American Journal of Cardiovascular Drugs

, Volume 6, Issue 2, pp 87–101 | Cite as

Preventing Cardiovascular Disease in the 21st Century

Therapeutic and Preventive Implications of Current Evidence
  • Martha L. Daviglus
  • Donald M. Lloyd-Jones
  • Amber Pirzada
Review Article


Cardiovascular disease (CVD), particularly coronary heart disease (CHD), remains a major cause of mortality, morbidity, and disability in the US and other Westernized societies. As a result of therapeutic and preventive measures to control the CVD/CHD epidemic, mortality has declined steadily during the last several decades with a consequent gain in life expectancy, but the 1990s witnessed a slowing of this decline. In response to these trends, a range of therapeutic regimens were developed to address adverse CVD risk factor levels and their deleterious effects. The scientific evidence regarding the efficacy, cost effectiveness, strengths, and limitations of a range of pharmacologic and lifestyle approaches to CVD prevention — both primary and secondary — are reviewed in depth. Clinical trials aimed at primary and secondary prevention of CVD have documented the efficacy and cost effectiveness of various drugs in lowering individual risk factor levels and in reducing clinical CVD events. More recently, the idea of a ‘polypill’ containing low doses of multiple drugs has generated much interest, with proponents arguing that, given the high prevalence of CVD risk factors and the effectiveness of pharmacologic interventions, such a drug combination would reduce CHD mortality by 88% if taken by all individuals aged α55 years. However, current treatments to control high BP and serum cholesterol, while effective, do not typically reduce morbidity and mortality to levels observed in low-risk individuals, i.e. those with favorable levels of all readily measured major risk factors. Rather, primary prevention of all major risk factors starting early in life is critical. Prospective population-based research has delineated multiple long-term benefits associated with low-risk status in young adulthood and middle age, i.e. markedly lower age-specific CVD and total mortality rates, increased life expectancy, lower healthcare costs, lower medication use and prevalence of chronic diseases, and higher self-reported quality of life at older ages. Unfortunately, despite declines in the prevalence of most major CVD risk factors, low-risk status remains rare among US adults. Data have also demonstrated that adverse levels of one or more major risk factors precede clinical CHD in 90% or more of all cases, undermining the assertion that major CVD risk factors account for ‘no more than 50%’ of CHD cases. Hence, while numerous treatment options exist for secondary prevention of CVD, strategies that focus on progressively increasing the proportion of low-risk individuals could greatly reduce the need for secondary prevention in the first place. Public health policies must focus on prevention of all major risk factors simultaneously, using lifestyle approaches from early ages onwards to reduce population CVD risk to endemic levels, rather than current epidemic levels.



The preparation of this manuscript was supported by grants from the National Heart, Lung, and Blood Institute (R01 HL62684 and HL21010).

The authors have no potential conflicts of interest that are directly relevant to the contents of this review.


  1. 1.
    Thorn T, Haase N, Rosamond W, et al. Heart disease and stroke statistics: 2006 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Committee. Circulation 2006 Feb 14; 113(6): e85–151.PubMedCrossRefGoogle Scholar
  2. 2.
    American Heart Association. International cardiovascular disease statistics [online]. Available from URL: identifier = 3001008 [Accessed 2005 May 1].
  3. 3.
    Stamler J, Dyer AR, Shekelle RB, et al. Relationship of baseline major risk factors to coronary and all-cause mortality, and to longevity: findings from long-term follow-up of Chicago cohorts. Cardiology 1993; 82(2–3): 191–222.PubMedCrossRefGoogle Scholar
  4. 4.
    Stamler J, Daviglus ML, Garside DB, et al. Relationship of baseline serum cholesterol levels in 3 large cohorts of younger men to long-term coronary, cardiovascular, and all-cause mortality and to longevity. JAMA 2000 Jul 19; 284(3): 311–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Miura K, Daviglus ML, Dyer AR, et al. Relationship of blood pressure to 25-year mortality due to coronary heart disease, cardiovascular diseases, and all causes in young adult men: the Chicago Heart Association Detection Project in Industry. Arch Intern Med 2001 Jun 25; 161(12): 1501–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Calle EE, Thun MJ, Petrelli JM, et al. Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 1999 Oct 7; 341(15): 1097–105.PubMedCrossRefGoogle Scholar
  7. 7.
