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............................................................................................................................................................................. 3.4.6. Inflammatory conditions Inflammatory conditions increase CVD risk both acutely and over time. The best evidence for chronic inflammation increasing CVD risk is available for rheumatoid arthritis, which increases CVD risk by approximately 50% beyond established risk factors.176 Hence, a low threshold for assessment of total CVD risk is appropriate in adults with rheumatoid arthritis, and one should consider increasing the risk estimate based on the level of disease activity.176 There is also evidence for an approximately 20% increased CVD risk in patients with active inflammatory bowel disease.265

In other chronic inflammatory conditions, such as psoriasis177 and ankylosing spondylitis,178 CVD risk may also be increased. However, the strength of the evidence is less strong, as is the independence of such increased risks from the classical ASCVD risk factors. Nonetheless, it seems prudent to at least consider CVD risk assessment in patients with any chronic inflammatory condition, and to take into account the presence of such conditions when there is doubt regarding initiation of preventive interventions. The cumulative disease burden and recent degree of inflammation are important determinants of the risk-enhancing effect. Apart from optimal anti-inflammatory treatment, CVD risk in inflammatory conditions should be treated with similar interventions as in the general high-risk population, as there is evidence that traditional methods to lessen risk (e.g. lipid-lowering treatment) are just as beneficial in preventing ASCVD.

3.4.7. Infections (human immunodeficiency virus, influenza, periodontitis) Infection with human immunodeficiency virus (HIV) is associated with a 19% increased risk of LEAD and CAD beyond that explained by traditional atherosclerotic risk factors.266,267 However, for those with sustained CD4 cell counts <200 cells/mm3, the risk of incident LEAD events is nearly two-fold higher, whereas for those with sustained CD4 cell counts >_500 cells/mm3, there is no excess risk of incident LEAD events compared with uninfected people.268 CVD and influenza have long been associated, due to an overlap in the peak incidence of each disease during winter months. Epidemiological studies have noted an increase in CV deaths during influenza epidemics, indicating that CV complications of influenza infection, including acute ischaemic heart disease and, less often, stroke, are important contributors to morbidity and mortality during influenza infection. The risk of AMI or stroke is more than four times higher after a respiratory tract infection, with the highest risk in the first 3 days after diagnosis.269 Preventing influenza, particularly by means of vaccination, could prevent influenza-triggered AMI.270 Studies have linked periodontal disease to both atherosclerosis and CVD,271273 and serological studies have linked elevated antibody titres of periodontal bacteria to atherosclerotic disease.274 Nevertheless, if active treatment or prevention of periodontitis improves, clinical prognosis requires further studies despite preliminary evidence.275277

3.4.8. Migraine Migraine is a highly prevalent condition affecting around 15% of the general population.278 There are two main types of migraine— migraine without aura, which is the most common subtype, and migraine with aura, which accounts for about one-third of all migraines; in many patients the two forms coexist.

Available data indicate that migraine overall is associated with a two-fold increased risk of ischaemic stroke and a 1.5-fold increase in the risk of cardiac ischaemic disease.179181,279,280 The associations are more evident for migraine with aura.179,180,280 Given the young mean age of the population affected by migraine, the absolute increase in risk is small at the individual level, but high at the population level because of the high migraine prevalence.281 Several lines of evidence also indicate that the vascular risk of subjects with migraine may be magnified by cigarette smoking182 and by the use of combined hormonal contraceptives.183,281283 Contraception using combined hormonal contraceptives should therefore be avoided in women with migraine.282,283 However, further information is needed as good-quality studies assessing risk of stroke associated with lowdose oestrogen use in women with migraine are lacking.

3.4.9.Sleep disorders and obstructive sleep apnoea Sleep disturbances or abnormal sleep durations are associated with increased CVD risk.284286 Regarding sleep duration, 7 h seems to be optimal for CV health.287 In the general population, the prevalence of general sleep disturbances is around 32.1%: 8.2% for insomnia, 6.1% for parasomnia, 5.9% for hypersomnolence, 12.5% for restless legs disorder and limb movements during sleep, and 7.1% for sleep-related breathing disorder [e.g. obstructive sleep apnoea (OSA)].288 All sleep disturbances are strongly associated with mental disorders and share hyperarousal as an underlying mechanism.289,290 The most important sleep-related breathing disorder is OSA, which is characterized by repetitive episodes of apnoea, each exceeding 10 seconds. Despite the strong associations of OSA with CVD, including hypertension, stroke, HF, CAD, and AF, treatment of OSA by positive airway pressure (PAP) has failed to improve hard CV outcomes in patients with established CVD.291293 Therefore, interventions that include behaviour change (reduction of obesity, alcohol abstinence), sleep hygiene, and stress reduction in addition to PAP are needed.290,294 Regarding hypertension and OSA, there are modest effects of PAP on BP levels, but only in patients with ABPM-confirmed resistant hypertension who use PAP for more than 5.8 h/night.295

3.4.10. Mental disorders The 12-month prevalence of mental disorders or mental health disorders in the general European population is between 27% and 38% depending on sources and definitions.296 All mental disorders (e.g. anxiety disorders, somatoform disorders, substance disorders, personality disorders, mood disorders, and psychotic disorders) are associated with the development of CVD and reduced life expectancy in both sexes.297300 The risk increases with the severity of the mental disturbance and vigilance for (often non-specific) symptoms is crucial.301 The onset of CVD is associated with an approximately 23-fold increased risk of mental disorders compared to a healthy population.115,302 In this context, screening should be performed at every consultation (or 24 times/year). The 12-month prevalence of mental disorders in CVD patients is around 40%, leading to significantly worse prognosis.100,108,303,304 The onset of CVD increases the risk of committing suicide.305 In this context, awareness of anxiety and depression symptoms should be increased. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026