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99 Percent of Heart Attacks and Strokes Are Linked to Modifiable Risk Factors
Doctors say even elevated levels of blood pressure, cholesterol and blood sugar can lead to health problems, and offer tips on how to keep these numbers in check
Yasu + Junko/Trunk Archive
Heart attacks, strokes and other serious cardiovascular events rarely strike without warning. A new study finds that more than 99 percent of people who went on to suffer a serious cardiovascular event already had at least one heart disease risk factor, such as above-optimal blood pressure, cholesterol and blood sugar levels. Current or past tobacco use was also considered in the large study, published Sept. 29 in the Journal of the American College of Cardiology.
Interestingly, the researchers found that levels of these key risk factors didn’t need to be alarmingly high prior to a heart attack or stroke. Even people who weren’t being treated for high blood pressure, high cholesterol or diabetes were at risk, explains Dr. Philip Greenland, the Harry W. Dingman Professor of Cardiology at Feinberg School of Medicine at Northwestern University, and a coauthor on the study.
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Heart disease remains the No. 1 killer in the U.S. and globally.
What are cardiovascular diseases?
They are diseases and conditions that impact your heart and blood vessels and include:
- Heart failure
- Arrhythmia
- Valve disease
- Peripheral artery disease
- Coronary artery disease/coronary heart disease
- Aortic disease
- Congenital heart disease
- Deep vein thrombosis
- Pericardial disease
- Cerebrovascular disease
These can lead to cardiovascular events such as heart attack, sudden cardiac arrest and stroke.
A closer look at the study
The researchers evaluated data from more than 9.3 million people from South Korea and nearly 7,000 from the United States, and assessed people for the following nonoptimal risk factors:
- Blood pressure of or higher than 120/80 mm Hg, or those on treatment to lower it
- Total cholesterol of or greater than 200 mg/dL, or those on lipid-lowering treatment
- Fasting glucose at 100 mg/dL, or a diabetes diagnosis or on a glucose-lowering treatment
- Being a current or past smoker at any point before the cardiovascular event
In a secondary analysis, the team also looked at people with higher levels of these risk factors, around what doctors often use for diagnosis and treatment:
- Blood pressure at or higher than 140/90 mm Hg, or those on treatment to lower it
- Total cholesterol of or greater than 240 mg/dL or those on lipid-lowering treatment
- Fasting glucose at or higher than 126 mg/dL or a diabetes diagnosis or on a glucose-lowering treatment
- Current tobacco smoking status at the last exam before the cardiovascular event
Know your numbers
Standard ranges for blood pressure, total cholesterol and blood sugar are:
Blood pressure :
- Normal: Systolic blood pressure lower than 120 mm Hg and diastolic blood pressure lower than 80 mm Hg
- Elevated: Systolic between 120 and 129 mm Hg and diastolic lower than 80 mm Hg
- Hypertension (stage 1): Systolic blood pressure between 130 and 139 mm Hg and diastolic blood pressure between 80 and 89 mm Hg
Total cholesterol:
- Normal: Less than 200 mg/dL
- Borderline high: 200 to 239 mg/dL
- High: At or above 240 mg/dL
Blood sugar (fasting plasma glucose):
- Normal: Under 100 mg/dL
- Prediabetes: 100 mg/dL to 125 mg/dL
- Diabetes: Over 126 mg/dL
More than 99 percent of people who experienced a cardiovascular event had at least one risk factor. For example, 0.7 percent of people in the South Korean cohort didn’t have risk factors compared with 0.5% in the American cohort. More than 93 percent of people had two or more.
“The goal now is to work harder on finding ways to control these modifiable risk factors,” said Greenland in a news release.
High blood pressure was the most common risk factor among people included in the study. Dr. Neha J. Pagidipati, an assistant professor of medicine and cardiovascular disease prevention specialist at Duke University School of Medicine, said in an accompanying editorial that uncontrolled high blood pressure is likely the biggest contributor to cardiovascular disease that people can change.
Above-optimal levels: What to know
Many people fall in the nonoptimal category with raised — but not terribly high — levels of key heart disease risk factors, says Dr. Paul Leis, a cardiologist at Mount Sinai Fuster Heart Hospital in New York City.
For instance, an older adult may have blood pressure that’s above normal (defined as less than 120/80 mm Hg) but is “still acceptable” and not high enough to warrant prescription medication, especially if the doctor is concerned about falls if their blood pressure gets too low, Leis explains.
Doctors need to help people stay as close to optimal levels, but in a way that the person can tolerate, he adds. “It’s not as black-and-white, because every patient reacts differently [to treatment],” Leis says.
When doctors look at the whole picture, including age and whether you’re higher than where you should be for a few risk factors, and not just one, it could mean that you may benefit from treatment, Leis says. “If you control one, you likely will improve the others as well,” he adds.
To lower cardiovascular risks, Dr. Michael Miller, a cardiologist at Penn Medicine in Philadelphia, says most people should aim for:
- Total cholesterol less than 200 mg/dL
- Blood pressure less than 120/80
- Fasting glucose less than 100 mg/dL
- No history of smoking, ideally
What do you do if you’re not at these optimal levels? If you have a blood pressure, cholesterol or blood sugar reading that’s above optimal, pay attention to it, Greenland tells AARP.
Doctors often advise patients to lower their levels and follow up to check progress, but that doesn’t always occur in a timely way. If your numbers are elevated, don’t wait six months to a year to follow up — do so two to three months after you get your blood work back and first learn about the issue, Greenland advises.
People should be making lifestyle modifications if they’re in that middle ground, Greenland says. In some cases, they may also benefit from medication.
“If you have a little elevation of blood pressure, a little elevation of cholesterol, that can mean that your risk is actually quite high,” Greenland says. “And in some cases, that would justify medication, but that’s an important individual decision.”
Doctors can also use risk scores to devise a treatment plan, Greenland says. Additionally, he recommends adhering to Life’s Essential 8 for good cardiovascular health, which, in addition to managing cardiovascular risk factors, promotes healthy habits such as regular exercise and adequate sleep.
Often the focus is on treating heart attacks after they happen, rather than preventing them in the first place, Miller says. “Hopefully, the new study provides a solid foundation so that doctors can focus more on preventing heart disease in the first place,” he says.
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