    Jacobs Jr DR, Adachi H, Mulder I, et al. for the Seven Countries Study Group. Cigarette smoking and mortality risk: twenty-five-year follow-up of the Seven Countries Study. Arch Intern Med 1999 Apr 12; 159(7): 733–40.PubMedCrossRefGoogle Scholar
  8. 8.
    Verschuren WM, Jacobs DR, Bloemberg BP, et al. Serum total cholesterol and long-term coronary heart disease mortality in different cultures: twenty-five-year follow-up of the seven countries study. JAMA 1995 Jul 12; 274(2): 131–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Uemura K, Pisa Z. Trends in cardiovascular disease mortality in industrialized countries since 1950. World Health Stat Q 1988; 41(3–4): 155–78.PubMedGoogle Scholar
  10. 10.
    Rosengren A, Dotevall A, Eriksson H, et al. Optimal risk factors in the population: prognosis, prevalence, and secular trends; data from Goteborg population studies. Eur Heart J 2001 Jan; 22(2): 136–44.PubMedCrossRefGoogle Scholar
  11. 11.
    Multiple Risk Factor Intervention Trial. Risk factor changes and mortality results: Multiple Risk Factor Intervention Trial Research Group. JAMA 1982; 248(12): 1465–77.CrossRefGoogle Scholar
  12. 12.
    Cutler JA, Neaton JD, Hulley SB, et al. Coronary heart disease and all-causes mortality in the Multiple Risk Factor Intervention Trial: subgroup findings and comparisons with other trials. Prev Med 1985; 14: 293–311.PubMedCrossRefGoogle Scholar
  13. 13.
    Multifactorial trial in the prevention of coronary heart disease: 3. Incidence and mortality results. Eur Heart J 1983 Mar; 4(3): 141–7.Google Scholar
  14. 14.
    Hjermann I, Holme I, Velve KB, et al. Effect of diet and smoking intervention on the incidence of coronary heart disease: report from the Oslo Study Group of a randomised trial in healthy men. Lancet 1981; II: 1303–10.CrossRefGoogle Scholar
  15. 15.
    Strandberg TE, Salomaa VV, Naukkarinen VA, et al. Long-term mortality after 5-year multifactorial primary prevention of cardiovascular diseases in middle-aged men. JAMA 1991; 266(9): 1225–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results: I. Reduction in incidence of coronary heart disease. JAMA 1984 Jan 20; 251(3): 351–64.CrossRefGoogle Scholar
  17. 17.
    Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results: II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984 Jan 20; 251(3): 365–74.CrossRefGoogle Scholar
  18. 18.
    Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia: safety of treatment, changes in risk factors, and incidence of coronary heart disease. N Engl J Med 1987; 317: 1237–45.PubMedCrossRefGoogle Scholar
  19. 19.
    Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994 Nov 19; 344(8934): 1383–9.Google Scholar
  20. 20.
    The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998 Nov 5; 339(19): 1349–57.CrossRefGoogle Scholar
  21. 21.
    Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996 Oct; 335(14): 1001–9.PubMedCrossRefGoogle Scholar
  22. 22.
    LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005 Apr 7; 352(14): 1425–35.PubMedCrossRefGoogle Scholar
  23. 23.
    Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995 Nov 16; 333(20): 1301–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Downs JR, Clearfield M, Weis S, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. JAMA 1998 May 27; 279(20): 1615–22.PubMedCrossRefGoogle Scholar
  25. 25.
    Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo controlled trial. Lancet 2002 Jul 6; 360(9326): 7–22.CrossRefGoogle Scholar
  26. 26.
    Collaborators CTTC. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90056 participants in 14 randomised trials of statins. Lancet 2005; 366: 1267–78.CrossRefGoogle Scholar
  27. 27.
    Lloyd-Jones DM, O’Donnell CJ, D’Agostino RB, et al. Applicability of cholesterol-lowering primary prevention trials to a general population: the Framingham heart study. Arch Intern Med 2001 Apr 9; 161(7): 949–54.PubMedCrossRefGoogle Scholar
  28. 28.
    Mihaylova B, Briggs A, Armitage J, et al. Cost-effectiveness of simvastatin in people at different levels of vascular disease risk: economic analysis of a randomised trial in 20,536 individuals. Lancet 2005 May; 365(9473): 1779–85.PubMedCrossRefGoogle Scholar
  29. 29.
    SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991 Jun 26; 265(24): 3255–64.CrossRefGoogle Scholar
  30. 30.
    Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension: the Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997 Sep 13; 350(9080): 757–64.PubMedCrossRefGoogle Scholar
  31. 31.
    Liu L, Wang JG, Gong L, et al. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension: Systolic Hypertension in China (Syst-China) Collaborative Group. J Hypertens 1998; 16 (12 Pt 1): 1823–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Franklin SS, Jacobs MJ, Wong ND, et al. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives. Hypertension 2001; 37: 869–74.PubMedCrossRefGoogle Scholar
  33. 33.
    Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000 Mar 11; 355(9207): 865–72.PubMedCrossRefGoogle Scholar
  34. 34.
    Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003 Dec 1; 42(6): 1206–52.PubMedCrossRefGoogle Scholar
  35. 35.
    Pearce KA, Furberg CD, Psaty BM, et al. Cost-minimization and the number needed to treat in uncomplicated hypertension. Am J Hypertens 1998; 11(5): 618–29.PubMedCrossRefGoogle Scholar
  36. 36.
    The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002 Dec 18; 288(23): 2981–97.CrossRefGoogle Scholar
  37. 37.
    Bakris GL. A practical approach to achieving recommended blood pressure goals in diabetic patients. Arch Intern Med 2001; 161: 2661–7.PubMedCrossRefGoogle Scholar
  38. 38.
    UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998 Sep 12; 317(7160): 703–13.CrossRefGoogle Scholar
  39. 39.
    Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA 2003; 289: 2534–44.PubMedCrossRefGoogle Scholar
  40. 40.
    Bosch J, Yusuf S, Pogue J, et al. Use of ramipril in preventing stroke: double blind randomised trial. BMJ 2002; 324(7339): 699–703.PubMedCrossRefGoogle Scholar
  41. 41.
    Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients: the Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000 Jan 20; 342(3): 145–53.PubMedCrossRefGoogle Scholar
  42. 42.
    Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005; 366(9489): 895–906.PubMedCrossRefGoogle Scholar
  43. 43.
    Poulter NR, Wedel H, Dahlof B, et al. Role of blood pressure and other variables in the differential cardiovascular event rates noted in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA). Lancet 2005; 366(9489): 907–13.PubMedCrossRefGoogle Scholar
  44. 44.
    Amery A, Birkenhager WH, Brixko P, et al. Influence of antihypertensive drug treatment on morbidity and mortality in patients over the age of 60 years: EWPHE results: subgroup analysis based on entry stratification. J Hypertens 1986; 4 Suppl. 6: S642–7.Google Scholar
  45. 45.
    Bulpitt CJ, Beckett NS, Cooke J, et al. Results of the pilot study for the hypertension in the very elderly trial. J Hypertens 2003 Dec; 21(12): 2409–17.PubMedCrossRefGoogle Scholar
  46. 46.
    Gueyffier F, Bulpitt C, Boissel J-P, et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. Lancet 1999 Mar 6; 353(9155): 793–6.PubMedCrossRefGoogle Scholar
  47. 47.
    Perry HM, Smith WM, McDonald RH, et al. Morbidity and mortality in the systolic hypertension in the elderly program (SHEP) pilot study. Stroke 1989; 20: 4–13.PubMedCrossRefGoogle Scholar
  48. 48.
    Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991 Nov 23; 338(8778): 1281–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Chaudhry SI, Krumholz HM, Foody JM. Systolic hypertension in older persons. JAMA 2004 Sep 1; 292(9): 1074–80.PubMedCrossRefGoogle Scholar
  50. 50.
    Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial: HOT Study Group. Lancet 1998 Jun 13; 351(9118): 1755–62.PubMedCrossRefGoogle Scholar
  51. 51.
    Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial: Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003; 361: 1149–58.PubMedCrossRefGoogle Scholar
  52. 52.
    US Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Washington, DC: US Department of Health and Human Services, 1990. DHHS Publication (CDC) 90–8416.Google Scholar
  53. 53.
    Wilhelmsson C, Vedin JA, Elmfeldt D, et al. Smoking and myocardial infarction. Lancet 1975 Feb 22; I (7904): 415–20.CrossRefGoogle Scholar
  54. 54.
