10-year Coronary Heart Disease Risk Research Articles

Performance of the Framingham risk models and pooled cohort equations for predicting 10-year risk of cardiovascular disease: a systematic review and meta-analysis

BackgroundThe Framingham risk models and pooled cohort equations (PCE) are widely used and advocated in guidelines for predicting 10-year risk of developing coronary heart disease (CHD) and cardiovascular disease (CVD) in the general population. Over the past few decades, these models have been extensively validated within different populations, which provided mounting evidence that local tailoring is often necessary to obtain accurate predictions. The objective is to systematically review and summarize the predictive performance of three widely advocated cardiovascular risk prediction models (Framingham Wilson 1998, Framingham ATP III 2002 and PCE 2013) in men and women separately, to assess the generalizability of performance across different subgroups and geographical regions, and to determine sources of heterogeneity in the findings across studies.MethodsA search was performed in October 2017 to identify studies investigating the predictive performance of the aforementioned models. Studies were included if they externally validated one or more of the original models in the general population for the same outcome as the original model. We assessed risk of bias for each validation and extracted data on population characteristics and model performance. Performance estimates (observed versus expected (OE) ratio and c-statistic) were summarized using a random effects models and sources of heterogeneity were explored with meta-regression.ResultsThe search identified 1585 studies, of which 38 were included, describing a total of 112 external validations. Results indicate that, on average, all models overestimate the 10-year risk of CHD and CVD (pooled OE ratio ranged from 0.58 (95% CI 0.43–0.73; Wilson men) to 0.79 (95% CI 0.60–0.97; ATP III women)). Overestimation was most pronounced for high-risk individuals and European populations. Further, discriminative performance was better in women for all models. There was considerable heterogeneity in the c-statistic between studies, likely due to differences in population characteristics.ConclusionsThe Framingham Wilson, ATP III and PCE discriminate comparably well but all overestimate the risk of developing CVD, especially in higher risk populations. Because the extent of miscalibration substantially varied across settings, we highly recommend that researchers further explore reasons for overprediction and that the models be updated for specific populations.

Reclassification of coronary heart disease risk in a primary prevention setting: traditional risk factor assessment vs. coronary artery calcium scoring.

In a primary prevention screening program of asymptomatic middle-aged subjects, we sought to assess the degree of risk-reclassification provided by traditional risk assessment vs. coronary artery calcification scoring (CACS). A total of 1,806 consecutive asymptomatic subjects (age 55 years, 76% men), who underwent comprehensive screening in a primary prevention clinic between 3/2016 and 9/2017 were included. Standard risk factors, C-reactive protein (CRP) and CAC scoring were performed. % 10-year coronary heart disease (CHD) risk was calculated using Reynolds Risk Score (RRS), atherosclerotic cardiovascular disease (ASCVD) score and multiethnic study on subclinical atherosclerosis (MESA) CACS were calculated. % 10-year CHD risk for all scores was categorized as follows: <1%, 1-5%, 6-10% and >10%. Mean CRP, RRS, ASCVD and MESA-CACS were 2.1±4.2, 3.7±4, 4.9±6, 4.9±5; 54% had CAC of 0, while 21% had CAC >75th percentile. There was a significant, but modest correlation between MESA-CAC score and (I) RRS (r=0.62) and (II) ASCVD scores (r=0.65, both P<0.001). Compared to MESA-CAC, for RRS, (I) 188 (10%) patients had a downgrade in risk and (II) 538 (30%) patients had an upgrade in risk (40% reclassification of risk). Similarly, compared to MESA-CAC, for ASCVD score, (I) 412 (23%) patients had a downgrade in risk and (II) 329 (18%) patients had a downgrade in risk (41% reclassification of risk). In a primary prevention screening program of asymptomatic middle-aged patients, RRS overestimates and ASCVHD underestimates 10-year CHD risk vs. MESA-CACS. Addition of CACS results in significant risk reclassification.

