Global Cardiovascular Risk Assessment Research Articles

CORRELATION OF LIPOPROTEIN(a) AND CORONARY ARTERY DISEASES

<div><p><strong>INTRODUCTION:</strong> Cardiovascular diseases (CVD) continue to be one of the leading causes of mortality worldwide. While factors such as diabetes, sedentariness, psychostress, genetic predisposition, hypertension, smoking, and hyperlipidemia are well-known in the etiology of atherosclerosis (Ath) of coronary arteries. Recent studies have also identified high concentrations of lipoproteins (a) [Lp(a)] as a risk factor. In fact, high concentrations of Lp(a) above 30mg/dl (reference value-30mg/dl) have been found to be a risk factor for Ath, leading experts to develop medications aimed at reducing Lp(a) concentrations and preventing atherosclerotic manifestations. <a href="https://eas-society.org/"><em>The European Atherosclerosis Society</em></a> has also released clinical guidelines for testing and treating high concentrations of Lp(a) as part of the global assessment of cardiovascular risk.</p><p><strong>THE GOAL OF THE STUDY:</strong> The goal of this study is to investigate the concentration of Lp(a) in patients with coronary disease and its connection to the presentation of atherosclerosis of the coronary arteries in patients with CVD compared to a control group of healthy individuals. Through this study, we hope to gain a better understanding of the role of Lp(a) in CVD and its potential as a target for prevention and treatment. By identifying and addressing risk factors like high Lp(a) concentrations, we can work towards reducing the global burden of CVD and improving health outcomes for individuals around the world.</p><p><strong>THE AIM OF THE STUDY:</strong> The aim of this study is to determine the concentration of lipoprotein(a) in patients with coronary disease, its connectivity and role in the presentation of atherosclerosis of the coronary arteries in patients with CVD compared to the control group of healthy individuals.</p><p><strong>MATERIAL AND METHODS:</strong> As working material, the blood taken from the vein of patients with coronary disease was used - N0=80, (with an identical average age of 55.70±6.00 years old, of which 35 were female while 45 were male. In the study, there was also a control group: N0=80 healthy volunteers (45 were male and 35 female) with the same age as the patients. Blood for analysis was taken at 8 o'clock in the morning, at room temperature of 19-24°C, every three months in a period of 12 months.</p><p>Echocardiography and EKG were also performed on all the patients with Toshiba SSH-140A machine, color Doppler probe 3.7Hz, sectorial type, taking into account as key parameters the thickness of the back wall of the left ventricle and the thickness of-Left ventricular internal diameter end diastole (LVPVd) and interventricular septal end diastole (IVSd>12 mm). Together with the examination of Lp(a) concentrations, the lipid profile was also analyzed. The analyzes were done at the Clinical Laboratory Institute at the University Clinical Center of the Faculty of Medicine – Skopje, North Macedonia.</p><p><strong>STATISTICAL PROCESSING OF THE MATERIAL:</strong> From the statistical methods, arithmetic mean value, standard deviation X±SD were used. The comparative statistics of the lipid parameters between the analyzed groups were analyzed with students ‘t’ dependent and independent samples according to the Mann-Whitney U-test and Wilcoxon - test. The results of the lipid fractions will be shown tabularly (see table 3) with the statistical program SPSS V26.</p><p><strong>RESULTS:</strong> The obtained values of lipids (Col.Total, TG, HDL-ch, LDL-ch) and lipoprotein (a) in both groups are presented with mean values and standard deviation X-SD. Due to the fact that in the obtained results of Lp(a) in both sexes, in patients with coronary disease, we did not notice any significant difference, we will present them as common for both groups, with CVD with maximum values of 78.00-16,00 mg/dl while in the control group =15.20-4.30 mg/dl, with a statistically significant difference with p<0.000. The same difference was found from the obtained results of lipid concentrations between the two groups with p <0.0001 (as presented in the tables below).</p><p><strong>CONCLUSION:</strong> The results obtained in the paper proved that high concentrations of Lp(a) > 30 mg/dl are risk factors for the occurrence of Ath of the coronary arteries and that these patients are at a 5-8 times higher risk for the development of Ath of coronary arteries, compared to individuals with normal Lp(a) values, therefore the treatment of high concentrations of Lp(a) should be started at the beginning of their appearance. In conclusion, we can suggest that the adequate treatment of high Lp(a) concentrations and the balancing of the lipid profile can apparently affect the prevention of atherosclerotic processes of the coronary arteries, therefore we prefer that in individuals with a history of CAD and those with coronary disease, the examination of Lp(a) and lipid profile should be one of the initial examinations during the management of patients with CAD.</p><p><strong>Keywords: </strong>Lipoprotein (a), atherosclerosis, Cardiovascular Arterial Diseases (CAD), lipid profile.</p></div>

Comentario del CEIPV a las nuevas Guías Europeas de Prevención Cardiovascular 2021

We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease Prevention in Clinical Practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global cardiovascular disease risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (steps 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After step 1, considering proceeding to the intensified goals of step 2 is mandatory, and this intensification will be based on 10-year cardiovascular disease risk, lifetime cardiovascular disease risk and treatment benefit, comorbidities and patient preferences.The updated SCORE algorithm ?SCORE2, SCORE2-OP? is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal cardiovascular disease events (myocardial infarction, stroke) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according to different age groups (<50, 50-69, ≥70 years).Different flow charts of cardiovascular disease risk and risk factor treatment in apparently healthy persons, in patients with established atherosclerotic cardiovascular disease, and in diabetic patients are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.

Comentario del CEIPV a las nuevas Guías Europeas de Prevención Cardiovascular 2021

We present the Spanish adaptation of the 2021 European Guidelines on Cardiovascular Disease prevention in clinical practice. The current guidelines besides the individual approach greatly emphasize on the importance of population level approaches to the prevention of cardiovascular diseases. Systematic global cardiovascular diseases risk assessment is recommended in individuals with any major vascular risk factor. Regarding LDL-cholesterol, blood pressure, and glycemic control in patients with diabetes mellitus, goals and targets remain as recommended in previous guidelines. However, it is proposed a new, stepwise approach (step 1 and 2) to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile. After step 1, considering proceeding to the intensified goals of step 2 is mandatory, and this intensification will be based on 10-year cardiovascular diseases risk, lifetime cardiovascular diseases risk and treatment benefit, comorbidities and patient preferences. The updated SCORE algorithm ?SCORE2, SCORE2-OP? is recommended in these guidelines, which estimates an individual's 10-year risk of fatal and non-fatal cardiovascular diseases events (myocardial infarction, stroke and vascular mortality) in healthy men and women aged 40-89 years. Another new and important recommendation is the use of different categories of risk according different age groups (<50, 50-69, ≥70 years).Different flow charts of cardiovascular diseases risk and risk factor treatment in apparently healthy persons, in diabetic patients, and in patients with established atherosclerotic cardiovascular diseases are recommended. Patients with chronic kidney disease are considered high risk or very high-risk patients according to the levels of glomerular filtration rate and albumin-to-creatinine ratio. New lifestyle recommendations adapted to the ones published by the Spanish Ministry of Health as well as recommendations focused on the management of lipids, blood pressure, diabetes and chronic renal failure are included.

Assessment of global cardiovascular risk in patients admitted with an acute coronary syndrome

Assessment of global cardiovascular risk in patients admitted with an acute coronary syndrome

Low lung function, sudden cardiac death and non-fatal coronary events in the general population

BackgroundMany of those who suffer from a first acute coronary event (CE) die suddenly during the day of the event, most of them die outside hospital. Poor lung function is...

Knowledge, attitude and practice of family physician regarding global cardiovascular risk assessment in PSMMC primary health care centers in Riyadh, Saudi Arabia

Background: Most cardiovascular diseases (CVD) can be prevented by addressing their risk factors. The conventional clinical approach to primary prevention of cardiovascular disease relies on identification and treatment of individual risk factors. There are several guidelines that recommend CV risk assessment tools to support CV prevention strategies (ATP III, European guidelines that include Systematic Coronary Risk Evaluation SCORE 2003, ACC/AHA cardiovascular disease risk 2013 based on Framingham risk score. This study aimed to assess knowledge, attitude and practice of family physician regarding global cardiovascular risk assessment, aiming to improve cardiovascular prevention services.Method: A cross-sectional study conducted among family physicians working in family medicine clinics of Prince Sultan Military Medical City (Riyadh, Saudi Arabia) between November 2019 and June 2020. 188 physicians asked to fill a questionnaire that based on knowledge, attitude and practice questions regarding global CV risk assessment. Results: A total 188 physicians were included in this study. The majority (61.2%) of the physicians were between 25 and 30 years. ASCVD of AHA was the most frequent (75.5%) cardiovascular risk assessment tool used in practice. The majority of physicians often used the cardiovascular risk assessment tools regularly (62.8%). Less than half of physicians believed that assessment tools depend on investigations that patients can afford (46.8%). The majority (58.5%) of the physician had unsatisfactory self-assessment of own knowledge and skills. Unsatisfactory self-assessment of own knowledge and skills was significantly associated with lower knowledge and attitude (49.5% versus 68.1%, p=0.004). Satisfactory self-assessment of own knowledge and skills was significantly associated with higher knowledge and attitude (50.5% versus 29.7%, p=0.004). Conclusion: A high proportion of physicians reported using clinical guidelines for primary CVD prevention. However, laboratory investigations and time constrain were common reasons for not using global CV risk assessment tools. Unsatisfactory self-assessment of own knowledge and skills was significantly associated with lower knowledge and attitude of physicians.

Co nowego w wytycznych Europejskiego Towarzystwa Kardiologicznego 2019? Wytyczne dotyczące postępowania w zaburzeniach lipidowych

An update of the guidelines for the management of dyslipidaemia was released in 2019. First, this is needed to assess cardiovascular risk and to classify the patient into one of four cardiovascular risk groups. The class of recommendations for using of imaging techniques and assessment of lipids and lipoproteins (including apolipoprotein B and apolipoprotein A) in the assessment of global cardiovascular risk has been strengthened. Values of LDL cholesterol were significantly reduced for each of risk group. The role of ezetimibe and PCSK9 inhibitors was strengthened, and the role of combination therapy in the treatment of dyslipidaemia was increased.

Global cardiovascular risk assessment: a national training course for General Practitioners

Abstract Background Identification of high risk individuals is one of the main goals of the primary prevention of cardiovascular disease (CVD) and constitutes the basis for implementing actions aiming at reducing modifiable risk factors at individual level through changing life styles or drug interventions. The most appropriate method for identifying high risk individuals is the absolute risk assessment, a probability indicator of incidence, predictable on the basis of risk factors levels. Objectives The CUORE project score of the National Institute of Health-ISS is adopted in Italy; since 2007 ISS has implemented a national training course for General Practitioners-GPs with the aim of supporting and facilitating the use of CVD risk assessment in clinical practice as a preventive action in the general population. Results The training course is based on five sequential packages linked to educational credits: packages 1-2 facilitate the adoption of standardised methodologies for the assessment of CVD risk score; in package 3 patients are invited by GPs to assess the risk score; packages 4-5 evaluate and discuss data collected with GPs and stakeholders. A cascade training was implemented: ISS personnel provided training to local GPs who in turn provided the same training to other GPs. Two manuals for the training course were published. Since 2007 about 4,300 GPs were trained; about 320,000 10-year CVD risk assessments were performed in 260,000 men and women aged 35-69 years. Feedback was provided to all GPs participating to the 4th-5th packages of the training courses. Conclusions Implementation of the training course for the use of CVD risk assessment in the population represents a primary preventive action according to the recommendation of the EU Guideline on CVD prevention. The collected data may play an important role in the identification of strengths and weaknesses of preventive actions and represents the first step to improve good clinical practices standards.

Achievement of low density lipoprotein (LDL) cholesterol targets in primary and secondary prevention: Analysis of a large real practice database in Italy

Background and aimsTarget and intensity of low-density lipoprotein cholesterol (LDL-C) lowering therapy should be tailored according to the individual global cardiovascular (CV) risk. We aimed at retrospectively evaluating real-life LDL-C goal attainment and predictive factors for predefined LDL-C therapeutic goals both in primary and secondary prevention. MethodsWe collected data from a large cohort of outpatients aged 40–65 years, followed by general practitioners, cardiologists and diabetologists in Italy. All data were centrally analysed for global CV risk assessment and rates of control of major CV risk factors, including LDL-C. Study population was stratified according to the presence or absence of previous CV events, including coronary artery disease (CAD), peripheral artery disease (PAD) or stroke/TIA. CV risk profile characterization was based on the European SCORE. Predefined therapeutic goals were set according to the European guidelines on dyslipidaemia: LDL-C levels <70 mg/dl for very high CV risk patients in primary prevention and for those in secondary prevention; <100 mg/dl LDL-C levels for high CV risk patients in primary prevention. Logistic regression analysis with clinical covariates was used to identify predictive factors for achieving these goals; lipid lowering therapy entered in the analysis as continuous (model 1) or categorical variable (model 2). ResultsWe included 4,142 outpatients (43,7% female, age 58.0 ± 5.2 years, BMI 28.5 ± 5.0 kg/m2) among whom 2,964 (71.6%) in primary and 1,178 (28.4%) in secondary prevention. In primary prevention, none of the patients at very high CV risk had LDL-C <70 mg/dl and 8.9% of patients at high CV risk showed LDL-C <100 mg/dl. Only 5.8% of patients in secondary prevention had LDL-C levels <70 mg/dl, specifically 6.5% of patients with CAD, 2.6% of patients with PAD and 4.7% of patients with CVD (p < 0.001). Beyond diabetes and lipid lowering therapy, high risk SCORE estimation resulted a strong and independent predictor for the lack of achieving all predefined therapeutic targets, including LDL-C <100 mg/dl [OR: 0.806 (0.751–0.865)); p < 0.001], and LDL-C <70 mg/dl [OR: 0.712 (0-576-0.880); p = 0.002], in primary prevention. ConclusionsDespite high or very high SCORE risk and use of lipid lowering therapies, we observed poor achievement of LDL-C targets in this large cohort of outpatients followed in a setting of real practice in Italy.

Correlation between HDL Level with Clinical and Biochemical Markers of Atherogenesis

Introduction: HDL cholesterol (HDL-C) level is an independent predictor of risk for cardiovascular events in both genders, low levels of which have been demonstrated to have an inverse association with cardiovascular disease and mortality. Anthropometric measurements serve as surrogate markers for atherogenic burden. Atherosclerosis represents a chronic inflammatory process and low HDL being an inflammatory state, inflammatory markers such as high-sensitivity C Reactive Protein (hs-CRP) may provide an adjunctive method for global assessment of cardiovascular risk. TG/HDL ratio has been proved to have a high association with prevalence of metabolic syndrome and with insulin resistance.Aim: To find out the correlation between High Density Lipoprotein (HDL) level with clinical and biochemical markers of atherogenesis.Materials and Methods: This cross-sectional study was conducted with a study population of 200 individuals, who were either in-patients or outpatients in the Department of Medicine at Kasturba Medical College (KMC), Manipal Karnataka, India. (Study period July 2012-July 2014). Individuals aged 18-70 years being investigated for dyslipidemia for the first time were included. Data was collected by in person interview by specific questionnaire. Height, weight, waist circumference and hip circumference were measured as per standard protocol. Laboratory reports were noted for the estimation of Fasting Blood Sugar (FBS), HDL and Triglycerides (TG), hs-CRP, fasting insulin. Serum LDL was calculated. Statistical data analysis was done using SPSS 16.0 version. Mean and median values were calculated corresponding to the data. Results were analysed using Pearson’s and Spearman’s correlation coefficient. Independent t- est and Mann-Whitney’s tests were used for calculation of significance of correlation.Results: Among the studied individuals 53% (106) were males and 47% (94) were females. A total of 77%(154) of the individuals with low HDL and 70%(140) individuals with normal HDL had abnormal waist circumference. Mean Waist Hip Ratio (WHR) was same across groups with low and normal HDL. Mean Body Mass Index (BMI) was similar in both the groups among males; however, a statistically significant difference was found among females. Abnormal waist circumference was found similar across both the groups. Median hs-CRP showed a statistically significant higher values among individuals with lower HDL. Fasting insulin and HOMA-IR was higher among individuals with low HDL (vs normal HDL), but it was statistically insignificant. Median TG/HDL ratio among 41 individuals were found to be 3.08, which was higher than the cut-off to signify insulin resistance. HOMA-IR and TG/HDL ratio showed a statistically significant positive correlation suggesting that TG/HDL ratio can be used as a marker of insulin resistance.Conclusion: This study revealed that anthropometric indices showed an inverse correlation with HDL levels, with BMI being a better predictor of HDL-C changes. HDL was lower in individuals with insulin resistance, with TG/HDL ratio being a significant marker of insulin resistance.