    Wilson K, Gibson N, Willan A, et al. Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies. Arch Intern Med 2000 Apr 10; 160(7): 939–44.PubMedCrossRefGoogle Scholar
  55. 55.
    Hermanson B, Omenn GS, Kronmal RA, et al. Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease: results from the CASS registry. N Engl J Med 1988 Nov 24; 319(21): 1365–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA 2003 Jul 2; 290(1): 86–97.PubMedCrossRefGoogle Scholar
  57. 57.
    Rea TD, Heckbert SR, Kaplan RC, et al. Smoking status and risk for recurrent coronary events after myocardial infarction. Ann Intern Med 2002 Sep 17; 137(6): 494–500.PubMedGoogle Scholar
  58. 58.
    Goldenberg I, Jonas M, Tenenbaum A, et al. Current smoking, smoking cessation, and the risk of sudden cardiac death in patients with coronary artery disease. Arch Intern Med 2003 Oct 27; 163(19): 2301–5.PubMedCrossRefGoogle Scholar
  59. 59.
    Kawachi I, Colditz GA, Stampfer MJ, et al. Smoking cessation and decreased risk of stroke in women. JAMA 1993 Jan 13; 269(2): 232–6.PubMedCrossRefGoogle Scholar
  60. 60.
    US Department of Health and Human Services. Smoking cessation: information for specialists. Rockville (MD): US Department of Health and Human Services. Agency for Health Care Policy and Research; 1996. DHHS Publication 96–0694.Google Scholar
  61. 61.
    Joseph AM, Norman SM, Ferry LH, et al. The safety of transdermal nicotine as an aid to smoking cessation in patients with cardiac disease. N Engl J Med 1996; 335(24): 1792–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Benowitz NL, Gourlay SG. Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. J Am Coll Cardiol 1997; 29(7): 1422–31.PubMedCrossRefGoogle Scholar
  63. 63.
    Karnath B. Smoking cessation. Am J Med 2002 Apr 1; 112(5): 399–405.PubMedCrossRefGoogle Scholar
  64. 64.
    Hurt RD, Sachs DPL, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997 Oct 23; 337(17): 1195–202.PubMedCrossRefGoogle Scholar
  65. 65.
    Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999 Mar 4; 340(9): 685–91.PubMedCrossRefGoogle Scholar
  66. 66.
    Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation: Agency for Health Care Policy and Research. JAMA 1997 Dec 3; 278(21): 1759–66.PubMedCrossRefGoogle Scholar
  67. 67.
    Cohen C, Kodas E, Griebel G. CB1 receptor antagonists for the treatment of nicotine addiction. Pharmacol Biochem Behav 2005; 81(2): 387–95.PubMedCrossRefGoogle Scholar
  68. 68.
    Foulds J, Burke M, Steinberg M, et al. Advances in pharmacotherapy for tobacco dependence. Expert Opin Emerg Drugs 2004; 9(1): 39–53.PubMedCrossRefGoogle Scholar
  69. 69.
    The Diabetes Control and Complications Trial (DCCT) Research Group. Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial. Am J Cardiol 1995 May 1; 75(14): 894–903.CrossRefGoogle Scholar
  70. 70.
    The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993 Sep 30; 329(14): 977–86.CrossRefGoogle Scholar
  71. 71.
    Dormandy JA, Charbonnel B, Eckland DJ, et al. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet 2005; 366(9493): 1279–89.PubMedCrossRefGoogle Scholar
  72. 72.
    Colhoun PHM, Betteridge PDJ, Durrington PPN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004 Aug 21; 364(9435): 685–96.PubMedCrossRefGoogle Scholar
  73. 73.
    Brandie M, Davidson MB, Schriger DL, et al. Cost effectiveness of statin therapy for the primary prevention of major coronary events in individuals with type 2 diabetes. Diabetes Care 2003 Jun; 26(6): 1796–801.CrossRefGoogle Scholar
  74. 74.
    Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005 Mar 31; 352(13): 1293–304.PubMedCrossRefGoogle Scholar
  75. 75.
    Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med 1989 Jul 20; 321(3): 129–35.CrossRefGoogle Scholar
  76. 76.
    Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002 Jan 12; 324(7329): 71–86.CrossRefGoogle Scholar
  77. 77.
    Lloyd-Jones DM, Leip EP, Larson MG, et al. Novel approach to examining first cardiovascular events after hypertension onset. Hypertension 2005 Jan; 45(1): 39–45.PubMedGoogle Scholar
  78. 78.
    Daviglus ML, Liu K, Yan LL, et al. Body mass index in middle age and health-related quality of life in older age: the Chicago heart association detection project in industry study. Arch Intern Med 2003 Nov 10; 163(20): 2448–55.PubMedCrossRefGoogle Scholar
  79. 79.
    Yan LL, Daviglus ML, Liu K, et al. BMI and health-related quality of life in adults 65 years and older. Obes Res 2004 Jan; 12(1): 69–76.PubMedCrossRefGoogle Scholar
  80. 80.
    Ferraro KF, Su YP, Gretebeck RJ, et al. Body mass index and disability in adulthood: a 20-year panel study. Am J Public Health 2002 May; 92(5): 834–40.PubMedCrossRefGoogle Scholar
  81. 81.
    Colditz GA, Willett WC, Rotnitzky A, et al. Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 1995 Apr 1; 122(7): 481–6.PubMedGoogle Scholar
  82. 82.
    Sjostrom CD, Lissner L, Sjostrom L. Relationships between changes in body composition and changes in cardiovascular risk factors: the SOS Intervention Study. Swedish Obese Subjects. Obes Res 1997; 5: 519–30.PubMedGoogle Scholar
  83. 83.
    Sjostrom L, Lindroos A-K, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004 Dec 23; 351(26): 2683–93.PubMedCrossRefGoogle Scholar
  84. 84.
    Williamson DF, Pamuk E, Thun M, et al. Prospective study of intentional weight loss and mortality in never-smoking overweight US white women aged 40–64 years. Am J Epidemiol 1995 Jun 15; 141(12): 1128–41.PubMedGoogle Scholar
  85. 85.
    Kolotkin RL, Crosby RD, Williams GR, et al. The relationship between health-related quality of life and weight loss. Obes Res Sep 2001; 9(9): 564–71.CrossRefGoogle Scholar
  86. 86.
    Fontaine KR, Barofsky I, Bartlett SJ, et al. Weight loss and health-related quality of life: results at 1-year follow-up. Eat Behav 2004 Jan; 5(1): 85–8.PubMedCrossRefGoogle Scholar
  87. 87.
    Fontaine KR, Barofsky I, Andersen RE, et al. Impact of weight loss on health-related quality of life. Qual Life Res 1999 May; 8(3): 275–7.PubMedCrossRefGoogle Scholar
  88. 88.
    Maciejewski ML, Patrick DL, Williamson DF. A structured review of randomized controlled trials of weight loss showed little improvement in health-related quality of life. J Clin Epidemiol 2005 Jun; 58(6): 568–78.PubMedCrossRefGoogle Scholar
  89. 89.
    Van Gaal LF, Rissanen AM, Scheen AJ, et al. Effects of the cannabinoid-1 receptor blocker rimonabant on weight reduction and cardiovascular risk factors in overweight patients: 1-year experience from the RIO-Europe study. Lancet 2005 Apr; 365(9468): 1389–97.PubMedCrossRefGoogle Scholar
  90. 90.
    Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obes Res 1998 Mar; 6(2): 97–106.PubMedGoogle Scholar
  91. 91.
    Multifactorial trial in the prevention of coronary heart disease: 2. Risk factor changes at two and four years. Eur Heart J 1982 Apr; 3 (2): 184–190.Google Scholar
  92. 92.
    Kornitzer M, Rose G. WHO European Collaborative Trial of Multifactorial Prevention of Coronary Heart Disease. Prev Med 1985; 14: 272–8.PubMedCrossRefGoogle Scholar
  93. 93.
    Holme I, Hjermann I, Helgeland A, et al. The Oslo Study: diet and antismoking advice: additional results from a 5-year primary preventive trial in middle-aged men. Prev Med 1985 May; 14(3): 279–92.PubMedCrossRefGoogle Scholar
  94. 94.
    The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). JAMA 2002 Dec 18; 288(23): 2998–3007.CrossRefGoogle Scholar
  95. 95.
    The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2000 Apr 19; 283(15): 1967–75.CrossRefGoogle Scholar
  96. 96.
    Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003 Jun 28; 326(7404): 1419.PubMedCrossRefGoogle Scholar
  97. 97.
    Franklin BA, Kahn JK, Gordon NF, et al. A cardioprotective “polypill”? Independent and additive benefits of lifestyle modification. Am J Cardiol 2004 Jul 15; 94(2): 162–6.PubMedCrossRefGoogle Scholar
  98. 98.
    The Hypertension Detection and Follow-up Program Cooperative Research Group. Mortality findings for stepped-care and referred-care participants in the Hypertension Detection and Follow-up Program, stratified by other risk factors. Prev Med 1985; 14: 312–35.CrossRefGoogle Scholar
  99. 99.
    The Pooling Project Research Group. Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events: final report of the pooling project. J Chronic Dis 1978 Apr; 31(4): 201–306.CrossRefGoogle Scholar
  100. 100.
    Stamler J, Stamler R, Neaton JD, et al. Low risk-factor profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: findings for 5 large cohorts of young adult and middle-aged men and women. JAMA 1999 Dec 1; 282(21): 2012–8.PubMedCrossRefGoogle Scholar
  101. 101.
    Daviglus ML, Stamler J, Pirzada A, et al. Favorable cardiovascular risk profile in young women and long-term risk of cardiovascular and all-cause mortality. JAMA 2004 Oct 6; 292(13): 1588–92.PubMedCrossRefGoogle Scholar
  102. 102.
    Daviglus ML, Liu K, Greenland P, et al. Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs. N Engl J Med 1998 Oct 15; 339(16): 1122–9.PubMedCrossRefGoogle Scholar
  103. 103.
    Daviglus ML, Liu K, Pirzada A, et al. Favorable cardiovascular risk profile in middle age and health-related quality of life in older age. Arch Intern Med 2003 Nov 10; 163(20): 2460–8.PubMedCrossRefGoogle Scholar
  104. 104.
    Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation 2000 Dec 19; 102(25): 3137–47.PubMedCrossRefGoogle Scholar
  105. 105.
    Manolio T, Chen J, Sorlie P, et al. US Trends in prevalence of low coronary risk, National Health and Nutrition Examination Surveys (NHANES). Circulation 2004; 109: e71–144.Google Scholar
  106. 106.
    National Center for Health Statistics. Health, United States 2004: with chartbook on trends in the health of Americans [online]. Available from URL: [Accessed 2005 Jul 1].
  107. 107.
    Miura K, Greenland P, Stamler J, et al. Relation of vegetable, fruit, and meat intake to 7-year blood pressure change in middle-aged men: the Chicago Western Electric Study. Am J Epidemiol 2004 Mar 15; 159(6): 572–80.PubMedCrossRefGoogle Scholar
  108. 108.
    Stamler J, Elliott P, Dennis B, et al. INTERMAP: background, aims, design, methods, and descriptive statistics (nondietary). J Hum Hypertens 2003 Sep; 17(9): 591–608.PubMedCrossRefGoogle Scholar
  109. 109.
    Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997 Apr 17; 336(16): 1117–24.PubMedCrossRefGoogle Scholar
  110. 110.
    Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet: DASH-Sodium Collaborative Research Group. N Engl J Med 2001 Jan 4; 344(1): 3–10.PubMedCrossRefGoogle Scholar
  111. 111.
    Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA 2004 Sep 22; 292(12): 1433–9.PubMedCrossRefGoogle Scholar
  112. 112.
    Greenland P, Knoll MD, Stamler J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA 2003 Aug 20; 290(7): 891–7.PubMedCrossRefGoogle Scholar
  113. 113.
    Robinson JG, Maheshwari N. A “poly-portfolio” for secondary prevention: a strategy to reduce subsequent events by up to 97% over five years. Am J Cardiol 2005 Feb 1; 95(3): 373–8.PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Martha L. Daviglus
    • 1
    • 2
  • Donald M. Lloyd-Jones
    • 1
    • 3
  • Amber Pirzada
    • 1
  1. 1.Department of Preventive Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.Department of Medicine, Division of Geriatrics, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  3. 3.Division of Cardiology, Feinberg School of MedicineNorthwestern UniversityChicagoUSA

Personalised recommendations