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Risk Factors

Risk factors are conditions or habits that increase your risk of developing a disease. However, many heart and circulatory diseases are caused by risk factors that can be controlled, treated or modified.


What are the Modifiable risk factors?

  • Smoking

  • High blood pressure

  • Diabetes

  • Physical inactivity

  • Being overweight

  • High blood cholesterol

  • Excessive alcohol

  • Excessive stress


Non-modifiable risk factors include:

  • Age

  • Family history of heart disease

  • Gender

  • Ethnicity


Although it is not possible to change non-modifiable risk factors, it is possible to influence and somewhat mitigate them through lifestyle changes and by controlling modifiable risk factors.


Smoking and Heart Disease

Smokers are twice as likely to have heart disease compared to non-smokers.

The chemicals found in cigarettes make the walls of the arteries sticky thus letting fatty material stick to them more easily.

If the arteries get damaged and clogged, the person can suffer a heart attack.


What dangerous chemicals are found in cigarettes?

  • Cigarettes contain around 4000 chemicals, including poisons and carcinogens which are inhaled into the lungs.

  • Carbon monoxide: is a poisonous gas that is inhaled while smoking. Red cells (which give the colouring of the blood) carry oxygen around our body but having a high concentration of carbon monoxide, will reduce the oxygen level in our circulation resulting into a greater risk of having heart disease.

  • Tar: When one smokes, 70% of the tar stays in our lungs and damages them. The aerosol of Tar droplets condenses in the air sacs and airways. This may cause cancer. Tar causes smokers’ cough, phlegm, chest infections and other diseases.

  • Nicotine: An addictive chemical, increases heart rate and blood pressure.



Quitting Smoking

It is never too late to quit smoking, even though the person has been smoking since his/her teens. The effects over time on one’s health after quitting smoking are listed below:

  • 20 mins: Your heart rate and blood-pressure return to normal.

  • 8-12 hours: Nicotine and carbon monoxide start to leave your body and oxygen levels return to normal.

  • 24 hours: Your lungs start to clear mucus and other smoking debris.

  • 48-72 hours: Nicotine has been eliminated from your body and your sense of smell and taste improve.

  • 2-12 weeks: Exercise becomes easier and your breathing improves.

  • 3-9 months: Any coughs, wheezing and breathing problems are reduced as your lungs repair.

  • 1 year: Your risk of coronary heart disease is now half that of a smoker.

  • 10-15 years: Your risk of lung cancer is halved, and your risk of heart and circulatory disease has significantly decreased.

  • Other benefits include: Increased energy and freedom from thoughts of damaging your health as well as causing more stress on your family.

How to Quit

Quitting smoking is an excellent decision for one’s health. Most of the time it is very difficult, and the person might need support from family members and even close friends.

  • Set a quit date and tell family and friends about your decision.

  • It is important to be committed and ready to make changes in your life.

  • Try to keep quit date stress-free.

  • Choose healthy snacks and drinks to avoid unhealthy treats.

  • Think about how you will deal with cravings to smoke.

  • Stay motivated, set a goal. For example, save the money you usually spend on smoking and give yourself a reward. This will keep you on track.

  • If you always smoke when you are stressed, tired or drinking alcohol, plan for these moments in order to cope.

  • If you need support to quit, use helpline: 23266000 or Quitline: 23266116. Freephone: 80073333 for an appointment. Counselling services are available at Floriana and Mosta Health Centres.

  • If you are struggling to quit, one can attend Smoking Cessation Programmes. The person leading the program will be able to help you find the best way to stop smoking and suggest medication or nicotine replacement therapy.

  • Think positive. You may experience withdrawal symptoms once you stop smoking ex: cough, sleep disturbances and feeling more irritable. Don’t worry these are signs that are perfectly normal and will disappear within few weeks.

  • The use of Nicotine Replacement therapies is very helpful and may help the person quit smoking. Examples of NRT: Patches, Quick Mist spray and Chewing Gum. Drugs can be offered as well: Bupropion or Varenicline.

