The global burden of cardiovascular disease (CVD) has been acknowledged for several decades. Worldwide, CVD is considered to be the leading cause of death and loss of disability-adjusted life years.1 Noteworthy is that 80% of this global mortality and disease burden occurs in low-income and middle-income countries; however, minimal epidemiologic data on risk factor prevalence and trends have been available for these "developing" countries.1 INTERHEART, a case-control study of acute myocardial infarction (AMI), was designed as an initial step to assess the major modifiable risk factors for coronary heart disease (CHD) worldwide.2 Participants (n = 15,152 cases; 14,820 controls) were recruited from 52 countries in Asia, Europe, the Middle East, Africa, Australia, North and South America. Specifically, INTERHEART was designed to determine the strength of association between risk factors and AMI in the overall study population and to ascertain if this association varied by geographic region, ethnic origin, sex, or age. The population attributable risk (PAR) for individual risk factors and their combinations was also assessed. Results indicated that 9 potentially modifiable and easily assessed risk factors account for a large proportion (over 90%) of risk for AMI.2

Smoking, abnormal lipids, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, alcohol, and regular physical activity explained most of the risk of AMI worldwide in both males and females. Worldwide, the most important risk factors were smoking and abnormal lipids; together they accounted for approximately two-thirds of the PAR of AMI.2 Although their relative effect varied in different regions of the world, psychosocial factors, abdominal obesity, diabetes, and hypertension were the next most important risk factors in women and men. Noteworthy is that smoking accounted for approximately 36% of the PAR of AMI worldwide (~44% in men), whereas regular consumption of fruits and vegetables was associated with a 30% relative risk reduction. 2 Although INTERHEART had some methodological limitations, the major results (with implications for population-based prevention efforts) are similar to those reported in other studies including the Nurses Health Study3 and the Lyon Heart Study.4 Indeed, potentially modifiable lifestyle behaviors are major determinants of CHD.

In another major effort to reduce the global burden of CVD, the World Heart and Stroke Forum (WHSF) of the World Heart Federation (WHF) recommends that every country develop a policy on CVD prevention.5 Endorsing the World Health Report of 2002,6 the WHSF urges countries to adopt policies and programs to promote population-wide CVD preventive-interventions designed to reduce use of tobacco, encourage higher consumption of fruits and vegetables, increase physical activity, reduce saturated fat in the national diet and salt in processed food.5 In a call to action to address this challenge, the benefits of international professional collaboration among the societies of cardiology are emphasized.5 By necessity, effective implementation of such policies would also require collaboration between and among government officials, researchers, healthcare providers, and consumers. This WHSF scientific statement includes a template for the development of national clinical guidelines targeting individuals with established CVD and those at high risk for CVD.5 Five of the 10 strategic principles suggest the involvement of national professional societies in research (i.e., prospective collection of validated national vital statistics on causes and outcomes of CVD), facilitation of education and training for health professionals in CVD prevention, clinical practice initiatives (assessment of compliance with national guidelines), and advocacy efforts (i.e., informing policymakers of risk factor targets and appropriate drug therapies and asking government to incorporate CVD prevention into legislation.5 In addition, the principles emphasize assessment of total CVD risk (based on epidemiological risk factor data appropriate to the population), professional judgment in the application and translation of evidence-based guidelines, and prevention of CVD as an integral part of daily clinical practice.5

Cardiovascular nurses in developed and developing countries are well-positioned to assume leadership roles in clinical and population- based CVD prevention efforts, education and training for CVD prevention, teaching and mentoring the next generation of healthcare professionals for roles in both primary and secondary prevention of CVD, and advocating for national policies designed to reduce the global burden of CVD. International collaboration with professional (cardiovascular) societies and organizations that share the "global mission" of CVD prevention holds much promise. To this end, the Preventive Cardiovascular Nurses Association (PCNA), the Council on Cardiovascular Nursing of the American Heart Association (CVN-AHA), and the European Society of Cardiology's (ESC) Working Group on Cardiovascular Nursing7 have begun to collaborate in education/ training, research, and practice initiatives. Ultimately, these efforts will increase the capacity and contributions of nurses and nursing to primary and secondary prevention of CVD worldwide.

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