Metabolic Equivalents (METs) & Cardiovascular Health

Assessment, Risks, and Preventive Strategies

TANMAI AASRITH VARMA AYENAMPUDI | Progress Medical University, Gyumri

 Metabolic Equivalents (METs) & Cardiovascular Health

Overview of Cardiovascular Diseases

Cardiovascular Diseases (CVD) encompass a spectrum of conditions affecting the heart and blood vessels. They are a leading cause of mortality worldwide and
include various disorders that impact the cardiovascular system.

Types of Cardiovascular Diseases:

1. Atherosclerosis: Characterized by the buildup of plaque in arteries, leading to their narrowing and impaired blood flow.
2. Coronary Heart Disease (CHD): A type of heart disease caused by atherosclerosis in the coronary arteries supplying blood to the heart muscle.
3. Cerebrovascular Disease: Affects blood vessels supplying the brain, often resulting in strokes or transient ischemic attacks (TIAs).
4. Peripheral Artery Disease (PAD): Occurs due to atherosclerosis in arteries of the limbs, causing reduced blood flow and potential complications like
claudication or limb ischemia.
5. Aortic Atherosclerosis: Involves plaque buildup in the aorta, which can lead to aneurysms or dissections.

Atherosclerosis Coronary Heart Disease Cerebrovascular Disease Peipheral Artery Disease

Symptoms and Manifestations

Each type of CVD presents with unique symptoms and manifestations, ranging from chest pain, shortness of breath, and fatigue (common in CHD) to sudden
weakness, numbness, or difficulty speaking (indicative of cerebrovascular involvement).

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 Metabolic Equivalents (METs) & Cardiovascular Health

Metabolic Syndrome Contributing to Cardiovascular Diseases

Traditional Risk Factors

1. Hypertension (High Blood Pressure): Elevated blood pressure damages arteries, accelerating atherosclerosis and increasing the risk of heart attack,
stroke, and heart failure.
2. Diabetes Mellitus (DM): Increases the likelihood of atherosclerosis, making individuals more prone to heart disease and stroke.
3. Hyperlipidaemia (High Cholesterol): Elevated LDL cholesterol levels contribute to plaque buildup in arteries, leading to a higher risk of
atherosclerotic CVD.
4. Cigarette Smoking: A major risk factor that damages blood vessels, raises blood pressure, and accelerates the development of atherosclerosis.
5. Family History of ASCVD: Genetic predisposition to heart disease increases the risk of developing CVD.
6. Obesity: Increases the risk of developing hypertension, diabetes, and dyslipidaemia, all contributing to atherosclerosis and CVD.

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 Metabolic Equivalents (METs) & Cardiovascular Health

Additional Risk-Enhancing Factors

1. Physical Inactivity: Sedentary lifestyles contribute to obesity, hypertension, and metabolic disorders, raising the risk of CVD.
2. Unhealthy Diet: Excessive consumption of processed foods, meat, dairy, saturated fats, and high-sugar content contributes to atherosclerosis and
obesity.
3. Stress and Mental Health: Chronic stress and mental health conditions can impact blood pressure and heart health.

ASCVD Risk Assessment Approach

Target Population

Adults between 20 to 75 Years: ASCVD risk assessment involves evaluating factors like age, cholesterol levels, blood pressure, diabetes, smoking, family
history, weight, activity level, and diet. Tools like ACC/AHA Risk Estimator or Framingham Risk Score calculate risk based on these factors. This helps
categorize individuals into low, intermediate, or high-risk groups for heart disease/stroke. Preventive measures, lifestyle changes, or medications are
recommended based on the risk level, aiming to lower the likelihood of cardiovascular events. Regular reassessment is essential as factors can change over
time.

Regular Risk Assessments: Periodic evaluations to identify risk factors and guide specific management strategies.

