Editorial comments: focus on cardiovascular risk burden

This edition of the European Journal of Preventive Cardiology focuses on the cardiovascular risk burden and strategies for enhancing cardiovascular prevention in various clinical settings. High noise exposure not only negatively impacts sleep but may also represent a risk factor for arterial hypertension, chronic coronary artery disease, heart failure, and arrhythmia.1 Despite the association between this risk factor and cardiovascular disease, the molecular and biological mechanisms underlying this phenomenon are not well known. Kvandová et al.2 conducted an experimental study on mice exposed to aircraft noise and found that noise exposure may lead to endothelial dysfunction in various arteries through adenosine monophosphate-activated protein kinase (α1AMPK). Three different interventions were identified to mitigate the negative impact of noise exposure: exercise, intermittent fasting, and pharmacological activation of α1AMPK. A deeper understanding of the biological mechanisms of environmental risk factors for cardiovascular health is necessary in order to formulate appropriate prevention and therapy strategies. While a family history of heart disease is widely recognized as a cardiovascular risk factor, with advancements in genetic and clinical risk factors, it is not well known whether a self-reported family history of heart disease may be considered an additional risk factor on top of the known genetic and clinical risk factors. In a cross-sectional study conducted by Jowell et al.3 in a large cohort of patients, a combined model of genetic and clinical risk factors could only explain 36% of the likelihood of reporting a family history of heart disease. Consequently, the additional cardiovascular risk associated with family history is not well established. Further research should focus on this knowledge gap, considering social and environmental risk factors, to better identify comprehensive risk scores. In addition to the social and functional impacts of mental disorders on affected individuals, it has been observed that these individuals may experience a shorter life expectancy compared with the general population, across various types of mental disorders.4 Most of these premature deaths are attributed to physical diseases. In a study conducted by Park et al.,5 a large population of young individuals with different mental disorders was followed for up to 7.6 years, revealing a higher risk for both myocardial infarction and ischaemic stroke. Notably, this increased risk cannot be solely attributed to unfavourable lifestyle behaviours or a worse metabolic profile when compared with the general population. Therefore, it is imperative to place greater emphasis on cardiovascular prevention measures for these patients, not only addressing their mental health but also aiming to reduce the excess mortality observed. Scientific efforts have been made to identify clinical risk factors for the recurrence of atrial fibrillation after ablation. However, in this preliminary study, Vanharen et al.6 demonstrated that advanced practitioner nurse care following atrial fibrillation ablation led to a reduction in alcohol intake, increased physical activity, and a decreased recurrence rate of atrial fibrillation. Further studies with longer follow-up periods are needed to confirm whether appropriate educational interventions after arrhythmia ablation can effectively reduce their recurrence rates, thereby positively impacting not only patients’ health but also the economic burden associated with cardiovascular diseases. Inflammatory bowel disease (IBD) has been associated with an increased risk of cardiovascular disease.7 In a cross-sectional study conducted by Sleutjes et al.,8 it was observed that individuals with IBD are at a higher risk of heart failure and coronary heart disease. Interestingly, this elevated risk of cardiovascular disease does not align with the risk score algorithm used to estimate the 10-year cardiovascular risk (SCORE2). Specifically, patients with IBD exhibited a lower prevalence of hypercholesterolaemia and were overweight, but they presented with higher waist circumferences, arterial hypertension rates, and triglyceride levels. This study suggests that there may be a need for new disease-specific cardiovascular risk scores to accurately stratify these patients, as general risk scores may not perform well in specific high-risk conditions such as IBD. No specific association has been investigated between extreme temperatures and cardiovascular mortality. Given the implications of climate change on temperature, Al-Kindi et al.9 conducted a 30-year follow-up study to explore the relationship between non-optimal temperatures and both cardiovascular deaths and disability-adjusted life years (DALYs). It was found that non-optimal temperatures, particularly high temperatures, have a detrimental impact on cardiovascular mortality and DALYs. Additionally, individuals residing in lower socioeconomic regions appeared to be more vulnerable to these effects than those in higher socioeconomic regions. With ongoing environmental changes, it is imperative that cardiovascular prevention efforts not only consider established genetic and clinical risk factors but also take into account the evolving environmental conditions over the years. Cardiac rehabilitation stands out as one of the most effective and affordable ways to reduce morbidity and mortality risk in patients