Cardiovascular Disease (CVD) still remains the major cause of mortality worldwide and the most common and severe subtype of CVD is the Coronary Artery Disease (CAD). Even though there have been some advancements in the field of medicine and risk factor modification, the prevalence of CAD among the general population remains high, especially in developing nations. The recent studies estimate that cardiovascular diseases are responsible for about one-third of all global mortality and therefore require additional preventative measures [1].

The pathogenesis of CAD is based on the presence of non-modifiable risk factors, such as age, sex and genetic susceptibility, as well as several other risk factors, which are considered to be modifiable and include such diseases as hypertension, diabetes mellitus, dyslipidemia, obesity, smoking, physical inactivity and poor nutritional behavior. Traditional methods of prevention were directed at managing these risk factors; however, recent researches prove that they can be not sufficient enough [2].

It was found out that atherosclerosis usually starts from childhood or even from adolescence and develops over many years without any obvious signs until it becomes clinically noticeable. The role of early exposure to unhealthy lifestyle choices, such as poor nutrition, physical inactivity and smoking, in the progression [3].

Primordial prevention, hence, has come to focus as an intervention measure whose goal is to prevent the development of cardiovascular risk factors before they develop. The measures go beyond individual lifestyle modification to take a more broad-based approach involving social, environmental and policy measures. Socioeconomic conditions, education level, urbanization and availability of health care services have considerable effects on cardiovascular risks and must be considered for effective results [4].

Moreover, there is the life course approach that looks at the fact that cardiovascular risk factors build up over time and early-life preventive measures lead to favorable long-lasting results even when applied in adulthood. There are interventions done at childhood, adolescence and early adulthood periods that have been seen to reduce the chances of developing cardiovascular risk factors [5].

Due to the ever-increasing burden of CAD, there is a dire need to move away from reactive models and embrace preventive models. Thus, the purpose of this review is to examine how primordial prevention can help reduce the burden of coronary artery disease with emphasis on early-life interventions, lifestyle change and multi-level approaches that involve behavioral, environmental and policy determinants of health.

Risk factors for CAD are divided into modifiable and non-modifiable risk factors. First, we will talk about non-modifiable risk factors:

• Age: The prevalence of CAD increases beyond the age of 35 years for both males and females. The lifetime risk of getting CAD after the age of 40 years for men and women is 49 and 32%, respectively

• Gender: Males have a higher risk than females

• Ethnicity: Some ethnicities have a higher risk of CAD morbidity and mortality than others. These include Blacks, Hispanics, Latinos and Southeast Asians

• Family History: Family history is also a risk factor. The patients who have a family history of premature cardiac diseases before 50 years have an increased risk of CAD mortality

According to another article, the following are considered risk factors for CAD:

• Father/Brother <55 years

• Mother/Sister <65 years [6]

The modifiable risk factors have a minor but important influence. However, only two-thirds of people get proper medication therapy. In case of providing it, there will be considerable decrease in CAD events. According to one study, people who had proper risk factors profile demonstrated much lower death rates due to cardiovascular diseases. HT is a very big reason of coronary artery disease development and acute ischemic syndromes together with other major cardiovascular risk factors [7]. People with diabetes are at high risk of having secondary complications of the heart-related vascular complications. Main manifestations include CHD, MI, SCD [8]. Hyperlipidemia is a known risk factor for coronary artery disease development and the progression of atherosclerosis. Increase in some kind of plasma fat can worsen atherosclerotic involvement of coronary arteries [9]. Due to the fact that obesity directly influences the incidence of cardiovascular risk factors such as dyslipidemia, type 2 diabetes, hypertension and sleep disorders. Besides, obesity causes the development of cardiovascular disease and the mortality from cardiovascular disease independently of other cardiovascular risk factors [10]. There are well-known negative effects of cigarette smoking on cardiovascular system with the emphasis on atherosclerosis and atherothrombosis, by which smoking influences such life-threatening conditions, including endothelial dysfunction, inflammation [12].