Initiating ASCVD Risk Assessments

• Commencement Age: Start discussions at 20 years or first encounter beyond this age.
• Reassessment Intervals:
o Low (<5%) or Borderline (5 to 7.4%) 10-year ASCVD risk: Reassess every four to six years.
o Intermediate (7.5 to 19.9%) risk or new risk factor identification: More frequent reassessment.
o Cease screening beyond 75 years, unless requested or after ASCVD identification.

Assessment Procedure

• Identify Traditional Risk Factors: Gather history and conduct physical exams to recognize hypertension, diabetes, smoking, familial history, obesity,
etc.
• Lipid Profile Analysis: Assess lipids based on age, sex, and identified risk factors.
• Utilize Risk Calculators: Estimate 10-year ASCVD risk using validated calculators based on individualized characteristics.
• Consider Lifetime Risk: Particularly for low 10-year risk individuals ≤59 years, calculate 30-year (lifetime) ASCVD risk.

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 Metabolic Equivalents (METs) & Cardiovascular Health

Implications of ASCVD Risk Estimation

• Tailored Preventive Measures: Stratify patients into low, intermediate, or high-risk categories for personalized intervention strategies.
• Optimizing Therapies: Initiate appropriate therapies for high-risk individuals (≥20% 10-year ASCVD risk), focusing on lifestyle modifications or
pharmacologic interventions.
• Family Involvement: Counsel first-degree relatives of high-risk patients for ASCVD risk assessment.

Reassessment Frequency

• Dynamic Risk Status: ASCVD risk is dynamic; periodic reassessment necessary due to evolving clinical status and lifestyle influences.
• Low Risk: Reassess every four to six years.
• Intermediate Risk: Regular reassessment to optimize risk factors and guide interventions.

Different Cardiovascular disease risk scores

Risk score (year)
Framingham risk score (1998)
Variables included Key variables excluded Endpoint assessed
• Age
• Gender
• Blood pressure • CHD death
• Total or LDL cholesterol (mg/dL)
treatment (yes or no) • Nonfatal MI
• HDL cholesterol (mg/dL)
• Family history of • Unstable angina
• Systolic blood pressure (mmHg) CVD (yes or no) • Stable angina
• Diabetes mellitus (yes or no)
• Current smoking (yes or no)

Adult Treatment Panel (ATP
III) hard CHD risk score (2002)
• Age
• Gender
• Total cholesterol (mg/dL) • Diabetes mellitus
(yes or no) • CHD death
• HDL cholesterol (mg/dL)
• Family history of • Nonfatal MI
• Systolic blood pressure (mmHg) CVD (yes or no)
• Blood pressure treatment (yes or no)
• Current smoking (yes or no)

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 Metabolic Equivalents (METs) & Cardiovascular Health

SCORE CVD death risk score
(2003)
• Age
• Gender • Blood pressure
treatment (yes or no)
• Total cholesterol (mg/dL) • CVD death (including CHD, arrhythmia, heart failure,
• Diabetes mellitus
• HDL cholesterol (mg/dL) stroke, aortic aneurysm, and peripheral vascular
(yes or no)
• Systolic blood pressure (mmHg) disease)
• Family history of
• Current smoking (yes or no) CVD (yes or no)
• Region of Europe (high risk or low risk region)

QRISK and QRISK2 risk
calculators (2007)
• Age
• Gender
• Total cholesterol (mg/dL)
• HDL cholesterol (mg/dL) • CHD death
• Systolic blood pressure (mmHg) • Nonfatal MI
• Blood pressure treatment (yes or no) • Coronary insufficiency or angina
• Diabetes mellitus
• Current smoking (yes or no) • Coronary revascularization
(yes or no)
• Family history of CVD in first degree relative aged <60 • Fatal or nonfatal stroke
years (yes or no) • Transient ischemic attack
• Region of United Kingdom (score based on levels of • Intermittent claudication
unemployment, overcrowding, car ownership, home
ownership)
• Body mass index (kg/m2)

