1.1. Background on Cardiovascular Health Globally and in Saudi Arabia

Cardiovascular diseases (CVDs) represent the main cause of mortality and morbidity worldwide; millions are suffering, which places a gross strain on health care. They range from coronary artery disease, heart failure, hypertensive heart disease, and stroke, all having common risk factors. The major modifiable reservoirs of risk for the development and progression of CVDs include hypertension, high cholesterol, diabetes, smoking, obesity, and sedentary lifestyle. Although medical science, particularly pharmacology, has offered immense strides in the management and prognosis of these diseases, they still create immense burdens globally [1]. CVD is an important public health challenge that perturbs Saudi Arabia and is further aggravated by rapid urbanization and large shifts in lifestyle. The prevalence of risk factors such as diabetes, obesity, and smoking has dramatically increased, reflecting a global trend with regional specificities that call for unique approaches. Demographic and epidemiological peculiarities in the Saudi population, genetic predispositions, and cultural practices all influence the extent and expression of CVDs in this population. Variables like these underscore the need for individually tailored public health strategies and interventions. This alone presents the challenge of dual healthcare infrastructure in Saudi Arabia: dealing with CVD and taking preventive measures to curb their incidences in the future. It is important to know how this interplay of these two local factors functions to develop an interventional health approach and policies that would be more effective [2].

1.2. Importance of Studying CVDs in Saudi Arabia

It is important to undertake research on CVDs in Saudi Arabia for a variety of reasons. First is the high prevalence of risk factors for diabetes and obesity, diseases that are exploding disproportionately in the Gulf region, which requires specific research into their effects on cardiovascular health. At the same time, Saudi Arabia is undergoing huge socioeconomic changes affecting health behaviors and access to health care. The understanding of these dynamics becomes critical for the design of effective intervention strategies. Finally, the known genetic and cultural factors in the Saudi population may well influence preconditions and progressions of CVDs, demanding region-specific studies [3]. It also places a considerable economic burden on the Saudi healthcare system in terms of direct and indirect costs for treatment, hospitalization, and productivity loss. An effective reduction in CVDs would lead to a substantial decrease in healthcare expenditure and a dramatic improvement in the quality of life of subjects. Finally, Saudi Arabia’s commitment under Vision 2030 to increase health care and healthy living further underlines the need for focused research and law reform action toward having an effective and winning strategy for health care against CVD [4].

1.3. Objectives: Analyze Risk Factors and Explore Pharmacological Preventive Strategies

This study has two main objectives: first, to critically review the main risk factors responsible for the high incidence of CVD in Saudi Arabia; second, to investigate pharmacological preventive strategies fitting special needs among the Saudi population. In particular, the objectives are as follows.

2.1. Incidence, Prevalence, and Demographic Distribution

With their rates of incidence and prevalence increasing at an alarming rate over the last few decades, CVDs now account for a high percentage of various diseases in Saudi Arabia. The overall prevalence of CVDs, including coronary artery disease, hypertension, and heart failure, was very high. According to studies, nearly one-quarter of the adult population may be affected by some kind of cardiovascular condition [5]. Acute coronary syndrome and myocardial infarction have also increased, reflecting the increasing burden of atherosclerotic diseases (ADs). Hypertension, sometimes referred to as a silent killer, is indeed very prevalent, as a significant percentage of the adult population is diagnosed to have high blood pressure, many of which oftentimes progress to complications such as stroke and heart failure. By the same token, the prevalence of hyperlipidemia, which is another critical risk factor for coronary artery disease, also increases, further compounding this burden of CVDs [6]. The demographic distribution of CVDs in Saudi Arabia shows some interesting trends. It is highest in middle-aged and elderly individuals, but worryingly enough, there is also a trend of appearance of CVDs in more youthful age groups, likely as a result of lifestyle change characteristics such as bad eating habits, sedentary lifestyle, and stress. Gender-wise, the difference is striking, as it is usually observed that CVDs are more common in men compared to women; however, the cardiovascular danger does surge considerably in postmenopausal women [7]. There are geographical differences in the distribution of CVDs within Saudi Arabia. Cities have higher rates of CVD compared to rural regions due to increased pollution, sedentary lifestyles, and changes in dietary patterns. However, rural areas are not far behind as the effects of adopting an urban lifestyle and diet spread. In addition, morbidity and mortality are noticed more in certain areas that have low accessibility to health services due to late diagnosis and poor treatment [8]. The demographic distribution of CVDs in Saudi Arabia is also critical with respect to interplaying genetic factors. Familial hypercholesterolemia (FH) and other genetic predispositions to cardiovascular conditions are relatively common, underpinning cases of very early-onset CVDs in several individuals. It is these genetic factors that, along with those induced by environmental and lifestyle factors, cumulatively contribute to a complex epidemiological landscape; this demands specially aimed intervention strategies to nail down the biggest “moveable feast” contributors [7].

