Cardiovascular disease prevention and management

Guidelines & practical strategies in nutrition and preventative practices

Author: Holly Giles

Speakers: Dr Ebiambu Agwara

Panellists: Professor Sumantra Ray, Wanja Nyaga, Sarah Armes

Reviewers: Sarah Anderson, Sarah Armes

Introduction to cardiovascular disease (CVD)

Cardiovascular disease (CVD) is the leading cause of death worldwide and is associated with substantial morbidity, loss of quality-adjusted life years (QALYs), and significant economic burden on healthcare systems. The primary modifiable risk factors for CVD include hypertension, tobacco use, type 2 diabetes mellitus, dyslipidaemia, unhealthy dietary patterns, and sedentary behaviour. These risk factors often coexist and interact synergistically, accelerating the progression of atherosclerosis and other cardiovascular pathologies.

Primary prevention strategies, such as early lifestyle modification, regular screening of cardiometabolic markers (e.g., blood pressure, lipid profile, glucose levels), and community-level health promotion, are crucial to reducing the incidence and prevalence of CVD. Other preventative strategies include stress management and patient education, which empower patients with information about CVD risk factors and lifestyle changes. This can support long-term behavioural change.

How do diet and lifestyle influence our CVD risk?

Diet and lifestyle are fundamental determinants of cardiovascular health and play a key role in both the development and prevention of CVD. Evidence-based dietary patterns such as the Mediterranean diet, the Dietary Approaches to Stop Hypertension (DASH) diet, and plant-based diets have been consistently associated with reduced CVD risk. These diets emphasise the intake of dietary fibre, unsaturated fats (particularly omega-3 fatty acids), whole grains, fruits, vegetables, legumes, and plant-based proteins, while limiting saturated fats, trans fats, added sugars, and excessive sodium.

Current clinical guidelines for CVD prevention strongly advocate for the adoption of a heart-healthy lifestyle. This includes maintaining a balanced diet, engaging in regular physical activity (at least 150 minutes of moderate-intensity exercise per week), abstaining from tobacco use, and moderating alcohol intake. These lifestyle modifications are considered the first-line strategy in primary prevention and are most effective when paired with regular health monitoring, such as assessments of blood pressure, lipid profiles, blood glucose, and body weight.

While lifestyle changes are often prioritised before initiating pharmacological therapy, medication may be required for individuals with established risk factors or those who do not achieve target health outcomes through lifestyle modification alone (as illustrated below).

What are Diet Quality scores?

Diet quality scores are standardised tools used to evaluate overall dietary patterns in relation to established nutritional guidelines and health outcomes, such as CVD risk. These scoring systems quantify how closely an individual’s diet aligns with evidence-based dietary recommendations, thereby offering a practical method for assessing nutritional adequacy and identifying areas for improvement.

Clinically, diet quality scores enable healthcare professionals to systematically assess a patient’s dietary habits, tailor dietary advice, and monitor changes over time. This facilitates personalised nutrition counselling and supports long-term behavioural change by providing measurable feedback.

Commonly used diet quality indices include the Mediterranean Diet Score, Healthy Eating Index (HEI), and DASH score. For example, adherence to the Mediterranean diet, as measured by its respective score, has been consistently associated with reduced CVD incidence, improved cardiovascular health, and greater longevity.

How Is CVD Risk Assessed?

Cardiovascular disease (CVD) risk scores are tools used by clinicians to estimate a patient’s likelihood of experiencing a cardiovascular event, typically over a 10-year period. These tools guide clinical decision-making by helping to stratify patients into risk categories (low, moderate, or high), which can inform recommendations for lifestyle modification and/or pharmacological intervention. While different regions use various models, all aim to predict CVD risk based on clinical and demographic factors.

Commonly used risk prediction models include the Framingham Risk Score, QRISK3 (UK), ASCVD Pooled Cohort Equations (US), and SCORE2 (Europe). These models incorporate variables such as age, sex, smoking status, systolic blood pressure, total and HDL cholesterol, diabetes status, and sometimes additional clinical or socioeconomic variables.

The benefits and drawbacks associated with each of these scoring systems are detailed in the image below. Typically, traditional risk scores overemphasise cholesterol and blood pressure, while underestimating the effect of lifestyle and diet on CVD risk. Most of these studies were completed with patients from Europe and America, meaning it is unknown how representative the models are in other contexts, such as in low-income countries. Scoring systems and research need to integrate a wide range of individuals to enable accurate scoring for all populations.

We need newer risk assessment tools that can integrate lifestyle variables, tailored to the population to which they are applied. This can be achieved using machine learning and AI to refine risk assessments and include lifestyle factors more precisely. These emerging tools offer new opportunities for personalised medicine for CVD prevention.

References

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Estruch, R. et al. (2018) ‘Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts’, New England Journal of Medicine, 378(25), pp. e34. https://doi.org/10.1056/NEJMoa1800389.

U.S. Department of Health and Human Services and U.S. Department of Agriculture (2020) Dietary Guidelines for Americans 2020–2025. 9th edn. Available at: https://www.dietaryguidelines.gov/ (Accessed: 8 May 2025).

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