10-year Absolute Risk Research Articles

Prehypertension--prevalence, health risks, and management strategies.

Prehypertension (blood pressure 120-139/80-89 mmHg) affects ~25-50% of adults worldwide, and increases the risk of incident hypertension. The relative risk of incident hypertension declines by ~20% with intensive lifestyle intervention, and by 34-66% with single antihypertensive medications. To prevent one case of incident hypertension in adults with prehypertension and a 50% 5-year risk of hypertension, 10 individuals would need to receive intensive lifestyle intervention, and four to six patients would need to be treated with antihypertensive medication. The relative risk of incident cardiovascular disease (CVD) is greater with 'stage 2' (130-139/85-89 mmHg) than 'stage 1' (120-129/80-84 mmHg) prehypertension; only stage 2 prehypertension increases cardiovascular mortality. Among individuals with prehypertension, the 10-year absolute CVD risk for middle-aged adults without diabetes mellitus or CVD is ~10%, and ~40% for middle-aged and older individuals with either or both comorbidities. Antihypertensive medications reduce the relative risk of CVD and death by ~15% in secondary-prevention studies of prehypertension. Data on primary prevention of CVD with pharmacotherapy in prehypertension are lacking. Risk-stratified, patient-centred, comparative-effectiveness research is needed in prehypertension to inform an acceptable, safe, and effective balance of lifestyle and medication interventions to prevent incident hypertension and CVD.

A Model to Determine Colorectal Cancer Risk Using Common Genetic Susceptibility Loci

Risk for colorectal cancer (CRC) can be greatly reduced through screening. To aid in the development of screening strategies, we refined models designed to determine risk of CRC by incorporating information from common genetic susceptibility loci. By using data collected from more than 12,000 participants in 6 studies performed from 1990 through 2011 in the United States and Germany, we developed risk determination models based on sex, age, family history, genetic risk score (number of risk alleles carried at 27 validated common CRC susceptibility loci), and history of endoscopic examinations. The model was validated using data collected from approximately 1800 participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, conducted from 1993 through 2001 in the United States. We identified a CRC genetic risk score that independently predicted which patients in the training set would develop CRC. Compared with determination of risk based only on family history, adding the genetic risk score increased the discriminatory accuracy from 0.51 to 0.59 (P = .0028) for men and from 0.52 to 0.56 (P = .14) for women. We calculated age- and sex-specific 10-year CRC absolute risk estimates based on the number of risk alleles, family history, and history of endoscopic examinations. A model that included a genetic risk score better determined the recommended starting age for screening in subjects with and without family histories of CRC. The starting age for high-risk men (family history of CRC and genetic risk score, 90%) was 42 years, and for low-risk men (no family history of CRC and genetic risk score, 10%) was 52 years. For men with no family history and a high genetic risk score (90%), the starting age would be 47 years; this is an intermediate value that is 5 years earlier than it would be for men with a genetic risk score of 10%. Similar trends were observed in women. By incorporating information on CRC risk alleles, we created a model to determine the risk for CRC more accurately. This model might be used to develop screening and prevention strategies.

The 10-year Absolute Risk of Cardiovascular (CV) Events in Northern Iran: a Population Based Study.

Background:The present study was conducted to estimate 10-year cardiovascular disease events (CVD) risk using three instruments in northern Iran.Material and methods:Baseline data of 3201 participants 40-79 of a population based cohort which was conducted in Northern Iran were analyzed. Framingham risk score (FRS), World Health Organization (WHO) risk prediction charts and American college of cardiovascular / American heart association (ACC/AHA) tool were applied to assess 10-year CVD events risk. The agreement values between the risk assessment instruments were determined using the kappa statistics.Results:Our study estimated 53.5%of male population aged 40-79 had a 10 –year risk of CVD events≥10% based on ACC/AHA approach, 48.9% based on FRS and 11.8% based on WHO risk charts. A 10 –year risk≥10% was estimated among 20.1% of women using the ACC/AHA approach, 11.9%using FRS and 5.7%using WHO tool. ACC/AHA and Framingham tools had closest agreement in the estimation of 10-year risk≥10% (κ=0.7757) in meanwhile ACC/AHA and WHO approaches displayed highest agreement (κ=0.6123) in women.Conclusion:Different estimations of 10-year risk of CVD event were provided by ACC/AHA, FRS and WHO approaches.

