What is cardiovascular disease (CVD)? Cardiovascular disease encompasses diseases such as arteriosclerosis, high blood pressure, heart failure and coronary heart disease, which are very common – especially in old age. According to the World Health Organization, CVD is the leading cause of death globally. But if you know the risk factors, there are things you can do in your everyday life to prevent cardiovascular disease.
Cardiovascular diseases such as atherosclerosis, hypertension, heart failure and coronary heart disease can end in heart failure, heart attack and stroke and are responsible for about 40 per cent of deaths.[1, 2] What’s more, did you know that over three-quarters of CVD deaths occur in low- or middle-income countries?
The good news is that you can significantly influence your risk of cardiovascular disease through diet and lifestyle. Researchers believe that the fact that more people are taking care of their health and paying attention to their diet is one of the reasons why fewer and fewer people in industrialised countries have been suffering from cardiovascular disease for the past three decades.
Find out how about CVD and which cardiovascular disease symptoms are most common, the risk CVDs have on our cardiovascular system – that is, on our heart and blood vessels – and how to prevent heart disease.
How does our cardiovascular system function?
Our heart and blood vessels are responsible for distributing oxygen and nutrients throughout our bodies by our blood. Our brain, muscles and our internal organs can only function because this blood flow supplies them with what they need.
The heart works like a pump: it creates pressure by contracting and pumping blood away from itself. This blood pressure ensures that blood can flow around our bodies and also reach smaller veins through the large aorta. The jerky contraction of the heart is the movement that we recognise as a heartbeat.
We have arteries, through which oxygen-rich blood travels away from the heart. They work together with our veins, through which deoxygenated blood returns to the heart. It takes about a minute for all our blood to flow once through the body.
Strictly speaking, we have two blood circulatory systems in the body: the pulmonary circulation connects our lungs to our heart and converts oxygen to carbon dioxide. The systemic circulation distributes blood from the heart to the rest of the body via the main artery (aorta).
What is cardiovascular disease?
CVD – that is, cardiovascular disease – are diseases that affect the heart and blood vessels. The term ‘CVD’ usually refers to when there is a build-up of fatty deposits inside a person’s arteries and when a person is particularly at risk of blood clots. Furthermore, cardiovascular disease can also refer to damage in other organs in the body, such as the brain, kidneys and eyes.
Many problems people have with their cardiovascular system influence different cardiovascular diseases and can be life-threatening – for example, leading to a heart attack, stroke or heart failure. As mentioned previously, cardiovascular disease is considered the most common cause of death worldwide.[1, 2]
Cardiovascular diseases often begin with the gradual development of high blood pressure or arteriosclerosis. Arteriosclerosis causes deposits to form in the arteries, which is also referred to as calcification of the blood vessels. If blood clots form, the blood vessels can become blocked, which can lead to a heart attack or stroke.
What are some common cardiovascular diseases?
There are many different diseases that affect our cardiovascular system. But some are particularly common and are the most common causes of life-threatening complications, such as heart attack and stroke.
We will go through and explore various common CVDs and how they affect our cardiovascular health, such as high blood pressure (hypertension), arteriosclerosis, atherosclerosis and coronary heart disease. Find out the most common cardiovascular disease symptoms here.
What are the warning signs of hypertension?
In order for our blood to reach the entire body, the heart pumps it through our veins with pressure. If the heart muscle contracts, systolic blood pressure develops; if it slackens, diastolic blood pressure occurs. Pressure is measured in millimetres of mercury. Optimal blood pressure is below 120 systolic and below 80 diastolic, which is abbreviated as 120/80 millimetres of mercury. Hypertension (high blood pressure) is said to occur when your values are higher than 140/90.
High blood pressure is considered a widespread disease: around one-third of adults in the United Kingdom are affected. According to data published, only around one-half of adults with high blood pressure have received a diagnosis or are receiving treatment.
High blood pressure is furthermore also a risk factor for other cardiovascular diseases. Studies show that lower systolic blood pressure over a long period of time is linked with a lower risk of cardiovascular disease.
What is arteriosclerosis?
Arteriosclerosis is when the blood vessels carrying oxygen around your body become thick or stiff. Similar to limescale build-up in water pipes, the disease causes plaque to build up in your blood vessels. The plaque consists of fat and accumulates in the walls of the arteries and causes them to harden. As a result, the blood vessels become narrower, and blood flow is disrupted. The carotid artery, arteries in the legs and the coronary arteries are frequently affected.
In the worst case, this leads to blood clots that cause regular blockages in the blood vessels. The result is a heart attack or, if there are clots in the brain, a stroke.
If your legs are affected by arteriosclerosis, this could lead to peripheral arterial disease (PAD) – also known as peripheral vascular disease (PVD). Affected people suffer from pain in their calves and thighs when walking and often have to stand still.
How is heart failure diagnosed?
If your heart is no longer able to transport enough blood through the blood vessels, this is called heart failure or cardiac insufficiency. If not enough blood flows through the body, too little oxygen and nutrients reach our organs and muscles.
Typical symptoms of heart failure include:
- shortness of breath and dry cough
- decreased performance
- water retention and oedema
Possible causes of heart failure include high blood pressure and coronary artery disease. Cardiac arrhythmias can also be both a cause and a consequence of heart failure.
What is coronary heart disease?
Coronary heart disease, also known as ischaemic heart disease or coronary artery disease, is known as one of the major causes of cardiovascular system-related deaths worldwide.
Symptoms of this disease are relatively generic and include chest pain, shortness of breath, pain throughout the body, feeling faint and nausea. Those who suspect they might have coronary heart disease may find the following diagnosis methods helpful:
- a treadmill test
- a CT scan
- an MRI scan
- coronary angiography
What is the basic cause of arrhythmia?
If your heart beats too fast, too slow, or irregularly, doctors refer to this as a cardiac arrhythmia. An irregular pulse can be associated with dizziness, nervousness, shortness of breath and unconsciousness, and in the worst cases can cause atrial fibrillation.
Possible causes include other cardiovascular diseases, severe stress, drugs, a lot of alcohol or caffeine, sleep apnea or a significant excess of calcium or magnesium.[10, 11]
Is heart disease a leading cause of death?
According to a study published in September 2019 in the journal The Lancet, cancer is actually now the most common cause of death in people between 35 and 70 in many high-income countries. In such countries, only 23 per cent of deaths in this age group are attributable to cardiovascular disease, according to the journal authors.[3, 4]
However, globally speaking, cardiovascular disease remains the leading cause of death overall, with the World Health Organization claiming that the world’s biggest killer is indeed ischaemic heart disease, followed by stroke and chronic obstructive pulmonary disease. Experts from the renowned organisation predict that as deaths from cardiovascular disease decrease overall in years to come, cancer will soon overtake it to become the leading cause of death worldwide.
How to prevent heart disease: risk factors of CVDs
Cardiovascular disease is considered to be particularly dependent on lifestyle. Obesity, lack of exercise, unhealthy diet, poor cholesterol levels – these and other factors contribute to an unhealthy heart and blood vessels.
For all cardiovascular diseases, age is a decisive risk factor: the older we are, the higher the probability that we will develop heart and blood vessel disease. Our genetics also plays a role. If there are many cases of cardiovascular disease in your family, your risk of developing CVD is probably also greater. Last but not least, gender plays a role: men are affected more often by cardiovascular disease than women.
While we cannot influence these risk factors, there are numerous other factors that are directly or indirectly related to lifestyle and diet. Let us explore the most important risk factors for cardiovascular disease.
How does obesity cause CVD?
Obesity is considered a significant risk factor for cardiovascular disease – this was most recently confirmed by a 2018 study, with data from nearly 300,000 people. According to the study authors, even a slightly elevated body mass index (BMI) provides a higher risk for heart and blood vessels.
You should aim to keep your body mass index (BMI) between 20 and 25. Your chest circumference should be less than 37 inches as a man and less than 31.5 inches as a woman.
Is there such thing as being healthy and overweight? According to some studies, a slightly greater weight in people who already have cardiovascular disease may have a protective effect. According to recent studies, however, the evidence for this is limited – and other research shows that even being slightly overweight can be unhealthy.
How does cholesterol affect CVD risk?
Studies have shown how influential cholesterol levels are for healthy heart and blood vessels. Along with healthy blood pressure, a low level of LDL cholesterol can lower your risk of cardiovascular disease. Researchers believe that better cholesterol levels and lower systolic blood pressure are best for lowering your risk of cardiovascular disease.
Your LDL cholesterol should ideally be below 3.0 millimoles per litre. Experts also recommend keeping HDL cholesterol high, at more than 1.0 millimoles per litre for men and more than 1.2 millimoles per litre for women. Triglyceride levels should be low, preferably below 1.7 millimoles per litre.
You should test your cholesterol levels regularly – by doing this, you can gain insights into your HDL and LDL levels, as well as your triglyceride and lipid levels. These tests are usually carried out by means of a blood test, which you can take at your doctor’s or at home with a health test kit that you can order online.
Find out about practical ways to lower your cholesterol levels in our dedicated Health Portal article!
Is omega 3 good for cardiovascular disease?
The unsaturated fatty acids omega 3 and omega 6 are generally considered healthy fats. They both affect blood vessels, but in different ways. While omega-3 fatty acids dilate blood vessels and have an anticoagulant effect, omega-6 fatty acids have the opposite effect. This is why you should aim to strike the perfect balance when it comes to your omega-3-to-omega-6-ratio. However, with our Western diets, we typically consume much more omega 6 than omega 3 – so, how do we perfect our omega ratio?
Many medical experts and professional societies recommend eating fish twice a week – this is because oily fish contains the most omega 3. Another option is to take omega-3 supplements. Scientists are still debating whether these supplements can really protect us against cardiovascular disease, and studies have not yet produced clear results.[14–16] Read more about the benefits of omega 3 and omega 6 in our dedicated blog article.
How does C-reactive protein cause heart disease?
Several years ago, scientists discovered that measuring the C-reactive protein (CRP) inside our liver helps identify any inflammation or infection in our blood vessels, which is a common trigger for heart attacks and atherosclerosis.
Measuring your CRP levels can indicate how at risk you are of developing cardiovascular disease. These levels are categorised as low, intermediate and high – and they increase with ageing, smoking and obesity.
How does blood sugar affect your cardiovascular system?
High blood glucose levels and, above all, diabetes are clear risk factors for cardiovascular disease. Among other things, they can cause vessels to constrict more quickly, which, in turn, increases the risk of heart attack and stroke.
Swedish researchers identified elevated blood glucose as one of the most important risk factors for cardiovascular disease. At the same time, they found that type 2 diabetics who had their blood glucose and other levels, such as blood pressure and LDL cholesterol, under control had only a minimally increased risk of disease.
Aim to keep your blood glucose in the healthy range. You can determine your blood glucose, for example, with your long-term blood glucose value HbA1c, which measures the degree of blood glucose attached to the haemoglobin in your blood. This value should be below 5.7 per cent for healthy people. An Hba1c test is recommended for those who are exhibiting possible symptoms of diabetes or prediabetes or who are at risk of developing diabetes.
How does vitamin D affect the heart?
It is not yet possible to say exactly how vitamin D affects your risk of cardiovascular disease. However, there are a number of studies that have been able to establish a connection. For example, in one long-term study, people with an average vitamin D level of 13.3 nanogrammes per millilitre or lower had a significantly increased chance of dying from cardiovascular disease.
In another study, vitamin D deficiency increased the risk of blood vessel and heart muscle disease, as well as hypertension. You should ensure that your vitamin D levels are at least 30 nanogrammes per millilitre of blood. You can test your levels with a vitamin D test – this way, you can ward off a potential vitamin D deficiency with the right steps of actions – including with vitamin D supplements.
Boost your cardiovascular system: tips on how to prevent heart disease
When it comes to preventing cardiovascular disease, many countries are on the right track: according to the National Center for Health Statistics, overall death rates caused by heart disease have dropped dramatically in the United States for both men and women over the past 40 years. However, the rate of people in the United States with obesity and diabetes has slightly increased recently.
In the United Kingdom, the number of deaths cause by ischaemic heart disease has dropped year on year; however, of the rate of people dying of other heart diseases or cardiac arrest has climbed steadily.
Tip 1: No smokingThe advice experts give about smoking is simple in theory: don’t consume tobacco, in any form. Harmful substances from smoke increase your risk of high blood pressure and atherosclerosis, for example.
Did you know that the number of smokers in the United Kingdom has been declining for around a decade? In 2011 around 20 per cent of UK adults smoked; in 2019 the figure was only 14 per cent.
Tip 2: Drink less alcohol
Drinking a lot of alcohol increases your risk of cardiovascular disease, including coronary heart disease, heart attack, stroke and sudden cardiac death. Many professional institutions and guidelines recommend moderate alcohol consumption.
The NHS advises that men and women should drink a maximum of 14 units of alcohol per week, but that alcohol should not be consumed every day. A total of 14 units corresponds to about six pints of beer or 10 glasses of wine.
Is red wine healthy every night?
However, recent studies have challenged this theory. One of them is a large study analysis that appeared in the journal The Lancet in 2018. According to the authors, alcohol offers at most minimal protection against heart attacks, and only for certain groups of people.
The results of older studies can be explained by statistical anomalies, according to researchers, and by the fact that non-drinkers usually include dry alcoholics. They agree with British scientists who wrote in 2015: if factors such as marital status, education, obesity and smoking were included, the benefits of moderate drinking would disappear from the statistics.
In the 1990s, researchers observed that people in France died relatively rarely from heart attacks, even though they ate fatty foods and smoked frequently. Some attributed this to regular consumption of red wine. Red wine contains resveratrol, an antioxidant that has shown potential to protect against cancer and cardiovascular disease in laboratory studies. However, studies on humans have not yet been able to confirm this health benefit. Some medical experts also warn that the harmful effects of red wine clearly overshadow the benefits of resveratrol.
Tip 3: Maintain a healthy diet
Saturated fatty acids and especially trans-fatty acids have been shown in studies to increase unhealthy LDL cholesterol and thus the risk of cardiovascular disease. They have also been linked to the risk of coronary heart disease.
According to nutrition experts, these trans fats should make up less than one per cent of your daily calorie intake. They are found primarily in high-fat and fried foods, such as fast food, sweets and margarine. Chips and crisps are particularly high in trans fats.
Does a vegetarian diet protect you against cardiovascular disease? This was investigated in a long-term study published in 2019. Vegetarians and vegans had healthier blood pressure, blood sugar and cholesterol levels and suffered less frequently from heart disease and heart attacks. This applied to people who ate fish but no meat. On the other hand, vegetarians and vegans exhibited a higher risk of having a stroke. Researchers believed that this could be due to lower levels of vitamin D, vitamin B12, essential amino acids and omega-3 fatty acids. To discover more about the benefits of a vegan diet, read our Health Portal article!
Tip 4: Watch your salt consumption
Your cardiovascular system will thank you for watching your salt intake. According to studies, too much salt increases the risk of high blood pressure and stroke because of the sodium it contains. The World Health Organization recommends consuming an average of no more than five grammes of salt a day, which corresponds to two grammes of sodium.
Is salt healthier than we thought? The recommendation to consume salt and sodium have recently been challenged. Analysis of data from the large-scale PURE study showed that salt intake only increased the risk of disease above five grammes of sodium. Below these levels, salt even showed health benefits.[32, 33]
Tip 5: Receive enough potassium
The mineral potassium, in turn, has been shown in several studies to reduce the risk of developing and dying from cardiovascular disease. Potassium is found in the following foods:
- Legumes such as beans, peas and lentils
- Bananas, apricots and citrus fruits
- Dried fruits such as dates and raisins
Tip: If you consistently eat your five-a-day, which means eating five servings of fruits and vegetables a day, you should be getting enough potassium.
Tip 6: Enjoy regular exercise
The NHS recommends that adults should engage in moderate activity for at least 150 minutes a week, preferably five times a week for 30 minutes each time. Even longer walks can have a positive effect on your health. Or you can exercise more intensively for 75 minutes a week. Whether you choose to do more intensive sport or go for regular long walks, the main thing is that you are active.
Physical activity has a positive effect on body weight, blood pressure, cholesterol and the risk of diabetes – all factors, which lead to cardiovascular disease.
Tip 7: Lower your blood sugar
Maintain a long-term blood glucose level of less than seven per cent – otherwise you will develop diabetes. Diabetes is a clear risk factor for various cardiovascular diseases. The most important measures to keep blood sugar low are a healthy body weight and regular exercise.
Tip: Discover what a normal blood sugar level is and how to maintain healthy blood glucose levels in our dedicated Health Portal article on Hba1c.
Tip 8: Reduce stress and prevent depression
Psychological stress and depression can increase your risk of cardiovascular disease. For example, chronic stress causes your body to release more of the stress hormone cortisol. This excess cortisol then causes greater inflammation in your blood vessels and thus increases your risk of atherosclerosis. Acute stress also causes blood pressure to skyrocket – but scientists are still debating whether chronic stress and elevated cortisol levels have an effect on the risk of high blood pressure.
According to a study in the journal The Lancet, emotional stress also leads to increased activity in the amygdala, which controls emotions in the brain including fear and anger. The researchers linked increased amygdala activity to inflammation in blood vessels, among other things. According to other studies, post-traumatic stress disorder (PTSD) and other stress-related disorders may increase the risk of cardiovascular disease.
So, never underestimate the importance of reducing stress in your everyday life. You can do so by adopting lifestyle changes, such as working less and spending more time with family. Planned downtime and relaxation techniques such as mediation, yoga and autogenic training most likely will help. You should also seek treatment from doctors and therapists for stress-related disorders, serious depression and burnout. You can also monitor your stress levels with a cortisol test – either at home or at your doctor’s.
How to prevent heart disease through medication
If your risk of cardiovascular disease is already high, doctors may prescribe medications to prevent risk factors from progressing further. For example, high blood pressure is often treated with antihypertensive drugs. Otherwise, if left untreated, high blood pressure would increase the likelihood of developing other diseases in the long run, such as heart failure or coronary heart disease. Doctors call these active preventive measures ‘primary prevention’.
Scientific studies show that secondary prevention is just as effective – if not more. This refers to lifestyle changes such as more exercise, a healthier diet and abstaining from alcohol and cigarettes. For people with an increased risk of cardiovascular disease, they should carry out preventive measures with both medication and lifestyle changes.
How can cardiovascular diseases be treated?
Many cardiovascular diseases cannot be cured. In most cases, the aim of treatment is to ensure that they do not progress further and that those affected suffer as little discomfort as possible. Medication is often used, and in severe cases, surgery is also possible, including heart transplants.
One problem is that cardiovascular disease symptoms are not easy to recognise. We humans cannot feel directly when our blood pressure is too high or when plaque builds up in our blood vessels. People affected by cardiovascular disease often show hardly any symptoms for a long time, meaning the CVD goes unnoticed and is not treated for a long time.
Many of the risk factors for cardiovascular disease are related to parameters that can be measured – for example with a cholesterol test, HbA1c test, vitamin D test or omega-3 test. If you find that, after taking such tests, your values are not where you’d like them to be or where you’d expect them to be, you can take targeted countermeasures to do something for your cardiovascular system.
How to prevent heart disease – at a glance
What is CVD?
Cardiovascular diseases are diseases that affect the heart and blood vessels. High blood pressure and arteriosclerosis often appear first. The result of these diseases can be heart failure, heart attack and stroke – which is why cardiovascular diseases are also the most common cause of death worldwide.
What are the most common cardiovascular diseases?
The most common cardiovascular diseases include high blood pressure (hypertension), arteriosclerosis (hardening of the arteries), coronary heart disease (ischaemic heart disease) and heart failure (cardiac insufficiency).
What are the risk factors of cardiovascular disease?
Known risk factors for cardiovascular disease include obesity, physical inactivity, smoking, high LDL cholesterol and high blood sugar.
Scientists suspect that deficiencies in the unsaturated fatty acid omega 3 and in vitamin D may also make diseases of the heart and blood vessels more likely.
How can I prevent cardiovascular disease?
There are many ways to reduce the risk of disease through lifestyle: stop smoking; maintain a healthy diet; exercise regularly, keep LDL cholesterol, blood sugar, and blood pressure low and reduce chronic stress.
If your risk of cardiovascular disease is already high, you should see your doctor and take preventive measures with medication, if necessary.
 Dornquast, C., Kroll, L. E., Neuhauser, H. K., Willich, S. N., Reinhold, T., Busch, M. A. “Regional Differences in the Prevalence of Cardiovascular Disease,” Dtsch. Aerzteblatt Online, Oct. 2016, doi: 10.3238/arztebl.2016.0704.
 GBD 2017 Causes of Death Collaborators, “Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017,” Lancet Lond. Engl., vol. 392, no. 10159, pp. 1736–1788, 10 2018, doi: 10.1016/S0140-6736(18)32203-7.
 Dagenais, G. R. et al., “Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study,” The Lancet, vol. 0, no. 0, Sep. 2019, doi: 10.1016/S0140-6736(19)32007-0.
 Statistisches Bundesamt (Destatis), “Todesursachen,” Statistisches Bundesamt, [Online], available at https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Todesursachen/_inhalt.html, accessed on September 4, 2019.
 Classen, M., Diehl, V., Schmiegel, W., Innere Medizin, 6th Edition Urban & Fischer Verlag/Elsevier GmbH, 2009.
 Centers for Disease Prevention and Control, “High Blood Pressure,” page reviewed on July 19, 2021, available at https://www.cdc.gov/bloodpressure/facts.htm, accessed on August 2, 2021.
 Ference, B. A. et al. “Association of Genetic Variants Related to Combined Exposure to Lower Low-Density Lipoproteins and Lower Systolic Blood Pressure With Lifetime Risk of Cardiovascular Disease,” JAMA, September 2019, doi: 10.1001/jama.2019.14120.
 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF), “Nationale VersorgungsLeitlinie Chronische KHK – Langfassung, 5. Auflage,” 2019, doi: 10.6101/AZQ/000419.
 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF), “Nationale VersorgungsLeitlinie Chronische Herzinsuffizienz – Kurzfassung, 2. Auflage.” 2017, doi: 10.6101/AZQ/000407.
 American Heart Association, “About Arrhythmia,” www.heart.org, [online], available at https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia, accessed on September 10, 2019.
 National Herat, Lung and Blood Institute, “Arrhythmia | National Heart, Lung, and Blood Institute (NHLBI),” [online], available at https://www.nhlbi.nih.gov/health-topics/arrhythmia, accessed on September 10, 2019.
 Piepoli M. F. et al., “2016 European Guidelines on cardiovascular disease prevention in clinical practiceThe Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR),” Eur. Heart J., vol. 37, no. 29, pp. 2315–2381, Aug. 2016, doi: 10.1093/eurheartj/ehw106.
 Iliodromiti, S. et al., “The impact of confounding on the associations of different adiposity measures with the incidence of cardiovascular disease: a cohort study of 296 535 adults of white European descent,” Eur. Heart J., vol. 39, no. 17, pp. 1514–1520, May 2018, doi: 10.1093/eurheartj/ehy057.
 Rangel-Huerta, O. D., Gil, A. “Omega 3 fatty acids in cardiovascular disease risk factors: An updated systematic review of randomised clinical trials,” Clin. Nutr. Edinb. Scotl., vol. 37, no. 1, pp. 72–77, 2018, doi: 10.1016/j.clnu.2017.05.015.
 Cao, Y. et al., “Omega-3 Fatty Acids and Primary and Secondary Prevention of Cardiovascular Disease,” Cell Biochem. Biophys., vol. 72, no. 1, pp. 77–81, May 2015, doi: 10.1007/s12013-014-0407-5.
 Rizos, E. C., Elisaf, M. S. “Does Supplementation with Omega-3 PUFAs Add to the Prevention of Cardiovascular Disease?,” Curr. Cardiol. Rep., vol. 19, no. 6, pp. 47, 2017, doi: 10.1007/s11886-017-0856-8.
 Rawshani, A. et al., “Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes,” N. Engl. J. Med., vol. 379, no. 7, pp. 633–644, Aug. 2018, doi: 10.1056/NEJMoa1800256.
 Dobnig, H. et al., “Independent Association of Low Serum 25-Hydroxyvitamin D and 1,25-Dihydroxyvitamin D Levels With All-Cause and Cardiovascular Mortality,” Arch. Intern. Med., vol. 168, no. 12, pp. 1340–1349, Juni 2008, doi: 10.1001/archinte.168.12.1340.
 Vacek, J. L., Vanga, S. R., Good, M., Lai, S. M., Lakkireddy, D., Howard, P. A, “Vitamin D deficiency and supplementation and relation to cardiovascular health,” Am. J. Cardiol., vol. 109, no. 3, pp. 359–363, Feb. 2012, doi: 10.1016/j.amjcard.2011.09.020.
 D. Ä. G. Ärzteblatt Redaktion Deutsches, “Zeitliche Trends kardiometaboler Risikofaktoren bei Erwachsenen,” Deutsches Ärzteblatt, October 21, 2016, [online], available at https://www.aerzteblatt.de/archiv/183030/Zeitliche-Trends-kardiometaboler-Risikofaktoren-bei-Erwachsenen, accessed on August 28, 2019.
 Statista, “Verbreitung des Rauchens in Deutschland bis 2025 | Statista,” [online], available at https://de.statista.com/statistik/daten/studie/596512/umfrage/verbreitung-des-rauchens-in-deutschland-nach-geschlecht/, accessed on September 5, 2019.
 Deutsches Krebsforschungszentrum, Tabakatlas Deutschland 2015. Lengerich, Westf: Pabst Science Publishers, 2015.
 National Health Service, “Alcohol units,” available at https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/, accessed on 3 September 2021.
 Ronksley, P. E., Brien, S. E., Turner, B. J., Mukamal, K. J., Ghali, W. A. “Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis,” BMJ, vol. 342, pp. d671, February 2011, doi: 10.1136/bmj.d671.
 Griswold, M. G., et al., “Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016,” The Lancet, vol. 392, no. 10152, pp. 1015–1035, September 2018, doi: 10.1016/S0140-6736(18)31310-2.
 Knott, C. S., Coombs, N., Stamatakis, E., Biddulph, J. P. “All cause mortality and the case for age specific alcohol consumption guidelines: pooled analyses of up to 10 population based cohorts,” BMJ, vol. 350, p. h384, February 2015, doi: 10.1136/bmj.h384.
 Bonnefont-Rousselot, D. “Resveratrol and Cardiovascular Diseases,” Nutrients, vol. 8, no. 5, May 2016, doi: 10.3390/nu8050250.
 Mozaffarian, D., Katan, M. B., Ascherio, A., Stampfer, M. J., Willett, W. C. “Trans Fatty Acids and Cardiovascular Disease,” N. Engl. J. Med., vol. 354, no. 15, pp. 1601–1613, Apr. 2006, doi: 10.1056/NEJMra054035.