436-P: Comparison of the ASCVD and UK Prospective Diabetes Study Risk Engine with Carotid Intima Media Thickness and Brachial-Ankle Pulse Wave Velocity

Object: We explored and compare the efficacy of ACC-AHA-atherosclerotic cardiovascular disease (ASCVD) risk score and UK Prospective Diabetes Study (UKPDS) risk engine with the presence of subclinical carotid and peripheral atherosclerosis in patients with type 2 diabetes(T2DM) patients. Methods: We studied 746 T2DM patients aged 20 years and older, who visited Hallym University Dongtan Sacred Heart Hospital from Noember 2012 to June 2014. Carotid atherosclerosis was defined as carotid intima-media thickness (IMT) &amp;gt; 1mm or the presence of carotid artery plaque. Peripheral atherosclerosis was defined as over than 1750 cm/s of brachial-ankle pulse wave velocity (baPWV). Ten-year coronary heart disease (CHD) risk was determined using the ASCVD and UKPDS risk engine. Results: The mean 10-year CHD risks of UKPDS and ASCVD were 13.9±13.0% and 12.7±13.3%, respectively. The prevalence of carotid atherosclerosis and peripheral atherosclerosis were 13.3% and 22.9%. The risk for carotid atherosclerosis and peripheral atherosclerosis increased 6.12 (95% CI 3.3-11.4) times and 10.0 (95% CI 5.9-17.1) times in high risk group (≥20% 10-year UKPDS risk) than low-risk group, respectively. The risk for carotid atherosclerosis and peripheral atherosclerosis increased 7.891 (95% CI 4.4-14.0) times and 15.6 (95% CI 9.2-26.2) times in high risk group (≥20% 10-year ASCVD-predicted coronary heart disease risk) than low-risk group, respectively. In multiple regression analysis with ASCVD and UKPDS risk for carotid atherosclerosis and peripheral atherosclerosis, only ASCVD risk were statically significant (all p&amp;lt;0.001). Conclusion: Carotid atherosclerosis and peripheral atherosclerosis were prevalent in patients with T2DM and positively correlate d with 10-year CHD risk. In comparison of ASCVD and UKPDS risk engine, ASCVD risk engine was more proper in patients with T2DM. Disclosure S. Hong: None. Y. Choi: None. E. Hong: None.

Landmark studies in coronary heart disease epidemiology. The Framingham Heart Study after 70 years and the Seven Countries Study after 60 years.

This year we celebrate anniversaries of two prospective studies that have contributed most to our understanding of the epi-demiology of coronary heart disease (CHD): the Framingham Heart Study (FHS) and the Seven Countries Study (SCS). The FHS was initiated 70 years ago and is continued in the subsequent generations using new research opportunities, including evaluation of the risk factors for chronic non-cardiovascular diseases. The SCS is now finished because the original study population are mostly deceased, and the study did not continue in the children and grandchildren of the participants. The FHS allowed identification of factors predisposing to CHD, which were referred to as "risk factors" for the first time. Based on the FHS findings, a multivariate model of the 10-year CHD risk was developed, known as the Framingham Heart Score. In addition, criteria of heart failure and risk factors for atrial fibrillation were defined. The SCS provided the first evidence for an association between nutrition and CHD and laid the foundations for recommending the Mediterranean diet for cardio-vascular disease prevention.

Advantages of Continuous-Valued Risk Scores for Predicting Long-Term Costs: The Framingham Coronary Heart Disease 10-Year Risk Score.

Background:The few studies that have examined the relationship between midlife cardiovascular disease risk and longer-term costs have differentiated risk using a small number of risk categories. In this paper, we illustrate the advantages of a continuous-valued score to examine the relationship between risk and longer-term costs: the Framingham 10-year coronary heart disease risk score.Methods:Our study cohort consisted of 1333 Second Generation Framingham Heart Study participants enrolled in fee-for-service Medicare for at least 8 quarters and who had a risk score assessment between age 40 and 50 years. We used generalized linear models to examine the relationships between quarterly Medicare costs and risk scores.Results:Using risk categories defined by the Framingham score, the cost differences between a low and high risk group were 40% to over 200% greater than differences in comparable studies using a small number of risk categories. A continuous-valued score facilitates comparison of the cost consequences of impacting risk score changes. For example, an intervention that is able to reduce a person’s score change between midlife and later-life from the 75th percentile to the 25th percentile would result in almost a 20% reduction in longer-term costs. In contrast, an intervention that is able to reduce a person’s midlife score from the 75th percentile to the 25th percentile would result in a 38% reduction in costs.Conclusions:A continuous-valued risk score has advantages compared to defining risk based on a small number of risk categories.