Predicting the effects of blood pressure-lowering treatment on major cardiovascular events for individual patients with type 2 diabetes mellitus: results from Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation.

Blood pressure-lowering treatment reduces cardiovascular risk in patients with diabetes mellitus, but the effect varies between individuals. We sought to identify which patients benefit most from such treatment in a large clinical trial in type 2 diabetes mellitus. In Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) participants (n=11 140), we estimated the individual patient 5-year absolute risk of major adverse cardiovascular events with and without treatment by perindopril-indapamide (4/1.25 mg). The difference between treated and untreated risk is the estimated individual patient's absolute risk reduction (ARR). Predictions were based on a Cox proportional hazards model inclusive of demographic and clinical characteristics together with the observed relative treatment effect. The group-level effect of selectively treating patients with an estimated ARR above a range of decision thresholds was compared with treating everyone or those with a blood pressure >140/90 mm Hg using net benefit analysis. In ADVANCE, there was wide variation in treatment effects across individual patients. According to the algorithm, 43% of patients had a large predicted 5-year ARR of ≥1% (number-needed-to-treat [NNT5] ≤100) and 40% had an intermediate predicted ARR of 0.5% to 1% (NNT5=100-`200). The proportion of patients with a small ARR of ≤0.5% (NNT5≥200) was 17%. Provided that one is prepared to treat at most 200 patients for 5 years to prevent 1 adverse outcome, prediction-based treatment yielded the highest net benefit. In conclusion, a multivariable treatment algorithm can identify those individuals who benefit most from blood pressure-lowering therapy in terms of ARR of major adverse cardiovascular events and may be used to guide treatment decisions in individual patients with diabetes. http://www.clinicaltrials.gov. Unique identifier: NCT00145925.

Self-reported walking difficulty predicts late-life mortality in Finnish war veterans: results from the Veteran 1992 Project Survey.

To determine risk factors and their combinations that predict late-life mortality. Postal questionnaire. Veteran 1992 Project Survey. Finnish Second World War veterans living in Finland (177,989 men, 48,745 women), with a participation rate of 93%. Main outcomes were total, cardiovascular disease (CVD), and accident and violence (AAV) mortality. Absolute 10-year mortality risks for total mortality with combinations of different risk factors were calculated. The strongest predictor of total mortality was self-reported walking difficulty (hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.71-1.76 in men without disability, HR = 1.62, 95% CI = 1.58-1.67 in men with disability, HR = 1.61, 95% CI = 1.57-1.65 in women). The highest HRs of CVD mortality were for self-reported walking difficulty among men without disability (HR = 1.98, 95% CI = 1.95-2.02) and among men with disability (HR = 1.88, 95% CI = 1.82-1.94). In women, the highest HR for CVD mortality was for multimorbidity (HR = 1.87, 95% CI = 1.79-1.96). For AAV mortality, the highest HRs were for falls in men and age in women. A combination of walking difficulty and multimorbidity had the highest absolute 10-year mortality risk for total mortality (0.730 in men without disability, 0.729 in men with disability, 0.487 in women). Self-reported walking difficulty was the most important predictor of total mortality in all veteran groups and for CVD mortality in men. The study demonstrates the importance of self-reported walking difficulty and multimorbidity as markers of high mortality risk in Finnish war veterans.

