Absolute Cardiovascular Disease Risk Research Articles

Defining high risk in the cardiovascular-kidney-metabolic syndrome and associated cardiovascular disease outcomes

Abstract Background The American Heart Association (AHA) recently developed the cardiovascular-kidney-metabolic (CKM) syndrome construct with stages 0-4 to comprehensively characterize the spectrum of cardiovascular disease (CVD) risk [1]. CKM Stage 3 is defined by subclinical CVD or high (≥20%) estimated 10-year CVD risk according to the newly-derived PREVENT models [2]. However, within CKM Stage 3, the burden of subclinical atherosclerosis equivalent to a ≥20% estimated CVD risk, and long-term CVD outcomes associated with CKM Stage 3, are not known. Purpose To (1) characterize the distribution of subclinical atherosclerosis by coronary artery calcium (CAC) according to PREVENT estimated CVD risk categories, and (2) quantify long-term CVD risk associated with CKM Stage 3, in two international cohorts of adults without prior CVD. Methods In participants of the Multi-Ethnic Study of Atherosclerosis (MESA, age 45-84 years) and the Rotterdam Study (age ≥55 years), the burden of CAC was calculated across estimated 10-year CVD risk (low, 0 to <5%; borderline 5 to <7.5%; intermediate, 7.5 to <20%; high, ≥20%). Participants were categorized into CKM stages according to CVD risk factors (body mass index, waist circumference, glycemic status, blood pressure, lipids, kidney function), estimated 10-year CVD risk (by AHA PREVENT model), and presence of CAC. The association of CKM syndrome stage with fatal or nonfatal CVD outcomes was evaluated with covariate-adjusted proportional hazards regression. Results Among 6,123 MESA participants (52% female, mean age 61.4 years) and 1,691 Rotterdam Study participants (46% female, mean age 67.1 years), the distribution of CAC across absolute 10-year CVD risk categories is shown in Figure 1. In high (≥20%) CVD risk adults, CAC score ≥100 was present in 50% of MESA participants and 48% of Rotterdam Study participants. Most participants were classified as CKM Stage 3 (53% in MESA, 83% in Rotterdam). Over a median follow-up of 17.5 years in MESA, CVD events occurred in 5% of CKM Stage 0, 6% of Stage 1, 9% of Stage 2, and 26% of Stage 3 participants. Over a median follow-up of 10.2 years in the Rotterdam Study, CVD events occurred in 0% of CKM Stage 0 and 1, 8% of Stage 2, and 17% of Stage 3 participants (Figure 2). The risk of total CVD was significantly higher in CKM Stage 3 participants relative to CKM Stage 0-2 (MESA: adjusted HR 2.74, 95% CI 2.32, 3.23; Rotterdam: adjusted HR 2.18, 95% CI 1.34, 3.54). Conclusions In an international, multi-ethnic sample of middle-aged adults, adults with high (≥20%) absolute 10-year CVD risk by PREVENT had substantial burden of CAC. Adults in CKM Stage 3 had approximately 2.2- to 2.7-times higher risk for CVD, compared with adults in lower CKM stages. Accounting for estimated CVD risk and burden of cardiovascular, kidney, and metabolic risk factors informs prevention of subclinical and clinical CVD.

Multi-modality deep learning prediction of heart age: insights from UK-Biobank

Abstract Background Identification of apparently healthy individuals at high cardiovascular risk who may benefit from targeted preventive strategies remains challenging. Predicted heart age, the chronological age of individuals with similar absolute cardiovascular disease (CVD) risk but with no risk factors, has been proposed to appropriately describe the absolute CVD risk over conventional prediction tools. Purpose To develop multi-modality based deep learning predictors for heart age in UK-Biobank individuals. Methods We used deep learning to develop a heart age predictor based on videos from heart magnetic resonance imaging (MRI) (anatomical dimension), electrocardiograms (ECG) (electrical dimension) or both from 45000 individuals of the UK Biobank cohort (age range 45-81 years) (Figure). We estimated the heritability of heart aging and identified single-nucleotide polymorphisms associated with accelerated heart aging. We performed X-wide association study to identify non-genetic factors potentially associated with accelerated heart aging. Results We predicted age with a mean absolute error (MAE) of 2.5±0.03 years (R2=85.6±0.6%) and found that accelerated heart aging is heritable at more than 35%. MRI-based anatomical features predicted age better than ECG-based electro-physiological features (MAE=2.29±0.03 years versus 4.90±.0.08 years), and heart anatomical and electrical aging were weakly correlated (Pearson correlation=0.249±0.002). Our attention maps highlighted the aorta, the mitral valve, and the interventricular septum as key anatomical features driving heart age prediction in videos that capture the entire heartbeat cycle. We found accelerated anatomical and electrical heart aging to be genetically correlated (Pearson correlation=0.508±0.089). The most significant locus was in TTN (Titin) and it was associated with heart anatomical aging. Cardiovascular diseases, general health status, and mental health disorders were highly associated with accelerated heart aging. Conclusions A multi-modality based deep learning approach was highly predictive of heart age. Accelerated heart age has a complex biological basis with genetic and environmental correlates. Leveraging of the described pipeline to predict survival and the onset of age-related cardiovascular diseases may shed light on heart aging role in health outcomes and effectively guide personalized preventive strategies.