2.2. Comparison With Global Trends

Comparing the epidemiology of CVDs in Saudi Arabia to global trends reflects several similarities and distinctions. Nevertheless, at a worldwide level, CVD remains one of the leading causes of death and disability. In industrialized countries, mortality rates from CVDs are now decreasing due to improved health care, early diagnosis, and proper control measures being instituted [9]. In contrast, Saudi Arabia, as in other developing and middle-income countries, is experiencing a rapid rise in the burden of CVD resulting from intense urbanization, lifestyle changes, and increases in cardiovascular risk factors such as diabetes, obesity, and hypertension [2]. Table 1 shows a comparative analysis based on epidemiological data and risk factors with nearby countries. The nation has some of the world’s highest prevalence rates for hypertension, diabetes, and hyperlipidemia, with markedly higher than average global diabetes prevalence, thereby greatly multiplying the risks for CVD. The factors confer lifestyle-related aspects, especially high-calorie diets and cigarette smoking, and physical inactivity is sharp due to high economic growth rates and cultural changes [16]. The traditional diet, characterized by saturated fats and excessive sugar intake, together with low activity of sedentary lifestyles, contributes a great way to high morbidity from CVDs. However, smoking remains prevalent among men, further increasing the risks of CVDs. Although CVD predominantly affects older adults worldwide, the trend in Saudi Arabia indicates increased prevalence in the younger population due to high obesity and diabetes rates attributable to the prevailing sedentary lifestyle [17]. Access to health care, however, remains a problem in certain parts, especially the rural areas of Saudi Arabia, leading to delayed diagnosis and increased mortality. Despite the massive investments made in the infrastructure for health care, inequities in the delivery of care exist [18]. As such, concentrated efforts are needed to enhance accessibility and quality of care. Education and policy interventions at the community level have decreased the incidence of CVD in many parts of the world through public health measures. Another country undergoing similar attempts but at a slower rate of influence is Saudi Arabia, due to sociocultural factors and variable public awareness. This includes efforts through Vision 2030 for healthier lifestyles and the improvement of health service quality within the country. This corroborates the global agenda on many of the risk factors and challenges for CVDs faced by Saudi Arabia, although it experiences many unique quips of local epidemiological and sociocultural features that raise disease liability [19]. Such challenges must be addressed with individual public health strategies tailored to meet Saudi population needs, while learning from successful global interventions.

2.3. Socioeconomic and Cultural Influences

Socioeconomic and cultural factors in Saudi Arabia remain prime determinants in the prevalence of CVDs and also in their management. Fast urbanization and economic growth caused a shift in lifestyle. Highly saturated fat, sugar, and processed food diets contribute to high indices of obesity [20], diabetes, and hypertension—the major risk factors for CVD [21]. A sedentary lifestyle has become common due to a lack of recreational spaces and extremely bad weather conditions; it is mostly the young population that is affected [22]. It is also seen that culture affects the practice of this physical activity. This is mainly found in women, where social norms act as constraints to carrying out exercise. Traditional eating habits also have a role. A Saudi diet, high in meat, rice, and soft drinks, contributes to very high rates of dyslipidemia and insulin resistance. Public health campaigns have little effect on changing entrenched eating habits. Large family structures and social norms of hospitality result in excesses of unhealthy foods being offered. Endorsement by community leaders and exploitation of social networks could be a potent means of promoting cardiovascular health [23]. However, other religious and cultural events, such as Ramadan, also impact health behaviors. This presents a challenge to cardiovascular health in the event of inappropriate planning, whereby a person has to fast all day only to consume extensive meals at nightfall. The strategies envisaged in addressing the risk factors of socioeconomic and cultural nature to cardiovascular health in Saudi Arabia include community-based intervention measures, culturally sensitive health promotion campaigns, and policy decisions to enhance accessibility to health care for all in the different socioeconomic groups [24]. More effective cardiovascular health initiatives can be developed for the Saudi population by understanding and addressing these influences.

