The Four Key Risk Factors Behind Nearly All Heart Attacks

A new analysis of Dutch cardiovascular research shows that nearly all heart attacks can be traced to just four modifiable risk factors, according to a report published in Welingelichte Kringen on June 17, 2026. The findings, based on a review of Dutch public health data and international studies, highlight that high blood pressure, smoking, high cholesterol, and diabetes account for more than 90% of preventable heart attack cases. Experts say the data underscores the critical role of early intervention and lifestyle changes in reducing cardiovascular mortality.

The report identifies the four key risk factors as:

• High blood pressure (hypertension), which contributes to nearly 40% of preventable heart attacks, according to the Dutch Heart Foundation.
• Smoking, responsible for roughly 30% of cases, with data from the Dutch National Institute for Public Health and the Environment (RIVM) showing a 50% higher risk among current smokers compared to non-smokers.
• High cholesterol, linked to about 20% of preventable heart attacks, with the World Health Organization (WHO) estimating that reducing LDL cholesterol by 1 mmol/L could prevent one in five heart attacks globally.
• Diabetes, accounting for around 10% of cases, with research from the European Heart Journal indicating that people with diabetes have a two- to four-fold higher risk of heart attack than those without the condition.

Dr. Marjolein Visser, a cardiologist at the University Medical Center Utrecht, told Welingelichte Kringen that the findings align with global trends. “We’ve known for decades that these four factors are the primary drivers of heart disease, but the Dutch data makes it starkly clear how much impact prevention can have,” she said. The report notes that while genetics and age play a role, lifestyle and medical management of these conditions remain the most effective tools for reduction.

The analysis also contrasts with earlier Dutch public health campaigns that often focused on broader lifestyle advice, such as diet and exercise. While those factors matter, the new data suggests targeted interventions—such as blood pressure medication for hypertensive patients or smoking cessation programs—could yield faster, measurable results. The Dutch Heart Foundation has already begun updating its prevention guidelines to reflect these priorities.

Internationally, the findings echo a 2023 study published in The Lancet, which found that 90% of heart attacks in high-income countries could be attributed to the same four risk factors. However, the Dutch data adds a local nuance: a 2025 RIVM survey revealed that while smoking rates have dropped by 15% over the past decade, hypertension remains underdiagnosed in rural areas, particularly among men aged 50–65.

What remains uncertain is how effectively new public health policies can address these disparities. The Dutch government has pledged €50 million over the next three years to expand screening programs, but critics argue that rural access to cardiologists and pharmacies remains a bottleneck. Meanwhile, the WHO has called for similar targeted approaches in other European nations, where heart disease remains the leading cause of death.

For readers seeking actionable steps, the Dutch Heart Foundation recommends regular check-ups for blood pressure and cholesterol, especially for those over 40 or with a family history of heart disease. Smoking cessation programs, available through general practitioners, have been shown to reduce heart attack risk by up to 35% within five years, according to RIVM data. Diabetes management, including HbA1c monitoring, is also emphasized as a critical preventive measure.

While the report does not address emerging risks like air pollution or sedentary lifestyles, experts note that these factors are secondary to the four primary ones. “The message is clear: if you control these four, you control the vast majority of heart attack risk,” said Visser. The analysis suggests that with sustained public health efforts, the Netherlands could see a 20% reduction in heart attack rates within a decade—a goal already achieved in Finland through similar targeted interventions in the 1970s.