In addition to the classical risk factors mentioned above for cardiovascular disease, some new risk factors have been investigated. They are: Non-Alcoholic Fatty Liver Disease (NAFLD); A recent study showed that patients with NAFLD have more than two times the risk for cardiovascular disease. In addition, the patients with liver fibrosis have four times higher chances of having this disease [13]. As the Chronic Kidney Disease (CKD) has been identified as an independent risk factor for Coronary Artery Disease (CAD). The mechanisms involved include inflammation, oxidative stress and reduction in nitric oxide leading to endothelial dysfunction. The silent myocardial infarctions are more frequent in these patients, possibly due to the higher prevalence of diabetes and uremic neuropathy in these patients with CKD [14]. The thyroid gland is a very important organ that affects the functioning of cardiovascular system. The mechanisms involved include the effects of thyroid hormone on dyslipidemia, heart function, atherosclerosis, vascular compliance and heart arrhythmias, the later having not been well researched yet [15].

While primary prevention is done by treating the risk factors in order to prevent cardiovascular disease, primordial prevention refers to the absence of the risk factors in the first place. Since atherosclerosis develops from young age [16]. 

Healthy lifestyles and good practices can help avoid the disease, lower blood pressure and increase the efficiency of treatment. The 2024 updated European Society of Hypertension clinical practice guidelines for the management of arterial hypertension identified 6 interventions to lower blood pressure: healthy nutrition, physical activity and exercise, body weight loss, sodium limitation, increase in potassium intake and restriction in alcohol intake [17]. This statement corresponds to the 2020 International Society of Hypertension Global Hypertension Practice Guidelines, which recommend 10 lifestyle changes: weight loss, sodium reduction, a healthy diet in general (e.g., Dietary Approaches to Stop Hypertension (DASH)), restriction in alcohol consumption and more frequent aerobic physical activity. Moreover, the guidelines discuss healthy beverages (coffee or tea), stress reduction, complementary and alternative medicines and decrease of exposure to air pollution and low temperatures as possible ways of hypertention prevention and treatment [18].

The complications that arise from diabetes contribute significantly to the burden of disease caused by diabetes in individuals and the health care systems alike. Lifestyle modifications aimed at balancing diet, exercising and stopping smoking are universally recommended for individuals with diabetes. The Look AHEAD Trial evaluated the impact of an intensive lifestyle intervention involving dietary restrictions and increasing physical activities [19]. Currently, according to ADA guidelines, lifestyle changes in form of dietary adjustments, physical activities and behavioural modifications are recommended in order to facilitate and maintain a 5% weight loss for people with T2DM who suffer from being overweight or obese but all interventions should be individualized [20]. At least 150 minutes per week of moderate aerobic physical activity for at least 3 days of the week is recommended for most adult patients with T2DM [21].

Hyperlipidemia could be prevented easily. Lifestyle modifications like having low saturated fat diet, having an active lifestyle, not smoking and avoiding alcohol consumption will prevent hyperlipidemia. Providers could  use  lifestyle  medicine providers,  nutrition counselors, exercise physiologists and behavior therapists in helping clients stop smoking and consuming alcohol for evidence-based care [22].

There is uncertainty as to whether exercise should be moderate or high-intensity to reduce hyperlipidemia. However, it is recommended that all adults exercise at least 150 minutes weekly of moderate exercise or 75 minutes weekly of high-intensity exercise. A study compared the effects of high-intensity interval training and moderate-intensity exercise and showed that high-intensity interval training had a large impact on reduction of the level of triglycerides by 32% [23]. Alcohol consumption was also found to be a factor of hyperlipidemia since alcohol is highly toxic for the liver where cholesterol is produced [24]. Cigarette smoke comprises more than 7000 compounds including ammonia, arsenic, lead, mercury, radioactive substances and carbon monoxide that results in endothelial injury and increased levels of TC, VLDL, LDL and TG [25].