Quantifying Importance of Major Risk Factors for Coronary Heart Disease

To optimize preventive strategies for coronary heart disease (CHD), it is essential to understand and appropriately quantify the contribution of its key risk factors. Our objective was to compare the associations of key modifiable CHD risk factors-specifically lipids, systolic blood pressure (SBP), diabetes mellitus, and smoking-with incident CHD events based on their prognostic performance, attributable risk fractions, and treatment benefits, overall and by age. Pooled participant-level data from 4 observational cohort studies sponsored by the National Heart, Lung, and Blood Institute were used to create a cohort of 22 626 individuals aged 45 to 84 years who were initially free of cardiovascular disease. Individuals were followed for 10 years from baseline evaluation for incident CHD. Proportional hazards regression was used to estimate metrics of prognostic model performance (likelihood ratio, C index, net reclassification, discrimination slope), hazard ratios, and population attributable fractions for SBP, non-high-density lipoprotein cholesterol (non-HDL-C), diabetes mellitus, and smoking. Expected absolute risk reductions for antihypertensive and lipid-lowering treatment were assessed. Age, sex, and race capture 63% to 80% of the prognostic performance of cardiovascular risk models. In contrast, adding either SBP, non-HDL-C, diabetes mellitus, or smoking to a model with other risk factors increases the C index by only 0.004 to 0.013. However, primordial prevention could have a substantial effect as demonstrated by population attributable fractions of 28% for SBP≥130 mm Hg and 17% for non-HDL-C≥130 mg/dL. Similarly, lowering the SBP of all individuals to <130 mm Hg or lowering low-density lipoprotein cholesterol by 30% would be expected to lower a baseline 10-year CHD risk of 10.7% to 7.0 and 8.0, respectively (absolute risk reductions: 3.7% and 2.7%, respectively). Prognostic performance decreases with age (C indices for age groups 45-54, 55-64, 65-74, 75-84 are 0.75, 0.72, 0.66, and 0.62, respectively), whereas absolute risk reductions increase (SBP: 1.1%, 2.3%, 5.4%, 10.3%, respectively; non-HDL-C: 1.1%, 2.0%, 3.7%, 5.9%, respectively). Although individual modifiable CHD risk factors contribute only modestly to prognostic performance, our models indicate that eliminating or controlling these individual factors would lead to substantial reductions in total population CHD events. Metrics used to judge importance of risk factors should be tailored to the research objectives.

White blood cell count: an independent predictor of coronary heart disease risk in middle-aged and elderly population with hyperuricemia.

Previous studies have shown that hyperuricemia is an independent risk factor for cardiovascular disease. The aim of the study was to examine the association between white blood cell (WBC) count and coronary heart disease (CHD) risk in middle-aged and elderly population with hyperuricemia.Data included in this analysis were from a population-based cross-sectional study, that is, the Xiangya Hospital Health Management Center Study. Hyperuricemia was defined as uric acid ≥416 μmol/L in male population and ≥360 μmol/L in female population. The WBC count was classified into 3 categories based on the tertile distribution of the study population. Framingham risk scores calculated by the Adult Treatment Panel III charts were used to estimate 10-year CHD risk for each participant. The relationship between WBC count and CHD risk in patients with hyperuricemia was examined using the multivariable logistic analysis.A total of 1148 hyperuricemia patients (855 males and 293 females) aged from 40 to 85 years were included and 418 (36.4%) of them were defined with relatively high 10-year CHD risk. Compared with the lowest tertile, the crude odds ratios (ORs) of high 10-year CHD risk were 1.43 (95% confidence interval [CI] 1.06–1.92) and 1.56 (95% CI 1.16–2.11) in the 2nd and 3rd tertiles of WBC count (P for trend = .004), and the multivariable adjusted ORs of high 10-year CHD risk were 1.39 (95% CI 1.03–1.89) and 1.47 (95% CI 1.08–2.00) in the 2nd and 3rd tertiles of WBC count (P for trend = .015).This study indicated that WBC count was associated with CHD risk in patients with hyperuricemia, suggesting that WBC count, an easily accessible biomarker, could probably predict CHD risk in middle-aged and elderly population with hyperuricemia.

Serum Alanine Aminotransferase Level as a Risk Factor for Coronary Heart Disease Prediction in Koreans: Analysis of the Korea National Health and Nutrition Examination Survey (V-1, 2010 and V-2, 2011).