3.1. Age

CVD is more likely to affect older adults. Age is one of the major nonmodifiable risk factors. A great correlation between aging and chronic inflammation is shown in a study by Sarker et al. The study showed that human polynucleotide phosphorylase plays an important role in pathological changes with age associated with the generation of proinflammatory cytokines and the generation of reactive oxygen species (ROS); additionally, the generation of cytokines with aging is also related to mitochondrial dysfunction, which directly or indirectly correlates with impairment of cellular physiological function such as normal cellular signaling pathway, cell cycle, and cell growth [25]. Also, aging has a negative impact on vascular and cardiac function such as a decrease in the elasticity of vasculature, an increase in its stiffness, and luminal enlargement, and these changes are accompanied by increased vascular calcification and endothelial dysfunction. The decline in cardiac function includes hypertrophy of the myocardium, thus decreasing ejection fraction, systolic and diastolic dysfunction, and cardiac muscle remodeling [26].

3.2. Gender

Gender difference is directly related to differences in physiological, psychological, and emotional differences in males and females. Several studies showed that males are more prone to cardiovascular disorders than females, and this can also be due to gender-based assumptions of facing more risky situations and more exposure to cigarette smoking and alcohol consumption. Now, according to the Global Gender Gap Report of 2012, the level of inequality (e.g., financial, educational, and medical) between men and women in North America and Europe has decreased considerably since 2006 due to economic responsibility. Along with these differences, hormonal differences and differences in the physiological makeup of both genders also play a part in the increased prevalence of CVD [27]. Studies found that estrogen acts as a protective agent against cardiovascular risk, which directly relates to the increased prevalence of CVD in males and postmenopausal females, whereas testosterone also offers minimal cardioprotective benefits, which signifies the risk of cardiac events in old males—suggesting hormonal replacement therapy (HRT) as an agent for the prevention of CVD [28].

4.1. Overview of Antihypertensives, Lipid-Lowering Agents, Antidiabetics, Antiplatelets, and Anticoagulants

Hypertension is a lifelong condition to control hypertension, and a medication regimen should be used continuously to prevent further cardiovascular complexity. Some of the important agents that maintain or ideally lower blood pressure affect different physiological systems. Some of the better examples are diuretics, which majorly impact the renin–angiotensin aldosterone system (RAAS), to control fluid balance to keep blood pressure in check, and diuretics are majorly prescribed by physicians either as monotherapy or as adjuvant agent (Figure 2). The major action of diuretics is on different parts of the nephron such as proximal convoluted tubule, distal convoluted tubule, and loop of Henle, which includes agents of class such as thiazide diuretics and potassium-sparing diuretics; moreover, these agent groups that mainly affect angiotensin include a group that interferes with angiotensin-converting enzyme (ACE) and aldosterone receptor blocking (ARB) agents. The major side effects of this class include electrolyte imbalance and changes in urine volume.

Other drugs that act centrally include adrenergic blockers such as beta blockers (BBs), which provide secondary cardioprotection to the myocardium by reducing stress and increasing oxygen susceptibility, which also has an action on beta-1 selectivity and intrinsic sympathomimetic activity. The major side effects of this class are due to its nonselectivity such as bronchospasm, risk of hyperglycemia, and risk of cardiac output with prolonged use. Along with BBs, alpha-blockers though not widely prescribed have well-established therapeutic efficacy agents such as prazosin and doxazosin, which are major pharmacological molecules of the class. One of the earliest groups of antihypertensive medications is centrally acting medication, which is still used to treat hypertension. The class’s archetypal medication, methyldopa, was first believed to have a peripheral effect, but later research revealed a central effect: Activation of α-adrenoceptors in the vasomotor center reduces sympathetic outflow, which lowers peripheral vascular resistance and slightly lowers heart rate and cardiac output. One of the most well-tolerated antihypertensive medications is still methyldopa. However, safe lower dosages can minimize the most common side effects of centrally acting medications, which include drowsiness, dry mouth, and impotence.

Another antihypertensive agent majorly includes vasodilators because of their adverse impact profiles, and directly acting vasodilators such as minoxidil and hydralazine are rarely used. Hydralazine is used to treat preeclamptic hypertension. Furthermore, male pattern baldness is treated topically with minoxidil due to its persistent effects. Vasodilators relax the smooth muscle in the arteries that provide resistance (arteriolar vessels). Adenosine triphosphate–dependent potassium channels in smooth muscle cell membranes allow minoxidil to accomplish this. By stimulating adenylate cyclase, hydralazine increases intracellular cyclic guanosine monophosphate. Vasodilatation causes RAS activation and reflex cardiac stimulation, which can lead to cardiac ischemia. Diuretics or BBs may counteract these compensatory responses [53, 54].