Prediction of absolute risk reduction of cardiovascular events with perindopril for individual patients with stable coronary artery disease — Results from EUROPA

BackgroundAngiotensin-converting-enzyme inhibition reduces the risk of cardiovascular events at a group level. Presumably, the absolute effect of treatment varies between individuals. We sought to develop multivariable prediction scores to estimate individual treatment effect of perindopril in patients with stable coronary artery disease (sCAD). MethodsIn EUROPA trial participants, we estimated the individual patient 5-year absolute risk reduction (ARR) of major adverse cardiovascular events(MACE) by perindopril. Predictions were based on a new Coxproportional-hazards model with clinical characteristics and an external risk score in combination with the observed relative risk reduction. Second, a genetic profile modifying the relative efficacy of perindopril was added. The individual patient ARR was defined as the difference in MACE risk with and without treatment. The group level impact of selectively treating patients with the largest predicted treatment effect was evaluated using net benefit analysis. ResultsThe risk score combining clinical and genetic characteristics estimated the 5-year absolute treatment effect to be absent or adverse in 27% of patients. On the other hand, the risk score estimated a small 5-year ARR of ≤2% (NNT5≥50) in 20% of patients, a modest ARR of 2–4% (NNT5 25–50) in 26%, and a large ARR of ≥4% (NNT5≤25) in 28%. The external risk score yielded similar predictions. Selective prediction-based treatment resulted in higher net benefit compared to treat everyone at any treatment threshold. ConclusionA prediction score combining clinical characteristics and genetic information can quantify the ARR of MACE by perindopril for individual patients with sCAD and may be used to guide treatment decisions. Trial registration numberISRCTN37166280

THE INFLUENCE OF AWARENESS OF PATIENTS WITH POSTMENOPAUSAL OSTEOPOROSIS ABOUT THE MAGNITUDE OF THE FRAX 10-YEAR ABSOLUTE RISK OF FRACTURE ON THE DECISION TO START AND THE ADHERENCE TO ANTIOSTEOPOROTIC TREATMENT (INTERIM RESULTS OF «CRYSTAL» STUDY)

To assess the influence of informing patients with postmenopausal osteoporosis about the their probability of 10-year absolute fracture risk calculated by FRAX tool on the patient ’s decision to start treatment and their adherence to therapy during 3 years of follow-up. Materials and Methods. Multicenter open randomized trial included 417 women (mean age 65.9 years). Patients of the 1 group (n=191) were informed about the value of their absolute risk of fracture by FRAX. Patients of the 2 group (the control; n=196) got usual advice and recommendations without calculating FRAX. All patients were recommended to take alendronate in a standard dose (70 mg a week) and calcium/vitamin D supplements. Results. During the first three months after initial visit 96.4% of patients started their treatment. The adherence to treatment at sixth month was 7% higher in the group 1; the compliance in the group 1 was 8% higher, than in the control group. 6.4% of patients developed adverse drug reactions, which led to cancellation of therapy in only 2.9% of patients.

Abstract 2921: Assessing colorectal cancer risk using known genetic susceptibility variants and family history accounting for endoscopy