BackgroundThe blood level of alanine aminotransferase (ALT) is associated with increased coronary heart disease (CHD) risk. However, its use as an independent factor for CHD risk prediction remains unclear in Asian populations. The purpose of this study was to examine the association between serum ALT levels and CHD risk in Koreans.MethodsThis was a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey (V-1, 2010 and V-2, 2011). The ALT levels of 3,215 individuals were analyzed. The Framingham Risk Score (FRS) modified by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) was used to compute the 10-year CHD risk prediction.ResultsPositive correlations were established between log-transformed ALT concentration and FRS (r=0.433, P<0.001). After adjusting for body mass index, low-density lipoprotein cholesterol, the amount of alcohol intake, and gamma-glutamyl transferase, the odds ratio (95% confidence interval) for intermediate or greater risk of 10-year CHD prediction (10-year risk ≥10%) for the lowest quartile of participants was 2.242 (1.405–3.577) for the second quartile, 2.879 (1.772–4.679) for the third quartile, and 3.041 (1.789–5.170) for the highest quartile.ConclusionIn Koreans, a higher serum ALT concentration was significantly correlated with 10-year CHD risk prediction according to NCEP ATP III guidelines.

Clinical Impact of 5Years of Liraglutide Treatment on Cardiovascular Risk Factors in Patients with Type 2 Diabetes Mellitus in a Real-Life Setting in Italy: An Observational Study.

IntroductionBased on existing data regarding the durability of liraglutide in type 2 diabetes, this study aimed to assess its long-term effectiveness at 5 years and its overall impact on cardiovascular (CV) risk.MethodsThis was a multicenter retrospective observational study. Liraglutide was used under routine clinical practice conditions. Changes from baseline to 60 months in HbA1c, fasting plasma glucose (FPG), body weight, blood pressure, and lipid profile were assessed. United Kingdom Prospective Diabetes Study (UKPDS) scores were calculated at baseline and after 60 months to assess changes in the estimated 5- and 10-year risk for fatal and nonfatal coronary heart disease (CHD) and fatal and nonfatal stroke.ResultsOverall, 103 patients (age 59.0 ± 7.9 years, diabetes duration 10.4 ± 6.8 years) were involved in the study. After 60 months, HbA1c levels were reduced by − 1.0 ± 1.2%, FPG levels by − 24.5 ± 43.4 mg/dl, body weight by − 5.3 ± 6.4 kg, systolic blood pressure by − 6.5 ± 18.5 mmHg, diastolic blood pressure by − 3.6 ± 11.8 mmHg, and total cholesterol by − 16.9 ± 37.4 mg/dl. The proportion of patients achieving HbA1c levels of < 7% increased from 12.7% to 39.8% (p = 0.02). Based on the UKPDS scores, statistically significant reductions in the 5- and 10-year risk of nonfatal CHD and fatal CHD were found, with no change in the 5- and 10-year risk of fatal and nonfatal stroke.ConclusionIn patients prolonging treatment with liraglutide for 5 years, the benefits in relation to metabolic control and CV risk factors are maintained. The UKPDS risk scores suggest that liraglutide is associated with a reduced CHD risk, but not with a reduced stroke risk.Electronic supplementary materialThe online version of this article (10.1007/s13300-018-0503-4) contains supplementary material, which is available to authorized users.

Metabolic surgery ameliorates cardiovascular risk in obese diabetic patients: Influence of different surgical procedures

BackgroundIn recent years, bariatric surgery was found to have therapeutic potential for the treatment of type 2 diabetes (T2D) in severely obese patients (body mass index [BMI] ≥35 kg/m2) and to reduce cardiovascular disease (CVD) risk and mortality. However, the benefit of CVD risk reduction after metabolic surgery in nonseverely obese T2D patients (BMI <35 kg/m2) remained to be proven. ObjectiveTo evaluate the CVD risk after metabolic surgery in T2D patients using The UK Prospective Diabetes Study score. SettingTertiary referral general hospital, Taiwan, Republic of China. MethodsOutcomes of 392 patients (235 women and 147 men) who had undergone sleeve gastrectomy (87) or gastric bypass (305) for treatment of T2D with 1-year follow-up were assessed. Data were prospectively collected for study, and cerebral and coronary heart disease risk was calculated by using The UK Prospective Diabetes Study risk engine. Outcomes of patients who had undergone different surgical procedures were assessed. ResultsOne year after surgery, weight and glycemic control with complete and partial remission of T2D were significant in most of the patients. The 10-year coronary heart disease risk and fatal coronary heart disease risk were also reduced from 8.8% to 4.6% and from 4.6% to 2.1%, respectively (both P < .001). Similar CVD risk reduction was seen in both patients with BMI ≥35 and BMI <35. Multivariable analysis confirmed that surgical procedure of sleeve gastrectomy was a negative independent predictor of CVD risk reduction after metabolic surgery. ConclusionThe present study confirms the efficacy of metabolic surgery for the T2D treatment and reduction of CVD risk up to 50% 1 year after surgery. Gastric bypass surgery has more power on CVD risk reduction than sleeve gastrectomy.