The main focus of lipid-lowering agents is to decrease LDL while maintaining high-density lipoprotein to decrease the risk of atherosclerosis and further related complications. The main function of statins is competitively inhibiting the rate-limiting 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, and statins lower the internal production of cholesterol. LDL-C receptor surface expression rises as a result of decreased internal synthesis of cholesterol, and this raises LDL-C uptake. Lower serum LDL-C, ApoB-100, and triglyceride levels are the end outcome of this. In clinical practice, the dose-dependent efficacy of statins is used to escalate treatment for at-risk patients from low-/medium-intensity to high-intensity statin medication due to the competitive inhibition of HMG-CoA. The major drawback of this class is rhabdomyolysis, which refrains prescribers from prescribing statins (Figure 2).

Another agent works by disrupting the Niemann-Pick C1-like 1 protein (NPC1L1), and ezetimibe specifically prevents the small intestine from absorbing cholesterol while leaving other minerals and vitamins intact. Patients with NPC1L1 mutations have significantly lower LDL-C values and a decreased risk of coronary heart disease (CHD). When used in conjunction with statin monotherapy, ezetimibe and statins reduce LDL-C by approximately 24%, ApoB-100 by approximately 14%, triglycerides by approximately 12%, and high-sensitivity C-reactive protein (hsCRP) by approximately 13%, all while preserving HDL-C levels [55].

Fibrates, which include fenofibrate, bezafibrate, and gemfibrozil, raise HDL-C by up to 20% depending on the fibrate class and decrease triglyceride concentrations by about 50% and LDL-C by 20%, respectively, by activating the peroxisome proliferator receptor alpha (PPAR-α). Treatment with fibrates is linked to an increased risk of gastrointestinal distress, skin rashes, myopathy, and elevation of liver enzymes.

Along with pharmacological options, nonpharmacological agents such as omega-3 fatty acids and fish oil supplements are also good choices for treatment to reduce triglycerides and lipoprotein. In vitro and in vivo experimental studies highlight EPA’s and DHA’s distinct effects on inflammation, cellular membranes, platelets, and triglycerides, which could lead to the observed differential MACE outcomes. These effects of differential treatment could also depend on the examined patient population, comparator, dosage schedule, and omega-3 fatty acid administered [56]. Patients with dyslipidemia are being treated with several additional pharmaceutical interventions, including niacin and bile acid sequestrants. By binding to intestinal cholesterol and preventing its absorption in the small intestine, bile acid sequestrants such as cholestyramine, colesevelam, and colestipol efficiently remove it from enterohepatic cholesterol circulation [57, 58].

Apart from insulin, which works on beta cells of the pancreas in the patient with diabetes mellitus, many other oral agents are responsible for maintaining blood sugar levels including sulfonylureas, as well as repaglinide and nateglinide, whose site of action is pancreatic B cells and the molecular target is SU receptors/K-ATP channels. The major adverse effects include hypoglycemia and weight gain. The other safe agent used in prescribing guidelines is metformin (biguanides), which is a widely used antidiabetic, whose major site of action is the liver (muscle) and has major side effects such as gastric disturbances and lactic acidosis. Other agents include acarbose, voglibose, and thiazolidinediones (pioglitazone and rosiglitazone) [58].

Antithrombotic medications are majorly those pharmacological compounds that suppress thrombolytic events by inhibiting platelet aggregation and coagulation. Antiplatelet drugs and oral anticoagulants are examples of antithrombotic medications and are among the most commonly prescribed drugs in both primary and secondary care. Antiplatelet drugs stop the platelet adhesion and aggregation process and inhibit the formation of platelet plugs. Different classes work on different sites of action to inhibit the main event. The major derivatives of anticoagulant agents are mostly vitamin K derivatives, which include heparin and its natural and synthetic derivatives. The major side effect of this class of medication includes severe blood loss if ill-monitored [59–61]. Current CVD treatment guidelines and real-world practices in Saudi Arabia demonstrate both alignment with and some discrepancies from international treatment recommendations. Saudi Arabia demonstrated its commitment to international CVD management standards through the publication of updated Dyslipidemia Management Guidelines in 2022 designed to establish an all-encompassing strategy for cardiovascular risk control. Saudi Arabia has put in place interventions to tackle common modifiable risk factors including obesity, hypertension, and diabetes within its population. Saudi Arabian research demonstrates that cardiac rehabilitation (CR) programs are successful in secondary prevention according to global health standards. International guidelines support the use of statins as a primary lipid-lowering treatment for patients suffering from chronic coronary disease. Although progress has been made, certain domains still need enhancement to achieve complete international recommendation alignment. Saudi Arabia fails to provide widespread access to CR programs although these programs have demonstrated significant benefits. Research demonstrates that LDL-cholesterol goals are met by approximately 30% of patients, which shows deficiencies in screening methods and treatment procedures along with shortcomings in adherence to international standards. Also, the Kingdom of Saudi Arabia has developed health promotion strategies for heart disease prevention, which remain unadopted on a large scale and lack enforcement. Saudi Arabia continues to work on establishing its national CVD risk screening program as advised in the 2022 CVD report. Saudi Vision 2030 plans to decrease CVD burdens by introducing comprehensive health care nationwide. National registries and digital platforms exist as proposals to enhance research specific to populations and boost CVD surveillance. The country investigates government-backed genetic testing options for detecting individuals at risk of CVD and prioritizes primary prevention methods through public health programs and educational campaigns. Saudi Arabia has successfully aligned its CVD management with international standards but still needs to improve in both the execution and reach of evidence-based treatments. Persistent work toward closing these existing healthcare service gaps remains vital to enhance cardiovascular health results among Saudi citizens [62].