The role of dietary pattern adherence for the primary prevention of CAD cannot be overemphasized as dietary pattern adherence has the potential to influence early pathophysiological processes before risk factors develop. Recent studies indicate that good quality of dietary pattern adherence has the potential to lead to better subclinical cardiovascular markers. In a recent study in 2024, a strong correlation was noted between adherence to the AHEI dietary pattern [26]. There is a protective relationship between physical activity and primary and secondary prevention of cardiovascular diseases as seen in literature. Any increase in physical activity is found to decrease the risk of cardiovascular diseases, diabetes, hypertension, obesity and premature death. Both aerobic and resistance exercises can be helpful in improving cardiovascular health even if they are done less than the recommended levels in current guidelines. Following the WHO physical activity recommendations leads to 30% reduction in cardiovascular mortality and 29% reduction in overall mortality. Not only physical exercises but other activities like walking, stair climbing, cycling for commuting and reduction of sedentary time are also seen to be beneficial in improving health. In total, physical activity is considered an effective way to maintain cardiovascular healthAll the literature describes the role of physical activity in protection from primary and secondary prevention of cardiovascular diseases. It has been found that even smaller amounts of physical activity have been related to lower risks of cardiovascular diseases, diabetes, hypertension, obesity and early mortality. Following the as per the co-recommendations of the literature, physical activity. Adhering to the World Health Organization's physical activity guidelines causes a decline of 30% in cardiovascular deaths and 29% in all-cause mortality. Apart from exercises, the activities in day-to-day lives such as walking, climbing stairs, cycling for commute and reduced sedentary behavior are said to cause healthy outcomes. Physical activity in general is considered as a useful approach to maintaining cardiovascular health [27].

Both acute and chronic psychological stress is considered a risk factor for developing coronary artery disease. Acute stress causes myocardial ischemia due to constriction of coronary arteries and heart load, whereas chronic stress leads to an increased risk of progression of atherosclerotic changes. Even though the influence of stress is less potent compared to traditional risk factors, there is sufficient evidence of its role in cardiovascular diseases development [28].

There are many evidence-based, non-medical methods of managing stress in children and teenagers that can be implemented not only at home but in the hospital or school environment as well and which address various problems [29]. 

• "Breathing exercises involve consciously changing the speed, rhythm and quality of breathing," but they are also regarded as being basic to physical, emotional and spiritual development that allows one to release tension, decrease stress, anxiety and depression [29]. Mindfulness is similar because it requires conscious awareness of the present experience in a non-judgmental and accepting way. It means focusing on observing thoughts, emotions and actions without judgment or reaction. For instance, when someone feels stress, he/she is aware of it and turns his/her focus to breathing [30]

Although addressing traditional risk factors for cardiovascular disease is necessary, social determinants of health (SDoH) including education, neighborhood environment, healthcare availability, economic stability and race/ethnicity make the heart healthier as well. All these factors determine people’s abilities to practice a healthy behavior, get appropriate medical care and take advantage of preventive therapy. Efficient prevention is impossible without healthcare providers' awareness of SDoH, engagement in the community, use of technology and government policies aimed at improving accessibility of health care services. Prompt detection and management of SDoH in conjunction with collaboration among patients, healthcare providers, communities and policy makers will contribute to primordial prevention and prevention of cardiovascular risk factors [31].

Aims of the Research

• To find out the most important modifiable determinants that cause coronary artery disease

• To find out the awareness of healthy behaviors among the population under study

• To find out the influence of healthy eating habits, physical exercise and smoking cessation in childhood years

• To study public health approaches for primordial prevention

The current study demonstrates the rising need to employ primordial prevention as a tool in decreasing the incidence of CAD. Cardiovascular risk starts at an early age and there is a clear correlation between lifestyle, socioeconomic determinants and environmental determinants and cardiovascular risk. It is known from scientific evidence that atherosclerotic processes can start in childhood. Therefore, there is a need to focus more on preventive measures addressing the origins of cardiovascular risk rather than treatment of risk factors [5]. This fact confirms the life-course approach according to which the cardiovascular risk accumulates throughout people’s lives and preventive measures implemented during early life can provide protective effects in later life [32].

The environmental factor, including air pollution and other environmental determinants, has a significant impact on cardiovascular risk. Measures aimed at enhancing the environmental conditions in schools, workplaces and other places can serve as indirect preventive measures. These measures address environmental determinants and do not depend on individuals’ willingness to take actions [33]. Obesity among youth is an excellent illustration of how a multi-level intervention looks like. It has been proven that interventions at three different levels-school-based programs aimed at healthy eating habits and physical activity, community programs where children can engage in exercises and get some social support and clinical programs which help to monitor risk factors for obese children-are much more efficient than interventions done at one level [34]. In this way, a number of determinants affecting the health of the patients will be addressed and it will be possible to implement the life course approach in order to prevent cardiovascular risks later in life.

