-C ≤0.91
mmol/L (35
mg/d1) and TG ≥2.75
mmol/L (250
mg/dl); a history of impaired glucose regulation should be screened with OGTT; if the screening result is normal, repeat the test after 3 years. Those aged >45 years, especially those with overweight (BML ≥24
OGIT should be performed regularly in people >45 years of age, especially if they are overweight (BMl ≥24 kg/m2). If the screening result is normal, repeat the test after 3 years.
3. For asymptomatic adults at low to moderate risk (6-10% 10-year risk of ischemic cardiovascular disease), coronary artery calcification (CAC) measurement by computed tomography (CT) can be applied if necessary.
4. For asymptomatic adults at moderate risk (10% to 20% 10-year risk of ischemic cardiovascular disease), at the time of cardiovascular disease risk assessment:
≤50 years old men or ≤60 years old women, CRP levels can be tested if necessary.
Urine microalbumin (MAU) may be measured if necessary in those without hypertension or diabetes.
An exercise ECG may be performed if necessary.
Carotid intima-media thickness (IMT) should be measured using ultrasound techniques.
Ankle-arm index (ABI) testing should be performed.
Coronary artery calcification (CAC) measurement can be performed by CT technique
5. For combined diabetes or a family history of coronary artery disease, or where previous risk assessment has suggested a high risk of coronary artery disease (e.g.
Asymptomatic adults with CAC scores ≥400 may use stress nuclear myocardial perfusion imaging (MPI) as a screening method for their advanced cardiovascular risk assessment.
6. For asymptomatic adults with hypertension,
When assessing cardiovascular risk:
Plasma homocysteine (HCY) levels should be measured.
Urine microalbumin (MAU) should be measured.
A resting 12-lead ECG should be routinely performed.
Echocardiography can be applied to detect left ventricular hypertrophy.
If necessary, peripheral arterial flow-mediated vasodilatory function (FMD) testing can be performed.
7. For asymptomatic adults with diabetes mellitus, when assessing the risk of cardiovascular disease:
Urine microalbumin (MAU) should be measured.
A resting 12-lead ECG should be routinely performed.
For asymptomatic adults with diabetes mellitus (without hypertension), to assess cardiovascular disease risk, plasma HCY levels may be measured if necessary.
If necessary, peripheral arterial flow-mediated vasodilatory function (FMD) testing may be performed.
If necessary, HbA1C can be measured.
CAC measurement is recommended for assessing cardiovascular disease risk in asymptomatic adults with diabetes mellitus ≥40 years of age.
Asymptomatic adults with diabetes or those previously assessed as being at high risk for coronary heart disease (e.g., CAC score ≥400) may have a loading MPI for advanced cardiovascular risk assessment, if necessary.
8. For patients with chronic stable angina with angina symptoms or previously diagnosed coronary artery disease:
Perform fasting blood glucose and lipid examination, and glucose tolerance test if necessary. Understand the risk factors of coronary heart disease.
Check hemoglobin. Find out if there is anemia (which may trigger cardiac pain).
Check thyroid function if necessary.
Perform urine routine, liver and kidney function, electrolytes, hepatitis-related antigen, human immunodeficiency virus (HIV) test and syphilis serologic test, which need to be performed before coronary angiography.
In patients with more pronounced chest pain, blood troponin (cTnT
or cTnl), creatine kinase (CK) and isoenzyme (CK I MB) to differentiate from acute coronary syndrome.
Resting electrocardiogram should be performed in all patients with chest pain. Obtain an ECG during the onset of chest pain and review it immediately after relief.
An ECG stress test is required for those without significant abnormalities on the resting ECG.
Chest X-ray is helpful to understand the condition of cardiopulmonary diseases, such as the presence of congestive heart failure, heart valve disease, pericardial disease, etc.
Echocardiography or nuclear myocardial perfusion imaging is performed in patients suspected of having chronic stable angina pectoris.
Exercise stress echocardiography or stress MPI may be performed in the following cases: abnormal resting ECG, LBBB, ST-segment drop >1mm, pacing rhythm, pre-excitation syndrome, and other cases where ECG exercise test is difficult to assess accurately. Those whose ECG exercise test cannot be concluded and coronary artery disease is more likely. Patients with previous revascularization (PCI or CABG) who have recurrence of symptoms and need to know the site of ischemia. Alternative to ECG exercise test when available. Those with atypical chest pain with a low probability of coronary artery disease, such as women, may substitute for ECG exercise testing. Evaluate the functional severity of coronary angiographic adventitia lesions. Those who have undergone coronary angiography and plan to undergo revascularization treatment and need to know the site of myocardial ischemia.
Drug loading tests: These include diphosphodamol, adenopril or dobutamine drug loading tests for patients who require exercise loading echocardiography or loading MPI tests but are unable to exercise. A negative stress test is associated with a low likelihood of coronary artery disease; a normal stress test in a person with known coronary artery disease is a low-risk patient with a low incidence of subsequent cardiovascular events.
Coronary angiography should be performed in those with: severe stable angina (those with CCS classification 3 or higher), especially if medication does not provide good symptomatic relief. Patients evaluated as high risk by non-invasive methods. Regardless of the severity of angina pectoris. Patients who survived cardiac arrest. Patients with severe ventricular arrhythmias. Patients who have undergone revascularization (PCI
Patients who have had early recurrence of moderate or severe angina with CABG. Patients with angina with chronic heart failure or significantly reduced left ventricular ejection fraction (LVEF). Patients with angina at moderate to high risk of non-invasive evaluation need to be considered for major non-cardiac surgery, especially vascular surgery (e.g. aortic aneurysm repair, carotid endarterectomy, femoral artery bypass grafting, etc.). Non-invasive tests are not conclusive: or those at intermediate – high risk of coronary artery disease, but the conclusions of different non-invasive tests are inconsistent. Patients with a high risk of restenosis after PCI at sites of prognostic importance.
The effective implementation of cardiovascular disease prevention requires a trusting partnership between physicians and patients, the use of interventions to reduce the overall cardiovascular disease risk in the early stages of the disease, and making more patients aware of the benefits and importance of cardiovascular disease prevention so that they can actively participate and adhere to it, I believe that with the efforts of all parties, we will also be able to bring down the morbidity and mortality of cardiovascular disease.