P622Reclassification of 10-year coronary heart disease risk in a primary prevention setting: traditional risk factor assessment vs. coronary artery calcium scoring

P622Reclassification of 10-year coronary heart disease risk in a primary prevention setting: traditional risk factor assessment vs. coronary artery calcium scoring

Cardiovascular risk goes up as your mood goes down: Interaction of depression and socioeconomic status in determination of cardiovascular risk in the CONSTANCES cohort

BackgroundRecent evidence suggests that the association of psychological variables with the risk of coronary heart disease (CHD) might depend upon socioeconomic status (SES). However, it is unclear whether the association between depressive symptoms and CHD risk might differ according to three SES indicators (education, occupational status and household monthly income). MethodsAmong 34,836 working participants of the French CONSTANCES cohort (16,221 men, mean age [SD]: 44.0 [10.4] years) without history of cardiovascular disease, depressive symptoms were assessed with the Center of Epidemiologic Studies Depression scale (CES-D). The Framingham risk equation calibrated to the French population estimated the participant's 10-year risk of CHD. Associations between depressive symptoms and CHD risk were estimated using linear regression models in SES strata. ResultsThe estimated 10-year risk of CHD was 16.9% in men and 1.8% in women. In men, the increased CHD risk in those with (versus without) depressive symptoms was more pronounced as occupational status decreased, being 0.65% (−0.57; 1.88), 1.58% (0.50; 2.66) and 3.19% (1.30; 5.07) higher in individuals of high, medium and low occupational status, respectively (p for interaction: 0.01). In contrast, effect modification by education or household income was less evident, despite similar trends. In women, no effect modification was found whatever the SES indicator. ConclusionsDepressive symptoms and 10-year estimated CHD risk were more tightly linked in individuals of lower SES, at least in men. Occupational status was the SES indicator that displays the most obvious effect modification on this association.

Levels of serum high mobility group box 1 were independently associated with cardiovascular risk in patients undergoing coronary angiography

BackgroundWe aimed to examine the association of serum high mobility group box 1 (HMGB1) level with cardiovascular risk in patients undergoing coronary angiography with no history of diabetes. MethodsWe enrolled patients with no history of diabetes who had been admitted for coronary angiography due to suspected or known coronary artery disease. Two to four weeks after the patients were discharged from the hospital, an oral glucose tolerance test (OGTT) was conducted and serum HMGB1 level was measured. Patients' 10-year coronary heart disease (CHD) risk was assessed using the Framingham Risk Scoring. ResultsA total of 476 patients were enrolled. Overall, mean serum HMGB1 level was 6.1 ± 1.3 pg/ml. Using linear regression analysis, high-density lipoprotein cholesterol was negatively associated with serum HMGB1 (β coefficient − 0.033, 95% CI −0.063 to −0.003, p = 0.033) after adjustment for several confounders. With regard to cardiovascular risk, levels of serum HMGB1 were positively associated with 10-year CHD risk (β coefficient 0.506, 95% CI 0.030 to 0.983, p = .037), independent of patients' undiagnosed abnormal glucose regulation. ConclusionsIn patients undergoing coronary angiography with no history of diabetes, levels of serum HMGB1 were positively associated with 10-year CHD risk, independent of patients' undiagnosed abnormal glucose regulation.

