Progress in Cardiovascular Diseases 70 (2022) 8–15

Contents lists available at ScienceDirect

Progress in Cardiovascular Diseases

journal homepage: www.onlinepcd.com

The importance of healthy lifestyle behaviors in the prevention of

cardiovascular disease
Leonard A. Kaminsky a,b,⁎, Charles German c, Mary Imboden d,e, Cemal Ozemek b,f,
James E. Peterman a,b, Peter H. Brubaker g
a
Fisher Institute of Health and Well-Being, College of Health, Ball State University, Muncie, IN, United States
b
Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IL, USA
c
Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
d
George Fox University, USA
e
Health Enhancement Research Organization, USA
f
Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
g
Wake Forest University, USA

a r t i c l e i n f o a b s t r a c t

Keywords: Cardiovascular disease (CVD) is the leading cause of death globally. Advancements in the treatment of CVD have
Lifestyle reduced mortality rates, yet the global burden of CVD remains high. Considering that CVD is still largely a pre-
Cardiorespiratory fitness ventable disease, prioritizing preventative measures through healthy lifestyle (HL) behaviors is necessary to
Nutrition lessen the burden of CVD. HL behaviors, such as regular exercise, healthy eating habits, adequate sleep, and
Sleep smoking cessation, can influence a number of traditional CVD risk factors as well as a less commonly measured
Obesity risk factor, cardiorespiratory fitness (CRF). It is important to note that cardiac rehabilitation programs, which tra-
Prevention
ditionally have focused on secondary prevention, also emphasize the importance of making comprehensive HL
behavior changes. This review discusses preventative measures to reduce the burden of CVD through an in-
creased uptake and assessment of HL behaviors. An overview of the importance of CRF as a risk factor is discussed
along with how to improve CRF and other risk factors through HL behavior interventions. The role of the clinician
for promoting HL behaviors to prevent CVD is also reviewed.
© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
PA And CRF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CRF as a CVD risk factor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Impact of PA/exercise training on CRF and CVD risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Other healthy lifestyle factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Smoking cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Clinical applications for cvd prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Assessment of atherosclerotic CVD Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Life's simple 7 and cardiovascular health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Emphasizing lifestyle modification in primary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Interventions to reduce CVD risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Abbreviations: AHA, American Heart Association; AHA/ACC, American Health Association/American College of Cardiology; BALL ST, Ball State Adult fitness program Longitudinal
Lifestyle STudy; CAC, coronary artery calcium; CRF, cardiorespiratory fitness; CPX, cardiopulmonary exercise test; CR, cardiac rehabilitation; CVD, cardiovascular disease; eCRF, estimated
cardiorespiratory fitness; CVH, cardiovascular health; FRIEND, Fitness Registry and the Importance of Exercise National Database; HL, healthy lifestyle; METs, metabolic equivalents; PA,
physical activity; PCE, pooled cohort equations; US, United States.
⁎ Corresponding author at: Fisher Institute of Health and Well-Being, Health and Physical Activity Building, Ball State University, Muncie, IN 47306, USA.
E-mail address: kaminskyla@bsu.edu (L.A. Kaminsky).

https://doi.org/10.1016/j.pcad.2021.12.001
0033-0620/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
L.A. Kaminsky, C. German, M. Imboden et al. Progress in Cardiovascular Diseases 70 (2022) 8–15

Summary and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Introduction
According to the American Heart Association (AHA), there are over
26 million adults in the United States (US) with cardiovascular disease
(CVD), excluding hypertension.1,2 Since 1921, CVD has been the leading
cause of death in the US with one CVD-related death occurring every
38 s on average.2–4 These trends are not limited to the US as CVD is
also the leading cause of death globally.5 Moreover, there are significant
monetary costs associated with CVD. For 2016–2017, the direct costs as-
sociated with CVD in the US were estimated at over $216 billion with
costs expected to increase to over $749 billion by 2035.1 Along with di-
rect healthcare costs, CVD is also associated with significant indirect
costs due to decreased productivity as well as reduced quality of life.1
As reported in many of the papers in this special section of PCVD,
there have been many advancements in treatments, which have re-
sulted in an impressive reduction in CVD mortality rates. However, the
global prevalence of CVD is still high.5 Further, it is important to recog-
nize and to emphasize that CVD is largely still a preventable disease.