Women living with HIV: identifying and managing their menopause, age-related, and psychosocial health needs in a metropolitan sexual health service in Sydney, Australia.

Background Aging women living with HIV are significantly affected by menopause and comorbidities, yet international and Australian HIV guidance on the management of women is scarce. This study aimed to identify gaps in clinical management of menopause, age-related comorbidities, and psychosocial health of women living with HIV attending our metropolitan sexual health service. Methods A clinical audit of all cisgender women who attended Sydney Local Health District Department of Sexual Health Medicine for ongoing routine HIV care between 1 January 2021 and 1 January 2023 was undertaken. Results Twenty-seven patient files were examined. Half (13/27, 48.1%) of women were age 45years and older, of whom 6/13 (46.2%) were postmenopausal and 4/13 (30.8%) did not have menopause status recorded. In the prior 12months, most women had their blood pressure (19/27, 70.4%), total cholesterol (21/27, 77.8%), glycated haemoglobin (21/27, 77.8%), estimated glomerular filtration rate (27/27, 96.3%), and liver function tests (26/27, 96.3%) measured. Smoking and alcohol intake was documented for less than half of women (13/27, 48.1%; and 12/27, 44.4%; respectively). In women aged 45years and older, absolute cardiovascular disease risk was calculated in 2/13 (15.4%), and none had a Fracture Risk Assessment Tool score or cognitive screen performed in the prior 12months. One-fifth (5/27, 18.5%) had a documented history of depression or anxiety. Of those screened, half (4/8, 50.0%) disclosed past intimate partner violence. Conclusions Our service has now implemented a reference tool to guide routine monitoring of women living with HIV, with sections dedicated to reproductive health and psychological wellbeing. Australian HIV management guidelines would benefit from specific guidance for women.

Absolute cardiovascular risk assessment using ‘real world’ clinic blood pressures compared to standardized unobserved and ambulatory methods: an observational study

Clinic blood pressure (BP) is recommended for absolute cardiovascular disease (CVD) risk assessment. However, in ‘real-world’ settings, clinic BP measurement is unstandardised and less reliable compared to more rigorous methods but the impact for absolute CVD risk assessment is unknown. This study aimed to determine the difference in absolute CVD risk assessment using real-world clinic BP compared to standardised BP methods. Participants were patients (n = 226, 59 ± 15 years; 58% female) with hypertension referred to a BP clinic for assessment. ‘Real-world’ clinic BP was provided by the referring doctor. All participants had unobserved automated office BP (AOBP) and 24-h ambulatory BP monitoring (ABPM) measured at the clinic. Absolute CVD risk was calculated (Framingham) using systolic BP from the referring doctor (clinic BP), AOBP and ABPM, with agreement assessed by Kappa statistic. Clinic systolic BP was 18 mmHg than AOBP and daytime ABPM and 22 mmHg higher than 24-h ABPM (p < 0.001). Subsequently, absolute CVD risk scores using clinic BP were higher compared to AOBP, daytime ABPM and 24-h ABPM (10.4 ± 8.1%, 7.8 ± 6.4%, 7.8 ± 6.3%, and 7.3 ± 6.1%, respectively, P < 0.001). As a result, more participants were classified as high CVD risk using clinic BP (n = 89, 40%) compared with AOBP (n = 44, 20%) daytime ABPM (n = 38, 17%) and 24-h ABPM (n = 38, 17%) (p < 0.001) with weak agreement in risk classification (κ = 0.57[0.45–0.69], κ = 0.52[0.41–0.64] and κ = 0.55[0.43–0.66], respectively). Real-world clinic BP was higher and classified twice as many participants at high CVD risk compared to AOBP or ABPM. Given the challenges to high-quality BP measurement in clinic, more rigorous BP measurement methods are needed for absolute CVD risk assessment.