DIFFERENCES IN LABORATORY FINDINGS OF HYPERTENSIVE PATIENTS DEPENDING ON RISK FACTORS, SETTLEMENT AND AGE

Objective: Hypertension is a chronic disease with growing incidence. Monitoring of laboratory parameters is important in global cardiovascular risk assessment of hypertensive patients and prevention of complications. Evaluation and comparison of laboratory results and risks in patients included in distinct age groups and those from urban and rural settlements. Design and method: The study was conducted on 127 hypertensive patients during the first three months of 2017 at an urban outpatient unit specialized on cardiovascular diseases. Serum samples of patients were processed with Konelab20XTi analyzer using photometric method. Glycemia and lipid profile, kidney and liver function were determined. Urine tests were performed using the HandUReader equipment. Statistical processing of data was made using the GraphPad InStat program. Threshold of significance was set at p < 0.05. Results: Mean age of the patients was 63 years, 56.7% were male subjects. Significant difference (p = 0.0475) occured between serum HDL-cholesterol concentration of rural (average 75.6 mg/dl ± 12.5 SD) and urban patients (average 49.1 mg/dl ± 13.0 SD). Significantly higher serum urea levels were found in the rural subgroup (mean: 44.3 mg/dl ± 13.0 SD) compared to those from urban settlements (mean: 36.4 mg/dl ± 15.0 SD). Pathological urine compounds were found in 43.3% of rural patients and in 29.9% of urban subjects. Significant difference could be observed between the comorbidities present in these subgroups: diabetes was twice as frequent in the rural subgroup compared to urban subjects, prevalence of dislipidemia was three times higher in the urban group compared to rural patients. Significant difference could be observed between creatinine-based glomerular filtration rate (average 57.7 mL/min) of elderly subjects (>70 years) compared to higher values of younger patients, especially those under 60 years of age. No significant difference could be noticed between glycemia, serum uric acid, triglyceride, total cholesterol concentration and transaminase activity of different subgroups based on age or settlement. Conclusions: We can conclude that rural patients present higher protective HDL-cholesterol level compared to urban subjects and lower prevalence of dislipidemia, probably related to their different diet, this might also be the background of their higher serum urea concentration.

Blood pressure profile is associated with microalbuminuria and retinopathy in hypertensive nondiabetic patients.

Target organ damage is important for global cardiovascular risk assessment. The aim of this study was to explore the association between the blood pressure profile and end-organ damage in ahypertensive non-diabetic cohort. A total of 560 consecutive hypertensive nondiabetic patients (mean age: 58.2± 13.3 years, 221 men) were included in the study. All patients underwent thorough physical examination including fundoscopic examination. First morning urine samples were obtained from each patient and measurement of the albumin-to-creatinine ratio in first morning urine collection samples was used for diagnosis of microalbuminuria. All patients underwent a24-h ambulatory blood pressure monitoring and were grouped as dippers and non-dippers according to the presence or absence of >10% decrease in blood pressure during the night, respectively. The non-dipper group consisted of 247 patients with a non-dipper blood pressure profile, 31patients with reverse dipping and 4patients with extreme dipping. Non-dipper patients were significantly older. Coronary artery disease, cerebrovascular disease, hypertensive retinopathy and microalbuminuria were significantly more prevalent in the non-dipper patients. Non-dipping hypertension increased the risk of hypertensive retinopathy by 1.89 times (95% confidence interval, CI:1.35-2.65, p< 0.001) and the risk of microalbuminuria by 2.23 times (95% CI:1.49-3.33, p< 0.001). Non-dipping hypertension was still significantly associated with hypertensive retinopathy and microalbuminuria when adjusted by age and sex. Non-dipping hypertension was associated with increased risk of hypertensive retinopathy and microalbuminuria. Blood pressure profiles should also be considered in assessing the risk for hypertensive patients.

OP.3C.01] COMPARISON BETWEEN EUROPEAN SYSTEMATIC CORONARY RISK EVALUATION AND ITALIAN CUORE ALGORITHMS IN ADULT OUTPATIENTS FOLLOWED BY GENERAL PRACTITIONERS AND SPECIALISED CENTRES