  • Keep your house clean and smoke-free. Remove ashtrays and lighters. Use air fresheners and open windows to let clean air inside your house.

For more information on Tobacco and cessation support go to


What to do when the cravings start?


Cravings often happen during the first few days after stopping and it gets worse for the first three to five minutes and then begins to diminish. When the craving starts, apply the 4Ds:

  • Delay smoking for at least three minutes – the urge will pass.

  • Drink a glass of water.

  • Distract yourself – move away from the situation which encourages you to smoke.

  • Take deep breaths. Breathe slowly and deeply.


Electronic cigarettes, known as e-cigarettes or vapourisers, are battery-powered devices that mimic the action of smoking, offering nicotine (in most cases), but without the toxic effect of tobacco smoke. Although the level of carcinogens and irritants is much lower than that found in conventional cigarettes, non-smokers are not advised to start vaping. More research is needed on the long-term impact of vaping on your heart and blood vessels, and on how people can most effectively use e-cigarettes to quit.

Some Facts about Cigarette Smoking alternatives

Some cigarette alternatives are worse for your health than others. The list below shows the types of alternatives with their side effects.

  • E-cigarettes: can contain less amount of nicotine but can still be addictive.

  • Light, mild or low-tar cigarettes: these are still harmful and can be detrimental to one’s health as normal cigarettes.

  • Vapes: are more likely used by teenagers. Can potentially cause coughing, shortness of breath and pulmonary disease.

  • Shisha: Still contain tobacco and other harmful chemicals including carbon monoxide.


Take control of your life. Do not waste it. Life is precious.


High Blood Pressure

What is blood pressure?

  • It is the measurement of the pressure of blood in your arteries. The heart pumps blood around our body to deliver oxygen and nutrients to our organs.

  • Blood pressure is necessary to get the blood circulating round the body.

  • It increases while moving around or doing any sort of activities.

  • Action must be taken when blood pressure remains high especially at rest and/or during sleep.

Blood pressure is measured in two readings: Systole and Diastole.

Systolic pressure: This is the highest reading of our blood pressure; when our heart beats it contracts to pump blood through our arteries.

Diastolic pressure: This is the lowest reading of our blood pressure; when our heart relaxes between beats.

SYSTOLIC – lower than 140 mmHg                  in diabetics: SYSTOLIC - <130 mmHg

DIASTOLIC – lower than 90 mmHg                                          DIASTOLIC - <80mmHg


What is Hypertension?

Blood pressure naturally goes up and down throughout the day and night, and is also effected by activity. However, if it remains persistently high even at rest, than you should take action to control it. Constant high blood pressure is medical referred to as hypertension. Hypertension means that the heart has to constantly work harder to pump blood around the body. High blood pressure is harmful to the arteries and is associated with coronary artery disease, stroke and renal disease.

Although there is not always an explanation why blood pressure increases, it can develop due to certain lifestyle factors or medical conditions including:

  • Being overweight

  • High salt intake in the diet

  • Excessive alcohol consumption

  • Physical inactivity

  • Kidney disease

  • Diabetes

  • Some medications, such as oral contraceptives and herbal medicine



Appropriate non-pharmacological approach must be considered in all persons. These include:

  • Salt restriction in diet.

  • Don’t add salt to your food at table.

  • Increase in fruit and vegetable intake.

  • Decrease in saturated and total fat intake.

  • Cut down on processed foods or readymade meals.

  • Limitation of alcohol consumption.

  • Smoking cessation.

  • Control of body weight.

  • Physical activity.

  • Manage and control stress.

Also seek advice from your pharmacist or doctor if you have concern about medicines that might affect your blood pressure.


Anti-hypertensive drugs: The goal of antihypertensive therapy is to help decrease blood pressure. There are a number of different medications that can help control blood-pressure. However, it is important to point out that patients who have a history of hypertension should combine anti-hypertensive treatment with a healthy lifestyle to achieve better control of their blood pressure.

To learn more about medications and treatment for high blood pressure, please click here.



