Help Patients Identify Risks for Premature Coronary Artery Disease

Heart disease is a broad term that covers several conditions, such as arrhythmias, congenital heart defects, coronary artery disease (CAD), disease of the heart muscles, and disease of the heart valves. Heart disease is the leading cause of death in men, women, and individuals of most ethnic and racial groups in the United States. This includes individuals who are Black, Alaska Native, Hispanic, and Indigenous, as well as White men. For women who are Alaska Native, Asian American, Hispanic, Indigenous, or Pacific Islander, heart disease is second only to cancer.¹

To understand the risks for heart disease, it is important to review how the heart works. The heart is divided into 4 chambers: 2 upper chambers (atria) and 2 lower chambers (ventricles). The right side of the heart moves blood into the lungs through pulmonary arteries, where it picks up oxygen. The blood then returns to the left side of the heart through pulmonary veins, where it gets pumped out to the rest of the body.² To keep blood flowing in the right direction, 4 valves open to let blood flow 1 way. These valves are the aortic, mitral, pulmonary, and tricuspid valves. They must open all the way and close tightly for the heart to function fully.²

The muscles of the heart contract and relax in a continuous cycle. During contraction (systole), the ventricles squeeze tight, which forces blood out of the heart and into the body and lungs. During relaxation (diastole), the ventricles fill with the blood from the atria.²

The heart’s electrical system keeps it beating regularly, ensuring the continuous exchange of oxygen-poor and oxygen-rich blood. Electrical signals begin in the right atrium, then travel through specialized pathways to the ventricles, prompting contraction.²

PREMATURE HEART DISEASE

Premature heart disease is defined as heart disease occurring in men younger than 45 years and women younger than 55 years. These cutoffs tend to vary among studies, ranging from ages 45 to 65 years.³

Between 4% and 10% of all heart attacks occur before age 45, and most strike men. CAD is responsible for approximately 80% of these heart attacks. Approximately 4% are triggered by inborn abnormalities of the coronary artery system anatomy, 5% are attributable to blood clots blocking a coronary artery, and 5% are the result of blood clotting disorders. Finally, 6% are caused by a wide range of problems, including chest trauma, illicit drug use, inflammation of the coronary arteries, and radiation therapy in the chest area.⁴

CORONARY ARTERY DISEASE

Coronary artery disease is defined as the reduction of blood flow to the heart muscle due to buildup of atherosclerosis in the arteries of the heart. Unfortunately, the incidence of premature CAD (PCAD) with 3 major known risk factors—diabetes, hypertension, and obesity—increased between 2000 and 2016.⁵ Risk factors for premature heart disease include the following:

• Family history of heart disease. Different types of heart disease and related conditions, such as high blood pressure (HBP) and high cholesterol, can run in families. Family history is a nonmodifiable risk factor. The most common inherited conditions include cardiomyopathies; conduction issues affecting heart rhythm, called channelopathies; and familial hypercholesterolemia.⁶
• Smoking. As a major modifiable risk factor for heart disease, smoking introduces chemicals into the body that damage the blood vessels and heart. This results in more plaque formation within the arteries, which leads to atherosclerosis.⁷
• High low-density lipoprotein (LDL) cholesterol. Cholesterol is a waxy substance in blood that the body needs to build healthy new cells. Elevated levels of LDL cholesterol can increase the risk of heart disease. This waxy substance can stick to the inside of blood vessels and grow, resulting in decreased blood flow. These deposits can break free and form a clot that causes a heart attack or stroke. Although high cholesterol is sometimes hereditary, it is most often the result of poor lifestyle choices, which can be prevented or treated. High cholesterol is a modifiable risk factor.⁴
• Hypertension. HBP can decrease the elasticity of the arteries. This impedes blood flow and oxygen to the heart, leading to heart disease. In turn, this can lead to angina, heart attacks, and heart failure.⁸
• Abdominal obesity. Obesity is associated with an increased risk of developing cardiovascular disease, particularly coronary heart disease and heart failure. Although the mechanisms with which this occurs are multifactorial and not well understood, the ability of adipose tissue to expand and produce inflammatory proteins that can impair diastolic and systolic function, as well as the formation of atherosclerotic plaques, plays a key role in heart disease. In addition, body composition changes typical of obesity can lead to structural changes to the heart.^9,10
• Diabetes. Individuals with diabetes are twice as likely to have heart disease as those who do not have the disease.¹¹ Over time, high blood glucose levels can damage the blood vessels and nerves serving the heart.
• Metabolic syndrome. Metabolic syndrome is a cluster of conditions occurring together, including diabetes, hypercholesterolemia, hypertension, and obesity.
• Elevated C-reactive proteins. Elevated circulating C-reactive proteins are an independent cardiovascular risk factor that is not fully understood. Investigating the molecular background of this association may provide new approaches to combating heart disease.