with ischaemic heart disease.10 Heimer et al.11 conducted a systematic review and meta-analysis to assess the role of eHealth-supported interventions in patients with coronary artery diseases. The eHealth group demonstrated significant improvements in physical activity, exercise capacity, and a decrease in systolic blood pressure after 6 months, compared with those receiving usual care. It is evident that effective prevention cannot rely solely on medical education provided during physical examinations, but rather, continuous education and feedback mechanisms through technologies, such as cell-phone applications, are essential for achieving and maintaining optimal cardiovascular prevention. However, it is essential to conduct further prospective studies involving larger populations to confirm these results. Chronic kidney disease significantly impacts morbidity and mortality.12 However, various methods can be employed to calculate the estimated glomerular filtration rate (eGFR), with one of the most widely used being the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. In a population-based cohort study conducted by Lu et al.,13 it was observed that the eGFR equation proposed by the European Kidney Function Consortium outperformed the CKD-EPI equation, particularly in terms of its prognostic value for both all-cause mortality and cardiovascular mortality in general non-black individuals. Further research is warranted to identify the most accurate method for eGFR, both in the general population and in specific clinical settings, in order to better stratify patients. A healthy lifestyle is widely recognized as one of the most efficient methods to reduce cardiovascular morbidity and mortality, especially in the context of coronary artery disease. However, when it comes to valvular heart disease, and considering genetic susceptibility, a clear association with lifestyle has not been well-established. In a study conducted by Jia et al.,14 it was observed that adopting a healthier lifestyle, with particular attention to factors such as smoking, alcohol consumption, diet, physical activity, and sleep, is associated with a reduced rate of valvular heart disease, particularly aortic stenosis, irrespective of genetic susceptibility. Improved prevention translates to reduced mortality and an overall better quality of life, as its effects positively impact health in all aspects. A healthy lifestyle can be summarized by focusing on eight life essentials: avoiding nicotine exposure, engaging in regular physical activity, maintaining a balanced diet, ensuring adequate sleep, managing body mass index, controlling blood pressure, regulating blood glucose levels, and monitoring blood lipids. Zhang et al.15 observed that even in individuals defined as high risk for cardiovascular events based on their polygenic risk scores, adopting a healthier lifestyle reduced the risk associated with genetic predispositions by up to 51.2%. Thus, it is crucial to embrace a healthy lifestyle as it significantly reduces the incidence of cardiovascular events, cardiovascular mortality, and all-cause mortality, regardless of one’s genetic risk. Mental illnesses and cardiovascular conditions have been demonstrated to be associated with each other. Therefore, it is important to screen for cardiovascular disease among patients who suffer from mental illnesses, and conversely, it is crucial to screen for mental illnesses in patients with cardiovascular conditions. Johnsen et al.16 have validated the use of three questionnaires—the World Health Organization-5, the Anxiety Symptom Scale-2, and the Major Depression Inventory-2—as replacements for the Hospital Anxiety and Depression Scale (HADS) to screen for anxiety and depression disorders. The authors found that the combination of these three questionnaires can effectively substitute for HADS. Even with simple tools such as questionnaires, physicians can identify ‘red flags’ for disorders such as anxiety and depression that require treatment. The most commonly used cardiovascular prognostic score, SCORE2, relies on factors such as age, gender, smoking habits, and blood pressure.17 However, other factors such as albuminuria, cardiac biomarkers, or calcium score computed tomography (CT) detected have emerged as additional prognostic indicators. Currently, these factors are not incorporated into the existing prognostic score. Hageman et al.18 revealed that the addition of calcium score CT-detected, B-type Natriuretic Peptide (NT-proBNP), and high-sensitivity troponin T to SCORE2 significantly improved its ability to predict cardiovascular disease. Given the advancements in cardiovascular prognostic factors, there is a growing need for a more comprehensive prognostic risk score. Almost all cardiovascular diseases affect patients’ mortality risk to varying degrees, depending on the specific disease. Prugger et al.19 conducted a study to assess the impact of 12 different cardiovascular diseases on mortality risk in comparison with individuals with no cardiovascular illnesses. Their findings revealed that all 12 cardiovascular diseases increased the risk of cardiovascular mortality, with the lowest risk seen in stable angina and the highest risk observed in haemorrhagic stroke. These results indicate that all cardiovascular diseases have an impact on mortality risk, although to different extents. Therefore, a comprehensive approach to prevention encompassing all cardiovascular diseases should be prioritized.