High Cholesterol

Cholesterol is a waxy-like substance in our blood which is mostly derived from the fat in the food we eat and partly produced naturally in our liver. Our body needs cholesterol to build healthy cells but high levels of cholesterol can develop fatty deposits in the blood vessels. By time, these deposits grow, making it difficult for enough blood to flow through the arteries.  This condition is called atherosclerosis and the fatty substance is known as atheroma.

Cholesterol is carried in our blood stream by proteins and when combine these are known as lipoproteins. There are two main types:

  • High-density lipoproteins (HDL): This is known as the ‘Good Cholesterol’.

HDL takes cholesterol that is not needed back to the liver to be broken down and then excreted from the body.

  • Low-density lipoprotein (LD): This is known as the ‘Bad Cholesterol’.

LDL delivers cholesterol from the liver to cells around the body. High level of this type of cholesterol will get stuck to the walls of the arteries.

  • Triglycerides: are another type of fatty substance in the blood.


What causes high Cholesterol?

Anyone can get high cholesterol and there are various causes. Hypercholesterolemia, the name given to high level of cholesterol in the blood can be caused by:

  • Things that we can control:

  • Eating unhealthy food (saturated and trans-fats). Example: butter, lard, fatty meat, cheese, cakes, biscuits etc.

  • Smoking – cigarettes may be a cause of high cholesterol level even if the person is having treatment. It stops the good cholesterol from doing its job of getting rid of the bad cholesterol.

  • Having too much body fat, especially around waist circumference.

  • Being inactive


  • Things that one cannot control:

  • Family history – inherited high blood cholesterol due to a condition known as familial hypercholesterolemia. LDL cholesterol is not removed effectively from the circulation resulting into abnormally high levels.

  • Getting older 

  • Ethnicity


How to get your cholesterol level down?

  • Adapt to a healthy lifestyle. Eat foods that are high in fibre, such as oats, pulses, lentils and nuts. Include more fruit and vegetables in the diet.

  • Swap full cream dairy products to low-fat products.

  • Cut off fat parts from meat before cooking. Eat more lean meat and fish.

  • Drink alcohol in moderation. Keep within sensible limits. Do not exced more than two (2) units per day.

  • Stop smoking.

  • Be more active, include exercise in your daily routine. Walk instead of using the car. Climb the stairs instead of using the lift.

  • Take medications. Statins are a long-term and effective medications, however it is important that adjust your lifestyle aswell.

  • Have your Cholesterol blood level checked regularly (every 6 months).


The aim is to have:

  • A low total cholesterol level of not more than: 5mmol/L

  • A low level of LDL cholesterol of not more than: 1.4mmo;/L

  • A high level of HDL cholesterol above: 1.45mmol/L

  • A low level of Triglycerides of not more than: 2.26mmol/L




Obesity has become a global epidemic over the last three decades with an estimated 500 million adults being classed as obese. Overweight and obesity are associated with an increased risk of developing cardiovascular disease.

Obesity can increase the risk of:

  • Increasing your blood pressure


  • Raising your blood cholesterol which can lead to the building up of fatty material in your arteries. This can lead to a heart attack if they become clogged.


  • Developing Type 2 Diabetes.


Factors that influence Obesity

  • Unhealthy Eating habits.

  • Lack of Physical activity.

An important indicator of risk in obesity is weight carried around the middle. Therefore it is important to measure both the Bod Mass Index (BMI) and waist circumference. You can use a BMI calculator (here).


To find out what you can do to eat more healthily and reduce weight, visit the healthy diet page for tips and information.




Stress alone does not cause heart and circulatory disease, but it is more likely linked to unhealthy habits which in return lead to an increased risk of developing heart disease. Stress may affect behaviours and factors that increase heart disease risk: high blood pressure and cholesterol levels, smoking, physical inactivity and overeating. Some people may choose to drink too much alcohol or smoke cigarettes to “manage” their chronic stress, however these habits can increase blood pressure and may damage artery walls. What may seem like small actions, these can sum up to uncontrollable behaviour causing long-term health problems.

For more stress-related information click on Stress Management and the psychological aspect of cardiovascular disease.