Modifiable risk factors have been shown to account for >90% of the
risk for developing CVD.6 This makes prioritizing preventative measures
that reduce CVD risk factors necessary to lessen the burden of CVD.7 Key
in the reduction of CVD risk factors is increasing healthy lifestyle (HL)
behaviors.8–10 HL behaviors can influence a number of CVD risk factors,
including smoking, diabetes, and obesity as well as the less commonly
measured risk factor, cardiorespiratory fitness (CRF). However, many
HL behaviors have worsened over the years. For example, performing
regular physical activity (PA) is important for decreasing CVD risk,11
yet since at least the 1950's, there has been a gradual decline in daily
levels of PA due to technology, society, and community changes.12–14
These decreases in PA are associated with worsening CVD risk factor
profiles such as increased obesity levels and decreased CRF levels.8,11
Accordingly, a greater emphasis is needed to encourage people to
adopt and practice HL behaviors and subsequently prevent initial as
well as subsequent CVD events (Figure 1).
There are a number of considerations that impact the adoption of HL
behaviors. Within the clinical setting, access to and engagement in CVD
risk screenings is important yet not all CVD risk factors are measured by
clinicians. One key risk factor which is rarely assessed, despite sugges-
tions by the AHA that it be considered a clinical vital sign, is CRF.15 Peri-
odic measurement of CRF is needed, as it is a stronger predictor of

Fig. 1. We have reached a fork in the road on the journey towards our CVD future. We can continue on our current rocky road or pivot towards a focus on HL behaviors. Emphasizing HL
behaviors in both the primary and secondary prevention setting can lead to a decreased CVD burden as well as other benefits.

9
L.A. Kaminsky, C. German, M. Imboden et al.
mortality and CVD risk than the traditional risk factors of obesity, diabe-
tes, and dyslipidemia.16–18 Having an assessment of the CRF risk factor
would provide clinicians with opportunities to counsel patients on the
importance of HL behaviors, such as the importance of PA for improving
CRF15 or the impact dietary habits have in contributing to obesity. Of
note, implementing successful and sustained HL behaviors is a complex
process8 and requires action from across the healthcare spectrum.19,20
The present paper provides a review of preventative measures to reduce
the burden of CVD across a variety of settings, with an emphasis on HL
behaviors. An overview of the importance of CRF as a risk factor is dis-
cussed along with how to improve CRF and other risk factors through
HL behaviors. While this review is focused on primary prevention, the
importance of HL behaviors is also relevant for CR, which focuses on sec-
ondary prevention and shares the common theme of helping individ-
uals make comprehensive behavior changes. The role of the clinician
for promoting HL behaviors to prevent CVD is also reviewed.
PA And CRF
CRF as a CVD risk factor
CRF is typically defined as maximum or peak oxygen consumption
and is considered a singular measure of whole-body physiological
function as it reflects the interplay between the pulmonary, cardio-
vascular, and muscular systems in transporting oxygen from the at-
mosphere to the working muscles.21 CRF can be measured directly
from cardiopulmonary exercise testing (CPX), as well as estimated
(eCRF) either from work rate achieved during a maximal or submax-
imal exercise test or from non-exercise prediction equations.15,22 Due
to time constraints and ease of assessment, eCRF is more commonly
used. However, it is important to emphasize eCRF can be associated
with estimation error, which may impact the risk assessment reduc-
ing the sensitivity of the measure, whereas CPX provides an accurate
and more precise assessment of CRF.23–26 Nonetheless, over the past
three decades, numerous studies have reported that both directly
measured CRF and eCRF are strong and independent predictors of
CVD and mortality.18,27–31
The seminal study by Blair et al. in 198929 clearly established CRF
as an important risk factor. This report from the Aerobic Center Lon-
gitudinal Study cohort assessed >13,000 healthy participants who
had eCRF determined from a maximal exercise test. Participants
were then classified into 5 quintiles of CRF and followed up for ap-
proximately 8 years. A strong, inverse relationship between CRF
and mortality was found with low fit men and women having >3-
fold and 5-fold higher risk of all-cause mortality compared to their
high fit counterparts, respectively. Noteworthy, the greatest risk re-
duction in this population occurred between the lowest (<6 meta-
bolic equivalents [METs]) and next lowest (6–8 METs) CRF groups,
suggesting that the least fit group could receive the greatest survival
benefit by increasing CRF.
