New Coronary Heart Disease Risk Factors

Major coronary risk factors include smoking, hyperlipidemia, hypertension, diabetes mellitus, age, obesity, a sedentary lifestyle, and a positive family history for premature manifestations of coronary artery disease, such as an acute myocardial infarction. In recent years, several new risk factors have been identified. Some risk factors are quite unusual, such as a history of premature birth. Recognizing the presence of one or more of these new risk factors should trigger attempts by the clinician to minimize more traditional major risk factors. Diseases such as gout, inflammatory bowel disease, autoimmune collagen vascular diseases, and psoriasis are all associated with an increased tendency to develop coronary artery disease, presumably because they increase the activity of the inflammasome.1Cipolletta E Tata LJ Nakafero G Avery AJ Mamas MA Abhishek AL Association between gout flare and subsequent cardiovascular events among patients with gout.JAMA. 2022; 328: 440-450Crossref PubMed Scopus (18) Google Scholar, 2Mahtta D Gupta A Ramsey DJ et al.Autoimmune rheumatic diseases and premature atherosclerotic cardiovascular disease: an analysis from the VITAL registry.Am J Med. 2020; 133: 1424-1432.e1Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 3Lee MT Mahtta D Chen L et al.Premature atherosclerotic cardiovascular disease risk among patients with inflammatory bowel disease.Am J Med. 2021; 134: 1047-1051.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Patients with a recent gout flare have an augmented probability of developing an acute cardiovascular event such as a myocardial infarction or stroke.1Cipolletta E Tata LJ Nakafero G Avery AJ Mamas MA Abhishek AL Association between gout flare and subsequent cardiovascular events among patients with gout.JAMA. 2022; 328: 440-450Crossref PubMed Scopus (18) Google Scholar Studying a large Veterans Affairs database, VITAL (Veterans wIth premaTure atheroscLerosis), Mahtta et al noted that patients diagnosed with rheumatoid arthritis, systemic lupus erythematosus, or both had higher odds for concomitant premature and extremely premature coronary artery disease.2Mahtta D Gupta A Ramsey DJ et al.Autoimmune rheumatic diseases and premature atherosclerotic cardiovascular disease: an analysis from the VITAL registry.Am J Med. 2020; 133: 1424-1432.e1Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Patients with inflammatory bowel disease (ie, Crohn's disease and ulcerative colitis) also had an increased tendency to develop coronary artery disease.3Lee MT Mahtta D Chen L et al.Premature atherosclerotic cardiovascular disease risk among patients with inflammatory bowel disease.Am J Med. 2021; 134: 1047-1051.e2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Psoriasis increases activation of several factors in the inflammatory milieu (eg, tumor necrosis factor alpha, interferons, and cytokines). Patients with psoriasis are up to 50% more likely to develop cardiovascular disease.4Garshick MS Ward NL Krueger JG Berger JS Cardiovascular risk in patients with psoriasis: JACC Review topic of the week.J Am Coll Cardiol. 2021; 77: 1670-1680Crossref PubMed Scopus (31) Google Scholar Several maternal and childhood factors are associated with an increased risk for developing coronary artery disease: gestational diabetes, pre-eclampsia, delivering a child of low birth weight, preterm delivery, and premature or surgical menopause. The factor or factors increasing the risk for coronary artery disease associated with each of these conditions is not known but may be the result of increased cytokine and oxidative stress.5Bassily E Bell C Verma S Patel N Patel A Significance of obstetrical history with future cardiovascular disease risk.Am J Med. 2019; 132: 567-571Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Honigberg MC Zekavat SM Aragam K et al.Association of premature natural and surgical menopause with incident cardiovascular disease.JAMA. 2019; 322: 2411-2421Crossref PubMed Scopus (150) Google Scholar, 7Levine LD Ky B Chirinos JA et al.Prospective evaluation of cardiovascular risk 10 years after a hypertensive disorder of pregnancy.J Am Coll Cardiol. 2022; 79: 2401-2411Crossref PubMed Scopus (8) Google Scholar An unusual and yet unexplained association has been observed between migraine headaches with aura in women and incident cardiovascular disease.8Kurth T Rist PM Ridker PM Kotler G Bubes V Buring JE Association of migraine with aura and other risk factors with incident cardiovascular disease in women.JAMA. 2020; 323: 2281-2289Crossref PubMed Scopus (53) Google Scholar Also of interest is the association of early-life trauma and the risk of adverse cardiovascular outcomes in young and middle-aged individuals with a history of myocardial infarction.9Almuwaqqat Z Wittbrodt M Young A et al.Association of early-life trauma and risk of adverse cardiovascular outcomes in young and middle-aged individuals with a history of myocardial infarction.JAMA Cardiol. 2021; 6: 336-340Crossref Scopus (9) Google Scholar These investigators suggested that adverse childhood experiences could have contributed to cardiovascular risk through a pathway that involved inflammation possibly secondary to increased glucocorticoid signaling. Another gender-related situation linked to augmented cardiovascular risk is seen in transgender patients who present for gender-affirming care. Here, the increase in coronary artery disease risk may possibly be related to high rates of anxiety and depression.10Denby KJ Cho L Toljan K Patil M Ferrando CA Assessment of cardiovascular risk in transgender patients presenting for gender-affirming care.Am J Med. 2021; 134: 1002-1008Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar An increased incidence of coronary artery disease has been related to 2 environmental factors that may themselves be connected: low socioeconomic status and air pollution.11Hamad R Penko J Kazi DS et al.Association of low socioeconomic status with premature coronary heart disease in US adults.JAMA Cardiol. 2020; 5: 899-908Crossref PubMed Scopus (52) Google Scholar, 12Rajagopalan S Landrigan PJ Pollution and the heart.N Engl J Med. 2021; 385: 1881-1892Crossref PubMed Scopus (56) Google Scholar, 13Chen R Jiang Y Hu J et al.Hourly air pollutants and acute coronary syndrome onset in 1.29 million patients.Circulation. 2022; 145: 1749-1760Crossref PubMed Scopus (21) Google Scholar Hamad et al suggested that increased psychosocial stressors, limited educational and economic opportunities, and lack of peer influence favoring healthier lifestyle choices may be causative elements leading to enhanced coronary artery disease in individuals with low socioeconomic living conditions.11Hamad R Penko J Kazi DS et al.Association of low socioeconomic status with premature coronary heart disease in US adults.JAMA Cardiol. 2020; 5: 899-908Crossref PubMed Scopus (52) Google Scholar Air pollution was estimated to have caused 9 million deaths worldwide in 2019 with 62% due to cardiovascular disease (coronary artery disease = 31.7% and stroke = 27.7%).12Rajagopalan S Landrigan PJ Pollution and the heart.N Engl J Med. 2021; 385: 1881-1892Crossref PubMed Scopus (56) Google Scholar Etiologic factors connected to air pollution include increased incidences of hypertension and diabetes, alterations in vascular tone, increased arterial intimal thickness and calcification, and insulin resistance. Severely polluted environmental aerosols also contain several toxic metals such as lead, mercury, arsenic, and cadmium.12Rajagopalan S Landrigan PJ Pollution and the heart.N Engl J Med. 2021; 385: 1881-1892Crossref PubMed Scopus (56) Google Scholar Chen et al13Chen R Jiang Y Hu J et al.Hourly air pollutants and acute coronary syndrome onset in 1.29 million patients.Circulation. 2022; 145: 1749-1760Crossref PubMed Scopus (21) Google Scholar reported that transient exposure to a variety of air pollutants may trigger the onset of an acute coronary syndrome. Investigators have also reported several lifestyle risk factors for coronary artery disease other than poor diet and lack of exercise. Trudel et al observed that long working hours in patients with a first myocardial infarction increased the risk for a recurrent event possibly because of prolonged exposure to work stressors.14Trudel X Brisson C Talbot D Gilbert-Ouiment M Milot A Long working hours and risk of recurrent coronary events.J Am Coll Cardiol. 2021; 77: 1616-1625Crossref PubMed Scopus (8) Google Scholar Rong et al noted that skipping breakfast was linked to increased cardiovascular and all-cause mortality. Detrimental effects of skipping breakfast included general obesity, metabolic syndrome, hypertension, higher fasting insulin, and lipid levels.15Rong S Snetselaar LG Xu G et al.Association of skipping breakfast with cardiovascular and all-cause mortality.J Am Coll Cardiol. 2019; 73: 2025-2032Crossref PubMed Scopus (76) Google Scholar Long-term consumption of beverages containing sugar or artificial sweeteners was also associated with increased cardiovascular mortality probably related to the same entities as skipping breakfast (obesity, metabolic syndrome, hypertension, and diabetes).16Malik VS Li Y Pan A et al.Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortality in US adults.Circulation. 2019; 139: 2113-2125Crossref PubMed Scopus (203) Google Scholar As always, I am happy to hear from readers about this or any other commentary at [email protected] or [email protected]