• Age
• Total cholesterol (mg/dL)
• HDL cholesterol (mg/dL)
• Diabetes mellitus • Cardiovascular death
• Systolic blood pressure (mmHg)
(yes or no)* • Nonfatal MI
Reynolds CVD risk score • Diabetes mellitus assessed by hemoglobin A1c
• Blood pressure • Nonfatal stroke
(2007/2008) (percent)*
treatment (yes or no) • Coronary revascularization
• Current smoking (yes or no)
• Parental history of MI before age 60 years (yes or no)
• Serum hs-CRP (mg/L)

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 Metabolic Equivalents (METs) & Cardiovascular Health

• Age
• CHD death
• Gender
• Nonfatal MI
• Total cholesterol (mg/dL)
• Coronary insufficiency or angina
• HDL cholesterol (mg/dL) • Family history of
Framingham general CVD risk • Fatal or nonfatal ischemic or haemorrhagic stroke
• Systolic blood pressure (mmHg) CVD (yes or no)
score (2008) • Transient ischemic attack
• Blood pressure treatment (yes or no)
• Intermittent claudication
• Diabetes mellitus (yes or no)
• Heart failure
• Current smoking (yes or no)

• Age (validated only in patients 40 to 79 years of age)

• Gender
• Total cholesterol (mg/dL) • CHD death
• HDL cholesterol (mg/dL) • Family history of • Nonfatal MI
ACC/AHA pooled cohort hard
• Systolic blood pressure (mmHg) CVD (yes or no) • Fatal stroke
CVD risk calculator (2013)
• Blood pressure treatment (yes or no) • Nonfatal stroke
• Diabetes mellitus (yes or no)
• Current smoking (yes or no)

• Age
• Gender
• Ethnicity
• Total cholesterol (mg/dL) • CHD death
• HDL cholesterol (mg/dL) • Nonfatal MI
• Systolic blood pressure (mmHg) • Coronary insufficiency or angina
• Blood pressure treatment (yes or no) • None • Coronary revascularization
JBS3 risk score (2014)
• Diabetes mellitus (yes or no) • Fatal or nonfatal stroke
• Current smoking (yes or no) • Transient ischemic attack
• Family history of CVD in first degree relative aged <60 • Intermittent claudication
years (yes or no)
• Chronic kidney disease
• Atrial fibrillation
• Rheumatoid arthritis

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 Metabolic Equivalents (METs) & Cardiovascular Health

• Region of United Kingdom (score based on levels of

unemployment, overcrowding, car ownership, home
ownership)
• Body mass index (kg/m2)

MESA risk score (2015)
• Age
• Gender
• Ethnicity (non-Hispanic White people, Chinese
American people, African American people, Hispanic
people)
• Total cholesterol (mg/dL) • CHD death
• HDL cholesterol (mg/dL) • Family history of • Nonfatal MI
• Lipid lowering treatment (yes or no) CVD other than MI • Resuscitated cardiac arrest
• Systolic blood pressure (mmHg) • Coronary revascularization in patient with angina
• Blood pressure treatment (yes or no)
• Diabetes mellitus (yes or no)
• Current smoking (yes or no)
• Family history of MI at any age (yes or no)
• Coronary artery calcium score

• Age
• Gender
• Total cholesterol (mg/dL)
• HDL cholesterol (mg/dL)
• Lipid lowering treatment (yes or no)
• Systolic blood pressure (mmHg) • CHD death
China-PAR risk predictor • Blood pressure treatment (yes or no) • None • Nonfatal MI
(2016) • Diabetes mellitus (yes or no) • Fatal or nonfatal stroke
• Current smoking (yes or no)
• Waist circumference (cm)
• Geographic region (northern or southern China)
• Urbanization (yes or no, only in males)
• Family history of ASCVD (yes or no, only in males)

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 Metabolic Equivalents (METs) & Cardiovascular Health

LDL: low density lipoprotein; HDL: high density lipoprotein; CVD: cardiovascular disease; CHD: coronary heart disease; MI: myocardial infarction; hs-CRP: high sensitivity
C-reactive protein; ASCVD: atherosclerotic cardiovascular disease.

