COMMENTARY

New Coronary Heart Disease Risk Factors

Major coronary risk factors include smoking, hyperlipid- MATERNAL AND CHILDHOOD FACTORS
emia, hypertension, diabetes mellitus, age, obesity, a seden- Several maternal and childhood factors are associated with
tary lifestyle, and a positive family history for premature an increased risk for developing coronary artery disease:
manifestations of coronary artery disease, such as an acute gestational diabetes, pre-eclampsia, delivering a child of
myocardial infarction. In recent years, several new risk fac- low birth weight, preterm delivery, and premature or surgi-
tors have been identified. Some risk factors are quite cal menopause. The factor or factors increasing the risk for
unusual, such as a history of premature birth. Recognizing coronary artery disease associated with each of these condi-
the presence of one or more of these new risk factors should tions is not known but may be the result of increased cyto-
trigger attempts by the clinician to minimize more tradi- kine and oxidative stress.5-7 An unusual and yet
tional major risk factors. unexplained association has been observed between
migraine headaches with aura in women and incident car-
diovascular disease.8 Also of interest is the association of
early-life trauma and the risk of adverse cardiovascular out-
DISEASES THAT INCREASE SYSTEMIC comes in young and middle-aged individuals with a history
INFLAMMATION, THE INFLAMMASOME of myocardial infarction.9 These investigators suggested
Diseases such as gout, inflammatory bowel disease, that adverse childhood experiences could have contributed
autoimmune collagen vascular diseases, and psoriasis to cardiovascular risk through a pathway that involved
are all associated with an increased tendency to develop inflammation possibly secondary to increased glucocorti-
coronary artery disease, presumably because they coid signaling. Another gender-related situation linked to
increase the activity of the inflammasome.1-3 Patients augmented cardiovascular risk is seen in transgender
with a recent gout flare have an augmented probability patients who present for gender-affirming care. Here, the
of developing an acute cardiovascular event such as a increase in coronary artery disease risk may possibly be
myocardial infarction or stroke.1 Studying a large Veter- related to high rates of anxiety and depression.10
ans Affairs database, VITAL (Veterans wIth premaTure
atheroscLerosis), Mahtta et al noted that patients diag-
nosed with rheumatoid arthritis, systemic lupus erythe- ENVIRONMENTAL FACTORS
matosus, or both had higher odds for concomitant An increased incidence of coronary artery disease has been
premature and extremely premature coronary artery dis- related to 2 environmental factors that may themselves be
ease.2 Patients with inflammatory bowel disease (ie, connected: low socioeconomic status and air pollution.11-13
Crohn’s disease and ulcerative colitis) also had an Hamad et al suggested that increased psychosocial stres-
increased tendency to develop coronary artery disease.3 sors, limited educational and economic opportunities, and
Psoriasis increases activation of several factors in the lack of peer influence favoring healthier lifestyle choices
inflammatory milieu (eg, tumor necrosis factor alpha, may be causative elements leading to enhanced coronary
interferons, and cytokines). Patients with psoriasis are artery disease in individuals with low socioeconomic living
up to 50% more likely to develop cardiovascular conditions.11 Air pollution was estimated to have caused
disease.4 9 million deaths worldwide in 2019 with 62% due to cardio-
vascular disease (coronary artery disease = 31.7% and
Funding: None. stroke = 27.7%).12 Etiologic factors connected to air pollu-
Conflict of Interest: None. tion include increased incidences of hypertension and dia-
Authorship: The author is solely responsible for the content of this betes, alterations in vascular tone, increased arterial intimal
manuscript. thickness and calcification, and insulin resistance. Severely
Requests for reprints should be addressed to Joseph S. Alpert, MD,
University of Arizona College of Medicine, Sarver Heart Center, 1501 N.
polluted environmental aerosols also contain several toxic
Campbell Avenue, Tucson, AZ 85724-5037. metals such as lead, mercury, arsenic, and cadmium.12
E-mail address: [email protected] Chen et al13 reported that transient exposure to a variety of

0002-9343/© 2022 Elsevier Inc. All rights reserved.