PHARMACISTS' ROLE

Pharmacists can help ensure modifiable risk factors that are associated with premature heart disease are controlled by verifying that patients are filling their cholesterol, diabetes, hypertension, and weight management medications in a timely manner. Pharmacists can also troubleshoot adherence issues and counsel patients about different methods of smoking cessation and weight loss. In addition, pharmacists can provide patients with other resources to find more information on their conditions.

CONCLUSION

The good news is that most risk factors for premature heart disease are modifiable. The bad news is that lifestyle changes are incredibly difficult for many individuals, as they have been practicing these unhealthy habits all their lives. Pharmacists can contribute to helping make positive changes by actively listening to patients and offering small but important steps to help them on their journeys.

ABOUT THE AUTHOR

Kathleen Kenny, PharmD, RPh, is a clinical medical writer for Healthline Media in Colorado Springs, Colorado.

REFERENCES

1. Heart disease facts. CDC. Updated October 14, 2022. Accessed January 10, 2023. https://www.cdc.gov/heartdisease/facts.htm

2. How the blood flows through the heart. National Heart, Lung, and Blood Institute. Updated March 24, 2022. Accessed January 10, 2023. https://www.nhlbi.nih.gov/health/heart/blood-flow

3. Khoja A, Andraweera PH, Lassi ZS, et al. Risk factors for premature coronary artery disease (PCAD) in adults: a systematic review protocol. F1000Res. 2021;10:1228. doi:10.12688/f1000research.74926.1

4. Premature heart disease. Harvard Health Publishing. December 15, 2019. Accessed January 10, 2023. https://www.health.harvard.edu/heart-health/premature-heart-disease

5. Vikulova DN, Grubisic M, Zhao Y, et al. Premature atherosclerotic cardiovascular disease: trends in incidence, risk factors, and sex-related differences, 2000 to 2016. J Am Heart Assoc. 2019;8(14):e012178. doi:10.1161/JAHA.119.012178

6. Family history. British Heart Foundation. Updated December 2021. Accessed January 10, 2023. https://www.bhf.org.uk/informationsupport/risk-factors/family-history

7. How smoking affects the heart and blood vessels. National Heart, Lung, and Blood Institute. Updated March 24, 2022. Accessed January 10, 2023. https://www.nhlbi.nih.gov/health/heart/smoking

8. High blood pressure symptoms and causes. CDC. Updated May 18, 2021. Accessed January 10, 2023. https://www.cdc.gov/bloodpressure/about.htm#:~:text=High%20blood%20pressure%20can%20damage%20your%20arteries%20by%20making%20them,Chest%20pain%2C%20also%20called%20angina

9. Powell-Wiley TM, Poirier P, Burke LE, et al; American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention; and Stroke Council. Obesity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021;143(21):e984-e1010. doi:10.1161/CIR.0000000000000973

10. Carbone S, Canada JM, Billingsley HE, Siddiqui MS, Elagizi A, Lavie CJ. Obesity paradox in cardiovascular disease: where do we stand? Vasc Health Risk Manag. 2019;15:89-100. doi:10.2147/VHRM.S168946

11. Diabetes and your heart. CDC. Updated June 20,2022. Accessed January 10, 2023. https://www.cdc.gov/diabetes/library/features/diabetes-and-heart.html