Cardiovascular risk and prevention among men living with HIV in Islamabad: a qualitative study

Impact of psychological status on cardiovascular diseases: Is it time for upgrading risk score charts?

<h3>Objectives</h3> The guidelines of the American College of Cardiology/American Heart Association, the British National Institute for Health and Clinical Excellence and the European Guidelines on cardiovascular disease prevention are worldwide disseminated. They recommend the use of different tables to estimate cardiovascular risk: atherosclerotic cardiovascular disease risk-ASCVD, the QRISK2 and the SCORE. ASCVD and QRISK2 measure risk of cardiovascular morbidity and mortality due to atherosclerosis disease and due to coronary heart disease and stroke, respectively, and SCORE measures risk of cardiovascular death. According to ASCVD a high-risk person is considered when risk is &gt;7.5%, according to QRISK2 &gt;10% and according to SCORE &gt;5%, in the next ten years. The objective was to evaluate and compare the impact of using the American, the British and the European guidelines on the identification of high risk patients and on the percentage of patients requiring statin therapy in a Spanish working population. <h3>Method</h3> Observational study conducted among Spanish workers whose companies had contracted health monitoring services from the <i>Sociedad de Prevencion de Ibermutuamur</i>, who underwent a medical examination between 2004–2007. Cardiovascular risk was calculated for each worker using the SCORE cardiovascular risk tables for low-risk countries, as well as the tables recommended by the American and British guidelines. Diabetic patients were excluded. Following the recommendations of the European Guidelines on Cardiovascular Prevention, treatment targets for patients at high (SCORE 5%–9%) or very high risk (SCORE &gt;10%) are LDL-C concentrations of &lt;100 mg/dL and &lt;70 mg/dL, respectively. NICE and ACC/AHA recommendations do not stipulate therapeutic targets for LDL-C, therefore all patients at high risk are considered candidates for lipid lowering therapy. On top of that, ACC/AHA recommends treatment with lipid lowering therapy when LDL-C is &gt;190 mg/dl, regardless the cardiovascular risk. <h3>Results</h3> A total of 227 371 workers between 40 and 65 years were included (75.54% men; mean age, 47.96 years; 42.62% were smokers; 10.1% were hypertensives; 11.0% had dyslipidemia; 7.2% were treated with antihypertensive drugs; 3.7% were treated with lipid lowering drugs). Individuals at high risk was found in 4.42% of the population according to the SCORE tables and in 17.79% and 26.02% according to the British and American tables, respectively. Lipid lowering treatment would be recommended in these high risk patients, except for the American Guidelines that the percentage would increase up to 33.74% (after including non-high risk patients with LDL-C &gt;190 mg/dl). <h3>Conclusions</h3> We observed marked differences on the percentages of high risk patients when comparing the three different cardiovascular risk charts. The application of the American and British compare to the European guidelines would result in identifying more high risk patients and in treating a larger fraction of the population with lipid lowering drugs and with other intensive preventive pharmacotherapy such as use aspirin and anti-hypertensive agents, which would result in substantially increase costs. Clinicians may need to interpret cardiovascular risk estimates with caution in order to avoid overestimation of risk and overtreatment.

SP0165 How to Evaluate Cardiovascular Risk in Patients with Inflammatory Joint Disease – A Review of the Evidence

The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators. RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK®2 or the JBS3 lifetime risk calculator. This was a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks. A total of 173 patients eligible for NHS Health Check and 15 practitioners. The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention). Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8-38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance. The main limitations were under-recruitment in some general practices and the resulting imbalance between groups. Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations. Current Controlled Trials ISRCTN10443908. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information.