Abstract Colorectal cancer (CRC) is one of the most commonly diagnosed cancers, and remains the second leading cause of cancer death, despite the fact that rates have declined and that being among the most preventable of cancers. Current screening recommendations are based only on age, family history of CRC, and previous screening results, whereas risk varies substantially in the population and most cases occur in those without a positive family history. The recent substantial progress in identifying CRC associated common genetic variants has offered new opportunities to refine risk-prediction models and provide more accurate risk stratification for those at risk. We developed risk-prediction models for men and women based on age, family history, and 28 CRC-associated common genetic variants identified to date, accounting for history of endoscopy, in 5,811 cases and 6,302 controls, and validated the models in an independent study of 866 cases and 869 controls. The genetic risk score derived from CRC-associated common variants provides an independent risk predictor and significantly improves the discriminatory accuracy over the model that includes only family history for both men (AUC = 0.60 vs. 0.51, p-value = 4.6e-6) and women (AUC=0.57 vs. 0.52, p-value=0.02). Including the genetic risk score may also improve risk stratification. Considering, for example, the average 10-year risks of 60-year-old men (2.68%) and women (1.49%) in the absence of endoscopy as the thresholds for screening, then the age to start screening for men with positive family history would be 54, and 61 years old otherwise. For women the starting age would be 57 and 61 years old, respectively. Including additional genetic variants information leads to a wider range, from 51 years old for those with positive family history and the genetic risk scores at the 90% to 68 years old for those without positive family history and the genetic risk scores at the 10%. For women, the range would be from 53 years old to 66 years old, respectively. We also derived estimates of 10-year absolute risk for men and women given their age, family history status, risk alleles carried, and endoscopy. To illustrate, for a 60-year-old man who does not have positive family history, but who carries 28 risk alleles (top 20%), and has not had an endoscopy, risk for developing CRC is 5.49% (95% CI, 3.63 to 7.35); however, if he has undergone endoscopy, his risk is reduced to 1.67% (95% CI, 1.10 to 2.25). For a 60-year-old woman who has a similar profile, risk of developing CRC is 2.41% (95% CI, 1.98 to 2.83) in the absence of endoscopy and is reduced to 1.23% (95% CI, 1.00 to 1.46) if she has undergone endoscopy. Our development and validation of a risk-prediction model are first steps towards utilizing genetic information for more tailored screening and prevention strategies, which should improve the cost-effectiveness of screening and, perhaps, adherence. Citation Format: Li Hsu, Jihyoun Jeon, Hermann Brenner, Sonja Berndt, Andrew T. Chan, Jenny Chang-Claude, Stephen B. Gruber, Tabitha Harrison, Michael Hoffmeister, Polly Newcomb, John Potter, Fredrick Schumacher, Martha Slattery, Duncan Thomas, Emily White, Yingye Zheng, Ulrike Peters, Colorectal Transdisciplinary Study; Genetics and Epidemiology of Colorectal Cancer Consortium. Assessing colorectal cancer risk using known genetic susceptibility variants and family history accounting for endoscopy. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2921. doi:10.1158/1538-7445.AM2014-2921

A prospective clinical trial of specialist renal nursing in the primary care setting to prevent progression of chronic kidney: a quality improvement report.

BackgroundEarly detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at ‘high risk of CKD progression’, defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.MethodsThe study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several ‘intermediary’ secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.ResultsThere was a significant improvement in ACR (average decrease of −6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.ConclusionsThe results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.Trial registrationAustralian and New Zealand Clinical Trials Registry number: ACTRN12613000791730Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2296-15-155) contains supplementary material, which is available to authorized users.

Obesity as a causal risk factor for deep venous thrombosis: a Mendelian randomization study.

To test the hypothesis that obesity is causally associated with deep venous thrombosis (DVT). A Mendelian randomization design. The Copenhagen General Population Study and the Copenhagen City Heart Study combined. Body mass index (BMI) measurements were available for 87, 574 individuals of Danish descent from the adult general population. All subjects completed questionnaires and were genotyped for the FTO rs9939609 variant. First events of DVT with or without pulmonary embolism (PE). The results were assessed using Cox regression, instrumental variable analysis and Poisson regression. Observationally, the risk of DVT increased with increasing BMI (P-trend < 0.0001). The multivariable-adjusted hazard ratio [95% confidence interval (CI)] for DVT was 1.3 (1.1-1.6) in overweight, 1.8 (1.4-2.2) in moderately obese and 3.4 (2.6-4.6) in severely obese compared with normal-weight individuals. For DVT complicated by PE, corresponding hazard ratios (95% CI) were 1.2 (0.8-1.8), 2.1 (1.3-3.5) and 5.1 (2.8-9.2). FTO AA versus TT genotype was associated with a 2.4% increase in BMI with hazard ratios (95% CI) of 1.09 (0.95-1.25) for DVT and 1.54 (1.12-2.10) for DVT complicated by PE. In instrumental variable analysis, the causal odds ratio (95% CI) for an increase in BMI of 1 kg m(-2) was 1.13 (0.92-1.39) for DVT alone and 1.86 (1.14-3.02) for DVT complicated by PE. The absolute 10-year risk of DVT in a high-risk group (i.e. those aged >60 years and homozygous for Factor V Leiden) was 35% in obese individuals and 18% in normal-weight individuals. A strong observational association between obesity and DVT with or without PE, supported by a direct genetic association between the obesity-specific locus FTO and DVT with PE, implies that obesity is likely to be causally associated with DVT.

