The following are key points to remember from a state-of-the-art review on cardiovascular (CV) risk assessment and management of severe mental illness (SMI):

1. Patients with SMI including schizophrenia and bipolar disorder die on average 15–20 years earlier than the general population often due to sudden death that, in most cases, is caused by cardiovascular disease (CVD).
2. This state-of-the-art review aims to address the complex association between SMI and CV risk, explore disparities in CV care pathways, describe how to adequately predict CV outcomes, and propose targeted interventions to improve CV health in patients with SMI.
3. These patients have an adverse CV risk factor profile due to an interplay between biological factors such as chronic inflammation, patient factors such as excessive smoking, and health care system factors such as stigma and discrimination. There is a need to establish equality in the management of CV risk factors and treatment of CVD and ensure sufficient accessibility to CV examinations for patients with SMI, comparable with the standards observed in the general population.
4. Several disparities in CV care pathways have been demonstrated in patients with SMI, resulting in a 47% lower likelihood of undergoing invasive coronary procedures and substantially lower rates of prescribed standard secondary prevention medications compared with the general population.
5. Primary prevention strategy goals should target several risk factors:
   • Hypertension is frequent in patients with SMI, but antihypertensive treatment is often underutilized or patients are undertreated. Patients should be screened for hypertension early and regularly. Blood pressure control and timely initiation of sufficient antihypertensive treatment are essential to mitigate CVD risk in these patients.
   • Dyslipidemia plays an important role in the premature development of atherosclerotic CVD in patients with SMI. Patients, even without other risk-enhancing factors, may potentially benefit from a more aggressive approach to lipid management. Although statin treatment is equally effective in lowering low-density lipoprotein cholesterol levels in patients with SMI as in the general population, statins are underutilized in these patients.
   • Diabetes is common at an early stage in patients with SMI, often exacerbated by antipsychotic treatment by altering glucose metabolism and promoting weight gain. Regular monitoring of glycated hemoglobin levels to assess long-term glucose control is important. Treatment plans should be tailored to both individual needs and comorbidities including ischemic heart disease, heart failure, or nephropathy, where sodium–glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists are indicated. Management should extend beyond medications to include lifestyle modifications and collaborative care.
   • Smoking rates are increased in patients with SMI, and smoking cessation interventions are generally underutilized. Specialized treatment such as bupropion and varenicline shows improved long-term efficacy and high safety in these patients.
   • Physical inactivity, obesity, unhealthy diet, and substance misuse in patients with SMI are also highly prevalent CV risk factors. Clinicians are strongly encouraged to actively screen for these risk-enhancing factors and implement targeted management strategies by providing guidance on lifestyle interventions, patient education, and integrated care approaches.
6. Secondary prevention strategy goals include:
   • Patients with SMI may potentially benefit more from the standard secondary prevention treatment that is offered to the general population following a diagnosis of CVD.
   • The largest treatment gap is potentially within post–acute coronary syndrome care, where patients with SMI and myocardial infarction (MI) are less likely to receive aspirin, P2Y₁₂ inhibitors, beta-blockers, statins, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, or mineralocorticoid receptor antagonists compared with the general population. The majority of patients with SMI have a lower likelihood of undergoing invasive coronary procedures. When treated sufficiently, no differences in post-MI mortality are observed between patients with SMI and the general population.
7. Although early CV risk prediction is important, conventional risk prediction models do not accurately predict long-term CV outcomes, as CVD and mortality are only partly driven by traditional risk factors in this patient group.
8. As such, SMI-specific risk prediction models and clinical tools such as the electrocardiogram and echocardiogram are necessary when assessing and managing CV risk associated with SMI.
9. There is a necessity for differentiated CV care in patients with SMI. By addressing factors involved in the excess CV risk, reconsidering risk stratification approaches, and implementing multidisciplinary care models, clinicians can take steps towards improving CV health and long-term outcomes in patients with SMI.
10. Finally, multidisciplinary care models bridging the gap between mental health, primary care, and cardiology can contribute to more comprehensive and effective management of the excess CV risk in patients with SMI. A comprehensive and individualized approach to managing risk factors is essential for optimizing CV health in the SMI population.

Clinical Topics: Prevention

Keywords: Cardiometabolic Risk Factors, Mentally Ill Persons

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