 Elmadfa, I. und Leitzmann, C., Ernährung des Menschen, 6th Edition, Stuttgart: Eugen Ulmer KG, 2019.
 Tong, T. Y. N. et al., “Risks of ischaemic heart disease and stroke in meat eaters, fish eaters, and vegetarians over 18 years of follow-up: results from the prospective EPIC-Oxford study,” BMJ, vol. 366, pp. l4897, September 2019, doi: 10.1136/bmj.l4897.
 World Health Organization (WHO), Guideline: Sodium intake for adults and children. Place of publication not identified: World Health Organization, 2016.
 D. Ä. G. Ärzteblatt Redaktion Deutsches, “Salz könnte weniger Menschen schaden, als bisher angenommen,” Deutsches Ärzteblatt, August 10, 2018, [online], available at https://www.aerzteblatt.de/nachrichten/97041/Salz-koennte-weniger-Menschen-schaden-als-bisher-angenommen, accessed on September 6, 2019.
 Mente, A. et al., “Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study,” The Lancet, vol. 392, no. 10146, pp. 496–506, Aug. 2018, doi: 10.1016/S0140-6736(18)31376-X.
 C. Waller et al., “Blunted Cortisol Stress Response and Depression-Induced Hypocortisolism Is Related to Inflammation in Patients With CAD,” J. Am. Coll. Cardiol., vol. 67, no. 9, pp. 1124–1126, March 2016, doi: 10.1016/j.jacc.2015.12.031.
 American Heart Association, “Managing Stress to Control High Blood Pressure,” www.heart.org, [online], available at https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-stress-to-control-high-blood-pressure, available at September 10, 2019.
 Tawakol, A. et al., “Relation between resting amygdalar activity and cardiovascular events: a longitudinal and cohort study,” The Lancet, vol. 389, no. 10071, pp. 834–845, February 2017, doi: 10.1016/S0140-6736(16)31714-7.
 Fang, F. et al. “Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study,” The BMJ, vol. 365, 2019, doi: 10.1136/bmj.l1255.
 Kolenda, K-D., “Sekundärprävention der koronaren Herzkrankheit: Effizienz nachweisbar - Wirksamkeit von Lebensstilveränderungen im Vergleich zur medikamentösen Therapie,” Dtsch. Ärztebl. Int., vol. 102, no. 26, 2005.
 World Health Organization, “Cardiovascular diseases (CVDs),” available at https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds), accessed on August 2, 2021.
 National Health Service “Cardiovascular disease,” page reviewed on September 17, 2018, available at https://www.nhs.uk/conditions/cardiovascular-disease/, accessed on August 2, 2021.
 Centers for Disease Control and Prevention, “Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association’s 2017 Hypertension Guideline—NHANES 2013–2016external icon,”Atlanta, GA, US Department of Health and Human Services, 2019.
 World Health Organization, “The top 10 causes of death,” available at https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death, accessed on August 2, 2021.
 Centers for Disease Control and Prevention, “Age-adjusted death rates for selected causes of death, by sex, race, and Hispanic origin: United States, selected years 1950–2018, available at https://www.cdc.gov/nchs/data/hus/2019/005-508.pdf, accessed on August 2, 2021.
 Centers for Disease Control and Prevention, “Current Cigarette Smoking Among Adults in the United States,” available at https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm, accessed on August 2, 2021.
 Blood Pressure UK, “Blood Pressure Facts and Figure,” available at http://www.bloodpressureuk.org/news/media-centre/blood-pressure-facts-and-figures/, accessed on 3 September 2021.
 Office for National Statistics, ‘Total deaths in the UK in 2020 and deaths from heart attacks, heart disease, cancer, and Alzheimer's and dementia, 2016 to 2020’, available at https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/totaldeathsintheukin2020anddeathsfromheartattacksheartdiseasecancerandalzheimersanddementia2016to2020, accessed on 3 September 2021.
 Office for National Statistics, ‘Adult smoking habits in the UK: 2019’, available at https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2019, accessed on 3 September 2021.