https://doi.org/10.1016/j.amjmed.2022.08.002
332 The American Journal of Medicine, Vol 136, No 4, April 2023

air pollutants may trigger the onset of an acute coronary 3. Lee MT, Mahtta D, Chen L, et al. Premature atherosclerotic cardiovas-
syndrome. cular disease risk among patients with inflammatory bowel disease.
Am J Med. 2021;134:1047–1051.e2.
4. Garshick MS, Ward NL, Krueger JG, Berger JS. Cardiovascular risk
in patients with psoriasis: JACC Review topic of the week. J Am Coll
LIFESTYLE FACTORS Cardiol. 2021;77:1670–80.
Investigators have also reported several lifestyle risk factors 5. Bassily E, Bell C, Verma S, Patel N, Patel A. Significance of obstetri-
cal history with future cardiovascular disease risk. Am J Med.
for coronary artery disease other than poor diet and lack of 2019;132:567–71.
exercise. Trudel et al observed that long working hours in 6. Honigberg MC, Zekavat SM, Aragam K, et al. Association of prema-
patients with a first myocardial infarction increased the risk ture natural and surgical menopause with incident cardiovascular dis-
for a recurrent event possibly because of prolonged exposure ease. JAMA. 2019;322:2411–21.
to work stressors.14 Rong et al noted that skipping breakfast 7. Levine LD, Ky B, Chirinos JA, et al. Prospective evaluation of cardio-
vascular risk 10 years after a hypertensive disorder of pregnancy. J
was linked to increased cardiovascular and all-cause mortal- Am Coll Cardiol. 2022;79:2401–11.
ity. Detrimental effects of skipping breakfast included gen- 8. Kurth T, Rist PM, Ridker PM, Kotler G, Bubes V, Buring JE.
eral obesity, metabolic syndrome, hypertension, higher Association of migraine with aura and other risk factors with
fasting insulin, and lipid levels.15 Long-term consumption of incident cardiovascular disease in women. JAMA. 2020;323:
beverages containing sugar or artificial sweeteners was also 2281–9.
9. Almuwaqqat Z, Wittbrodt M, Young A, et al. Association of early-life
associated with increased cardiovascular mortality probably trauma and risk of adverse cardiovascular outcomes in young and mid-
related to the same entities as skipping breakfast (obesity, dle-aged individuals with a history of myocardial infarction. JAMA
metabolic syndrome, hypertension, and diabetes).16 Cardiol. 2021;6:336–40.
As always, I am happy to hear from readers about 10. Denby KJ, Cho L, Toljan K, Patil M, Ferrando CA. Assessment of car-
this or any other commentary at [email protected]. diovascular risk in transgender patients presenting for gender-affirm-
ing care. Am J Med. 2021;134:1002–8.
edu or [email protected]. 11. Hamad R, Penko J, Kazi DS, et al. Association of low socioeconomic
status with premature coronary heart disease in US adults. JAMA Car-
Joseph S. Alpert, MD diol. 2020;5:899–908.
Editor in Chief, 12. Rajagopalan S, Landrigan PJ. Pollution and the heart. N Engl J Med.
The American Journal of Medicine, 2021;385:1881–92.
13. Chen R, Jiang Y, Hu J, et al. Hourly air pollutants and acute coro-
University of Arizona School of
nary syndrome onset in 1.29 million patients. Circulation.
Medicine, Tucson 2022;145:1749–60.
14. Trudel X, Brisson C, Talbot D, Gilbert-Ouiment M, Milot A. Long
working hours and risk of recurrent coronary events. J Am Coll Car-
References diol. 2021;77:1616–25.
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2. Mahtta D, Gupta A, Ramsey DJ, et al. Autoimmune rheumatic dis- 16. Malik VS, Li Y, Pan A, et al. Long-term consumption of sugar-sweet-
eases and premature atherosclerotic cardiovascular disease: an analy- ened and artificially sweetened beverages and risk of mortality in US
sis from the VITAL registry. Am J Med. 2020;133:1424–1432.e1. adults. Circulation. 2019;139:2113–25.