* Diabetes mellitus, as assessed by Haemoglobin A1c or Glycated Haemoglobin was included in the Reynolds risk score for women but NOT included for men.

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 Metabolic Equivalents (METs) & Cardiovascular Health

Identifying ASCVD Risk Factors

Traditional Risk Factors

• Hypertension: Recognize elevated blood pressure levels.

• Cigarette Smoking: Identify current or past smoking habits.
• Diabetes Mellitus: Evaluate for diabetes history or diagnoses.
• Hyperlipidaemia: Assess lipid profiles, including familial history or elevated cholesterol.
• Premature Family History of ASCVD: Consider familial history of early cardiovascular events.
• Obesity: Recognize BMI or other indicators of obesity.

Lipid Profile Assessment

• Baseline Lipid Profile (≥20 Years): Conduct lipid analysis; severely elevated LDL cholesterol (≥190 mg/dL) prompts aggressive treatment with
lifestyle modifications and lipid-lowering medications.

Age-Specific Assessments

• >40 Years Without ASCVD: Utilize validated ASCVD risk calculators to estimate risk based on identified risk factors.
• 20-39 Years: While calculators may not provide explicit guidance, informal risk assessments may guide care, especially for individuals with specific
risk factors.

Risk-Enhancing Factors

• Beyond Traditional Risks: Acknowledge additional factors shaping ASCVD risk (e.g., chronic kidney disease, inflammatory conditions) to refine risk
discussions and intervention strategies.

Specific Risk Groups

• Younger Patients (<40 Years): Considerations for FH, early onset DM, family history, or imaging findings suggesting atherosclerosis merit tailored
risk discussions and aggressive risk management.

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 Metabolic Equivalents (METs) & Cardiovascular Health

Lifetime Risk Assessment and Special Populations

Lifetime ASCVD Risk

• Progressive Increase: Lifetime risk escalates with the number and intensity of risk factors, offering a broader perspective than the 10-year risk
assessment.
• Framingham Study Insights: Data from cohorts highlight stark differences in lifetime ASCVD risks based on optimal, not optimal, and major risk
factors.

Age-Specific Considerations

• Patients Under 40 Years: Limited data for ASCVD risk assessment. Emphasize discussions on lifetime risk, especially in subsets like familial
hypercholesterolemia (FH) or juvenile onset DM.
• Heterozygous FH: Caution with 10-year or lifetime risk estimates. Aggressive management with statins due to potential underestimation of risk.
• Type 1/Type 2 DM: Management focus without rigidly using risk calculators. Aggressive risk factor controls due to heightened ASCVD risk.

Negative Risk Factors

• Altering Risk Assessments: Identification of negative risk factors may downgrade risk assessment significance.
• CAC Scores as Negative Factors: Extremely low or absent coronary artery calcium scores significantly reduce ASCVD risk prediction.

Patients Over 75 Years

• Shared Decision-Making: Engage patients in discussions about primary preventive therapies, considering individual functional status and life
expectancy.
• Continued Preventive Strategies: Encourage continuation of ASCVD preventive strategies, tailored to patient tolerability and overall prognosis.

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 Metabolic Equivalents (METs) & Cardiovascular Health

Dietary Modifications for Hypertension & Hyperlipidaemia

Hypertension Management: Controlling blood pressure involves dietary changes that focus on reducing sodium intake, following the DASH (Dietary
Approaches to Stop Hypertension) diet, and increasing consumption of potassium-rich foods.

o Reduced Sodium Intake: (Sources of High Sodium - Processed foods, canned soups, fast foods, and pre-packaged snacks are often high in
sodium. Cutting back on these items can significantly reduce daily sodium intake.)
o Tips for Reducing Sodium:
1. Read Labels: Pay attention to sodium content on food labels and choose low-sodium or no-added-salt options.
2. Cook from Scratch: Prepare meals at home using fresh ingredients to have better control over salt content.
3. Use Herbs and Spices: Flavour foods with herbs, spices, citrus, and vinegar instead of salt.
• DASH Diet: Emphasis and watching what food we intake
o Fruits and Vegetables: Aim for multiple servings of colourful fruits and vegetables daily.
o Whole Grains: Choose whole-grain foods like brown rice, quinoa, and whole-grain bread over refined grains.
o Lean Proteins: opt for plant-based proteins like beans and lentils.
o Dairy, Meat-Free Food: Food that comes from animals, dairy or poultry farming uses sodium in food processing.
o Potassium-Rich Foods: (Sources of Potassium – Fruits such as Bananas, oranges, melons, and avocados. Vegetables such as Leafy greens,
tomatoes, potatoes, and sweet potatoes. Beans and Legumes like Kidney beans, lentils, and peas are good sources.
• Dietary Recommendations:
o Moderate Alcohol Intake: Limit alcohol consumption as excessive drinking can raise blood pressure.
o Portion Control: Watch portion sizes to manage overall calorie intake and maintain a healthy weight.

Hyperlipidaemia Control:

o Reduce Trans/Saturated Fats: Cut down on processed and fried foods containing trans fats. Opt for leaner meats and healthier oils (olive oil).
o Increase Fiber: Focus on foods rich in soluble fiber such as oats, fruits, vegetables, and legumes to help lower LDL cholesterol.
o Omega-3 Fatty Acids: Incorporate fatty fish like salmon and mackerel, or consider omega-3 supplements (under guidance) to reduce triglyceride
levels.
o Plant-Based Focus: Base meals on fruits, vegetables, whole grains, nuts, and seeds.
o Healthy Fats: Swap saturated fats with healthier options like olive oil, avocados, and nuts.
o Limit Processed Foods: Avoid processed and fried items high in unhealthy fats.

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Pharmacological Interventions, Exercise Recommendations & Impact on Risks

• Statins: Statins are cornerstone medications in ASCVD prevention. They effectively lower LDL cholesterol levels, reducing the risk of plaque buildup
in arteries. Their role extends beyond cholesterol reduction, offering anti-inflammatory benefits that can stabilize existing plaques. This helps in
preventing plaque rupture and subsequent cardiovascular events.
• Aspirin: Aspirin has been traditionally used for its antiplatelet properties, which can prevent blood clot formation. However, its routine use in primary
prevention is now more nuanced due to potential risks of bleeding, and its use is often weighed against individual patient risks and benefits.
• Antihypertensives: Controlling hypertension is crucial in managing ASCVD risk factors. Antihypertensive medications like ACE inhibitors, ARBs,
beta-blockers, and calcium channel blockers help lower blood pressure, reducing strain on the heart and arteries. This diminishes the risk of heart
attacks, strokes, and other cardiovascular complications.

Exercise Recommendations & Impact on Risks

• Diet: Healthy eating habits, such as a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet, complement pharmacotherapy. These
diets emphasize fruits, vegetables, whole grains, lean proteins, and healthy fats, contributing to lower cholesterol levels and better overall heart health.
• Exercise: Regular physical activity is pivotal. Exercise improves cardiovascular fitness, helps manage weight, lowers blood pressure, and improves
cholesterol levels. It complements medications by enhancing overall cardiovascular health.
• Smoking Cessation: Quitting smoking significantly reduces the risk of ASCVD. Combined with medications, it greatly enhances the effectiveness of
treatment in preventing further cardiovascular damage.
• Weight Management: Maintaining a healthy weight, especially through the reduction of visceral fat, positively impacts cholesterol levels, blood
pressure, and overall cardiovascular health.

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 Metabolic Equivalents (METs) & Cardiovascular Health

*Some Protocols for Assessing CVD Risk (Source: UpToDate)

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