Cardiovascular disease remains the leading cause of morbidity and mortality worldwide, driven in large part by two modifiable risk factors: high blood pressure (hypertension) and high cholesterol (hypercholesterolemia).
Michael D. Shapiro, D.O., MCR, FACC, FAHA, FASPC
Fred M. Parrish Professor of Cardiology and Molecular Medicine; Director, Center for Prevention of Cardiovascular Disease, Department of Cardiovascular Medicine, Wake Forest University School of Medicine; President, American Society for Preventive Cardiology
Despite significant advances in treatment, a substantial proportion of patients remain undertreated or unaware of their cardiovascular risk. Addressing these challenges requires a multifaceted approach that combines early identification, personalized treatment strategies, and a commitment to lifestyle and pharmacologic interventions.
The silent epidemic of hypertension
Hypertension, often referred to as the “silent killer,” affects nearly half of the U.S. adult population. Its asymptomatic nature leads many individuals to remain undiagnosed until complications arise, such as stroke, heart attack, or heart failure. Guidelines emphasize the importance of early and accurate diagnosis, yet blood pressure control rates remain suboptimal.
Recent updates in hypertension management advocate for a more aggressive approach, particularly in high-risk populations. The 2017 ACC/AHA Hypertension Guidelines lowered the diagnostic threshold to a systolic blood pressure (top number) of 130 mmHg or a diastolic blood pressure (bottom number) of 80 mmHg, reflecting growing evidence that even “mild” elevations contribute to increased cardiovascular risk. Home blood pressure monitoring and ambulatory blood pressure measurements now allow for more accurate diagnosis and treatment adjustments.
Beyond lifestyle modifications, such as sodium reduction, weight management, and increased physical activity, pharmacologic treatment remains central to achieving blood pressure targets. Combination therapy, often initiated earlier in treatment, has demonstrated superior efficacy compared to monotherapy, reducing the burden of uncontrolled hypertension and its downstream complications.
Cholesterol management: A paradigm shift
Cholesterol management has evolved significantly over the past decade, driven by evidence demonstrating that lower low-density lipoprotein cholesterol (LDL-C) levels are associated with reduced cardiovascular risk. Beyond optimizing lifestyle, statins remain the foundation of lipid-lowering therapy, given their well-established benefits in reducing cardiovascular events. However, for individuals who do not achieve adequate reductions in LDL-C with statins alone, or those who are statin-intolerant, newer therapies provide additional options. Ezetimibe, bempedoic acid, PCSK9 inhibitors, and inclisiran have expanded the lipid-lowering arsenal, allowing for more effective, long-term cholesterol control.
The introduction of non-statin therapies is particularly impactful for patients with familial hypercholesterolemia (FH), who often require intensive LDL-C lowering from a young age. Additionally, elevated lipoprotein(a), a genetically determined cholesterol-rich particle associated with residual cardiovascular risk, has emerged as an important target for future therapeutic interventions. While no FDA-approved therapies currently exist to lower Lp(a) specifically, novel therapies are in late-stage development and hold promise for high-risk patients.
Integrating precision medicine in cardiovascular care
The landscape of cardiovascular prevention is shifting toward precision medicine, with a growing emphasis on individualized risk assessment and tailored therapeutic strategies. Advances in non-invasive cardiovascular imaging techniques, biomarker analysis, and polygenic risk scores enable clinicians to refine treatment decisions beyond traditional risk factors. For example, the coronary artery calcium scoring can identify individuals at high cardiovascular risk who may benefit from earlier or more aggressive lipid-lowering therapy, even if their traditional risk scores suggest moderate or low risk. Similarly, inflammatory biomarkers such as high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) are gaining attention as potential adjuncts in determining residual inflammatory risk and guiding the use of anti-inflammatory therapies.
Empowering patients through awareness and access
Ultimately, the success of cardiovascular disease prevention hinges on patient education and access to care. Many patients remain unaware of their risk factors or struggle with medication adherence due to cost, side effects, or lack of understanding. Digital health tools, such as wearable blood pressure monitors and mobile applications for medication reminders, have shown promise in improving patient engagement and self-management.
Public health initiatives and policy changes, including efforts to reduce medication costs and expand preventive care coverage, will be crucial in ensuring equitable access to lifesaving therapies. Additionally, clinician-patient discussions must emphasize the importance of long-term adherence to both lifestyle and pharmacologic interventions to achieve sustained cardiovascular protection.
As we advance our understanding of cardiovascular disease prevention, a proactive, patient-centered approach is essential. By integrating early screening, personalized treatment strategies, and innovative therapies, we can make meaningful strides in reducing the burden of cardiovascular disease, ultimately improving outcomes for millions at risk.