Applying Framingham Risk Score 2008 to Predict the 10-Year Risk of Cardiovascular Disease in a Group of Office Workers in Hanoi, Vietnam

Fit Is It for Cardiovascular Disease Prediction, Prevention, and Treatment

Although an impressive progress has been achieved in the treatment of cardiovascular diseases, they are at the top of the mortality statistics in Hungary. Prevention of these diseases is an essential task of the primary health care. Cardiovascular prevention is carried out at primary, secondary and tertiary levels using risk group and population preventive strategies. The two main tasks of primary cardiovascular prevention are health promotion and cardiovascular disease prevention, and its main programs are ensuring healthy nutrition, improving physical training and accomplishing an anti-smoking program. The essential form of secondary prevention is the screening activity of the primary health care. The majority of cardiovascular risk factors can be discovered during the doctor-patient consultation, but laboratory screening is needed for assessing metabolic risks. The official screening rules of the cardiovascular risk factors and diseases are based on diagnostic criteria of the metabolic syndrome; however, nowadays revealing of global cardiometabolic risks is also necessary. In patients without cardiovascular diseases but with risk factors, a cardiovascular risk estimation has to be performed. In primary care, there is a possibility for long term follow-up and continuous care of patients with chronic diseases, which is the main form of the tertiary prevention. In patients with cardiovascular diseases, ranking to cardiovascular risk groups is a very important task since target values of continuous care depend on which risk group they belong to. The methods used during continuous care are lifestyle therapy, specific pharmacotherapy and organ protection with drugs. Combined health education and counselling is the next element of the primary health care prevention; it is a tool that helps primary, secondary and tertiary prevention. Changes needed for improving cardiovascular prevention in primary care are the following: appropriate evaluation of primary prevention, health education and counselling, renewal of the cardiovascular screening system based on the notion of global cardiometabolic risk, creating a unified cardiovascular prevention guideline, and operating primary care cardiovascular prevention within the framework of an integrated prevention system.

In 2016, a new version of the European Guidelines on Cardiovascular Prevention was released, representing a partnership between the European Association for Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology (ESC) and nine European societies, including Wonca-Europe. The ESC guidelines underscore the importance of a lifetime approach to cardiovascular (CV) risk since both CV risk and prevention are dynamic and continuous as patients’ age and/or accumulate co-morbidities. Healthy people of all ages should be encouraged to adopt a healthy lifestyle, as well as improved lifestyle and reduced risk factor levels are paramount in patients at increased risk of developing cardiovascular disease (CVD) and in those with established CVD. Healthcare professionals, and especially general practitioners, play an important role in helping patients achieve this and should set a personal example of healthy lifestyle behaviour. The ESC guidelines are based on ‘to do’ and ‘not to do’ messages. Of note, what remains uncertain is stated at the end of each dedicated chapter, confirming that guidelines are not absolute rules, and should be interpreted in the light of the healthcare worker’s knowledge and experience, patient preferences and the local social, cultural and economic situation.

Revising the atherosclerotic cardiovascular disease calculator without race

Background and Aims Based on intervention thresholds [1], statins are recommended in kidney transplant recipients (KTRs) who are at high risk for major cardiovascular (CV) events. However, in this population, evidence of statin effectiveness is sparse and non-conclusive. The objective of this study is to assess the effect of statins on CV events in KTRs. Method 613 consecutive KTRs from a single-center cohort were retrospectively included between 2006 and 2019. Exposure to statins (indicated in primary or secondary CV prevention) and atherosclerotic CV events during the study period were comprehensively documented. The primary outcome was the incidence of CV events in all statin users compared to that of non-users, based on the Cardiovascular and Stroke Endpoint Definitions for Clinical Trials [2]. In this study, only atherosclerotic events were selected (peripheral vascular stenosis, stroke, myocardial infarction, angina pectoris and transitional ischemic attack). The secondary outcomes were the incidence of CV events (i) in KTRs using statins indicated in primary CV prevention and (ii) in KTRs using statins indicated in secondary CV prevention compared to that of non-users. Cox proportional hazard models including statin exposure as a time-dependent covariate and fitted with inverse probability treatment weighting (IPTW) were used, as well as a multivariable Cox proportional hazard model. Results During a median [interquartile range (IQR)] follow-up period of 4.6 [2.7–10.0] years, CV events occurred in 88 KTRs: 48 (55.5%) KTRs had peripheral vascular stenosis, 24 (27.3%) had myocardial infarction, 12 (13.6%) had stroke, three (3.5%) had angina pectoris and one (1.1%) had a transitional ischemic attack. The incidence of CV events was 24.8 per 1000 person-years. In the Cox models fitted with IPTW, exposure to statins, regardless of the indication or indicated in primary and secondary CV prevention, was not associated with a decrease in CV events: Hazard Ratio (HR) [95% confidence interval (CI)]: 1.22 [0.73–2.03] (P = .435), HR: 1.12 [0.66–1.89] (P = .672), and HR: 2.78 [1.19–6.53] (P = .018), respectively. In the multivariable Cox model, diabetes mellitus was strongly associated with CV events (HR: 4.39 [2.79–6.90], p&amp;lt;0.001), and statin exposure was not (HR: 1.25 [0.78–2.03]). In a subgroup of KTRs exposed to statins after kidney transplantation but not before (n=314), the median [IQR] levels of LDL-c was 3.48 [2.89–4.08] mmol/L when starting statins and 2.74 [2.14–3.35] mmol/L after one year of statin exposure, i.e. a significant decrease of 0.74 [0.60–0.85] mmol/L (p&amp;lt;0.001). The median [IQR] levels of triglyceride was 1.99 [1.47–2.91] mmol/L when starting statins and 1.72 [1.20–2.50] mmol/L after one year of statin exposure, i.e. a significant decrease of 0.27 [0.17–0.42] mmol/l (p&amp;lt;0.001). There were no significant changes in HDL-c levels. Conclusion Despite an improvement in the lipid profile including a reduction of LDL-c and triglyceride levels, statin exposure was not associated with a decrease in CV events in a long-term KTR cohort. Other CV risk factors than dyslipidemia, such as diabetes mellitus, were more likely related to such events.