4.2. Current Practices in Saudi Arabia: Prescribing Patterns, Accessibility, and Affordability

When the prescribing pattern of Saudi Arabia was compared with national guidelines, it seemed to have deviation by a great percentage. Furthermore, just 35% of patients who begin medication therapy are prescribed diuretics, defying Saudi guidelines that suggest thiazide diuretics be used in the majority of cases of mild, uncomplicated hypertension. Contrarily, a large portion of doctors (60%) prescribe BBs, calcium channel blockers (CCBs), and angiotensin-converting enzyme inhibitors (ACEIs)—drugs that are only advised for specific, rare cases of moderate hypertension. In the cases of pregnancy guidelines to manage hypertensive patients, the recommended medication for pregnant hypertensive women is methyldopa, whereas labetalol is recommended for those with concurrent renal disorders, according to SHMG. Regarding this, this study found a reasonable level of adherence to such standards (about 60%). Remarkably, there was a significant trend toward direct vasodilators, which are not included in the SHMG recommendations at all. Regardless of the type of facility, the aforementioned trends were almost the same in the majority of cases [63]. When compared to a less-intensive BP strategy, the study’s findings indicate that patients in Saudi Arabia who are at high risk of CVD might benefit financially from more intense blood pressure management. This result thus offers compelling evidence in favor of this strategy’s implementation in the Saudi healthcare system. Along with hypertension, AD is the leading cause of death worldwide and in Saudi Arabia. A meta-analysis highlights the proportion of patients with coronary artery disease and peripheral artery disease. In patients with CAD and PAD, the recommended targets for blood pressure, blood glucose, and LDL-C were identified as 40% and 36%, 70% and 66%, and 32% and 28% of physicians, respectively. Physicians with CAD and PAD recommended starting antiplatelet medicines, ACEIs, statins, and nicotine replacement treatment for smokers, respectively, 98% and 97%, 52% and 34%, 61% and 56%, and 50% and 43%. There are gaps in information and action regarding the extent of physician understanding of atherosclerosis risk reduction therapy in Saudi Arabia. It is necessary to issue a call to action to put into practice practical measures that will motivate medical practitioners to employ prevention therapy and raise public awareness [4, 64, 65]. Table 2 shows a review of studies selected for their focus on CVD prevalence among Saudi Arabia’s population together with an evaluation of their methodological quality and regional health insights. The CAPTURE study received focused attention because of its direct topic relevance and its wide multinational reach combined with noninterventional research methodology. The study stands out in this field because its weighted prevalence and extensive sample size enhance the reliability of its conclusions. The research opted for an analytical cross-sectional observational study to highlight primary healthcare centers. The study’s cross-sectional approach sheds important light on health behaviors and CVD risk factors that help to explain cardiovascular health circumstances in Saudi Arabia. The study from King Abdulaziz University (KAU) made it to our analysis because it centered on young adult participants. Researchers applied randomized sampling and controlled environments to conduct a longitudinal study, which provides enhanced insight into CVD within this key population group. The study that applied a successive sampling strategy received selection due to its dynamic sampling technique. The research examined clinical manifestations while monitoring temporal changes to enable effective CVD population evolution tracking. The research team included a treatment-comparative randomized study because of its strong methodology and randomized approach. While its primary focus is treatment effectiveness research, this study delivers an additional understanding about CVD prevalence, making it a useful contribution to the field literature.

5.1. Primary Prevention: Public Health Initiatives, Lifestyle Programs, and Early Detection

5.1.2. Lifestyle Changes

The risk of CVDs can be further reduced by employing lifestyle changes. This includes several factors, which are described briefly (Figure 3).

