Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Opinion
  • Published:

Short-term vascular risk: time to take notice?

Nature Reviews Cardiology volume 7, pages 409–411 (2010)Cite this article

Subjects

Abstract

Current guidance around the prevention of cardiovascular events is based on long-term risk, typically calculated over 10 years. A growing body of evidence, however, suggests that vascular risk fluctuates greatly over much shorter time periods. We suggest a new paradigm for cardiovascular risk management that is based on targeting interventions during periods of enhanced risk. During such high-risk time windows, prophylactic therapy could have a disproportionately large absolute benefit, altering the risk–benefit balance and cost-effectiveness of available treatments. Major surgery is an example of an exposure known to lead to a transient increase in vascular risk. Emerging evidence supports the usefulness of short-term preventative interventions in the perioperative period. Influenza infection is another exposure known to increase the risk of vascular events, and cardiovascular mortality and morbidity are likely to be major features associated with pandemic influenza. Important questions remain, however, before preventative interventions can be offered as a routine part of influenza management.

Access through your institution
Buy or subscribe

This is a preview of subscription content, access via your institution

Access options

Access through your institution

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Incidence ratio of myocardial infarction in days following presentation with a respiratory tract infection.

Similar content being viewed by others

References

  1. Grundy, S. M. et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J. Am. Coll. Cardiol. 44, 720–732 (2004).

    Article  PubMed  Google Scholar 

  2. National Institute for Health and Clinical Excellence. Statins for the prevention of cardiovascular events. National Institute for Health and Clinical Excellence [online], (2006).

  3. Smeeth, L. et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N. Engl. J. Med. 351, 2611–2618 (2004).

    Article  CAS  PubMed  Google Scholar 

  4. Warren-Gash, C., Smeeth, L. & Hayward, A. C. Influenza as a trigger for acute myocardial infarction or death from cardiovascular disease: a systematic review. Lancet Infect. Dis. 9, 601–610 (2009).

    Article  PubMed  Google Scholar 

  5. Madjid, M. & Casscells, S. W. Of birds and men: cardiologists' role in influenza pandemics. Lancet 364, 1309 (2004).

    Article  PubMed  Google Scholar 

  6. Devereaux, P. J. et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 173, 627–634 (2005).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Tonetti, M. S. et al. Treatment of periodontitis and endothelial function. N. Engl. J. Med. 356, 911–920 (2007).

    Article  CAS  PubMed  Google Scholar 

  8. Bhaskaran, K. et al. Effects of air pollution on the incidence of myocardial infarction. Heart 95, 1746–1759 (2009).

    Article  CAS  PubMed  Google Scholar 

  9. Bhaskaran, K. et al. Effects of ambient temperature on the incidence of myocardial infarction. Heart 95, 1760–1769 (2009).

    Article  CAS  PubMed  Google Scholar 

  10. Mittleman, M. A. et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N. Engl. J. Med. 329, 1677–1683 (1993).

    Article  CAS  PubMed  Google Scholar 

  11. Wilbert-Lampen, U. et al. Cardiovascular events during World Cup soccer. N. Engl. J. Med. 358, 475–483 (2008).

    Article  CAS  PubMed  Google Scholar 

  12. 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 360, 7–22 (2002).

  13. Baigent, C. et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 366, 1267–1278 (2005).

    Article  CAS  PubMed  Google Scholar 

  14. National Institute for Health and Clinical Excellence. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. National Institute for Health and Clinical Excellence [online], (2010).

  15. Laufs, U. et al. Rapid effects on vascular function after initiation and withdrawal of atorvastatin in healthy, normocholesterolemic men. Am. J. Cardiol. 88, 1306–1307 (2001).

    Article  CAS  PubMed  Google Scholar 

  16. Li, J. J., Fang, C. H., Qian, H. Y. & Hu, W. L. Time course of rapid C-reactive protein reduction by pravastatin in patients with stable angina. Angiology 57, 1–7 (2006).

    Article  CAS  PubMed  Google Scholar 

  17. Hulten, E., Jackson, J. L., Douglas, K., George, S. & Villines, T. C. The effect of early, intensive statin therapy on acute coronary syndrome: a meta-analysis of randomized controlled trials. Arch. Intern. Med. 166, 1814–1821 (2006).

    Article  CAS  PubMed  Google Scholar 

  18. Antithrombotic Trialists' (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 373, 1849–1860 (2009).

  19. Ho, P. M. et al. Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 299, 532–539 (2008).

    Article  CAS  PubMed  Google Scholar 

  20. Montalescot, G. et al. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 373, 723–731 (2009).

    Article  CAS  PubMed  Google Scholar 

  21. Wallentin, L. et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N. Engl. J. Med. 361, 1045–1057 (2009).

    Article  CAS  PubMed  Google Scholar 

  22. Law, M. R., Morris, J. K. & Wald, N. J. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 338, b1665 (2009).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Mega, J. L. et al. Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46): a randomised, double-blind, phase II trial. Lancet 374, 29–38 (2009).

    Article  CAS  PubMed  Google Scholar 

  24. Connolly, S. J. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 361, 1139–1151 (2009).

    Article  CAS  PubMed  Google Scholar 

  25. Murry, C. E., Jennings, R. B. & Reimer, K. A. Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 74, 1124–1136 (1986).

    Article  CAS  PubMed  Google Scholar 

  26. Hausenloy, D. J. et al. Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial. Lancet 370, 575–579 (2007).

    Article  PubMed  Google Scholar 

  27. Shaw, E., Tofler, G. H., Buckley, T., Bajorek, B. & Ward, M. Therapy for triggered acute risk prevention: a study of feasibility. Heart Lung Circ. 18, 347–352 (2009).

    Article  CAS  PubMed  Google Scholar 

  28. Kapoor, A. S., Kanji, H., Buckingham, J., Devereaux, P. J. & McAlister, F. A. Strength of evidence for perioperative use of statins to reduce cardiovascular risk: systematic review of controlled studies. BMJ 333, 1149 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Dunkelgrun, M. et al. Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann. Surg. 249, 921–926 (2009).

    Article  PubMed  Google Scholar 

  30. Schouten, O. et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N. Engl. J. Med. 361, 980–989 (2009).

    Article  CAS  PubMed  Google Scholar 

  31. POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371, 1839–1847 (2008).

  32. Bangalore, S. et al. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet 372, 1962–1976 (2008).

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

Patrick Vallance contributed to discussions and Raymond Macallister provided useful comments on an earlier draft of the article. L. Smeeth is supported by a senior clinical fellowship from the Wellcome Trust (082178) and A. D. Hingorani is supported by a senior fellowship from the British Heart Foundation. The funders played no role in the preparation and content of the article.

Author information

Authors and Affiliations

  1. Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK

    Liam Smeeth

  2. Department of Epidemiology and Public Health and Centre for Clinical Pharmacology, University College London, Brook House, 2–16 Torrington Place, London, WC1E 7HN, UK

    Aroon D. Hingorani

Authors
  1. Liam Smeeth
    View author publications

    Search author on:PubMed Google Scholar

  2. Aroon D. Hingorani
    View author publications

    Search author on:PubMed Google Scholar

Corresponding author

Correspondence to Liam Smeeth.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Smeeth, L., Hingorani, A. Short-term vascular risk: time to take notice?. Nat Rev Cardiol 7, 409–411 (2010). https://doi.org/10.1038/nrcardio.2010.64

Download citation

  • Published:

  • Issue date:

  • DOI: https://doi.org/10.1038/nrcardio.2010.64

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing