American College Of Cardiology/American Heart Association Research Articles

Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide

The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline recommends moderate-intensity to high-intensity statin therapy in eligible patients. To examine adoption of the 2013 ACC/AHA guideline in US cardiology practices. Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among 4 mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Interrupted time series analysis was used to evaluate for differences in trend in use of moderate-intensity to high-intensity statin and nonstatin LLT use in hierarchical logistic regression models. Participants were a population-based sample of 1 105 356 preguideline patients (2 431 192 patient encounters) and 1 116 472 postguideline patients (2 377 219 patient encounters). Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD). Moderate-intensity to high-intensity statin and nonstatin LLT use before and after publication of the 2013 ACC/AHA guideline. Time trend in the use of moderate-intensity to high-intensity statin and nonstatin LLT. In the study cohort, the mean (SD) age was 69.6 (12.1) years among 1 105 356 patients (40.2% female) before publication of the guideline and 70.0 (11.9) years among 1 116 472 patients (39.8% female) after publication of the guideline. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, such a trend was already present before publication of the guideline. No significant difference in trend in the use of moderate-intensity to high-intensity statins was observed in other groups. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication of the guideline) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol levels (ie, ≥190 mg/dL), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. In hierarchical logistic regression models, there was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (P < .01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods in the hierarchical logistic regression models for all of the risk groups. Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.

LEVELS OF OBESITY AND ACCURACY OF THE ATHEROSCLEROTIC CARDIOVASCULAR RISK EQUATION IN A LARGE COMMUNITY-BASED COHORT

Background: The accuracy of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equation for atherosclerotic cardiovascular disease (ASCVD) events across different levels of obesity is not known. Methods: The target population for consideration of primary

Preventive Statin Use Recommended by US Task Force.

The US Preventive Services Task Force (USPSTF) in November 2016 became the latest in a string of organizations to recommend wider preventive use of statins for otherwise healthy individuals based on their risk of a heart attack or stroke. The USPSTF guidance, which was based on a systematic review of the literature, reflects a growing consensus in medicine that the potential benefits of preventive statin use likely outweigh the risks for patients who meet certain criteria. The USPSTF recommendations are very similar to those from the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline, which initially proved controversial because of a shift from cholesterol targets to risk-based eligibility for statins. This change led to an increase by millions in the number of US individuals who were eligible for preventive statins. Since then, other groups have also recommended wider use of the medications to prevent heart attacks and strokes, including the Joint British Societies, the Department of Veterans Affairs, the Canadian Cardiovascular Society, and the UK National Institute for Health and Care Excellence. “It’s reassuring that groups that used similar methodologies and the highest quality of evidence came to independent but remarkably similar conclusions,” said Donald Lloyd-Jones, MD, a coauthor of the 2013 ACC/AHA guideline and chair of the department of preventive medicine at …

Comparison of different cardiovascular risk score calculators for cardiovascular risk prediction and guideline recommended statin uses

ObjectiveThe accuracy of various 10-year cardiovascular disease (CVD) risk calculators in Indians may not be the same as in other populations. Present study was conducted to compare the various calculators for CVD risk assessment and statin eligibility according to different guidelines. MethodsConsecutive 1110 patients who presented after their first myocardial infarction were included. Their CVD risk was calculated using Framingham Risk score- Coronary heart disease (FRS-CHD), Framingham Risk Score- Cardiovascular Disease (FRS-CVD), QRISK2, Joint British Society risk calculator 3 (JBS3), American College of Cardiology/American Heart Association (ACC/AHA), atherosclerotic cardiovascular disease (ASCVD) and WHO risk charts, assuming that they had presented one day before cardiac event for risk assessment. Eligibility for statin uses was also looked into using ACC/AHA, NICE and Canadian guidelines. ResultsFRS-CVD risk assessment model has performed the best as it could identify the highest number of patients (51.9%) to be at high CVD risk while WHO and ASCVD calculators have performed the worst (only 16.2% and 28.3% patients respectively were stratified into high CVD risk) considering 20% as cut off for high risk definition. QRISK2, JBS3 and FRS-CHD have performed intermediately. Using NICE, ACC/AHA and Canadian guidelines; 76%, 69% and 44.6% patients respectively were found to be eligible for statin use. ConclusionFRS-CVD appears to be the most useful for CVD risk assessment in Indians, but the difference may be because FRS-CVD estimates risk for several additional outcomes as compared with other risk scores. For statin eligibility, however, NICE guideline use is the most appropriate.

American College of Cardiology/American Heart Association (ACC/AHA) Class I Guidelines for the Treatment of Cholesterol to Reduce Atherosclerotic Cardiovascular Risk: Implications for US Hispanics/Latinos Based on Findings From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

American College of Cardiology/American Heart Association (ACC/AHA) Class I Guidelines for the Treatment of Cholesterol to Reduce Atherosclerotic Cardiovascular Risk: Implications for US Hispanics/Latinos Based on Findings From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Cardiovascular risk assessment in patients with rheumatoid arthritis: a correlative study of noninvasive arterial health testing.

This study aimed to determine the relationship between noninvasive measures of arterial health and both estimated 10-year cardiovascular risk and measures of disease activity over time in established rheumatoid arthritis. Fifty rheumatoid arthritis patients underwent noninvasive arterial health testing (brachial artery reactivity, aortic augmentation index [AIx], pulse wave velocity, carotid artery intima-media thickness, and carotid artery plaque presence) and assessment of clinical disease activity (tender or swollen joint counts, Clinical Disease Activity Index [CDAI], and Health Assessment Questionnaire II [HAQ-II]). Clinical measures during 3years before the study visit were averaged. Arterial health testing was compared with the American Heart Association/American College of Cardiology (AHA/ACC) Pooled Cohort Equation. Spearman methods identified correlations between disease activity measures, cardiac biomarkers, and arterial health parameters. Among the patients (mean age, 57.5years), disease activity was moderate (mean [SD] CDAI, 16.9 [15.3]). At the study visit, corrected aortic augmentation index correlated with CDAI (r=0.37, P=.009) and HAQ-II (r=0.33, P=.02). AIx correlated with time-averaged tender joint count (r=0.37, P=.008), CDAI (r=0.36, P=.01), HAQ-II (r=0.36, P=.01), swollen joint count (r=0.36, P=.10), patient global assessment (r=0.33, P=.02), physician global assessment (r=0.35, P=.01), and pain score (r=0.38, P=.007). The AHA/ACC low-risk group (<5% 10-year risk) had highest prevalence of carotid plaques. Arterial health testing may identify increased risk of cardiovascular disease compared with risk obtained through AHA/ACC Pooled Cohort Equation. Measures of arterial stiffness correlate with the burden of disease activity over time.

Application of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline to the Korean National Health and Nutrition Examination Surveys from 1998 to 2012.

BackgroundThe 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline for the treatment of blood cholesterol recommends statin therapy for individuals at high risk of atherosclerotic cardiovascular disease (ASCVD). The aim of this study was to investigate serial trends in the percentages of Korean adults considered eligible for statin therapy according to the new ACC/AHA cholesterol guideline.MethodsData from the Korean National Health and Nutrition Examination Survey (KNHANES) I (1998, n=7,698), II (2001, n=5,654), III (2005, n=5,269), IV (2007 to 2009, n=15,727), and V (2010 to 2012, n=16,304), which used a stratified, multistage, probability sampling design, were used as representative of the entire Korean population.ResultsThe percentage of adults eligible for statin therapy according to the ACC/AHA cholesterol guideline increased with time: 17.0%, 19.0%, 20.8%, 20.2%, and 22.0% in KNHANES I, II, III, IV, and V, respectively (P=0.022). The prevalence of ASCVD was 1.4% in KNHANES I and increased to 3.3% in KNHANES V. The percentage of diabetic patients aged 40 to 75 years with a low density lipoprotein cholesterol levels of 70 to 189 mg/dL increased from 4.8% in KNHANES I to 6.1% in KNHANES V. People with an estimated 10-year ASCVD risk ≥7.5% and aged 40 to 75 years accounted for the largest percentage among the four statin benefit groups: 9.1% in KNHANES I and 11.0% in KNHANES V.ConclusionApplication of the 2013 ACC/AHA guideline has found that the percentage of Korean adults in the statin benefit groups has increased over the past 15 years.

Limitations of the SCORE-guided European guidelines on cardiovascular disease prevention.

Recently, primary prevention with statins was liberalized in the USA and UK but restricted in many comparable European countries. Supported by risk-benefit and cost-effectiveness analyses, the 2013 ACC/AHA (American College of Cardiology/American Heart Association)1 and 2014 UK-NICE (National Institute for Health and Care Excellence)2 risk assessment and prevention guidelines lowered the risk threshold above which primary prevention with statins should be considered. In contrast, the 2016 update of the European guidelines on cardiovascular disease prevention in clinical practice,3 issued jointly by the European Society of Cardiology (ESC) and nine other societies, continued a conservative position on statin use in primary prevention by preserving the high-risk decision threshold introduced in 2003: 5% 10-year risk for fatal atherosclerotic cardiovascular disease (ASCVD) estimated by SCORE (Systematic Coronary Risk Evaluation).4 The 5% high-risk threshold introduced by the SCORE-based 2003 ESC prevention guidelines4 was chosen because 5% 10-year risk for fatal ASCVD was considered to equate with 20% 10-year risk for fatal and non-fatal coronary heart disease (CHD) arbitrarily defined as high-risk under previous ESC guidelines. No rationale was provided for choosing ≥20% 10-year CHD risk as high risk when introduced in 1994,5 neither for preserving it as ≥5% 10-year risk for fatal ASCVD.4 Hence, except for UK and possibly a few other European countries, the most important threshold for initiating primary prevention with statins has not been revised in Europe for more than 20 years, during which time long-awaited generic and inexpensive statins became available, and their efficacy and safety convincingly documented. Considering that the prevalence and treatment costs of ASCVD remain high, such a development would normally favour a more widespread use of statins in primary prevention. However, because SCORE depends solely on the ultimate cause of death, in countries with declining ASCVD mortality it is becoming harder …

Muscle Mass and Body Fat in Relation to Cardiovascular Risk Estimation and Lipid-Lowering Eligibility

This cross-sectional population-based study aimed to evaluate the relationships of muscle-mass and body-fat phenotypes to 10-yr risk of cardiovascular disease (CVD) events and eligibility for lipid management. Participants were Korean adults (N = 7315; 3163 men, 4152 women) aged 40–79 yr, free from stroke and coronary heart disease, who provided complete data for estimating 10-yr CVD risk and body composition during the Fifth Korea National Health and Nutrition Examination Survey (2009–2010). Four levels of combined muscle mass and body fat were determined using sex-specific quintiles of appendicular skeletal muscle mass divided by height squared, and sex-specific quintiles of total body fat percentage. Ten-year CVD risk was calculated using Pooled Cohort Equations and Framingham risk scores. Lipid-lowering medication eligibility was determined using American College of Cardiology/American Heart Association (ACC/AHA) and Adult Treatment Panel (ATP) III guidelines. Compared with the reference group, the risk of CVD events was higher in men with low muscle mass, high body fat, or the 2 factors combined. CVD risk was lower in women with low muscle mass, higher in women with high body fat, and nonsignificant in women with the 2 factors. Participants with low muscle mass and high body fat had higher odds for medication eligibility using the ACC/AHA guidelines but not the ATP III guidelines. Higher estimated 10-yr CVD risk was associated with combined phenotypes of low muscle mass and high fat in men but not in women. Also, the relationship of these phenotypes to lipid-lowering medication eligibility was guideline-specific.

Effect of selected clinical trial publication on adjunctive nonstatin medication prescribing in the Veterans Health Administration system.

The question of whether publication of selected clinical trials is temporally followed by changes in prescribing of adjunctive lipid-lowering medications was evaluated. In this retrospective preanalysis and postanalysis, Veterans Health Administration (VHA) patients 18 years or older who received a new or renewed order for any lipid-lowering medication between April 2, 2004, and September 2, 2014, were included. This period was chosen based on the publication dates of three trials investigating the efficacy of nonstatin medications: Simvastatin with or without Ezetimibe in Familial Hypercholesterolemia (ENHANCE, April 3, 2008), Effects of Combination Lipid Therapy in Type 2 Diabetes Mellitus (ACCORD Lipid, March 14, 2010), and Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy (AIM-HIGH, December 15, 2011). Annual prescribing rates for ezetimibe, fibrates, and niacin were analyzed for 4 years before and after the ENHANCE, ACCORD, and AIM-HIGH trial publication dates, respectively (3 years for niacin in AIM-HIGH) and reported as percent of patients in the cohort. Among patients receiving lipid-lowering medications, relatively low overall prescribing rates were observed for all three target medications. Prescribing rates for each medication decreased after its respective trial publication, with ezetimibe having the greatest change. Prescribing of fibrates, niacin, and ezetimibe in the VHA system decreased after the publication of landmark trials assessing their addition to a statin, consistent with the recommendations in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline, which did not encourage routine use of adjunctive therapies to lower the risk of cardiovascular disease.

Correction to: Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association.

HomeCirculationVol. 134, No. 22Correction to: Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association Originally published29 Nov 2016https://doi.org/10.1161/CIR.0000000000000469Circulation. 2016;134:e534This article corrects the followingRecommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart AssociationIn the article by Van Horn et al, “Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association,” which published ahead of print October 27, 2016, and appeared in the November 29, 2016, issue of the journal (Circulation. 2016;134:e505–e529. doi: 10.1161/CIR.0000000000000462), several corrections were needed.On page e1, in the first paragraph, the fifth sentence read, “Importantly, there are many options for successful adaptation of one of the recommended dietary patterns that in general advocate emphasis on vegetables, fruits, and whole grains; include low-fat dairy products, poultry, fish, legumes, nontropical (not coconut or palm kernel oil) vegetable oils, and nuts; and limit intake of sweets, sugar-sweetened beverages (SSBs), red meats, and processed foods.” The sentence has been updated to read, “Importantly, there are many options for successful adaptation of one of the recommended dietary patterns that in general advocate emphasis on vegetables, fruits, and whole grains; include low-fat or fat-free dairy products, poultry, fish, legumes, nontropical (not coconut or palm kernel oil) vegetable oils, and nuts; and limit intake of sweets, sugar-sweetened beverages (SSBs), salty or highly processed foods, and fatty or processed meats (choose lean or extra-lean meats instead).”On page e7, the following updates have been made to Table 2, first column (“Food Group [Subgroups]”):•In row 2, the entry read, “Vegetables, cups/wk.” It has been updated to read, “Vegetables: fresh/frozen/canned,§ cups/d.”•In rows 3 through 7, under “Vegetables,” the measurement “cups/wk” has been added to each entry.•In row 11, the entry read, “Protein foods, oz eq/wk.” It has been updated to read, “Protein foods, oz eq/d.”•In rows 12 and 13, under “Protein foods,” the measurement “oz eq/wk” has been added to each entry.•In row 14, the entry read, “Nuts, seeds, legumes.” It has been updated to read, “Nuts, seeds, legumes, oz eq/wk (unsalted preferred).”•In the table legend, the following footnote has been added: “§Rinse vegetables canned with salt to reduce sodium.”On page e20, in the Writing Group Disclosures table, Dr. Karmally’s employment was listed as “NYU Irving Institute for Clinical and Translational Research.” It has been updated to “Irving Institute for Clinical and Translational Research, Columbia University.”These corrections have been made to the current online version of the article, which is available at http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000462.FootnotesCirculation is available at http://circ.ahajournals.org. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Yamamoto K, Tsuchihashi-Makaya M, Kinugasa Y, Iida Y, Kamiya K, Kihara Y, Kono Y, Sato Y, Suzuki N, Takeuchi H, Higo T, Miyazawa Y, Miyajima I, Yamashina A, Yoshita K, Washida K, Kuzuya M, Takahashi T, Nakaya Y, Hasebe N and Tsutsui H (2020) Japanese Heart Failure Society 2018 Scientific Statement on Nutritional Assessment and Management in Heart Failure Patients, Circulation Journal, 10.1253/circj.CJ-20-0322, 84:8, (1408-1444), Online publication date: 22-Jul-2020. Tani S, Imatake K, Suzuki Y, Matsuo R and Takahashi A (2019) Construction of Evidence to Clarify the Importance of Dietary Management for Prevention of Cerebral Cardiovascular Disease: Relationship between Fish Intake and Cardio-metabolic Risk –and Study Design and Rationale日本総合健診医学会 第47回大会・シンポジウム2 包括的リスク管理チャートの健診応用 脳心血管病予防のための食事管理の重要性を明確にするためのエビデンスの構築─魚摂取量とCardio-metabolic Riskとの関係─：研究デザインと論理的根拠, Health Evaluation and Promotion, 10.7143/jhep.46.497, 46:5, (497-503), Online publication date: 10-Sep-2019. Cenko E, Amaduzzi P and Bugiardini R (2018) Microvascular Angina as a Cause of Ischemia: An Update Gender Differences in the Pathogenesis and Management of Heart Disease, 10.1007/978-3-319-71135-5_9, (135-163), . Related articlesRecommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart AssociationLinda Van Horn, et al. Circulation. 2016;134:e505-e529 November 29, 2016Vol 134, Issue 22 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIR.0000000000000469PMID: 27895029 Originally publishedNovember 29, 2016 PDF download Advertisement