Abstract P164: Cognitive Impairment Among Adults With Incident Heart Failure

Background: Cognitive impairment is as high as 70% among adults with heart failure (HF) and its prevalence increases with the duration and severity of HF. However, little is known about the prevalence of cognitive impairment early in the course of HF. This is important, as high cognitive impairment at diagnosis would suggest that earlier screening would be warranted. We examined the prevalence and correlates of cognitive impairment among adults with incident HF. Methods: We used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, an observational, longitudinal cohort study of 30,239 community-dwelling adults &gt; 45 recruited from 2003 to 2007. Blacks and residents of the stroke belt were oversampled. Global cognitive status was assessed annually by telephone with the Six-item Screener (SIS) and the diagnosis of incident HF was validated by physicians using medical records and standard clinical criteria. Participants who were hospitalized for incident HF from 2004 until 2016 with a SIS completed &gt; 1 month but &lt; 18 months before the index hospitalization were included. After determining the prevalence of cognitive impairment among this cohort, we identified which of their baseline characteristics were independently associated with cognitive impairment using multivariable logistic regression. We then compared the prevalence of cognitive impairment among adults with incident HF to the prevalence of cognitive impairment among age, sex, and race matched participants without HF, stratifying by 10-year Framingham Coronary Heart Disease Risk Scores (FRS) (&lt;10%, 10-20%, and &gt; 20%). Results: Of the 436 participants with incident HF, 14.9% had cognitive impairment. In an age-adjusted model, older age (OR 1.04 [95% CI 1.01 - 1.08], black race (OR 1.88 [95% 1.08-3.28]), &lt; high school education (OR 1.89 [95% 1.02-3.51]), and anticoagulation (OR 3.01 [95% 1.05 - 8.63]) were independently associated with higher odds of cognitive impairment, whereas female sex (OR 0.54 [95% 0.31 - 0.94]) was associated with lower odds of cognitive impairment. The prevalence of cognitive impairment among participants with incident HF was higher than the prevalence of cognitive impairment among controls with low FRS (9.4%) but was less than the prevalence of cognitive impairment among controls with high FRS (21.9%). Conclusion: The prevalence of cognitive impairment among adults with incident HF was greater than the prevalence of cognitive impairment among matched participants with low CHD risk, but less than the prevalence of cognitive impairment among matched participants with the highest CHD risk. This suggests that the majority of cognitive decline in HF may occur later in the course of the disease. Increased awareness of cognitive impairment among newly diagnosed patients, as well as ways to mitigate cognitive decline in the context of HF management, are warranted.

Association of antipsychotic and antidepressant treatment with metabolic syndrome and 10 years' coronary heart disease risk

Background: Cardiovascular risk is becoming a growing concern in patients receiving psychotropic medications. An increased Framingham risk score (FRS) and 10-year coronary artery disease risk has been reported in patients suffering from mental diseases. Aim: This study aims to evaluate the cardiometabolic risk profile in patients suffering from psychiatric disorders being treated with antipsychotics and antidepressants. Materials and Methods: This cross-sectional study was conducted on 68 patients diagnosed with psychiatric disorders according to International Statistical Classification of Diseases-10 at a tertiary health-care center. Patient's demographic details, family history, level of education, duration of disease, use of alcohol and or nicotine, use of concomitant medications, psychotropic drug history, history of treatment of diabetes, dyslipidemia, hypertension, or any other medical conditions were also recorded. Waist circumference, blood pressure, fasting blood sugar, triglyceride, and high-density lipoprotein values were estimated by taking fasting venous samples under aseptic measures. Metabolic syndrome was diagnosed using the International Diabetes Federation Criteria. Ten-year cardiovascular risk was assessed using the FRS. Statistical evaluation was done using appropriate parametric and nonparametric statistical methods. Results: A total of 49 patients were being treated with antipsychotic drugs and 19 were receiving antidepressants. The mean age of patient receiving antipsychotics were 37.51, and those receiving antidepressant were 34.15. The metabolic syndrome was 36.76% in patients taking antipsychotics as compared to 11.76% in patients on antidepressant. The mean FRS score in antipsychotic group was 7.48, and those receiving antidepressants were 4.7. The 10-year coronary heart disease (CHD) risk score was significantly higher in patients receiving antipsychotics as compared to patients on antidepressants. Conclusion: Treatment with antipsychotics is associated with significantly higher 10-year CHD risk scores as compared to treatment with antidepressants.