Following this landmark study, several investigations have been per-
formed highlighting the prognostic value of CRF in diverse populations
of both clinical and apparently healthy cohorts. In 2009, a meta-
analysis by Kodama et al30 provided a systematic review of the quanti-
tative relationship between either CRF or eCRF and all-cause mortality
and CVD events in healthy men and women. Data were extracted
from 33 studies with a total of ~103,000 participants with CRF values
converted into METS. Kodama et al. found that for each 1 MET higher in-
crement in CRF, there was a 15% and 13% reduction in all-cause mortal-
ity and CVD events, respectively. An additional update to the Kodama
et al. paper was provided by Harber et al. in 2017.27
Given the estimation error associated with eCRF noted above, the re-
lationship between CRF and CVD was examined more recently using di-
rectly measured CRF obtained from CPX. Imboden et al.18 analyzed data
from apparently healthy adults from the Ball State Adult Fitness Pro-
gram Longitudinal Lifestyle STudy (BALL ST) cohort who performed
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Progress in Cardiovascular Diseases 70 (2022) 8–15
CPX between 1968 and 2016. The cohort participants were grouped
into CRF tertiles (low, moderate, and high) based on the Fitness Registry
and the Importance of Exercise National Database (FRIEND).32,33
FRIEND provides age and sex specific reference values for CPX-derived
CRF for adults in the US using either treadmill or cycle modes of testing.
The results confirmed earlier reports using eCRF. Specifically, in the
overall cohort, risk for CVD mortality was reduced by approximately
16% per 1 MET increase in CRF. Further, men categorized as low-fit
had a 49% greater likelihood of dying from CVD compared to high-fit
men, while low-fit women had a 34% increased risk of dying from
CVD compared to high-fit women (Figure 2) (Imboden 2018).
Laukkanen et al.28 have also reported a similar relationship between
CRF and mortality risk in 1294 Finnish men using CPX. Men with low
CRF had a 2.76-fold and 3.09-fold higher risk of all-cause and CVD mor-
tality, respectively. These studies highlight the clinical importance of
CRF and the value in assessing low fitness when determining patient
risk.
Impact of PA/exercise training on CRF and CVD risk
CRF is a modifiable risk factor that is influenced by age, sex, genetics,
as well as lifestyle and health parameters, including exercise status. For
example, exercise training programs typically result in improvements in
CRF of 1–2 METs following 3–6 months of moderate to vigorous
exercise.34 The impact of these training programs on mortality risk has
been examined by longitudinal studies and suggests that long-term
(>5 years) improvements in CRF result in lower mortality risk. In a sub-
sequent ACLS study, mortality risk was assessed in men who performed
two preventative maximal exercise tests that were approximately 5-
years apart.35 Results showed a 16% reduction in all-cause mortality
risk per 1 MET improvement. Laukkanen et al36 also assessed the influ-
ence of the long-term change in CRF with all-cause mortality using CPET
(11 years between tests). Each 1 MET increase was associated with ~30%
reduction in risk of all-cause mortality independent of baseline CRF.
Similarly, this strong association was found in the BALL ST cohort be-
tween the long-term change in directly measured CRF and mortality
(~9 years between tests). Each 1 MET improvement was associated
with 38% and 51% lower risk of all-cause and CVD mortality, respec-
tively.
Imboden et al37 sought to better understand the influence of
changes in CRF following short-term exercise training on mortality
risk. Following 4-months of exercise training, participants of the BALL
ST cohort improved their CRF by ~15%. A 25% lower all-cause mortality
risk per 1-MET improvement was observed, which was independent of
sex and baseline CRF. This finding should be emphasized as this rela-
tively small (1 MET) improvement in CRF is achievable by most individ-
uals starting an exercise program. Further, when directly comparing
either CRF at baseline to CRF measured following exercise training, the
post-exercise training measure was a stronger predictor of mortality
outcomes.
Favorable changes in mortality risk following exercise training are
also seen in secondary prevention. Martin et al.38 have also assessed
the association of changes in eCRF post-exercise training with mortality
risk but in a population of cardiac patients following a 12-week moder-
ate cardiac rehabilitation exercise program. Overall, patients increased
their eCRF by approximately 0.9 METs (~14%) after training and there
was a reported 13% reduction in mortality risk per 1 MET increase.
These findings highlight the importance of PA, or more specifically exer-
cise training, as a HL behavior across a variety of populations. It suggests
beginning and regularly participating in an exercise training program,
designed to improve CRF, will help to reduce risk of CVD and mortality.
Further, these observations support the AHA's recommendation to mea-
sure CRF routinely as a clinical vital sign as it is a powerful prognostic
measure.15 Having a measurement of CRF creates an opportunity for cli-
nicians to counsel patients on the importance of HL behaviors to one's
health, function and longevity.
L.A. Kaminsky, C. German, M. Imboden et al.
Fig. 2. Mortality risk is lower for both men and women with higher CRF. Reprint from Imboden, M.T. et al. J Am Coll Cardiol. 2018;72(19):2283–92. (Reproduced with permission of
Elsevier).
Other healthy lifestyle factors
Nutrition
Mounting evidence supports the powerful modulatory effects of an
individual's dietary habits on health status and CVD risk factors.8–10 Eat-
ing foods that are fried, high in saturated fats, calorically dense, proc-
essed and regularly consuming sugary beverages (referred to in the
US as a ‘Southern diet’, however, also common around the globe) have
been linked to an increased risk of developing chronic health
conditions.39 The latest findings from the Reasons for Geographic and
Racial Differences in Stroke longitudinal study demonstrate that indi-
viduals who had a high intake of foods characterized as the Southern
diet had a 56% higher hazard of acute coronary heart disease compared
to those who had a lower consumption of these foods.39 Moreover, high
consumption of the Southern diet was associated with a lower con-
sumption of dietary fiber, vegetables, and fruits; foods that are common
in the Mediterranean diet (rich in fruits, vegetables, olive oil, whole
grains, fish, nuts, and low in saturated fats) have been widely associated
with reducing the risk of adverse health events.40–42 Additionally, the
Mediterranean diet has been shown to reduce low-density lipoprotein
cholesterol, glucose, blood pressure, and body weight, which collec-
tively lowers the risk of developing CVD. Despite this understanding,
economic, social, cultural, environmental and individual factors may
serve as barriers to adopting healthy eating habits.42,43 Similar to the
concept of ‘moving more and sitting less’ to confer positive health
benefits,44,45 robust evidence from the Prospective Urban Rural Epide-
miology prospective cohort study suggests that even moderate fruit,
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Progress in Cardiovascular Diseases 70 (2022) 8–15
vegetable and legume intake can significantly lower risk of CVD and
non-CVD mortality compared to those that have less than one serving
per day.46 This is a particularly meaningful message that challenges
the ‘all or nothing’ concept. Rather than initially attempting to meet di-
etary guidelines, individuals are encouraged to gradually increase their
intake of vegetables, fruits, whole grains, opt for low-fat or fat-free dairy
products, poultry, fish, legumes, and nuts; and reduce consumption of
sugar, salt, processed foods and fatty meats.47
Smoking cessation
Well-coordinated efforts have brought widespread awareness to the
health consequences associated with smoking and have contributed to a