A Systematic Examination of the 2013 ACC/AHA Pooled Cohort Risk Assessment Tool for Atherosclerotic Cardiovascular Disease

BackgroundThe 2013 American College of Cardiology/American Heart Association updated cholesterol guidelines recommend the use of Pooled Cohort Equations to estimate 10-year absolute risk for atherosclerotic cardiovascular disease (ASCVD) in primary prevention. ObjectivesThis study sought to systematically examine the Pooled Cohort Equations to determine risk factor levels required to exceed risk thresholds outlined in new cholesterol guidelines. MethodsWe entered continuous risk factor levels in isolation and in specified combinations with the risk tool, and we observed predicted risk output patterns. We used the 10-year ASCVD risk threshold of ≥7.5% as a clinically relevant risk threshold. ResultsWe demonstrated that a hypothetical man or woman can reach clinically relevant risk thresholds throughout the eligible age spectrum of 40 to 79 years of age, depending on the associated risk factor burden in all race-sex groups. Age continues to be a major determinant of 10-year ASCVD risk for both men and women. Compared with the previous risk assessment tool used in cholesterol guidelines, the inclusion of a stroke endpoint and use of race-specific coefficients permit identification of at-risk African Americans and non-Hispanic white women at much younger ages and lower risk factor levels. ConclusionsThese data provide context of specific risk factor levels and groups of individuals who are likely to have 10-year ASCVD risk estimates ≥7.5%. Age continues to be a major driver of risk, which highlights the importance of the clinician-patient discussion before statin therapy is initiated.

ST2 may not be a useful predictor for incident cardiovascular events, heart failure and mortality

ObjectivesWe hypothesised that soluble ST2 (sST2) levels can identify people with elevated risk of subsequent cardiovascular disease (CVD) and add to existing risk prediction algorithms.BackgroundST2 is a receptor for the...