Objective: Global cardiovascular (CV) risk stratification based on either European Systematic Coronary Risk Evaluation (SCORE) or Italian CUORE algorithms should be performed in all adult outpatients by both general practitioners (GPs) and specialised physicians (SPs). Design and method: To compare individual CV risk profile by using either European SCORE and Italian CUORE algorithms in adult outpatients followed by GPs and SPs in Italy. All available data were centrally analysed for global CV risk assessment and rates of control of major CV risk factors, including blood pressure (BP), serum cholesterol, triglycerides and glucose levels. CV risk profile characterization was based on both SCORE and CUORE algorithms. Study population was stratified according to referring physicians (GPs, cardiologists, diabetologists, other SPs). Results: We analysed data from an overall population sample of 10,404 adult outpatients (age 60.76.5 years, BMI 28.34.9 kg/m2, BP 136.714.4/82.18.2 mmHg, total cholesterol 212.240.7 mg/dl, HDL cholesterol 50.812.3 mg/dl), among whom 7,767 (74.7%) were followed by GPs, 1,239 (11.9%) by cardiologists, 1,006 (9.7%) by diabetologists and 392 (3.8%) by other SPs. Systolic/diastolic BP, total/LDL cholesterol and triglycerides levels were higher and HDL cholesterol was lower in patients followed by GPs and cardiologists compared to other groups. Conversely, BMI and fasting glucose levels were higher in patients followed by diabetologists than in other groups. All major CV risk factors and comorbidities were more frequently reported and controlled in patients followed by cardiologists than in the other groups, with the only exception of diabetes. Both European SCORE (4.74.5) and Italian CUORE (13.711.5) were significantly higher in outpatients followed by cardiologists than in those followed by GPs (4.03.6 and 11.59.7) and diabetologists (3.73.5 and 10.39.2) or other SPs (3.32.8 and 9.47.4; P < 0.001 for all comparisons). Conclusions: Despite proper use of drugs and better pharmacological control of major risk factors, both European SCORE and Italian CUORE algorithms reported higher CV risk profile in patients followed by cardiologists than in patients followed by diabetologists, GPs, and other SPs.

Global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews

ObjectiveTo identify, critically appraise and summarise existing systematic reviews on the impact of global cardiovascular risk assessment in the primary prevention of cardiovascular disease (CVD) in adults.DesignSystematic review of systematic...

Pharmacological management of dyslipidemia in high and very high cardiovascular risk patients.

Dyslipaemia is one of the main risk factors in the development of cardiovascular diseases. Currently, there are different alternatives available (amongst which statins occupy a pre-eminent place), to optimise the treatment of patients at high or very high cardiovascular risk. Despite this, the percentage of patients that achieve good lipid control is low. The causes of the mismatch with proposed objectives include lack of patient adherence and therapeutic inertia. This review uses available evidence and the latest clinical guides as a basis to assess the pharmacological treatment of dyslipaemia in patients with a background of arteriosclerotic vascular disease, diabetes, chronic kidney disease, cardiovascular risk at ≥5% calculated by SCORE and familial hypercholesterolaemia. The treatment of hypertriglyceridemia is also reviewed along with the special consideration that poly-pharmacy deserves in patients treated with statins, making mention of the treatment of dyslipaemia with HIV infection. The global assessment of cardiovascular risk is of high priority to adapt treatment to the specific objectives of the c-LDL for each risk category.

Cardiovascular risk calculators: understanding differences and realising economic implications.

In recent years, the concept of "global cardiovascular risk assessment" has grown in interest for its role in primary prevention of cerebro-cardiovascular diseases. Interventions for reducing the risk of relapse for persons with past history of these diseases are well agreed-on. On the contrary, the risk status of persons without such a history varies greatly, and this variability implies a range in the intensity of interventions. In several countries, guidelines for general practitioners have been diffused about pharmaceutical prescriptions in presence of various risk degrees. In particular, in Italy, a governmental drug management commission has established that statins, the most used cholesterol lowering medicines, can be refunded by the National Healthcare System only if prescribed to hyper-cholesterol patients with a global risk greater than 20%. The question is: how to calculate the risk? We performed a review of both the web and the literature and we found a lot of different "risk calculators". By means of a simulation study, we showed that these tools, when applied to the same person, may lead to very different results. We estimated the economic impact of using one or another calculator.

Global Cardiovascular Risk Assessment: Strengths and Limitations.