Remnant cholesterol reduction of 2 mmol/L likely reduces absolute 10-year risk of atherosclerotic cardiovascular disease by 6-17% in primary prevention.

Remnant cholesterol reduction of 2 mmol/L likely reduces absolute 10-year risk of atherosclerotic cardiovascular disease by 6-17% in primary prevention.

Comparison of Patients Classified as High-Risk between International Cardiovascular Disease Primary Prevention Guidelines.

Background: Cardiovascular disease (CVD) primary prevention guidelines classify people at high risk and recommended for pharmacological treatment based on clinical criteria and absolute CVD risk estimation. Despite relying on similar evidence, recommendations vary between international guidelines, which may impact who is recommended to receive treatment for CVD prevention. Objective: To determine the agreement in treatment recommendations according to guidelines from Australia, England and the United States. Methods: Cross-sectional analysis of the National Health and Nutrition Examination Survey (n = 2647). Adults ≥ 40 years were classified as high-risk and recommended for treatment according to Australia, England and United States CVD prevention guidelines. Agreement in high-risk classification and recommendation for treatment was assessed by Kappa statistic. Results: Participants were middle aged, 49% were male and 38% were white. The proportion recommended for treatment was highest using the United States guidelines (n = 1318, 49.8%) followed by the English guidelines (n = 1276, 48.2%). In comparison, only 26.6% (n = 705) of participants were classified as recommended for treatment according to the Australian guidelines. There was moderate agreement in the recommendation for treatment between the English and United States guidelines (κ = 0.69 [0.64-0.74]). In comparison, agreement in recommendation for treatment was minimal between the Australian and United States guidelines (κ = 0.47 [0.43-0.52]) and weak between the Australian and English guidelines (κ = 0.50 [0.45-0.55]). Conclusions: Despite similar evidence underpinning guidelines, there is little agreement between guidelines regarding the people recommended to receive treatment for CVD prevention. These findings suggest greater consistency in high-risk classification between CVD prevention guidelines may be required.

Implementing absolute cardiovascular disease risk assessment into pathology collection services.

Pathology services represent an ideal setting to integrate absolute cardiovascular disease (CVD) risk estimation when patients attend for routine cholesterol testing. This study aimed to explore the process of implementing CVD risk estimation into point-of-care service delivery by pathology staff to inform future implementation and sustainability. A new service for CVD risk estimation via a self-directed screening station was implemented into 14 pathology service sites across Tasmania, Australia. Before implementation, observations at pathology services (n = 26) and semi-structured interviews were undertaken with 26 pathology staff (88% female, 77% aged 41-60 years) to identify factors that could impact implementation of the service. The process of implementation was then evaluated using participant observations and clinical trial recruitment data. Transcripts and field notes were analysed thematically according to the Medical Research Council Framework and used to develop a programme logic model to understand how the service could be adapted to be successfully integrated into routine workflow at pathology services. Eight key themes were identified during the pre-implementation phase as important factors that could impact upon integration of CVD risk estimation into pathology services. Themes related to factors within the organisation, including available resources, logistics and workflow, as well as having sufficient time to complete the intervention. Additional factors related to the individual motivations of staff, collaborative leadership and patient characteristics. Success of implementation varied among sites, requiring the trialling of different strategies to support uptake of the service and patient recruitment. Implementing CVD risk estimation into point-of-care pathology services required an understanding of the core implementation components specific to each context, and for implementation strategies to be targeted to the individual and organisational contexts. The generated programme logic model may be useful in guiding future implementation endeavours within these services and aiding the selection of apt implementation strategies. ClinicalTrials.gov Identifier: NCT04896021, registered 19/05/2021, https://clinicaltrials.gov/study/NCT04896021.

#886 Prevalence and prognostic relevance of electrocardiographic abnormalities among patients with ANCA-associated vasculitis