Correction

HomeCirculationVol. 129, No. 25_suppl_2Correction Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection Originally published24 Jun 2014https://doi.org/10.1161/CIR.0000000000000067Circulation. 2014;129:S74–S75This article corrects the following2013 ACC/AHA Guideline on the Assessment of Cardiovascular RiskIn the article by Goff et al, “2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,” which published online November 12, 2013, and appears in the supplement to the June 24, 2014, issue of the journal (Circulation. 2014;129[suppl 2]:S49–S73), several corrections were needed.These corrections have been made to the print version and to the current online version of the article, which is available at http://circ.ahajournals.org/lookup/doi/10.1161/01.cir.0000437741.48606.98.On the title page, the first footnote paragraph now reads, “This document was approved by the American College of Cardiology Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, and The Obesity Society Board of Trustees in November 2013. The Academy of Nutrition and Dietetics affirms the value of this guideline.” The footnote previously did not refer to the Academy of Nutrition and Dietetics.On the title page, Robert A. Guyton, MD, FACC, was listed as a member of the ACC/AHA Task Force. His name has been removed from the list of Task Force members.Appendixes have been reordered and renumbered to maintain the journal style of publishing authors’ and peer reviewers’ RWI first as Appendix 1 and Appendix 2, respectively. Callouts in the text have been modified accordingly.Throughout the article, callouts to the “Full Work Group Report Supplement” have been hyperlinked to the report.Throughout the article, the web-based calculator links have been updated to:• http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx and• http://my.americanheart.org/cvriskcalculatorIn Table 4,• The “Assessment of 10-Year Risk of a First Hard ASCVD Event” section, in the “NHLBI Evidence Statements” column, recommendation 2 read, “Appendix 2 CQ2/ES1.” It has been changed to read, “N/A.”• The header “CQ1: Use of Newer Risk Markers After Quantitative Risk Assessment” has been added after recommendation 2, and the header “CQ2: Long-Term Risk Assessment” has been added after recommendation 3.In Section 4, the last paragraph, a referral to the downloadable spreadsheet has been replaced with a referral to the web-based application sites http://my.americanheart.org/cvriskcalculator and http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx.In Section 6.1.1, the last paragraph, the following text has been added: “….by Den Ruijter et al18 reviewed during the ACC/AHA update period…”In Section 7,• Figure 1, a referral and reference number to the “Lifestyle Management (56)” guideline has been added in the 3 boxes on the right.• First paragraph, reference 56 has been added to the following sentence: “Hence, for patients outside this age range, providers should refer to applicable clinical practice guidelines (ie, pediatric53 and adult primary prevention guidelines44,54,56).”• First paragraph, references 20 and 21 have been added to the following sentence: “Beginning at age 40 years, formal estimation of the absolute 10-year risk of ASCVD is recommended.20,21”After the references, “Key Words” have been added: “AHA Scientific Statements ◼ biomarkers ◼ cardiovascular disease ◼ cholesterol ◼ primary prevention ◼ risk assessment ◼ risk reduction behavior.”In Appendix 2, the following note has been added to the footnote: “This table represents the relationships of reviewers with industry and other entities that were self-disclosed at the time of peer review. It does not necessarily reflect relationships with industry at the time of publication. To review the NHLBI and ACC/AHA’s current comprehensive policies for managing relationships with industry and other entities, please refer to http://www.nhlbi.nih.gov/guidelines/cvd_adult/coi-rwi_policy.htm and http://www.cardiosource.org/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/Relationships-With-Industry-Policy.aspx.”In Appendix 3, (Appendix 6 in published document), the table note “Risk calculators noted above include hyperlinks to the respective webpage” has been deleted. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Li Z, Liu J, Shen Y, Zeng F and Zheng D (2016) Increased Lipoprotein-associated phospholipase A2 activity portends an increased risk of resistant hypertension, Lipids in Health and Disease, 10.1186/s12944-016-0184-9, 15:1, Online publication date: 1-Dec-2016. Related articles2013 ACC/AHA Guideline on the Assessment of Cardiovascular RiskDavid C. Goff, et al. Circulation. 2014;129:S49-S73 June 24, 2014Vol 129, Issue 25_suppl_2 Advertisement Article InformationMetrics © 2014 The Expert Work Group Members. The Journal of the American College of Cardiology is published on behalf of the American College of Cardiology Foundation by Elsevier Inc.; Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDervis License, which permits use, distribution, and reproduction in any medium, provided that the Contribution is properly cited, the use is non-commercial, and no modifications or adaptations are made.https://doi.org/10.1161/CIR.0000000000000067 Originally publishedJune 24, 2014 PDF download Advertisement

Common Carotid Intima-Media Thickness Measurements Do Not Improve Cardiovascular Risk Prediction in Individuals With Elevated Blood Pressure

Carotid intima-media thickness (CIMT) is a marker of cardiovascular risk. It is unclear whether measurement of mean common CIMT improves 10-year risk prediction of first-time myocardial infarction or stroke in individuals with elevated blood pressure. We performed an analysis among individuals with elevated blood pressure (ie, a systolic blood pressure ≥140 mm Hg and a diastolic blood pressure ≥ 90 mm Hg) in USE-IMT, a large ongoing individual participant data meta-analysis. We refitted the risk factors of the Framingham Risk Score on asymptomatic individuals (baseline model) and expanded this model with mean common CIMT (CIMT model) measurements. From both models, 10-year risks to develop a myocardial infarction or stroke were estimated. In individuals with elevated blood pressure, we compared discrimination and calibration of the 2 models and calculated the net reclassification improvement (NRI). We included 17 254 individuals with elevated blood pressure from 16 studies. During a median follow-up of 9.9 years, 2014 first-time myocardial infarctions or strokes occurred. The C-statistics of the baseline and CIMT models were similar (0.73). NRI with the addition of mean common CIMT was small and not significant (1.4%; 95% confidence intervals, −1.1 to 3.7). In those at intermediate risk (n=5008, 10-year absolute risk of 10% to 20%), the NRI was 5.6% (95% confidence intervals, 1.6–10.4). There is no added value of measurement of mean common CIMT in individuals with elevated blood pressure for improving cardiovascular risk prediction. For those at intermediate risk, the addition of mean common CIMT to an existing cardiovascular risk score is small but statistically significant.