drop in rates from 42.6% in 196548 to 13.7% in 2018 in the US.49 This is
still of major concern as tobacco use is the leading cause of preventable
death globally.50 Even smoking in moderation (1–4 cigarettes per day)
or on nonconsecutive days has been found to increase the risk of myo-
cardial infarction51 or mortality52 compared to nonsmokers. Whereas
smoking cessation sustained for ≥5 years significantly lowers risk of
all-cause mortality compared to current smokers.52 Though many indi-
viduals attempt to quit smoking on their own, 80–90% relapse in
3 months and 95–97% in 6–12 months.53 Rather, an approach that com-
bines pharmacotherapy and behavior change interventions have been
shown to be the most successful at achieving sustained cessation.54 An
understanding of the individual's level of nicotine dependence is crucial
to prescribing the correct dose of the pharmacologic agent.55 Addition-
ally, many behavioral interventions exist that consist of face-to-face
meetings, group sessions, and/or text messaging support. The most
L.A. Kaminsky, C. German, M. Imboden et al.
successful interventions have been those that incorporated in-person
contact and have been shown to increase the likelihood of abstinence
by 10–20%.56 Providing both pharmacologic and behavioral interven-
tions will likely require the assembly of a multidisciplinary team that
specializes in the respective areas. Additionally, increasing access to
such services to community members is critical as it appears as though
decreases in smoking rates attributed to public awareness campaigns
has plateaued.
The emergence of e-cigarettes and vaping devices have presented
new challenges to eradicating the use of tobacco products. In 2018,
roughly 8 million adults reported vaping in the US.49 Many perceive
the use of electronic smoking devices as a risk-free alternative to ciga-
rettes, however, mounting evidence has established a strong link with
endothelial dysfunction, increased oxidative stress, and platelet
activation.57,58 A large number of individuals have turned to these de-
vices to facilitate cessation of smoking even though they are not ap-
proved for this purpose by the Food and Drug Administration.59 Yet,
previous reports have indicated that over 40% of individuals using elec-
tronic smoking devices continue to smoke cigarettes.60 More sobering is
the large percentage of children that have used e-cigarettes,61 likely be-
cause of an enticing array of flavors that can be purchased.62 Accord-
ingly, in addition to promoting the cessation of electronic smoking
devices in adults, a concerted effort will need to be made to screen
and educate children on the harms associated with e-cigarettes and
vaping devices. Due to the limited volume of evidence-based tools and
resources to inform adolescents about these harms, more research will
be necessary to identify effective cessation strategies.63
Sleep
Poor sleep is often underrecognized as a risk factor for CVD, which is
troubling given roughly 50–70 million US adults suffer from insufficient
sleep or a sleep disorder.64 Epidemiological research has provided much
insight into the relationships between sleep duration, cardiometabolic
risk, and hard CVD outcomes. Specifically, short sleep duration is associ-
ated with an increased risk of diabetes mellitus, hypertension, coronary
heart disease, stroke, and metabolic syndrome, with similar metabolic
effects noted among individuals with long sleep duration.65 Given the
U-shaped relationship between sleep and CVD outcomes, most guide-
lines recommend obtaining 7–8 h of sleep per night for optimal
benefit.66,67
Among the various sleep disorders, obstructive sleep apnea is the
most common sleep disordered breathing condition, characterized
by recurrent apnea and hypopnea upper airway events. Those with
obstructive sleep apnea have an increased risk of hypertension, dia-
betes, metabolic syndrome, heart failure, coronary artery diseases,
atrial fibrillation/arrythmia, and mortality.68 Given the devastating
cardiovascular consequences of obstructive sleep apnea, screening
should be offered to all individuals with established risk factors,
which include male sex, older age, and overweight and obesity. Var-
ious treatment options are available, ranging from continuous posi-
tive airway pressure to upper airway surgery, though behavioral
lifestyle modifications provide a foundation for improving obstruc-
tive sleep apnea and its associated downstream cardiometabolic dis-
eases, which should be utilized in tandem with more targeted
obstructive sleep apnea therapy.
