Health: Multiple risk factors for heart disease

When it comes to heart disease, health care and the media focus on LDL cholesterol (and occassionally mention a handful of other risk factors).

Cardiovascular disease is a multi-factor disease – there are many causes beyond LDL (this does not mean that LDL is not a factor).

(This is not medical advice – but a list created from online resources.)

Official Source

Association of Lipid, Inflammatory, and Metabolic Biomarkers With Age at Onset for Incident Coronary Heart Disease in Women – PMC

Major ASCVD risk factors

This list compiled from online searches:

• Age (risk rises with older age)
• Sex (male sex and post‑menopausal women)
• Family history / genetics (premature coronary disease in first‑degree relatives; familial hypercholesterolemia, Lp(a) elevation)
• Low income
• Hypertension (sustained elevated blood pressure)
• Smoking (current tobacco use and exposure to smoke)
• Diabetes mellitus (type 2 > type 1; duration and glycemic control matter)
• Insulin resistance and prediabetes (impaired fasting glucose / impaired glucose tolerance)
• Obesity or being overweight, especially central/visceral adiposity (waist circumference / waist:hip ratio)
• Sedentary lifestyle / low cardiorespiratory fitness – Lack of exercise/physical activity
• Alcohol consumption (New research links even low alcohol consumption to cancer, heart disease, and premature death | EurekAlert!)
• Atherogenic dyslipidemia besides LDL: high triglycerides, low HDL, small dense LDL, high remnant cholesterol, elevated apoB and Lp(a) — these predict risk independent of LDL-C
• Metabolic syndrome (cluster of the above: central obesity, high TG, low HDL, elevated BP, elevated fasting glucose)
• Chronic inflammation (elevated hs‑CRP, chronic inflammatory diseases)
• Prothrombotic states (high fibrinogen, plasminogen activator inhibitor‑1, hypercoagulability)
• Chronic kidney disease / albuminuria (even moderate CKD increases ASCVD risk)
• Unhealthy diet (excess refined carbs, trans fats, ultra‑processed foods, high sugar)
• Sleep disorders and short sleep duration (including untreated obstructive sleep apnea)
• Psychosocial stress, depression, low socioeconomic status (linked to behaviors and biologic stress pathways)
• Alcohol (heavy use raises risk)
• Air pollution and environmental exposures (ambient particulate matter)
• Microplastics – Microplastics and nanoplastics in matched human blood, bone, and intervertebral discs: Accumulation patterns and risks | npj Emerging Contaminants
• Vitamin B deficiencies and high homocysteine levels

• Among all STEMI hospitalizations: 77.2% were in men; tobacco use was the most prevalent traditional risk factor; and low income was the most prevalent nontraditional risk factor. About 65% of women used tobacco compared to 61% of men, and nearly 35% of the women were in the lowest income level compared to nearly 29% of men.
• Among the NSTEMI group: 66.2% were men; high blood pressure was the most prevalent traditional risk factor in nearly 70% of men and 69% of women; low income was the most prevalent nontraditional risk factor for both sexes, though higher among women at about 38% compared to men at 32%.

Heart attack deaths rose between 2011 and 2022 among adults younger than age 55 | American Heart Association

What is “metabolic health”

• Metabolic health refers to the absence (or control) of metabolic abnormalities that drive cardiometabolic disease.
• Normal fasting glucose / no insulin resistance (no diabetes or prediabetes)
• Normal blood pressure (or controlled on medications)
• Normal triglycerides and HDL (no atherogenic dyslipidemia)
• Waist circumference / body fat distribution not centrally obese
• Absence of pro‑inflammatory / pro‑thrombotic markers (e.g., normal hs‑CRP, no albuminuria)
• Many definitions refer to having fewer than 2 to 3 of the metabolic syndrome criteria; conversely, “poor metabolic health” means presence of insulin resistance, central obesity, dyslipidemia, hypertension and/or hyperglycemia (i.e., metabolic syndrome) .

Why poor metabolic health increases heart disease risk

• Insulin resistance, central fat, and dyslipidemia produce atherogenic changes: higher triglyceride‑rich particles and apoB, small dense LDL, endothelial dysfunction, chronic inflammation, oxidative stress, and prothrombotic tendency — all accelerate plaque formation, progression, and rupture, increasing ASCVD events .

Yet media stories focus on two things:

1. Your LDL level (and more recently sometimes mentioning CAC, and apo-B and lp(a))
2. and what you eat Dear Doctor: Is eating 2 eggs a day contributing to my higher coronary artery score? – oregonlive.com

My Story

I had a heart attack.

My risk factors

• Age (risk rises with older age)
• Sex (male sex and post‑menopausal women)
• [NONE] Family history / genetics (premature coronary disease in first‑degree relatives; familial hypercholesterolemia, Lp(a) elevation)
• [N/A] Low income
• [MIXED, most of the time was ok] Hypertension (sustained elevated blood pressure)
• [NEVER] Smoking (current tobacco use and exposure to smoke)
• [NEVER]Diabetes mellitus (type 2 > type 1; duration and glycemic control matter)
• [NEVER]Insulin resistance and prediabetes (impaired fasting glucose / impaired glucose tolerance)
• [POSSIBLE] Obesity or being overweight, especially central/visceral adiposity (waist circumference / waist:hip ratio)
• [NEVER]Sedentary lifestyle / low cardiorespiratory fitness – Lack of exercise/physical activity [I was a lifelong jogger and bicyclist until my untreated broken foot in 2020, untreated because Oregon was the only the country to prohibit access to health care for non-life threatening emergencies]
• [NEVER]Alcohol consumption (New research links even low alcohol consumption to cancer, heart disease, and premature death | EurekAlert!)
• [NEVER]Atherogenic dyslipidemia besides LDL: high triglycerides, low HDL, small dense LDL, high remnant cholesterol, elevated apoB and Lp(a) — these predict risk independent of LDL-C
• [NEVER]Metabolic syndrome (cluster of the above: central obesity, high TG, low HDL, elevated BP, elevated fasting glucose)
• [LIKELY] Chronic inflammation (elevated hs‑CRP, chronic inflammatory diseases)
• [UNKNOWN] Prothrombotic states (high fibrinogen, plasminogen activator inhibitor‑1, hypercoagulability)
• [NEVER]Chronic kidney disease / albuminuria (even moderate CKD increases ASCVD risk)
• [Was pseudo vegetarian for years] Unhealthy diet (excess refined carbs, trans fats, ultra‑processed foods, high sugar)
• [POSSIBLE] Sleep disorders and short sleep duration (including untreated obstructive sleep apnea)
• [NO] Psychosocial stress, depression, low socioeconomic status (linked to behaviors and biologic stress pathways)
• [NO] Air pollution and environmental exposures (ambient particulate matter)
• Vitamin B deficiencies and high homocysteine levels

Risk Factors From The Above List

My age and sex, not being at an ideal weight (which does not have a large risk factor impact), chronic inflammation (untreated broken foot, torn tendon, OA in right knee exposed due to inactivity caused by untreated broken foot, long term cracked wisdom tooth, additional 2 torn tendons, additional untreated broken bone in opposite foot, hip injury – all of this over 4 years), sleep issues caused by chronic pain, vitamin B deficiencies.

Of those, I suspect the 2 largest factors were

• ability to exercise ended in 2020 due to injuries and public health orders
• Chronic inflammation
• vitamin B deficiencies (raises homocysteine levels, a known risk factor) – this is potentially larger in the absence of other major risk factors.

Things that were not risk factors

• Cholesterol levels
• Diet