Abstract Background and Aims Cardiovascular disease (CVD) is one of the leading causes of death in patients with ANCA-associated vasculitis (AAV). However, in current clinical guidelines, limited evidence is available to support the recommendation of AAV-specific screening for cardiovascular comorbidities. This study reported the prevalence of electrocardiogram (ECG) abnormalities and investigated associations between ECG abnormalities and fatal CVD in a validated cohort of patients with AAV compared to matched controls. Method Based on a retrospective matched cohort design, patients with granulomatosis with polyangiitis [ICD-10: DM31.3] or microscopic polyangiitis [ICD-10: DM3.17] and accessible ECGs were identified in nationwide Danish health care registers from 2000 to 2021. Patients with AAV were matched 1:3 on age, sex, and calendar year of ECG measurement with controls without AAV. Index date was defined as the date of ECG measurement. ECGs were hierarchically categorized as either no, minor, or major ECG abnormalities according to contemporary literature. The associations between ECG abnormalities and fatal CVD were assessed in multiple Cox regression models adjusted for age, sex, and comorbidities. Counterfactual G-estimation of hazard ratios (HRs) standardized to age and sex was performed to estimate the 5-year absolute risk (AR) of fatal CVD according to ECG-abnormalities. Results A total of 1431 patients with AAV were matched to 4293 controls. The median age of patients with AAV and matched controls was 69 (IQR 58-77) years, and 52.3% were males. Median study follow-up time was 4.8 (IQR, 2.7-7.8) years. AAV was associated with increased prevalence of left ventricular hypertrophy (17.5% vs. 12.5%, p &amp;lt; 0.001), ST-T deviations (10.1% vs. 7.1%, p &amp;lt; 0.001), atrial fibrillation (9.6% vs. 7.5%, p = 0.017) and corrected QT prolongation (5.9% vs. 3.6%, p &amp;lt; 0.001) compared to controls. When examining associations of fatal CVD across no, minor or major ECG abnormalities, only the patients with AAV and major ECG abnormalities had a higher risk of fatal CVD [HR 1.99 (95% CI, 1.49-2.65)], compared to matched controls. This corresponded to a significantly higher standardized 5-year AR of fatal CVD compared to controls: 19.14% (95% CI, 16-22%) vs. 9.41% (95% CI, 8-11%). Conclusion AAV was associated with a higher prevalence of major ECG abnormalities such as left ventricular hypertrophy, atrial fibrillation, and ST-T deviations compared to matched controls. Moreover, the patients with AAV demonstrating major ECG abnormalities had a particularly elevated risk of fatal CVD. This indicates that AAV patients with major ECG abnormalities are a distinct high-risk group within AAV patients prone to cardiovascular-related mortality.

The association between weight loss medications and cardiovascular complications.

Obesity and its cardiovascular complications are major causes of morbidity and mortality. Little is known in real-world settings about the effect of newly approved antiobesity medications (AOMs) on cardiovascular complications among patients with obesity. This retrospective cohort study examined the association between newly approved AOM use and cardiovascular events among Medicare patients with obesity using data from 2020 to 2022. Patient age, gender, comorbidity scores, socioeconomic status, and baseline cardiovascular comorbidities were compared descriptively. Subgroup analysis compared variables by medication type. Relative risk and absolute risk of cardiovascular disease (CVD) events were estimated using Cox and Aalen regression models. The analysis included 5926 patients treated with semaglutide and tirzepatide, including Ozempic (5404 patients), Wegovy (375 patients), or Mounjaro (147 patients). Hypertension, type 2 diabetes, and hyperlipidemia were the most common comorbidities. For patients with AOMs, less incidence of heart failure (4.89% vs. 6.13%, p < 0.0001), atrial fibrillation (3.83% vs. 5.17%, p < 0.0001), arrhythmia (3.59% vs. 4.14%, p < 0.0153), and peripheral vascular disease (3.44% vs. 2.94%, p < 0.0395) was found versus patients without AOMs. Patients receiving AOMs showed an 8% risk reduction in any CVD. Protective effect on CVD was apparent over the first 375 days. Results suggest that utilization of AOMs effectively alleviates the high prevalence of CVD.

Cardiovascular Disease Risk in Individuals Following Plant-Based Dietary Patterns Compared to Regular Meat-Eaters.

Plant-based diets (PBDs) have been associated with a lower risk of cardiovascular disease (CVD). The aim was to investigate the predicted 5-year and 10-year risk of developing CVD in individuals following PBDs compared to regular meat-eating diets. This cross-sectional study included n = 240 middle-aged adults habitually consuming dietary patterns for ≥6 months: vegan, lacto-ovo vegetarian (LOV), pesco-vegetarian (PV), semi-vegetarian (SV) or regular meat-eater (RME) (n = 48 per group). Predicted 5-year and 10-year CVD risks were quantified using the Framingham Risk Equation and the Australian Absolute CVD risk calculator, respectively. Multivariable regression analysis was used to adjust for age, sex, smoking status, physical activity, alcohol use and BMI. Over three-quarters of the participants were women, mean age of 53.8 yrs. After adjustments for potential confounders, there was no difference in the predicted risk of CVD between regular-meat diets and PBDs, although crude analyses revealed that vegans had a lower 5-year and 10-year predicted risk of CVD compared to RMEs. SVs, PVs and LOVs had lower CVD risk scores, however, not significantly. Vegans had a favourable cardiometabolic risk profile including significantly lower serum lipid levels, fasting blood glucose and dietary fats and higher dietary fibre intake compared to RMEs. This was the first study to purposefully sample Australians habitually following PBDs. We found that PBDs do not independently influence the predicted risk of CVD, although PBDs tended to have lower risk and vegans had significantly lower cardiometabolic risk factors for CVD.

Cardiovascular disease risk in Australians following plant-based dietary patterns compared to regular meat eaters

The adoption of dietary patterns emphasising higher intakes of plant foods and lower intakes of animal foods (plant-based diets, PBDs), continue to rise worldwide. PBDs have been associated with a lower risk of cardiovascular morbidity and mortality as well as major risk factors such as overweight/obesity and type 2 diabetes. Evidence regarding the dietary profile and disease risk associated with various PBDs in comparison to traditional meat-eating diets are scarce within the Australian population. The aim of this study is to investigate the 5-year and 10-year risk of developing cardiovascular disease (CVD) among Australians habitually following various PBDs compared to a regular meat diet (RMD). The Plant-based Diet (PBD) Study is a cross-sectional study consisting of healthy adults between aged 30-75 years from the Hunter Region (NSW) between 2021-2023. A validated FFQ was used to assess eligibility and categorise individuals who were habitually consuming one of five dietary patterns for at least 6 months into the following groups: vegan (nil animal products), lacto-vegetarian (LOV, including eggs and dairy), pesco-vegetarian (PV, including seafood with/without dairy and eggs), semi-vegetarian (SV, minimal consumption of animal products) or RMDs (including animal meat daily or multiple times/day)(1). 5-year and 10-year CVD risk was quantified using the Framingham Risk Equation(2) and the Australian Absolute CVD risk calculator, respectively. CVD risk and other quantitative measures was compared using One-way ANOVA or Kruskal Wallis, and Chi-square or Fisher’s Exact for qualitative data. Directed acyclic graphs displayed confounding variables and mediators and a regression model was used to adjust for these. A total of 240 participants (median age 55(16), 77.5% female) with 48 participants in each group showed a significant difference in predicted 5-year risk of CVD (P&lt;0.05), however 10-year risk did not significantly differ across groups. 5-year CVD risk was significantly lower in the vegan group (1%) compared to the RMD, SV, PV, and LOV diet groups (all 2%). In comparison to a vegan diet, crude association showed those consuming a RMD had a 2.4% (95% CI 0.7, 4.1) higher 5-year risk of developing CVD, followed by 1.7% in LOV (95% CI 0.6, 2.9), 1.8% in PV (95% CI 0.5, 3), and 1.1% in SV (95% CI 0.2, 2.1). Significance was lost after adjusting for confounders such as age, gender, smoking status, alcohol intake, physical activity levels and BMI. This is the first study to purposefully sample Australians habitually following PBD, presenting novel population-based evidence for CVD risk. These findings suggest more restrictive PBDs such as vegan diets when compared to RMD may lead to lower CVD risk, however population-based longitudinal studies primary investigating the development of CVDs in the context of PBDs are warranted.

Integration of a polygenic score into guideline-recommended prediction of cardiovascular disease.

It is not clear how a polygenic risk score (PRS) can be best combined with guideline-recommended tools for cardiovascular disease (CVD) risk prediction, e.g. SCORE2. A PRS for coronary artery disease (CAD) was calculated in participants of UK Biobank (n = 432 981). Within each tenth of the PRS distribution, the odds ratios (ORs)-referred to as PRS-factor-for CVD (i.e. CAD or stroke) were compared between the entire population and subgroups representing the spectrum of clinical risk. Replication was performed in the combined Framingham/Atherosclerosis Risk in Communities (ARIC) populations (n = 10 757). The clinical suitability of a multiplicative model 'SCORE2 × PRS-factor' was tested by risk reclassification. In subgroups with highly different clinical risks, CVD ORs were stable within each PRS tenth. SCORE2 and PRS showed no significant interactive effects on CVD risk, which qualified them as multiplicative factors: SCORE2 × PRS-factor = total risk. In UK Biobank, the multiplicative model moved 9.55% of the intermediate (n = 145 337) to high-risk group increasing the individuals in this category by 56.6%. Incident CVD occurred in 8.08% of individuals reclassified by the PRS-factor from intermediate to high risk, which was about two-fold of those remained at intermediate risk (4.08%). Likewise, the PRS-factor shifted 8.29% of individuals from moderate to high risk in Framingham/ARIC. This study demonstrates that absolute CVD risk, determined by a clinical risk score, and relative genetic risk, determined by a PRS, provide independent information. The two components may form a simple multiplicative model improving precision of guideline-recommended tools in predicting incident CVD.