Promoting the adoption of these lifestyle behaviors holds significant
clinical value considering the powerful effects each independently im-
parts on reducing the risk of developing CVD. Making progressive shifts
from a diet consisting of highly processed, calorically dense and sugary
foods towards a diet that resembles the Mediterranean diet may make
the change manageable and realistic. In the same regards, smokers
may benefit from working with healthcare professionals that can pre-
scribe pharmacologic agents that can facilitate smoking cessation with-
out abruptly eliminating nicotine consumption. Lastly, routine sleep
apnea screenings should be provided to those with established risk
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Progress in Cardiovascular Diseases 70 (2022) 8–15
factors in order to identify sleep disturbances early and to offer treat-
ments before other health issues develop as a consequence.
Clinical applications for cvd prevention
Assessment of atherosclerotic CVD Risk
Understanding atherosclerotic CVD risk is paramount when
discussing strategies for primary prevention. While many risk assess-
ment tools exist, the pooled cohort equation (PCE) remains the gold
standard in the US.69 The 2019 American Heart Association/American
College of Cardiology (AHA/ACC) Guidelines on the Primary Prevention
of CVD recommends using the PCE to assess risk as early as age 20 years,
with separate risk equations developed based on race/ethnicity and
sex.70 Knowledge of an individual's 10-year absolute atherosclerotic
CVD risk enables the clinician to guide medical decision making,
matching the level of risk to intensity of preventive interventions to re-
duce future CVD events.
Life's simple 7 and cardiovascular health
In 2010, the AHA released its ambitious 10-year impact goal, to im-
prove the cardiovascular health (CVH) of all Americans by 20% while re-
ducing deaths from CVD and stroke by 20%.71 Importantly, the authors
of the document defined CVH according to 7 health metrics termed
Life's Simple 7, with corresponding definitions for poor, intermediate,
and ideal status for each metric. In order to achieve ideal CVH, an indi-
vidual would need to meet ideal levels of all 7 components: 1) never
smoking or abstinence from smoking for >12 months, 2) body mass
index <25 kg/m2, 3) ≥150 min/week of moderate or ≥ 75 min/week of
vigorous PA, 4) 4–5 components of a commonly used healthy diet
score that promotes CVH, 5) total cholesterol <200 mg/dL, 6) blood
pressure < 120/<80 mm/Hg, 7) fasting plasma glucose <100 mg/dL.
Over a decade of research has solidified the notion that better CVH, as
defined by the AHA, translates to a lower risk of atherosclerotic CVD
and mortality.
Emphasizing lifestyle modification in primary prevention
A HL remains the foundation of CVD prevention. In fact, the 2019
AHA/ACC guidelines top 10 take home messages state, first, that “the
most important way to prevent atherosclerotic CVD, heart failure, and
atrial fibrillation is to promote healthy lifestyle throughout life.”70 The
Mediterranean, DASH, and plant-based diets, emphasizing fruits, vege-
tables, nuts, whole grains, legumes, fish, and foods low in sodium and
saturated fats have consistently been shown to reduce the risk of ath-
erosclerotic CVD and mortality, in both observational studies and clini-
cal trials. Concurrently, processed meats, sugar sweetened beverages,
both high and low-carbohydrate diets, refined grains, and trans fats
should be avoided due to their association with increased CVD events.70
Despite the well-known benefits of regular PA, few adults meet the
aerobic component of the US PA guidelines, and even fewer meet the
muscle strengthening component. Even more discouraging, PA is rarely
assessed by clinicians.72 In order to solve the problem of insufficient PA
and improve overall CVH of our population, all healthcare professionals
need to be better equipped with the necessary tools to empower their
patients to move more and sit less.