Body composition measures and cardiovascular risk in high-risk ethnic groups

Cardiovascular disease (CVD) is highly prevalent in Suriname, a middle-income country with predominantly people of African and Asian ancestry. We examined whether the more comprehensive body composition measures determined by bioelectrical impedance analysis (BIA) are superior to the more traditional BMI and waist measures in relation to cardiovascular risk. Data from the cross-sectional Healthy Life in Suriname (HELISUR) study were used to calculate BMI, waist-hip ratio, waist-to-height ratio, and waist circumference. BIA was used to estimate fat percentage, fat-free mass index, and fat-to-fat-free mass ratio. High cardiovascular risk was defined as 1) a 10-year Framingham coronary heart disease risk score ≥10% in African-Surinamese and ≥12% in Asian-Surinamese, and 2) an increased arterial stiffness (pulse wave velocity >10m/s). Using logistic regression analysis, we pre-selected the strongest correlate (i.e. lowest p-value below 0.05) of all body composition items for both outcomes of cardiovascular risk separately, and subsequently, used forward logistic regression modelling to determine whether other measures added value to the initial model with the strongest correlate (-2 log-likelihood (-2LL) of initial model minus-2LL of new model, χ-square statistic >3.841, 1 df). Analyses were adjusted for sex, age and ethnicity. We examined 691 participants (65% women; 48% African-Surinamese) with a mean age of 42 (SD 14) years. Waist circumference was the strongest correlate for high 10-year CVD risk in the total group, in men and African-Surinamese. In Asian-Surinamese, fat-free mass index was the strongest correlate of high 10-year CVD risk. Increased arterial stiffness was most strongly related with waist-to-height ratio in the total group and in African-Surinamese, and with BMI in men. None of the measures were significantly associated in women (for both outcomes) and Asian-Surinamese (for increased arterial stiffness). Forward selection showed that only BMI added value next to waist-to-height ratio in the total group in relation to increased arterial stiffness. Waist measures, in particular waist circumference and waist-to-height ratio, and BMI should be used in African and Asian-Surinamese to identify who is at increased cardiovascular risk. Overall, we found little advantage in using BIA measures rather than simple anthropometric measures.

Apolipoprotein E-containing high-density lipoprotein (HDL) modifies the impact of cholesterol-overloaded HDL on incident coronary heart disease risk: A community-based cohort study

Experimental studies have shown that cholesterol-overloaded high-density lipoprotein (HDL) can promote the formation of apolipoprotein E (APOE)-containing HDL, a process correcting the atherogenic function of cholesterol-overloaded HDL. The objective of the study was to explore whether APOE-containing HDL can attenuate the defective impact of cholesterol-overloaded HDL on the development of coronary heart disease (CHD) in humans. We measured APOE-HDL cholesterol (APOE-HDLC), HDL cholesterol (HDLC), and HDL particle number in 1112 participants aged 45 to 74years at baseline in a community-based cohort study. Cholesterol molecules per HDL particle (HDL-C/P ratio) were calculated as the ratio of HDLC to HDL particle number. The ratio of APOE-HDLC to total HDLC (APOE-HDLC/HDLC ratio) was calculated to assess the relative proportion of APOE-HDLC in total HDLC. The HDL-C/P ratio was strongly correlated with APOE-HDLC (partial-r: 0.615). Participants with cholesterol-overloaded HDL (indicated by the highest level of the HDL-C/P ratio) had a high APOE-HDLC/HDLC ratio. Baseline cholesterol-overloaded HDL significantly increased the 10-year risk of incident CHD (hazard ratio=2.42; 95% confidence interval=1.06-8.32), but this was attenuated by an increased APOE-HDLC/HDLC ratio. Participants with high HDL-C/P ratio and APOE-HDLC/HDLC ratio had a 42% lower risk, whereas those with a high HDL-C/P ratio and low APOE-HDLC/HDLC ratio had a 2.54-fold higher risk, than those with low HDL-C/P ratio and APOE-HDLC/HDLC ratio after multiple adjustments. Cholesterol-overloaded HDLs are related with increased APOE-containing HDL species. APOE-containing HDL was found to attenuate the impact of cholesterol-overloaded HDL on increased incident CHD risk, suggesting that APOE-containing HDL may correct the dysfunction of cholesterol-overloaded HDL.

Association of polycyclic aromatic hydrocarbons exposure with atherosclerotic cardiovascular disease risk: A role of mean platelet volume or club cell secretory protein.