Association of non-alcoholic fatty liver disease with cardiovascular disease and all cause death in patients with type 2 diabetes mellitus: nationwide population based study

ObjectiveTo investigate the risk of non-alcoholic fatty liver disease (NAFLD) for cardiovascular disease and all cause death in patients with type 2 diabetes mellitus (T2DM).DesignNationwide population based study.SettingLongitudinal cohort study...

Implementing decision aids for cardiovascular disease prevention: stakeholder interviews and case studies in Australian primary care.

Australian cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk assessment, but less than half of eligible patients have the required risk factors recorded due to fragmented implementation over the last decade. Co-designed decision aids for general practitioners (GPs) and consumers have been developed that improve knowledge barriers to guideline-recommended CVD risk assessment and management. This study used a stakeholder consultation process to identify and pilot test the feasibility of implementation strategies for these decision aids in Australian primary care. This mixed methods study included: (1) stakeholder consultation to map existing implementation strategies (2018-20); (2) interviews with 29 Primary Health Network (PHN) staff from all Australian states and territories to identify new implementation opportunities (2021); (3) pilot testing the feasibility of low, medium, and high resource implementation strategies (2019-21). Framework Analysis was used for qualitative data and Google analytics provided decision support usage data over time. Informal stakeholder discussions indicated a need to partner with existing programs delivered by the Heart Foundation and PHNs. PHN interviews identified the importance of linking decision aids with GP education resources, quality improvement activities, and consumer-focused prevention programs. Participants highlighted the importance of integration with general practice processes, such as business models, workflows, medical records and clinical audit software. Specific implementation strategies were identified as feasible to pilot during COVID-19: (1) low resource: adding website links to local health area guidelines for clinicians and a Heart Foundation toolkit for primary care providers; (2) medium resource: presenting at GP education conferences and integrating the resources into audit and feedback reports; (3) high resource: auto-populate the risk assessment and decision aids from patient records via clinical audit software. This research identified a wide range of feasible strategies to implement decision aids for CVD risk assessment and management. The findings will inform the translation of new CVD guidelines in primary care. Future research will use economic evaluation to explore the added value of higher versus lower resource implementation strategies.

Fostering active choice to empower behavioral change to reduce cardiovascular risk: A web-based randomized controlled trial.

To investigate the effect of an active choice (AC) intervention based on creating risk and choice awareness-versus a passive choice (PC) control group-on intentions and commitment to cardiovascular disease (CVD) risk-reducing behavior. Adults aged 50-70 (n = 743) without CVD history participated in this web-based randomized controlled trial. The AC intervention included presentation of a hypothetical CVD risk in a heart age format, information about CVD risk and choice options, and a values clarification exercise. The PC group received a hypothetical absolute numerical CVD risk and brief information and advice about lifestyle and medication. Key outcomes were reported degree of active choice, intention strength, and commitment to adopt risk-reducing behavior. More AC compared to PC participants opted for lifestyle change (OR = 2.86, 95%CI:1.51;5.44), or lifestyle change and medication use (OR = 2.78, 95%CI:1.42;5.46), than 'no change'. No differences were found for intention strength. AC participants made a more active choice than PC participants (β = 0.09, 95%CI:0.01;0.16), which was sequentially mediated by cognitive risk perception and negative affect. AC participants also reported higher commitment to CVD risk-reducing behavior (β = 0.32, 95%CI:0.04;0.60), mediated by reported degree of active choice. Fostering active choices increased intentions and commitment towards CVD risk-reducing behavior. Increased cognitive risk perception and negative affect were shown to mediate the effect of the intervention on degree of active choice, which in turn mediated the effect on commitment. Future research should determine whether fostering active choice also improves risk-reducing behaviors in individuals at increased CVD risk in real-life settings. ClinicalTrials.gov: NCT05142280. Prospectively registered.

Characterisation of Symptom and Polysomnographic Profiles Associated with Cardiovascular Risk in a Sleep Clinic Population with Obstructive Sleep Apnoea.