Individual risk of cutaneous melanoma in New Zealand: developing a clinical prediction aid.

BackgroundNew Zealand and Australia have the highest melanoma incidence rates worldwide. In New Zealand, both the incidence and thickness have been increasing. Clinical decisions require accurate risk prediction but a simple list of genetic, phenotypic and behavioural risk factors is inadequate to estimate individual risk as the risk factors for melanoma have complex interactions. In order to offer tailored clinical management strategies, we developed a New Zealand prediction model to estimate individual 5-year absolute risk of melanoma.MethodsA population-based case–control study (368 cases and 270 controls) of melanoma risk factors provided estimates of relative risks for fair-skinned New Zealanders aged 20–79 years. Model selection techniques and multivariate logistic regression were used to determine the important predictors. The relative risks for predictors were combined with baseline melanoma incidence rates and non-melanoma mortality rates to calculate individual probabilities of developing melanoma within 5 years.ResultsFor women, the best model included skin colour, number of moles > =5 mm on the right arm, having a 1st degree relative with large moles, and a personal history of non-melanoma skin cancer (NMSC). The model correctly classified 68% of participants; the C-statistic was 0.74. For men, the best model included age, place of occupation up to age 18 years, number of moles > =5 mm on the right arm, birthplace, and a history of NMSC. The model correctly classified 67% of cases; the C-statistic was 0.71.ConclusionsWe have developed the first New Zealand risk prediction model that calculates individual absolute 5-year risk of melanoma. This model will aid physicians to identify individuals at high risk, allowing them to individually target surveillance and other management strategies, and thereby reduce the high melanoma burden in New Zealand.

New possibilities for the treatment of glucocorticoid-induced osteoporosis

Glucocorticoid-induced osteoporosis (GIO) is the most common cause of secondary osteoporosis (OP) and a main cause of drug-induced OP. Fractures of the skeleton are registered in 30–50% of patients who have taken oral glucocorticoids (GCs) for a long time, during which the frac- tures develop with the use of any daily GC dose and with higher bone mineral density (BMD) than in postmenopausal OP. In patients who have taken oral GCs long or in high daily doses, decrease of BMD and low bone tissue quality leading to fractures are largely associated with the reduction of bone formation. This gives proof to the administration of antiosteoporotic agents that enhance the formation of bone during its remodeling. Teriparatide, a recombinant human parathyroid hormone, enhances osteoblast function, decreases the apoptosis of osteoblasts and osteocytes, increases the differentiation of osteoblast precursors, and can prevent the negative effect of exogenous GCs on bone. According to clinical trials results, teriparatide treatment increases BMD and reduces the risk of vertebral fractures in patients who have taken oral GCs long. In accordance of the clinical recommendations for the diagnosis, prevention, and treatment of GIO, which have been developed by the Russian Osteoporosis Association jointly with the Association of Rheumatologists of Russia and the Russian Respiratory Society, teriparatide is the drug of first choice for the treatment of GIO in men and women at high risk for fractures (with the history of fragility fractures or having high FRAX 10-year absolute fracture risk). Teriparatide may be prescribed in case of previous antiosteoporotic treatment failure (new fractures occurring during treatment and/or continuing to decrease BMD), as well as when other drugs to treat OP are intolerable or when there are contraindications to their use.