Comparison of cardiovascular risk assessment tools and their guidelines in evaluation of 10-year CVD risk and preventive recommendations: A population based study

BackgroundIdentification of individuals at risk of cardiovascular diseases (CVDs) results in better clinical outcomes and may help policy makers in conscious decision making for community based and national intervention strategies. The main aim of this study was to compare various CVD risk assessment tools and their related guidelines in estimation of 10-year CVD risk and subsequent therapeutic recommendations, respectively. MethodsData of 3086 subjects aged 40–74years from a cohort study of northern Iran were utilized in this cross-sectional study. The risks were calculated based on American College of Cardiology/American Heart Association (ACC/AHA) tool, two versions of Systematic Coronary Risk Evaluation (SCORE) equations (for low and high risk European countries) and Framingham approach. We also detected participants who ought to be recommended for treatment based on the specific guidelines related to each of the risk assessment tools. ResultsMean cardiovascular risks were 12.96%, 8.84%, 1.90% and 3.45% in men and 5.87%, 2.13%, 0.8% and 1.13% in women based on ACC/AHA, Framingham, SCORE equation for low-risk European countries and high-risk European countries, respectively. Based on ACC/AHA, Adult Treatment Panel III (ATPIII) and European Society of Cardiology (ESC) guidelines related to SCORE equations for low and high risk European countries 58.2%, 27.1%, 21.1% and 28.6% of men and 39.7%, 33.0%, 29.5% and 30.7% of women were recommended to statin therapy, respectively. ConclusionsIn conclusion, more individuals were recommended for treatment by ACC/AHA guideline than the other guidelines.

ACC/AHA guidelines superior to ESC/EAS guidelines for primary prevention with statins in non-diabetic Europeans: the Copenhagen General Population Study

AimWe compared the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and the 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines on prevention of atherosclerotic cardiovascular disease (ASCVD) using different risk prediction models [US Pooled Cohort Equations (US-PCE for any ASCVD) and European Systematic COronary Risk Evaluation system (European-SCORE for fatal ASCVD)] and different statin eligibility criteria.Methods and resultsWe examined 44 889 individuals aged 40–75 recruited in 2003–09 in the Copenhagen General Population Study, all free of ASCVD, diabetes, and statin use at baseline. We detected 2217 any ASCVD events and 199 fatal ASCVD events through 2014. The predicted-to-observed event ratio was 1.2 using US-PCE for any ASCVD and 5.0 using European-SCORE for fatal ASCVD. The US-PCE, but not the European-SCORE, was well-calibrated around decision thresholds for statin therapy. For a Class I recommendation, 42% of individuals qualified for statins using the ACC/AHA guidelines vs. 6% with the ESC/EAS guidelines. Using ACC/AHA- vs. ESC/EAS-defined statin eligibility led to a substantial gain in sensitivity (+62% for any ASCVD and +76% for fatal ASCVD) with a smaller loss in specificity (−35% for any ASCVD and −36% for fatal ASCVD). Similar differences between the ACC/AHA and ESC/EAS guidelines were found for men and women separately, and for Class IIa recommendations. The sensitivity and specificity of a US-PCE risk of 5% were similar to those of a European-SCORE risk of 1.4%, whereas a US-PCE risk of 7.5% was similar to a European-SCORE risk of 2.4%.ConclusionsThe ACC/AHA guidelines were superior to the ESC/EAS guidelines for primary prevention of ASCVD, that is, for accurately assigning statin therapy to those who would benefit.

Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association.

In 2013, the American Heart Association and American College of Cardiology published the "Guideline on Lifestyle Management to Reduce Cardiovascular Risk," which was based on a systematic review originally initiated by the National Heart, Lung, and Blood Institute. The guideline supports the American Heart Association's 2020 Strategic Impact Goals for cardiovascular health promotion and disease reduction by providing more specific details for adopting evidence-based diet and lifestyle behaviors to achieve those goals. In addition, the 2015-2020 Dietary Guidelines for Americans issued updated evidence relevant to reducing cardiovascular risk and provided additional recommendations for adopting healthy diet and lifestyle approaches. This scientific statement, intended for healthcare providers, summarizes relevant scientific and translational evidence and offers practical tips, tools, and dietary approaches to help patients/clients adapt these guidelines according to their sociocultural, economic, and taste preferences.

Error Prevalence in DXA Performance and Reporting: Improving DXA Quality is Essential

This cross-sectional population-based study aimed to evaluate the relationships of muscle-mass and body-fat phenotypes to 10-yr risk of cardiovascular disease (CVD) events and eligibility for lipid management. Participants were Korean adults (N = 7315; 3163 men, 4152 women) aged 40–79 yr, free from stroke and coronary heart disease, who provided complete data for estimating 10-yr CVD risk and body composition during the Fifth Korea National Health and Nutrition Examination Survey (2009–2010). Four levels of combined muscle mass and body fat were determined using sex-specific quintiles of appendicular skeletal muscle mass divided by height squared, and sex-specific quintiles of total body fat percentage. Ten-year CVD risk was calculated using Pooled Cohort Equations and Framingham risk scores. Lipid-lowering medication eligibility was determined using American College of Cardiology/American Heart Association (ACC/AHA) and Adult Treatment Panel (ATP) III guidelines. Compared with the reference group, the risk of CVD events was higher in men with low muscle mass, high body fat, or the 2 factors combined. CVD risk was lower in women with low muscle mass, higher in women with high body fat, and nonsignificant in women with the 2 factors. Participants with low muscle mass and high body fat had higher odds for medication eligibility using the ACC/AHA guidelines but not the ATP III guidelines. Higher estimated 10-yr CVD risk was associated with combined phenotypes of low muscle mass and high fat in men but not in women. Also, the relationship of these phenotypes to lipid-lowering medication eligibility was guideline-specific.

Knowledge Gaps in Cardiovascular Care of Older Adults: A Scientific Statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society: Executive Summary

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision-making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision-making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older adults and enhance person-centered care of older individuals with CVD in the United States and around the world.

CAC Score Improves Coronary and CV Risk Assessment Above Statin Indication by ESC and AHA/ACC Primary Prevention Guidelines

ObjectivesThe aim of this study was to assess the difference in indication for statin therapy by European Society of Cardiology (ESC) versus American Heart Association/American College of Cardiology (AHA/ACC) guidelines and to quantify the potential additional role of coronary artery calcification (CAC) score over updated guidelines in a primary prevention cohort. BackgroundRecently, ESC and AHA/ACC updated the guidelines regarding statin therapy in primary prevention. MethodsIn 3,745 subjects (59 ± 8 years of age, 47% men) from the population based longitudinal Heinz Nixdorf Recall cohort study without cardiovascular disease or lipid-lowering therapy at baseline CAC score was assessed between 2000 and 2003. Subjects remained unaware of their initial CAC score. Statin indication was determined according to 2012 ESC and 2013 AHA/ACC guidelines based on subjects individual baseline characteristics. ResultsThe frequency of statin recommendation was lower according to ESC compared to AHA/ACC guidelines (34% vs. 56%; p < 0.0001), whereas low CAC score (<100) was common in subjects with statin indication by both guidelines (59% for ESC, 62% for AHA/ACC). During 10.4 ± 2.0 years of follow-up, 131 myocardial infarctions occurred. For ESC recommendations, CAC score differentiated risk for subjects without (1.0 [95% confidence interval (CI): 0.4 to 1.5] vs. 6.5 [95% CI: 4.1 to 8.9] coronary events per 1,000 person-years for CAC 0 vs. ≥100) and with statin indication (2.6 [95% CI: 0.6 to 4.7] vs. 9.9 [95% CI: 7.3 to 12.5] per 1,000 person-years for CAC 0 vs. ≥100). Likewise, CAC score stratified proportions experiencing events subjects with statin indication according to AHA/ACC (2.7 [95% CI: 1.1 to 4.2] vs. 9.1 [95% CI: 7.0 to 11.0] per 1,000 person-years for CAC 0 vs. ≥100), whereas event rate in subjects without statin indication was low (1.1 [95% CI: 0.65 to 1.68] per 1,000 person-years). ConclusionsCurrent ESC and AHA/ACC guidelines lead to markedly different recommendation regarding statin therapy in a German primary prevention cohort. Quantification of CAC score in addition to the guidelines improves stratification between subjects at high versus low risk for coronary events, indicating that CAC scoring may help to match intensified risk factor modification to atherosclerotic plaque burden as well as actual risk while avoiding therapy in subjects with low coronary atherosclerosis that have low 10-year event rate.

Population Effect of Differences in Cholesterol Guidelines in Eastern Europe and the United States.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of blood cholesterol and the current European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines differ in how they identify adults in need of statin therapy; furthermore, it is unclear how this difference translates into numbers and characteristics of patients recommended for treatment. To determine the effect of the ACC/AHA and ESC/EAS cholesterol guidelines when applied to a population-based sample. We used nationally representative data for 3055 adults aged 40 to 65 years from the 2007-2012 National Health and Nutrition Examination Surveys (NHANES) for the United States and for 1060 adults aged 40 to 65 years from the 2011 Nadciśnięnie Tętnicze w Polsce survey for Poland. Data analysis was conducted from May 1, 2014, to December 31, 2015. The number and characteristics of adults recommended for statin therapy according to the ACC/AHA and ESC/EAS guidelines were evaluated, and characteristics were compared between adults with discordant recommendations. The 3136 US adults in NHANES (2007-2012) aged 40 to 65 years represented 100.1 million adults; after excluding the 81 patients with missing data, these population estimates translate to 97.9 million adults. Similarly, the 1060 Polish adults in NATPOL (2011) aged 40 to 65 years represent 13.5 million adults. Using weighted data, in the United States, 43.8% (95% CI, 40.9%-46.7%) of adults would be recommended for statin therapy according to ACC/AHA guidelines and 39.1% (95% CI, 36.4%-41.8%) according to ESC/EAS guidelines. In Poland, 49.9% (95% CI, 46.9%-52.9%) of adults would be recommended for statin therapy under ACC/AHA guidelines compared with 47.6% (95% CI, 44.6%-50.7%) under ESC/EAS guidelines. Among individuals without cardiovascular disease and not currently taking statins, 11.0% of US and 10.5% of Polish adults had discordant guideline recommendations. Compared with individuals recommended for statin therapy by the ESC/EAS guidelines but not the ACC/AHA guidelines, those recommended for statin therapy under the ACC/AHA guidelines only had less chronic kidney disease; however, these individuals were also more likely to smoke, have lower high-density lipoprotein cholesterol levels, and have higher predicted 10-year risk of cardiovascular disease. Despite differences in the ACC/AHA and EAS/ESC guidelines, the numbers of adults aged 40 to 65 years recommended for cholesterol-lowering therapy under each guideline were similar when applied to nationwide representative samples from both the United States and Poland. Discordant recommendations were driven by differences in the risk equations used in the 2 guidelines and different recommendations for adults with chronic kidney disease.