5.1.2.1. Physical Activity

Physical activity is one of the important factors for one’s better health. One of the main risk factors for CHD is physical inactivity [76]. Less than half of individuals, however, engage in the recommended level of frequent aerobic activity. With less than 20% of teenagers completing the recommended 60 min or more of physical activity each day, the situation is considerably worse for the younger generation [77]. Sedentary people have a 150%–240% greater risk of CHD than very physically active people [78]. The Physical Activity Guidelines for Americans 2018 recommend engaging in at least 150 min of moderate-intensity aerobic exercise or 75 min of vigorous exercise and muscle-strengthening activities at least twice a week; yet, only about 25% of Americans do the minimum [79]. It is reported that physical exercise dramatically reduces the chance of getting hypertension in the first place and the risk of adult weight gain according to the 2018 Physical Activity Guidelines Advisory Committee [74]. It is noteworthy that there exists a dose-dependent association between the risk of stroke and heart failure and the amount of physical activity [80]. Overall, physical activity produces only a small effect on lipid levels. The evidence for this is considered moderate according to the 2013 AHA/ACC Guidelines for Lifestyle Management [81]. Regular physical activity may help modestly raise high-density lipoprotein cholesterol but has little effect on LDLC [82]. According to the 2018 Advisory Committee on Physical Exercise for Americans, any quantity of physical exercise is better than none. About 75% of the maximum health advantages are gained by those who adhere to the guidelines, which call for 150 min of moderate or 75 min of strenuous activity every week [74]. Though the additional benefits are less significant, increasing physical activity improves cardiovascular health even further.

An example includes a primary healthcare center in northern Sweden performing a study. A total of 151 higher-risk CVD participants volunteered. Participants were randomly assigned to either the control group or the intervention group. The intervention included circuit and endurance training three times a week supervised by trainers for 3 months and five group sessions of dietary counseling administered by a dietitian. Compared with the control group, the intervention group had significant reductions after 1 year in waist circumference of 1.9 cm, p < 0.001; waist-to-hip ratio of 0.01, p < 0.01; and diastolic blood pressure of 2.3 mmHg, p < 0.05 [83].

5.1.2.2. Diet

Diet is another important lifestyle factor that helps to reduce the chances of CVD. The diet recommendation includes the addition of fish, fibers, whole grains, fruits, and vegetables and managing calories [84]. A unified approach is taken by the AHA’s nutritional guidelines, the Dietary Guidelines Advisory Committee Report (2015–2020), the 2020 Strategic Plan, and the 2013 AHA/ACC Guidelines. They emphasize dietary modifications and more significant lifestyle adjustments to enhance cardiovascular health and lower the risk of CVD [85, 86]. These guidelines consider the above as standard recommendations and often advocate for a diet rich in fruits, vegetables, and whole grains, especially high-fiber-containing ones, fish, legumes, nuts, and nonfat dairy. Consuming alcohol in moderation is also recommended for adult drinkers [87]. They also encourage reductions in refined cereals, sugary drinks, red and processed meats, and saturated and transfats. The recommendations also cannot emphasize enough the need to achieve energy or caloric balance to maintain a healthy weight and reduce the risk of CVD [88].

Evidence and articles about these so-called plant-based diets have increased a lot nowadays. The basic role of such diets is to consume ample amounts of their indicated food, meaning plants, fruits, and vegetables. A plant-based diet includes a low-fat diet, Mediterranean diet, DASH diet, and vegetarian diet. Diets limit the intake of fruits, vegetables, legumes, nuts, and abound red meat, processed meat, sugar, and oils [89–92]. In sharp contrast, recently, a study introduced an hPBDI and rated all the healthy plant foods such as whole grains, fruits/vegetables, nuts/legumes, oils, tea, and coffee in the negative but rated less healthy plant foods such as juices/sweetened beverages, refined grains, potatoes/fries, sweets, and animal foods in the positive, therefore creating a uPBDI. “Such a dietary pattern high in hPBDI would significantly reduce CHD, whereas a high uPBDI dietary pattern, with fewer of the most healthful plant foods, was associated with an increased CHD risk,” the authors conclude after studying 93,329 women in the Nurses’ Health Study and Health Professionals Follow-Up Study. There is a possibility of further lowering the risk of CVD by emphasizing plant-based diets [93]. A work by Bonekamp et al. highlights a network meta-analysis that compared the effects of various popular dietary patterns on cardiovascular risk factors in patients with CVD. A total of 17 randomized controlled trials with more than 6000 participants were included. When compared to minimal dietary intervention, moderate carbohydrate diets appeared to be the most effective in reducing body weight and systolic blood pressure. However, none of these dietary patterns appeared to favorably affect LDLC. Surprisingly, favorable effects seen at less than 6 months seemed to disappear after 12 months. Although some possibly important effects of dietary interventions on cardiovascular risk factors emerged, uncertainties remain due to study heterogeneity and low adherence, especially in medically treated CVD populations. Thus, it is still not very clear about ideal dietary patterns for secondary CVD prevention. However, recent clinical trials suggest that dietary patterns’ potential effects on reduced cardiovascular event risk may, alternatively, act through other physiological pathways [94]. Also, following a heart-healthy diet is recommended, which includes fruits, vegetables, whole grains, lean protein (plant-based and fish), and good fats, and it should be restricted to red and processed meat, refined carbohydrates, and added sugars [95]. In another study, Pant et al. researched the association between a Mediterranean diet and CVD risk with especial emphasis on women, believed to have not been captured widely in reviews until now. The authors presented a systematic analysis of 16 prospective cohorts involving a total of more than 72,000 women, reporting promising findings. They reported that women with high adherence to the Mediterranean diet had a significantly reduced incidence of CVD, total mortality, and CHD when compared to those adhering to it at lower levels. The association observed on incident stroke was not significant, but the trend was reduced. Conclusion: These results lend support to the possible role of the Mediterranean diet in primary prevention. CVD among women: From such observations, one may assume that it is of major importance to have gender-specific dietary guidelines in the prevention of chronic diseases as a whole [96].