Recent data have identified specific symptom and polysomnographic profiles associated with cardiovascular disease (CVD) in patients with obstructive sleep apnoea (OSA). Our aim was to determine whether these profiles were present at diagnosis of OSA in patients with established CVD and in those with high cardiovascular risk. Participants in the Sydney Sleep Biobank (SSB) database, aged 30-74 years, self-reported presence of CVD (coronary artery disease, cerebrovascular disease, or heart failure). In those without established CVD, the Framingham Risk Score (FRS) estimated 10-year absolute CVD risk, categorised as "low" (<6%), "intermediate" (6-20%), or "high" (>20%). Groups were compared on symptom and polysomnographic variables. 629 patients (68% male; mean age 54.3 years, SD 11.6; mean BMI 32.3 kg/m2, SD 8.2) were included. CVD was reported in 12.2%. A further 14.3% had a low risk FRS, 38.8% had an intermediate risk FRS, and 34.7% had a high risk FRS. Groups differed with respect to age, sex and BMI. OSA severity increased with established CVD and increasing FRS. The symptom of waking too early was more prevalent in the higher FRS groups (p=0.004). CVD and FRS groups differed on multiple polysomnographic variables; however, none of these differences remained significant after adjusting for age, sex, and BMI. Higher CVD risk was associated with waking too early in patients with OSA. Polysomnographic variations between groups were explained by demographic differences. Further work is required to explore the influence of OSA phenotypic characteristics on susceptibility to CVD.

Cardiovascular disease incidence rates: a study using routinely collected health data

BackgroundThere is substantial evidence that systemic anticancer therapies and radiotherapy can increase the long-term risk of cardiovascular disease (CVD). Optimal management decisions for cancer patients therefore need to take into account the likely risks from a proposed treatment option, as well as its likely benefits. For CVD, the magnitude of the risk depends on the incidence of the disease in the general population to which the patient belongs, including variation with age and sex, as well as on the treatment option under consideration. The aim of this paper is to provide estimates of CVD incidence rates in the general population of England for use in cardio-oncology and in other relevant clinical, research and health policy contexts.MethodsWe studied a population-based representative cohort, consisting of 2,633,472 individuals, derived by electronic linkage of records from primary care with those of admitted-patient care in England during April 1, 2010, to April 1, 2015. From 38 individual CVDs available via the linked dataset we identified five relevant categories of CVD whose risk may be increased by cancer treatments: four of heart disease and one of stroke.ResultsWe calculated incidence rates by age-group and sex for all relevant CVD categories combined, for the four relevant categories of heart disease combined, and for the five relevant CVD categories separately. We present separate incidence rates for all 38 individual CVDs available via the linked dataset. We also illustrate how our data can be used to estimate absolute CVD risks in a range of people with Hodgkin lymphoma treated with chemotherapy and radiotherapy.ConclusionsOur results provide population-based CVD incidence rates for a variety of uses, including the estimation of absolute risks of CVD from cancer treatments, thus helping patients and clinicians to make appropriate individualized cancer treatment decisions.Graphical Graphical : Cardiovascular incidence rates for use in cardio-oncology and elsewhere: A presentation of age- and sex-specific cardiovascular disease (CVD) incidence rates for use in calculation of absolute cardiovascular risks of cancer treatments, and in other clinical, research and health policy contexts. Abbreviations– CVD: cardiovascular disease; y: years

Development and Validation of the American Heart Association's PREVENT Equations.

Multivariable equations are recommended by primary prevention guidelines to assess absolute risk of cardiovascular disease (CVD). However, current equations have several limitations. Therefore, we developed and validated the American Heart Association Predicting Risk of CVD EVENTs (PREVENT) equations among US adults 30 to 79 years of age without known CVD. The derivation sample included individual-level participant data from 25 data sets (N=3 281 919) between 1992 and 2017. The primary outcome was CVD (atherosclerotic CVD and heart failure). Predictors included traditional risk factors (smoking status, systolic blood pressure, cholesterol, antihypertensive or statin use, and diabetes) and estimated glomerular filtration rate. Models were sex-specific, race-free, developed on the age scale, and adjusted for competing risk of non-CVD death. Analyses were conducted in each data set and meta-analyzed. Discrimination was assessed using the Harrell C-statistic. Calibration was calculated as the slope of the observed versus predicted risk by decile. Additional equations to predict each CVD subtype (atherosclerotic CVD and heart failure) and include optional predictors (urine albumin-to-creatinine ratio and hemoglobin A1c), and social deprivation index were also developed. External validation was performed in 3 330 085 participants from 21 additional data sets. Among 6 612 004 adults included, mean±SD age was 53±12 years, and 56% were women. Over a mean±SD follow-up of 4.8±3.1 years, there were 211 515 incident total CVD events. The median C-statistics in external validation for CVD were 0.794 (interquartile interval, 0.763-0.809) in female and 0.757 (0.727-0.778) in male participants. The calibration slopes were 1.03 (interquartile interval, 0.81-1.16) and 0.94 (0.81-1.13) among female and male participants, respectively. Similar estimates for discrimination and calibration were observed for atherosclerotic CVD- and heart failure-specific models. The improvement in discrimination was small but statistically significant when urine albumin-to-creatinine ratio, hemoglobin A1c, and social deprivation index were added together to the base model to total CVD (ΔC-statistic [interquartile interval] 0.004 [0.004-0.005] and 0.005 [0.004-0.007] among female and male participants, respectively). Calibration improved significantly when the urine albumin-to-creatinine ratio was added to the base model among those with marked albuminuria (>300 mg/g; 1.05 [0.84-1.20] versus 1.39 [1.14-1.65]; P=0.01). PREVENT equations accurately and precisely predicted risk for incident CVD and CVD subtypes in a large, diverse, and contemporary sample of US adults by using routinely available clinical variables.

Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association.

Cardiovascular-kidney-metabolic (CKM) syndrome is a novel construct recently defined by the American Heart Association in response to the high prevalence of metabolic and kidney disease. Epidemiological data demonstrate higher absolute risk of both atherosclerotic cardiovascular disease (CVD) and heart failure as an individual progresses from CKM stage 0 to stage 3, but optimal strategies for risk assessment need to be refined. Absolute risk assessment with the goal to match type and intensity of interventions with predicted risk and expected treatment benefit remains the cornerstone of primary prevention. Given the growing number of therapies in our armamentarium that simultaneously address all 3 CKM axes, novel risk prediction equations are needed that incorporate predictors and outcomes relevant to the CKM context. This should also include social determinants of health, which are key upstream drivers of CVD, to more equitably estimate and address risk. This scientific statement summarizes the background, rationale, and clinical implications for the newly developed sex-specific, race-free risk equations: PREVENT (AHA Predicting Risk of CVD Events). The PREVENT equations enable 10- and 30-year risk estimates for total CVD (composite of atherosclerotic CVD and heart failure), include estimated glomerular filtration rate as a predictor, and adjust for competing risk of non-CVD death among adults 30 to 79 years of age. Additional models accommodate enhanced predictive utility with the addition of CKM factors when clinically indicated for measurement (urine albumin-to-creatinine ratio and hemoglobin A1c) or social determinants of health (social deprivation index) when available. Approaches to implement risk-based prevention using PREVENT across various settings are discussed.

Abstract 14790: Association of Neighborhood Socioeconomic Disadvantage in Early Pregnancy and 30-Year Predicted Probability of Cardiovascular Disease 2-7 Years Postpartum

Introduction: To determine whether neighborhood socioeconomic disadvantage as measured by the Area Deprivation Index (ADI) in early pregnancy is associated with higher 30-year predicted risk of cardiovascular disease (CVD) by the Framingham Risk Score. Methods: A secondary analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be (nuMoM2b) Heart Health Study (HHS) longitudinal cohort. Participant home addresses in the first trimester were geocoded at the census-tract level. The exposure was neighborhood socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]). The primary outcome was the predicted 30-year risk of hard CVD using the Framingham Risk Score (composite of fatal and non-fatal coronary heart disease and stroke). The secondary outcome was predicted 30-year risk of total CVD (composite of “hard” CVD plus coronary insufficiency and angina pectoris, stroke, transient ischemic attack, intermittent claudication and heart failure). Outcomes were assessed categorically as high-risk defined as a predicted probability of CVD &gt; 10%, and secondarily as a continuous measure of absolute risk (%). Modified Poisson and linear regression models adjusted for age, insurance, education, and income. Results: Among 4,310 nulliparous individuals, the median age was 27 years (IQR: 23-31), and the median ADI was 43 (IQR: 22-74). At 2-7 years postpartum (median: 4 years), the median 30-year risk of hard CVD was 2.3% (IQR: 1.5-3.5), and total CVD was 5.5% (IQR: 3.7-7.9). Individuals living in neighborhoods in the highest tertile of socioeconomic disadvantage were more likely to have a high 30-year predicted risk of hard CVD (≥10%) compared with those in the lowest tertile (aRR: 2.25; 95% CI: 1.23, 4.11), with similar results for high 30-year predicted risk of total CVD (aRR: 1.36; 95% CI: 1.09, 1.69). Living in the highest ADI tertile was associated with a higher absolute risk of 30-year hard (adj. ß: 0.41; 95% CI: 0.19, 0.63) and total CVD (adj. ß: 0.76; 95% CI: 0.38, 1.14) when analyzed as a continuous outcome. Conclusions: Neighborhood socioeconomic disadvantage in early pregnancy is associated with higher predicted risk of 30-year CVD 2-7 years after delivery.