The 10-year absolute fracture risk and central DXA correlations in 505 Romanian menopausal women

The 10-year absolute fracture risk and central DXA correlations in 505 Romanian menopausal women

Factors associated with dropout in a lung cancer high-risk cohort - the Liverpool lung project

In long-term longitudinal cohort studies the dropout of participants occurring as a result of withdrawal or lost to follow-up may have greater impact on the effect estimates, if characteristics of participants who drop out and those still active in the study differ significantly. The study aimed to investigate factors associated with dropout in a 5-year follow-up of individuals at 'high‑risk' of lung cancer. We studied 'high‑risk' group of 1,486 individuals aged 45-79 selected from the Liverpool Lung Prospective (LLP) cohort study using a strategy reflecting only age, smoking duration and history of pulmonary disease. Study subjects were recalled annually from 2005-2009 for follow-up collection of specimens and questionnaire data. The dropout rate over the follow-up time was investigated using the Kaplan‑Meier survival curve and the Cox proportional hazard model. Dropout rate was 31% after an average of 3annual visits. Female gender hazard ratio (HR) 1.35 (95%CI 1.09-1.66), current smoking 1.26 (1.02-1.57), prior diagnosis of malignant disease 0.54 (0.36-0.79), home visits 0.67 (0.48-0.94) and systolic blood pressure 1.46 (1.10-1.94) were significantly associated with the dropout rate. Nearly 40% of individuals selected into the 'high‑risk' group by the old criteria were low risk with predicted 5-year absolute risk of less than 2.5%. In conclusion, follow-up of individuals is feasible within the LLP, but may be prone to selective withdrawal attributable to patient's state of health and mobility. We recommend future design of 'high‑risk' follow‑up studies to consider home visit as a useful strategy to encourage continued participation.

Visible Age-Related Signs and Risk of Ischemic Heart Disease in the General Population

Background— Cardiovascular disease is 1 of the most common age-related diseases, and also 1 of the most common causes of death in the general population. We tested the hypothesis that visible age-related signs associate with risk of ischemic heart disease (IHD), myocardial infarction (MI), and death in the general population, independent of chronological age. Methods and Results— 10,885 individuals aged 20 to 93 years free of IHD were followed from 1976 through 1978 until June 2011 with 100% complete follow-up. During these 35 years of follow-up, 3401 participants developed IHD and 1708 developed MI. Presence of frontoparietal baldness, crown top baldness, earlobe crease, and xanthelasmata was associated with increased risk of IHD or MI after multifactorial adjustment for chronological age and well-known cardiovascular risk factors. The risk of IHD and MI increased stepwise with increasing number of age-related signs with multifactorially adjusted hazard ratios up to 1.40 (95% confidence interval, 1.20–1.62) for IHD and 1.57 (1.28–1.93) for MI, in individuals with 3 to 4 versus no age-related signs at baseline ( P for trend &lt;0.001). In all age groups in both women and men, absolute 10-year risk of IHD and MI increased with increasing number of visible age-related signs. Conclusions— Male pattern baldness, earlobe crease, and xanthelasmata—alone or in combination—associate with increased risk of ischemic heart disease and myocardial infarction independent of chronological age and other well-known cardiovascular risk factors. This is the first prospective study to show that looking old for your age is a marker of poor cardiovascular health.

Individualizing osteoporosis medications

Mrs. JD is a 58-year-old postmenopausal woman having symptoms of hot flashes and night sweats. She has a dual-energy x-ray absorptiometry T-score of -2.4 in the femoral neck, consistent with low bone mass or osteopenia. She has a parental history of hip fracture. FRAX shows the 10-year absolute risk of major osteoporotic fracture equal to 18% and the 10-year risk of hip fracture above 3% at 3.2%, which meets the National Osteoporosis Foundation threshold. Mrs. JD is taking calcium 1,200 mg, between supplement and diet, and 1,000 IU vitamin D3 daily. How should she be treated?