Although high cardiovascular risk patients should be the main target of preventive strategies, modifiable risk factors are often inadequately controlled. To assess feasibility and results of a comprehensive personalized method for cardiovascular prevention in high risk patients followed by their general practitioner. Between 2004 and 2007, 12,513 patients (mean age 64.0 ± 9.5 years; 61.5% males) with multiple cardiovascular risk factors or history of atherosclerotic disease were identified and followed for five years. If control of major modifiable cardiovascular risk factors (hypertension, hypercholesterolaemia, diabetes, obesity, smoking, unhealthy diet, physical inactivity) was sub-optimal, at baseline and yearly thereafter general practitioners planned with patients, with the help of a brief checklist, preventive interventions to improve the global risk profile. Main outcome was the control of the seven major modifiable cardiovascular risk factors during follow-up. Secondary outcome was the incidence of cardiovascular deaths and hospitalization for cardiovascular reasons according to the improvement in global cardiovascular risk profile during the first year. Control of all major modifiable risk factors except physical inactivity improved gradually and significantly (p < 0.0001) during follow-up.The improvement in the global cardiovascular risk profile during the first year was independently and significantly associated with a lower rate of major cardiovascular events in the following years (hazard ratio 0.939; 95% confidence interval 0.887-0.994, p = 0.03). Our comprehensive, personalized method for cardiovascular risk prevention in people at high risk appears feasible in general practice. The improvement in the global cardiovascular risk profile was associated with a better prognosis.

BackgroundSince the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes.Main bodyThe Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy.ConclusionsDiabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk.

Understanding cardiovascular risk in hemophilia: A step towards prevention and management

Cardiology Patient Page. C-reactive protein: a simple test to help predict risk of heart attack and stroke.

Cardiovascular disease remains a leading cause of death worldwide despite the use of available cardiovascular disease risk prediction tools. Identification of high-risk individuals via risk stratification and screening at sub-clinical stages, which may be offered by ocular screening, is important to prevent major adverse cardiac events. Retinal microvasculature has been widely researched for potential application in both diabetes and cardiovascular disease risk prediction. However, the conjunctival microvasculature as a tool for cardiovascular disease risk prediction remains largely unexplored. The purpose of this review is to evaluate the current cardiovascular risk assessment methods, identifying gaps in the literature that imaging of the ocular microcirculation may have the potential to fill. This review also explores the themes of machine learning, risk scores, biomarkers, medical imaging, and clinical risk factors. Cardiovascular risk classification varies based on the population assessed, the risk factors included, and the assessment methods. A more tailored, standardised and feasible approach to cardiovascular risk prediction that utilises technological and medical imaging advances, which may be offered by ocular imaging, is required to support cardiovascular disease prevention strategies and clinical guidelines.