Inflammation may play an important role in the association between exposure to polycyclic aromatic hydrocarbons (PAHs) and atherosclerotic cardiovascular disease (ASCVD) risk. However, the underlying mechanisms remain unclear. To investigate the association of PAHs exposure with ASCVD risk and effects of mean platelet volume (MPV) or Club cell secretory protein (CC16) on the association. A total of 2022 subjects (689 men and 1333 women) were drawn from the baseline Wuhan residents of the Wuhan-Zhuhai Cohort study. Data on demography and the physical examination were obtained from each participant. Urinary monohydroxy PAH metabolites (OH-PAHs) levels were measured by a gas chromatography-mass spectrometry. We estimated the association between each OH-PAHs and the 10-year ASCVD risk or coronary heart disease (CHD) risk using logistic regression models, and further analyze the mediating effect of MPV or plasma CC16 on the association by using structural equation modeling. The results of multiple logistic regression models showed that some OH-PAHs were positively associated with ASCVD risk but not CHD risk, including 2-hydroxyfluoren (β=1.761; 95% CI: 1.194-2.597), 9-hydroxyfluoren (β=1.470; 95% CI: 1.139-1.898), 1-hydroxyphenanthrene (β=1.480; 95% CI: 1.008-2.175) and ΣOH-PAHs levels (β=1.699; 95% CI: 1.151-2.507). The analysis of structural equation modeling shows that increased MPV and increased plasma CC16 levels contributed 13.6% and 15.1%, respectively, to the association between PAHs exposure and the 10-year ASCVD risk (p<0.05). Exposure to PAHs may increase the risk of atherosclerosis, which was partially mediated by MPV or CC16.

An alternative approach identified optimal risk thresholds for treatment indication: an illustration in coronary heart disease

ObjectivesTreatment thresholds based on risk predictions can be optimized by considering various health (economic) outcomes and performing marginal analyses, but this is rarely performed. We demonstrate a general approach to identify treatment thresholds optimizing individual health (economic) outcomes, illustrated for statin treatment based on 10-year coronary heart disease (CHD) risk predicted by the Framingham risk score. Study Design and SettingCreating a health economic model for a risk-based prevention strategy, risk thresholds can be evaluated on several outcomes of interest. Selecting an appropriate threshold range and decrement size for the thresholds and adapting the health economic model accordingly, outcomes can be calculated for each risk threshold. A stepwise, or marginal, comparison of clinical as well as health economic outcomes, that is, comparing outcomes using a specific threshold to outcomes of the former threshold while gradually lowering the threshold, then takes into account the balance between additional numbers of individuals treated and their outcomes (additional health effects and costs). In our illustration, using a Markov model for CHD, we evaluated risk thresholds by gradually lowering thresholds from 20% to 0%. ResultsThis approach can be applied to identify optimal risk thresholds on any outcome, such as to limit complications, maximize health outcomes, or optimize cost-effectiveness. In our illustration, keeping the population-level fraction of statin-induced complications <10% resulted in thresholds of T = 6% (men) and T = 2% (women). Lowering the threshold and comparing quality-adjusted life-years (QALYs) after each 1% decrease, QALYs were gained down to T = 1% (men) and T = 0% (women). Also accounting for costs, net health benefits were favorable down to T = 3% (men) and T = 6% (women). ConclusionUsing a stepwise risk-based approach to threshold optimization allows for preventive strategies that optimize outcomes. Presenting this comprehensive overview of outcomes will better inform decision makers when defining a treatment threshold.

Carotid atherosclerosis and its relationship to coronary heart disease and stroke risk in patients with type 2 diabetes mellitus.

Carotid atherosclerosis (CA) and carotid plaque (CP) are highly correlated with cardiovascular disease. We aimed to determine the prevalence of CA and CP and their relationship with 10-year risks of stroke and coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM).We studied 1584 T2DM patients aged 20 years and older. CA and CP were detected using ultrasonography. Ten-year stroke and CHD risk were determined using the United Kingdom Prospective Diabetes Study (UKPDS) risk engine.The prevalence of CA and CP increased gradually with age. Men had a higher prevalence of CA than women (CA: 58.18% vs 51.54%, P < .01). The 10-year CHD risk (27.9% vs 15.4%, P < .001) and stroke risk (15.2% vs 5.70%, P < .001) were higher in patients with CA than that of those without CA. Compared with patients without CA, the odds ratios (ORs) of CHD in CA and CP group were 4.47 and 10.78 for men, and 4.19 and 5.20 for women, respectively; in the case of stroke, the OR in CA and CP group were 8.83 and 12.07 for men, and 4.35 and 4.90 for women, respectively (P < .001 for all). Multivariate binary logistic regression analysis showed that CA was an independent risk factor for CHD [OR = 2.66, 95% confidence interval (95% CI), 2.05–3.46, P < .001] and stroke (OR = 3.11, 95% CI, 2.38–4.07, P < .001).CA and CP were prevalent in patients with T2DM and positively correlated with 10-year CHD and stroke risk. CA was an independent risk factor for 10-year CHD risk.