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............................................................................................................................................................................. The precise mechanism by which mental disorders increase CVD remains uncertain. The detrimental effects are potentially caused by unhealthy lifestyle, increased exposure to socioeconomic stressors, and cardiometabolic side-effects of some medications,113 but also by direct effects of the amygdala-based fear-defence system and other direct pathophysiological pathways.303 Abuse of psychostimulants (e.g. cocaine) is a powerful trigger of myocardial ischaemia.306

Further, the capacity of these patients to adaptively use the healthcare systems is impaired due to their mental condition (e.g. not being able to trust other people and seek help, impaired capacity to be adherent).100 Barriers on the part of healthcare providers are stigmatizing attitudes, insufficient mental health literacy, and lack of confidence in mental healthcare.307309 Although patients with mental disorders have an increased CVD risk, they receive a lower rate of recognition and treatment of traditional ASCVD risk factors.310 Preliminary evidence suggests that taking mental disorders into account improves classical CVD risk models.311,312 Certain categories of patients with learning difficulties and associated disorders (such as Down’s syndrome) are at increased risk of CVD disease, but perhaps not specifically ASCVD. However, health inequalities and the prevalence of CV risk factors may be greater in these populations, although epidemiology research is scarce.

3.4.11. Non-alcoholic fatty liver disease Non-alcoholic fatty liver disease (NAFLD) has been associated with an increased risk of myocardial infarction and stroke. NAFLD represents accumulation of ectopic fat; persons with NAFLD are often overweight or obese, and not uncommonly have abnormal BP, glucose, and lipid levels. A recent study investigating whether NAFLD increases CV risk beyond traditional risk factors313 shows that after adjusting for established risk factors, the associations did not persist. Nevertheless, patients with NAFLD should have their CVD risk calculated, be screened for DM, and be recommended a healthy lifestyle with a reduction of alcohol intake.

3.4.12. Sex-specific conditions 3.4.12.1 Obstetric conditions Pre-eclampsia (defined as pregnancy-related hypertension accompanied by proteinuria) occurs in 12% of all pregnancies and is associated with an increase in CVD risk by a factor of 1.52.7 compared with all women,185,186,314 while the RR of developing hypertension is 3187 and DM is 2.184,185 It has not been established whether the increased CVD risk after preeclampsia occurs independently of CV risk factors. The rationale for screening these women for the occurrence of hypertension and DM is, however, quite strong. At present, no separate risk model for women with a history of hypertensive disorders of pregnancy seems necessary, despite their higher baseline risk.315 Pregnancy-related hypertension affects 1015% of all pregnancies. The associated risk of later CVD is lower than for preeclampsia but is still elevated (RR 1.72.5).193,314,316,317 Also, the risk for sustained or future hypertension is elevated (RRs vary, from 2.0 to 7.2 or even higher).187,318 Again, however, there was incomplete adjustment for conventional risk factors. The risk of developing DM is also elevated in these women (RR 1.62.0).314,319 Both preterm (RR 1.6) and stillbirth (RR 1.5) have been associated with a moderate increase in risk of CVD.316 Finally, gestational DM confers a sharply elevated risk of future DM, with up to 50% of affected women developing DM within 5 years after pregnancy, and an up to two-fold increased risk of CVD in the future.188,320 Screening by fasting glucose or HbA1c may be preferable to oral glucose tolerance testing.191,321

3.4.12.2 Non-obstetric conditions Polycystic ovary syndrome affects 5% of all women in their fertile years.322,323 It has been associated with an increased risk of CVD.314 The risk of developing hypertension is probably increased, but data are conflicting.324 Polycystic ovary syndrome is associated with a higher risk of developing DM (RR 24),189,190 suggesting that periodic screening for DM is appropriate. Premature menopause occurs in roughly 1% of women <_40 years of age. Up to 10% of women experience an early menopause, defined as that occurring by 45 years of age.314,325 Early menopause is associated with an increased risk of CVD (RR 1.5).326328 A linear inverse relationship between earlier menopause and CHD risk has been found, whereby each 1-year decrease in age at menopause portended a 2% increased risk of CHD.329

3.4.12.3 Erectile dysfunction Erectile dysfunction (ED), defined as the consistent inability to reach and maintain an erection satisfactory for sexual activity, has a multifactorial cause. It affects almost 40% and more than 50% of men over 40 years and 60 years of age, respectively.330,331 Men with ED have an increased risk of all-cause mortality [odds ratio (OR) 1.26, 95% CI 1.011.57] and CVD mortality (OR 1.43, 95% CI 1.002.05). ED and CVD share common risk factors (hypercholesterolaemia, hypertension, insulin resistance and DM, smoking, obesity, metabolic syndrome, sedentary lifestyle, and depression) and a common pathophysiological basis of aetiology and progression.332,333 Medication used to prevent CVD, such as aldosterone receptor antagonists, some beta-blockers, and thiazide diuretics, can cause ED.330,332335 ED is associated with subclinical vascular disease,336 and precedes CAD, stroke, and PAD by a period that usually ranges from 2 to 5 years (average 3 years). Men with ED have a 4459% higher risk for total CV events, 62% for AMI, 39% for stroke, and 2433% for allcause mortality, with a higher risk in those with severe ED.337341 There is strong evidence that CVD risk assessment is needed in men presenting with ED.336,342 In men with ED and low-to-intermediate CVD risk, detailed risk profiling by, for example, CAC score is suggested, but so far not supported by evidence.338,341 Assessment of ED severity and physical examination should be part of the first-line CVD risk assessment in men.333,341 Lifestyle changes are effective in improving sexual function in men: these include vigorous physical exercise,334,343 improved nutrition, weight control, and smoking cessation.343345

4 Risk factors and interventions

at the individual level

4.1. Treatment recommendations: classes, grades, and freedom of choice Clear communication about risks and benefits is crucial before any treatment is initiated. Risk communication is discussed in section 3.2.4, Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026