The workplace wellness program is a good example of environmental and organizational interventions influencing adults' cardiovascular health positively. They might include improving access to healthy food, organizing physical activities, providing health education and any kinds of incentives aimed at the promotion of healthy lifestyle. Some evidence shows that interventions based on the environment where a person lives might influence the level of physical activity, nutrition habits and even the risk factors for CVD [35].

At last but not least, policy interventions must be considered. Such measures as taxation of unhealthy products, regulating. In addition, achieving sustained behavioral change remains a significant challenge, as factors such as low motivation, cultural habits and environmental barriers may reduce adherence to healthy lifestyles [36]. Overcoming these challenges requires coordinated efforts across multiple sectors, continuous monitoring and adaptation of strategies to fit specific community needs. Integrating behavioral, environmental and policy-level interventions in a coherent framework is essential to maximize impact and achieve meaningful reductions in CAD risk.

Policy interventions are yet another key factor in primordial prevention. For example, taxing hazardous goods, regulation of tobacco uses and other risk factors for cardiovascular disease and implementing smoke-free environments have proven to lead to decreased exposure to the main risk factors [37]. Smoke-free environments not only help people avoid the risks associated with passive smoking but also encourage healthy behaviors and create a good ripple effect in particularly vulnerable groups [34,37,38]. It becomes clear then that primordial prevention requires the transition from individual interventions to population-based approaches that aim at altering the environment and structures that affect health.

The economic burden of coronary artery disease is significant for any healthcare system. Primordial prevention approaches are economically beneficial because it becomes possible to decrease expenses related to the treatment of complications and other medical problems. Introduction of digital health technology solutions such as mobile apps, wearables and telemedicine can be viewed as another way to enhance primordial prevention efforts by making interventions more efficient, especially those that target young people [39,40].

Though interventions discussed above are highly effective, there are certain barriers to their successful implementation and sustainability. Variability in outcomes may be related to the specifics of the to conclude, primordial prevention necessitates an integrative and multidimensional approach that deals with various determinants of behavior, environment and policies. It is extremely important to implement timely and persistent interventions, especially those that target youth and vulnerable populations. The success of these interventions depends on a great extent on collaboration and flexibility.

This review underscores the importance of primordial prevention in addressing the burden of Coronary Artery Disease (CAD) through the life cycle. While primary prevention refers to the control of already established risk factors, primordial prevention involves efforts to prevent the creation of risk factors. Studies indicate that risk factors for cardiovascular disease emerge early in life and are significantly influenced by lifestyle factors and other broader factors.

Practicing a healthy lifestyle, including eating a healthy diet, exercise, maintaining appropriate weight, quitting smoking and controlling stress, is significantly effective in lowering the risk of developing the main risk factors such as hypertension, diabetes and hyperlipidemia. Furthermore, factors like education, socioeconomic status and health care availability are important determinants of cardiovascular disease.

In summary, a multi-leveled approach involving individual behavior and environmental and policy-level factors is important in minimizing the burden of CAD globally.

Recommendations 

According to the results obtained from this review, several recommendations can be made. At an individual level, it is important to adopt and adhere to a healthy heart behavior which includes eating a well-balanced diet, having enough amount of fruits and vegetables, physical activities, which are at least 150 min per week, normal body weight, not smoking, moderate alcohol consumption and managing stress. People are highly recommended to start  with  small  changes,  such  as  walking  every  day, eating less fast and processed food, stopping smoking  andattending doctors' appointments, where people have their blood pressure, blood glucose and cholesterol checked. It is crucial to start doing this since early years, especially in adolescent and young adult age.

At a community level, it is necessary to pay special attention to the development of educational campaigns and programs, providing affordable and healthy food and creating environments, which will make physical activity more common. Schools, work places and communities can be considered as major platforms for implementing preventive measures and making them sustainable, while involvement of communities and cooperation with local organizations is important for conducting awareness campaigns and creating healthy environments. At a policy level, it is important to implement and strengthen

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