5.1.2.3. Weight

Another important risk factor for CVDs is obesity and overweight [97, 98]. It has been identified that obesity is individually a major risk factor for CVD according to AHA. Obesity is also correlated with other risk factors such as high blood pressure, dyslipidemia, metabolic syndrome, and diabetes [99]. An additional concern associated with body fat distribution is that abdominal obesity is a risk factor for CHD in and of itself [100]. Intraabdominal fat buildup encourages insulin resistance, which can result in hypertension, low HDL, increased triglycerides, and glucose intolerance. In 2013, the AHA, ACC, and the Obesity Society released new guidelines to better help clinicians in managing obesity. Key recommendations included the use of BMI to assess health risks. Other advice includes the fact that patients should be informed that a reasonable amount of weight loss can be achieved and maintained for a long time by making lifestyle changes and that this amount of weight loss may bring significant health benefits, including endorsed diets that lead to calorie reduction in order to lose weight, having enrollments of overweight or obese patients in comprehensive lifestyle programs for six months or more, and offering counseling to patients considering bariatric surgery when their BMI and comorbidity are at 40 or higher or BMI 30 or higher with obesity-related conditions, respectively [101]. Effective treatments for weight gain and obesity are basically through lifestyle changes: increasing physical activity and maintaining a healthy diet. It was shown by the Look AHEAD Trial, which uses the NxStage kidney dialysis, which is supported by NIH, that a 7% body weight reduction significantly improved most cardiovascular risk factors except for the levels of LDL cholesterol. However, it cannot show a decrease in the rate of cardiovascular events [102].

5.2. Secondary Prevention: Patient Education

Educating patients will greatly help in the prevention of CVDs as it creates awareness of risk factors for them and how they can be managed. By knowing controllable and uncontrollable risk factors such as high blood pressure, high cholesterol, smoking, poor diet, inactivity, excessive alcohol consumption, age, gender, and family history, patients usually take caution to become healthy [106]. Promotion of a healthy lifestyle would include the following: balanced diet, regular exercises, and maintenance of a healthy weight. Patients need to be told about the heart-healthy food included in the diet such as fruits, vegetables, whole grains, and lean proteins. Exercise can be in any form such as walking, jogging, and swimming [107].

Education on smoking cessation and reduction in alcohol intake, with resources and patronage to back it up, can drastically cut down the bundle of CVD risk. Regular follow-up of monitoring blood pressure, cholesterol, and diabetes allows for early detection and effective management [108]. For those already diagnosed, with some education on the risk factor involved, medication adherence improves compliance and health states [109]. Stress management techniques such as mindfulness, meditation, and relaxation exercises also decrease the risk of CVD [110, 111]. A support network can be built through family, friends, or support groups that will help the patient in making and most importantly maintaining healthy lifestyle changes. Technology can help patients track their health metrics by using mobile health applications and online resources to remind themselves about medications, appointments, and goals concerning allopathic treatment [112]. In general, patient education informs, motivates, and supports the adoption and maintenance of heart-healthy behaviors. Therefore, this type of education contributes to a great extent to reducing the incidence of CVDs and improving the resulting long-term health outcomes. In a recent study by Podvorica et al., patient education for heart disease patients was evaluated using a quasiexperimental approach in which 100 patients from a cardiology clinic in Pristina were enlisted, and education sessions were provided by a nurse to the patients at 30, 60, and 90 days. After 90 days, it has been shown that significant improvement was seen in the BMI, glycemic levels, HbA1c, and lipid profiles of patients; however, blood pressure had not changed. The conclusion obtained in this study is as follows: The fact that including patient education in the actual management of heart disease is indeed one very effective way to improve patients’ knowledge, self-care, and skills in self-management [113].