Diabetes is a condition that causes high levels of glucose (or sugar) in the blood. This glucose is the body’s main source of energy and comes from the food we eat. This condition develops when our body does not make enough insulin, a hormone made by the pancreas, or does not use well the insulin it makes. Glucose remains in the blood stream and will not be able to get into our cells to be used as energy. High levels of glucose in the bloodstream can damage the walls of the arteries, thus making them more likely to develop fatty deposits known as atheroma.


Types of Diabetes

  • Type 1: This type most commonly affects children and young adults. It is a result of the body’s immune system attacking the cells that produce insulin in the pancreas.


  • Type 2: Occurs mostly in adults, when the pancreas isn’t making enough Insulin, or the body is unable to use the insulin it makes. 

Type 2 diabetes is much more common than Type 1. It mostly develops gradually, as people get older – usually after the age of 40. But more and more people every year are being diagnosed at a much younger age.

It's closely linked with: 

  • Being obese, especially if you carry weight around your waist

  • Lack of physical activity

  • Having a family history of Type 2 diabetes.

What happens when we have diabetes?

When we eat, food is digested in the body, and carbohydrates are broken down into glucose. Insulin is release by the pancreas and this acts as a signal for the cells to absorb this glucose, which they use as fuel for energy.

In people who have Type 2 diabetes, the body doesn’t produce enough insulin or the insulin cannot be used, and therefore the cells cannot absorb the glucose. This leads to an accumulation of glucose in the bloodstream.

High blood glucose levels can damage the walls of arteries, and as a result this will make them more susceptible to develop fatty deposits. This can lead to a heart attack or stroke.

What are the signs and symptoms of diabetes?

Most common:

  • feeling thirsty more than usual

  • peeing more than usual, particularly at night

  • feeling tired most of the time

  • loss of weight unexpectedly

  • complaining of blurred vision

  • having genital itching or regular episodes of thrush

  • Noticing that cuts or wounds heal slowly.


 Steps that can help reduce the risk:

Managing your diabetes

One can control diabetes very successfully with medications and through lifestyle changes such as:

  • Losing weight if obese;

  • Be more physically active;

  • Eating a healthy diet;

  • Avoid sugary drinks and fatty food;

  • Yearly review with diabetologist and/or GP as advised.

  • Check your Hba1c levels regularly to see how stable your blood glucose has been over a period of time.



Alcohol can increase temporarily the heart rate and the blood pressure.


  • Weakened heart muscle – heavy alcohol consumption can lead to Cardiomyopathy. This is a condition which involves the heart muscle. It becomes weak and the heart will not be able to contract properly, which in turn makes it harder for the blood to circulate around the body.


  • High levels of Triglycerides – high consumption of alcohol increase the risk of elevated level of triglycerides in the blood stream. By time, this can clog the arteries and cause blockage.


  • Binge drinking (explain) - usually refers to when a person drinks lots of alcohol in a short space of time. Men and women are advised to:


  1. Not to exceed more than 14 units per week on a regular basis.

  2. Spread the drinking over the week if they regularly drink as much as 14 units a week.

  3. If they want to cut down, it is important to have several drink-free days each week.


  • Measurements of units(explain):


Unit Calculator


This site can be used to find out how many units are in particular drink or to check how much you are drinking.



Non-Modifiable Risk Factors


As one gets older the risk of cardiovascular disease increase. The changes that our body undergoes during the aging process can be visualised from the outside; for example, wrinkles on the face and grey hair but from the inside nothing is visible. Internal changes such as weaker and fragile bones and narrowing of arteries are by far more critical in terms of health.


Men are at greater risk of heart disease than pre-menopausal women. However, once past menopause, the risk for women is like that of men.

Family History

The risk is increased for the first-degree blood relative that has had coronary heart disease before the age of 55 years, for a male relative and 65years, for a female relative. It is therefore important to note family history of Coronary Artery Disease. A positive family history involving first degree relatives is generally associated with greater risk for the disease. It is a result of both genetic and behavioural factors. Adopting a healthy lifestyle behaviours earlier on in life is key to reducing the overall risk.


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