In the primary care setting, providers and staff must first assess their
patient's HL behaviors in order to gain a more complete understanding
of their risk factor profile.73 Physician inertia must be overcome, and the
proper amount of time should be given when evaluating HL behaviors,
which can be obtained by staff prior to the patient's visit with the phy-
sician, in order to cut down on wasted time and focus on targeted inter-
ventions when in clinic. Psychosocial barriers and social determinants of
health must also be taken into account to ensure patient success. Finally,
physicians must educate themselves on evidence-based HL counseling
L.A. Kaminsky, C. German, M. Imboden et al.
methods and behavior change strategies, while working in conjunction
with clinical exercise physiologists, dieticians, physical therapists, and
counselors to provide a more holistic and focused care plan unique to
the individual patient. Limited education on HL behaviors during train-
ing, coupled with high patient volumes represent significant barriers
physicians face when assessing their patients CVH. Thus, it is paramount
that healthcare providers develop strong relationships with allied
health providers and programs in their community to provide compre-
hensive care.
Interventions to reduce CVD risk
Obtaining adequate amounts of PA and adhering to a heart-healthy di-
etary pattern can lead to important reductions in weight, blood pressure,
blood glucose, and cholesterol, ultimately culminating in a reduction in
CVD risk. The steady increase in obesity rates over recent decades can
largely be attributed to easier access to calorically dense foods and drinks,
lower PA, and higher sedentary times. Roughly 40% of the US population
is now obese,74 which is cause for much concern considering that obesity
independently increases risk for metabolic disorders and CVD.75 In fact,
non-pharmacologic, pharmacologic and surgical interventions that facili-
tate the loss of excess adiposity in overweight and obese individuals dra-
matically reduces the risk of developing type 2 diabetes mellitus.76
Caloric restriction, increased PA, and behavioral modification remain
first line therapy for all individuals with overweight and obesity to help
promote weight loss, prevent weight gain, and reduce CVD risk. If these
interventions do not result in adequate weight loss, Food and Drug Ad-
ministration approved obesity medications can be considered, though
there is a lack of consistent randomized controlled trial data showing
these agents reduce incident CVD. Significant side effects also limit
their tolerability. Surgical weight loss can also be considered among cer-
tain obese adults who are unable to achieve healthy weight loss sus-
tained for a period of time with prior weight loss efforts.
Fig. 3. Prioritizing the importance of HL behaviors in both the primary and secondary prevention setting is necessary to lessen the burden of CVD. Highlighted here are five HL behaviors to
emphasize when interacting with patients.
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Progress in Cardiovascular Diseases 70 (2022) 8–15
While a focus on lifestyle modification is essential when formulating
a care plan, the addition of pharmacotherapy is often necessary in order
to reduce risk. Consideration of lipid lowering therapy is guided by the
PCE with decisions regarding statin initiation based on risk categories:
<5% 10-year atherosclerotic CVD risk (‘low risk’), 5% to <7.5% 10-year
atherosclerotic CVD risk (‘borderline risk’), 7.5% to <20% 10-year ath-
erosclerotic CVD risk (‘intermediate risk’), and ≥ 20% 10-year athero-
sclerotic CVD risk (‘high risk’).77 Individuals at ‘high risk’ often benefit
from statin therapy initiation in addition to aggressive lifestyle modifi-
cation, while individuals at ‘low risk’ may not require statin therapy,
though still benefit from improvement in lifestyle behaviors.
When the decision to initiate statin therapy is uncertain, principally
among those at ‘borderline’ or ‘intermediate risk,’ a coronary artery cal-
cium (CAC) score can be considered to further refine risk thereby aiding
in this decision. CAC scoring can also be useful in groups reluctant to ini-
tiate statins or who wish to better comprehend the risk-benefit ratio of
statin use, or among older patients who question the need for statin
therapy. If target low density lipoprotein cholesterol levels are not
reached, then adjuncts such as ezetimibe, bempedoic acid, proprotein
convertase subtilisin/kexin type 9inhibitors can be used.