Impact of clinical input variable uncertainties on ten-year atherosclerotic cardiovascular disease risk using new pooled cohort equations.

BackgroundRecently released American College of Cardiology/American Heart Association (ACC/AHA) guideline recommends the Pooled Cohort equations for evaluating atherosclerotic cardiovascular risk of individuals. The impact of the clinical input variable uncertainties on the estimates of ten-year cardiovascular risk based on ACC/AHA guidelines is not known.MethodsUsing a publicly available the National Health and Nutrition Examination Survey dataset (2005–2010), we computed maximum and minimum ten-year cardiovascular risks by assuming clinically relevant variations/uncertainties in input of age (0–1 year) and ±10 % variation in total-cholesterol, high density lipoprotein- cholesterol, and systolic blood pressure and by assuming uniform distribution of the variance of each variable. We analyzed the changes in risk category compared to the actual inputs at 5 % and 7.5 % risk limits as these limits define the thresholds for consideration of drug therapy in the new guidelines. The new-pooled cohort equations for risk estimation were implemented in a custom software package.ResultsBased on our input variances, changes in risk category were possible in up to 24 % of the population cohort at both 5 % and 7.5 % risk boundary limits. This trend was consistently noted across all subgroups except in African American males where most of the cohort had ≥7.5 % baseline risk regardless of the variation in the variables.ConclusionsThe uncertainties in the input variables can alter the risk categorization. The impact of these variances on the ten-year risk needs to be incorporated into the patient/clinician discussion and clinical decision making. Incorporating good clinical practices for the measurement of critical clinical variables and robust standardization of laboratory parameters to more stringent reference standards is extremely important for successful implementation of the new guidelines. Furthermore, ability to customize the risk calculator inputs to better represent unique clinical circumstances specific to individual needs would be highly desirable in the future versions of the risk calculator.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-016-0352-x) contains supplementary material, which is available to authorized users.

Integration of Flow-Gradient Patterns Into Clinical Decision Making for Patients With Suspected Severe Aortic Stenosis and Preserved LVEF: A Systematic Review of Evidence and Meta-Analysis

ObjectivesThis study was designed to evaluate the evidence base for the 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for severe aortic stenosis (SAS) and preserved left ventricular ejection fraction by comparing the natural history of the disease in subgroups of low-gradient (LG) aortic stenosis patients with high-gradient (HG) patients. BackgroundThe 2014 AHA/ACC valvular disease guidelines recommend estimation of stroke volume index by echocardiography in patients with suspected LG SAS and preserved left ventricular ejection fraction. MethodsPubMed, Embase, and Scopus databases were searched for all studies that have compared the natural history of SAS with preserved ejection fraction in flow-gradient patterns. We studied the following 3 subgroups: HG, low-flow low-gradient (LFLG), and normal-flow low-gradient (NFLG). The random effects model was used to pool individual study results. The end-point was long-term all-cause mortality. ResultsA total of 9 studies with 3,065 patients fulfilled the criteria. Compared to HG SAS, both LFLG and NFLG patients had a higher burden of comorbidities such as coronary artery disease and hypertension. Atrial fibrillation was more prevalent in LFLG patients. Moreover, end-diastolic volume index was smaller for LFLG patients and indexed aortic valve area was larger for NFLG patients. All-cause mortality was similar between HG and LFLG subgroups (relative risk: 1.07; 95% confidence interval: 0.83 to 1.38; p = 0.60), whereas patients with NFLG had a significantly lower all-cause mortality compared to the HG subgroup (relative risk: 0.64; 95% confidence interval: 0.47 to 0.86; p = 0.004). ConclusionsPatients with LFLG SAS have similar outcomes compared to HG SAS but worse compared to NFLG SAS. These findings support estimating stroke volume index in patients with suspected LG SAS. All analyses revealed high heterogeneity and further high-quality studies are necessary.