5.3. Healthcare Policy Roles: Government Initiatives, Insurance Coverage, and International Collaborations

Government initiatives are usually of a multidimensional nature ranging from public health campaigns to regulatory policies down to healthcare systems (Table 3). Some of the most outstanding and robust programs are Million Hearts in the United States; the National Program for Prevention and Control of Cancer; Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in India; the European Heart Health Charter in Europe; the China Hypertension Control Initiative (CHCI); and various global salt reduction initiatives.

Million Hearts: This is a program based in the United States that was launched in the year 2012. Scientists at the Department of Health and Human Services, for example, hope to prevent a million heart attacks and strokes in 5 years. This initiative identifies ABCS-driven practices: appropriate aspirin use, better blood pressure control, cholesterol reduction, and smoking cessation efforts. On one level, public awareness campaigns urge people to make heart-healthy choices, whereas on another level, healthcare system improvements encourage the use of electronic health records to permit data-driven treatment of patients. It has collaborated with numerous stakeholders in care and has reported remarkable improvement in blood pressure control, smoking cessation rates, and cholesterol management in the U.S. population [114].

The NPCDCS was initiated in India in 2010 to deal with the growing burden of NCDs, which also include CVDs. It provides health education, encourages early detection and diagnosis of CVDs, improves health infrastructure, and provides training to health professionals for the efficient management of patients with CVD. The program has appreciably enhanced access to CVD screening and treatment in the rural and most backward areas [115]. The European Heart Health Charter, launched in 2007 by the European Society of Cardiology and the European Heart Network, aims to help reduce the incidence of CVDs across Europe. It lobbies for change within policies. It informs the public about heart-healthy lifestyles and supports research into CVDs as well as working with national heart foundations and health bodies. This initiative influenced the policies of European authorities on tobacco control and the revision of dietary guidelines and stimulated physical activity. All this contributed to a decline in mortality from CVD in many European countries [116].

CHCI was launched in 2016. This is important for better management of hypertension, which turns out to be the major CVD risk factor. The initiative includes training programs for health professionals. There are standardized treatment protocols, public awareness campaigns, and monitoring systems for tracking advances. A range of patients among Chinese has steadily lowered their risk of suffering from a heart attack and stroke through better blood pressure control that emerged from this particular initiative [117]. Several salt reduction initiatives are active across the globe for reducing dietary salt intake, a major risk factor for hypertension and CVDs, and these include the U.K. Salt Reduction Strategy and the WHO’s global efforts and are done in this way to inform the public on risks of high salt intake, liaise with the food industry to reduce the salt content in processed foods, implement regulatory measures, and monitor salt consumption and health outcomes. The outcome is that this has led to successful reductions in average salt intake in several countries, with lower incidences of hypertension and CVD cases as a result [118, 119].

As part of Vision 2030, the “Health Transformation Strategy” was conceived and implemented by the Saudi Health Council under its umbrella. The Saudi healthcare system is therefore reshaped to help reduce NCDs, such as CVDs, while offering high-quality care. Modernization of healthcare facilities focuses on expanding access to services for diagnosis and treatment, promoting of healthy lifestyles, through improved diet, physical activity, and smoking cessation, and improving primary health care with regard to early detection and management of CVD risk factors. E-health records are also included in the concept in its effort to enhance monitoring of patients and coordination of their care. Also, as a result of this project, there has been better access to health care, better management of chronic diseases, and more public awareness of cardiovascular health [19]. A heart disease specialist and supporter of cardiovascular research and teaching, the National Heart Center was established by the Ministry of Health. It provides training programs in cardiology and cardiovascular surgery to healthcare professionals and sophisticated diagnostic and therapeutic treatments such as cardiac surgery and interventional cardiology; it also conducts research into the betterment of treatment for heart illness. Besides promoting professional developments in the field of cardiology and radically enhancing the level of care given for CVD within Saudi Arabia, the NHC delivers public health education regarding heart wellness through boutique workshops, seminars, and media campaigns [120]. The Saudi Hypertension Management Society (SHMS) works to improve hypertension management, a major CVD risk factor, through teaching, research, and public health programs. It creates and distributes guidelines for successful hypertension management, provides training sessions for healthcare providers on cutting-edge techniques, and conducts public awareness campaigns about the dangers of hypertension and the significance of regular blood pressure monitoring. SHMS also supports and conducts research to establish better treatment protocols and preventive strategies, hence improving hypertension care in Saudi Arabia.