In adults with elevated blood pressure or hypertension, interventions
including sodium reduction, adaption of a heart-healthy dietary pattern
with supplementation of dietary potassium, weight loss, increased PA,
and limited alcohol consumption are recommended to reduce blood
pressure.70 The PCE is also used to guide pharmacotherapy in adults
with Stage 1 hypertension (130–139/80–89 mmHg). If the estimated
10-year ASCVD risk is ≥10%, then blood pressure lowering medication is
recommended. Adults with stage 2 hypertension (≥140/90 mmHg) also
benefit from blood pressure lowering medication, regardless of risk.
Type 2 diabetes mellitus is a major contributor to the development
of CVD, and HL should be primarily emphasized in order to reduce
blood glucose and reduce CVD risk. If lifestyle interventions fail to im-
prove glycemic control, pharmacotherapy should be considered. US
L.A. Kaminsky, C. German, M. Imboden et al.
guidelines recommend metformin as first line therapy given its known
track record and safety profile,70 though newer agents have emerged in
recent years which may be superior to more traditional medications
used to treat type 2 diabetes mellitus. Sodium glucose transport protein
2 inhibitors and glucagon-like peptide-1 receptor agonists have been
shown to reduce cardiovascular endpoints across a wide range of pa-
tient populations with type 2 diabetes mellitus, and should be used
preferentially among those at risk or with existing CVD. The American
Diabetes Association and European Association for the Study of Diabetes
both recommend using these medications as part of a glucose lowering
regimen independent of hemoglobin A1C.78
Although CR programs provide secondary prevention services, there
may be opportunities to expand and embrace primary prevention. For
instance, apparently healthy spouses of patients with heart disease
have an increased likelihood of sharing unhealthy lifestyles, with similar
CVD risk factors as their partners.79 Enrolling spouses without estab-
lished CVD alongside their partners in a lifestyle modification program
like CR has been shown to significantly decrease markers of CVD
risk.80 Therefore, CR programs that offer Phase II and III services are en-
couraged to consider providing opportunities for spouses to enroll in
their Phase III program while their partner completes Phase II. It is how-
ever important to recognize that while it would be desirable to expand
services to individuals without CVD in existing CR programs, resources
and staffing may be limited. These individuals would benefit from an as-
sessment by a preventive cardiologist to better understand their risk
profile and provide tailored recommendations.
Given the number of complex risk factors associated with the devel-
opment of CVD, a multidisciplinary approach with experts in various
disciplines is necessary in order to provide optimal patient care
(Figure 3). Preventive cardiology represents a unique subspecialty
within cardiovascular medicine that has emerged to tackle the growing
burden of global CVD. These specialists come from diverse medical
backgrounds and gain specialized training in CVD risk assessment as
well as nonpharmacological and pharmacological treatment modalities.
Academic preventive cardiology programs encompass a wide range of
providers, including physicians, advanced practice providers, clinical
pharmacists, dietitians, genetic counselors, and clinical exercise
physiologists.81 When it comes to eliminating the leading killer in the
US and beyond, a multidisciplinary patient-centered approach will be
necessary to ultimately improve CVH.
Summary and conclusions
CVD is largely a preventable disease, yet unfortunately it remains the
leading cause of death worldwide. Healthcare systems need to prioritize
programming to make HL behaviors a routine part of all patient and cli-
ent communications. Regular PA that leads to improved CRF levels,
healthy eating habits, not smoking, healthy sleep habits, and weight
management would all pay major dividends in reducing the incidence
of CVD. Clinicians must work together to prioritize the incorporation
of HL behaviors into their messaging to patients. Physicians play a key
role and need to initiate the approaches reviewed to prevent CVD. How-
ever, physicians cannot do it alone, they need to work in collaboration
with other healthcare professionals with expertise in HL behaviors, in-
cluding clinical exercise physiologists, nurses, nutritionists, and health
behavior specialists.
Declaration of Competing Interest
None.
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