Global cardiovascular (CV) risk assessment tries to answer the questions: who will benefit from intervention? And when should non-pharmacologic and pharmacologic treatment be started? Used for the assessment of CV risk in the presence of one main CV risk factor, the presence of previous CV disease, diabetes, chronic kidney disease, coronary heart disease and severely elevated single risk factors, are situations with a high or very high risk. For the majority of subjects without any of the above, a calculation of risk can help to decide the best management. The methodology of assessing global CV risk has both strength and limitations. Several computational methods have been developed to assess global CV risk but no risk estimation can consider all the potential risk factors. The most used score chart is the Framingham CardioVascular Risk Score, although in Europe the Systematic Coronary risk evaluation is widespread. The strengths of the global CV risk scores depend on the methodology applied at the time of construction: (a) appropriate statistical methods (representative sample, sufficient power, clear definition of the outcomes); (b) inclusion of appropriate risk factors (age, sex, conventional risk factors, and inclusion of others that can be relevant). Once developed, the function requires internal and external validity as well as calibration. There are several limitations, which have been solved with different approaches. In the case of hypertension, one element is introduced in the score charts, the presence of hypertension-induced organ damage offering a refinement of the approach to the global CV risk.

Guest Editorial Challenges in Resistant Hypertension.

Hypertension is the major risk factor for disease and premature death. Although the efficacy of antihypertensive therapy is undisputed, few patients reach target blood pressure. Steps to improve treatment and control include assessment of global cardiovascular risk for the individual patient, improving caregiver support, education and organisation, increasing treatment persistence, using out of office blood pressure monitoring more often, detecting secondary hypertension forms, and referring patients with remaining uncontrolled hypertension to a specialist hypertension centre. In conclusion, there is room for improvement of blood pressure control in hypertensive patients. The clinical benefit of improved blood pressure control may be considerable. This may be particularly true for patients with resistant hypertension.

Use of Chronic Kidney Disease to Enhance Prediction of Cardiovascular Risk in Those at Medium Risk.

Based on global cardiovascular (CV) risk assessment for example using the Framingham risk score, it is recommended that those with high risk should be treated and those with low risk should not be treated. The recommendation for those of medium risk is less clear and uncertain. We aimed to determine whether factoring in chronic kidney disease (CKD) will improve CV risk prediction in those with medium risk. This is a 10-year retrospective cohort study of 905 subjects in a primary care clinic setting. Baseline CV risk profile and serum creatinine in 1998 were captured from patients record. Framingham general cardiovascular disease risk score (FRS) for each patient was computed. All cardiovascular disease (CVD) events from 1998–2007 were captured. Overall, patients with CKD had higher FRS risk score (25.9% vs 20%, p = 0.001) and more CVD events (22.3% vs 11.9%, p = 0.002) over a 10-year period compared to patients without CKD. In patients with medium CV risk, there was no significant difference in the FRS score among those with and without CKD (14.4% vs 14.6%, p = 0.84) However, in this same medium risk group, patients with CKD had more CV events compared to those without CKD (26.7% vs 6.6%, p = 0.005). This is in contrast to patients in the low and high risk group where there was no difference in CVD events whether these patients had or did not have CKD. There were more CV events in the Framingham medium risk group when they also had CKD compared those in the same risk group without CKD. Hence factoring in CKD for those with medium risk helps to further stratify and identify those who are actually at greater risk, when treatment may be more likely to be indicated.

Primary prevention of cardiovascular disease: global cardiovascular risk assessment and management in clinical practice

For the primary prevention of cardiovascular disease, the Framingham Risk Score (FRS) is the most well-known risk prediction method. However, there are limited data regarding physicians' method of risk assessment and guideline adherence in clinical practice. In the PARADIGM (Primary cARe AuDIt of Global risk Management) study (March 2009-10), 105 primary care physicians across Canada prospectively collected data for 3015 patients (mean age 56 years, 59% men) without known cardiovascular disease, diabetes, or lipid-lowering medications at baseline. For each patient, the treating physician determined their cardiovascular risk, and reported the risk stratification method and subsequent treatment decisions. Kappa statistics assessed the agreement between the study-calculated FRS and the treating physician's reported risk assessment. The FRS was the most commonly reported risk assessment method, but was used in only 34.0% of patients. Regardless of the method used (even if the FRS was reportedly used), there was only fair agreement between the risk stratification as reported by the physician and the study-calculated FRS. Moreover, physicians recommended statin initiation in 92% of all patients that they identified as high risk; however, according to the study-calculated FRS, only 56% of the truly high-risk patients were recommended statin therapy. For the primary prevention of cardiovascular disease, these findings indicate a need to improve risk assessment and stratification, as misclassification directly contributes to suboptimal risk factor management in real-world clinical practice. Future studies should establish the optimal risk stratification method with quality improvement strategies for its subsequent implementation. http://clinicaltrials.gov/ct2/show/NCT00950703; NCT00950703.