Management Of Cardiovascular Disease Risk Factors Research Articles

Abstract P056: Sex Differences in the Association of Diabetes With Cardiovascular Disease Outcomes Among African Americans in the Atherosclerosis Risk in Communities (ARIC) Prospective Cohort: 1987-2013

Epidemiologic studies have consistently shown in whites that the relative risk of diabetes for coronary heart disease (CHD) is greater for women than for men. However, little is known whether this differential sex association is mirrored among African Americans. We hypothesized that, similar to whites, there would be a multiplicative sex by diabetes interaction for cardiovascular disease (CVD) incidence among African Americans in the ARIC cohort. We conducted a prospective cohort analysis of 14,058, 27% African American and 73% white, participants from the ARIC study initially recruited in 1987-1989 and followed for incident cardiovascular events through 2013. CVD was defined as CHD, total stroke, peripheral artery disease (PAD), or heart failure. Race-specific Poisson regression was used to calculate incidence rates of CVD stratified by diabetes status and sex. Race-specific Cox proportional hazards models were run in three stages; stage 1 examined baseline diabetes status, stage 2 examined baseline diabetes status with the competing risk of non-CVD death, and stage 3 incorporated a time-varying model that updated diabetes status during follow-up and included a competing risk of non-CVD death. At each stage, three sequential models were run adjusting for potential confounders including age, body mass index (BMI), smoking status, physical activity, alcohol consumption, education, hypertension, LDL cholesterol, HDL cholesterol, and kidney function. There were 1,073 incident CVD events among African Americans and 2,475 among whites. In stage 1 analysis among African Americans with baseline diabetes, the CVD incidence rate was nearly identical in women and men, 26.8 and 28.1 per 1000 person years, respectively. Women with diabetes were at 2.3-fold increased hazard (95% CI: 2.0 to 2.7) of CVD compared to women without diabetes after adjustment for age, whereas the corresponding hazard ratio for men was 1.8 (95% CI: 1.5 to 2.1) (p for sex by diabetes interaction=0.014). After full adjustment for potential confounders, the diabetes hazard ratio was attenuated to 2.0 (95% CI: 1.8 to 2.3) in women and remained at 1.8 (95% CI: 1.5 to 2.1) for men (interaction p-value =0.058). This finding of synergy between being a woman and having diabetes on CVD risk was consistent across stages 2 and 3 with marginally significant p-values for interaction. The interaction of diabetes by sex was somewhat weaker among whites. Efforts to prevent diabetes and control CVD risk factors are important to both African American men and women, but are particularly relevant in women. While diabetes and CVD risk factor management have improved over the last several decades, there is a higher relative risk of CVD among African American women with diabetes compared with diabetic men, mirroring the sex differences seen in whites.

Life Expectancy and Cause-Specific Mortality in Type 2 Diabetes: A Population-Based Cohort Study Quantifying Relationships in Ethnic Subgroups

This study 1) investigated life expectancy and cause-specific mortality rates associated with type 2 diabetes and 2) quantified these relationships in ethnic subgroups. This was a cohort study using Clinical Practice Research Datalink data from 383 general practices in England with linked hospitalization and mortality records. A total of 187,968 patients with incident type 2 diabetes from 1998 to 2015 were matched to 908,016 control subjects. Abridged life tables estimated years of life lost, and a competing risk survival model quantified cause-specific hazard ratios (HRs). A total of 40,286 deaths occurred in patients with type 2 diabetes. At age 40, white men with diabetes lost 5 years of life and white women lost 6 years compared with those without diabetes. A loss of between 1 and 2 years was observed for South Asians and blacks with diabetes. At age older than 65 years, South Asians with diabetes had up to 1.1 years' longer life expectancy than South Asians without diabetes. Compared with whites with diabetes, South Asians with diabetes had lower adjusted risks for mortality from cardiovascular (HR 0.82; 95% CI 0.75, 0.89), cancer (HR 0.43; 95% CI 0.36, 0.51), and respiratory diseases (HR 0.60; 95% CI 0.48, 0.76). A similar pattern was observed in blacks with diabetes compared with whites with diabetes. Type 2 diabetes was associated with more years of life lost among whites than among South Asians or blacks, with older South Asians experiencing longer life expectancy compared with South Asians without diabetes. The findings support optimized cardiovascular disease risk factor management, especially in whites with type 2 diabetes.

The Impact of Diabetes on Mortality Among Elderly Patients Admitted for Treatment at a Hospital for Cardiovascular Disease in Southern Brazil.

Diabetes has been shown to be associated with increased mortality and morbidity worldwide. This study explored whether diabetes significantly impacts on outcomes among elderly adults with cardiovascular disease (CVD) admitted to a specialist hospital in Southern Brazil. A prospective cohort study of 411 patients admitted to hospital after a cardiac event between 2008 and 2010. The primary end point was death by all causes during the follow up period of 6 months from admission. All hospital death reports matched those reported by the Brazilian Public Health Death Records. Cumulative probability of survival by Kaplan-Meier plot and log rank tests compared hospital admissions with or without diabetes. Adjusted and unadjusted hazard ratios (HR) for overall mortality were calculated. The mean ± SD age of the subjects was 69.8 years ± 14 and 50% were men. Overall study mortality was 8.7%. Half of the deaths occurred in patients ≥80 years (p=0.001). Diabetes was associated with 53% of the overall mortality (p<0.01) and 79% of the CVD-related deaths (p<0.03). The adjusted HR was 2.88 (95% CI 1.42-5.84) for diabetic patients aged ≥80 years. In conclusion, the results suggest that elderly patients of European origin with diabetes residing in Southern Brazil admitted to hospital for specialist CVD treatment have poorer survival and higher risk of further CVD events 6 months after hospital discharge compared with those without. We recommend that better strategies for managing CVD risk factors among elderly diabetic patients from similar patient cohorts in Brazil are necessary.

Trends in Nonlipid Cardiovascular Disease Risk Factor Management in the Women's Interagency HIV Study and Association with Adherence to Antiretroviral Therapy.

Cardiovascular disease (CVD) is increasingly common among women with HIV, but literature on nonlipid CVD risk factor management is lacking. We examined semiannual trends from 2006 to 2014 in hypertension treatment and control (blood pressure <140/90 mmHg), diabetes treatment and control (fasting glucose <130 mg/dL), and smoking quit rates in the Women's Interagency HIV Study. Unadjusted and adjusted Poisson regression models tested time trends and differences between HIV+ and HIV- women. Among antiretroviral therapy (ART) users, we examined the association of ART adherence and virologic suppression with each outcome. We evaluated 1636 HIV+ and 683 HIV- women, with a hypertension prevalence of 40% and 38%, respectively; diabetes prevalence of 21% and 22%; and smoking prevalence of 37% and 48%. Hypertension treatment was higher among HIV+ than HIV- women (77% vs. 67%, p < 0.001) and increased over time with no difference in trend by HIV status. Hypertension control was greater among HIV+ women (56% vs. 43%, p < 0.001) and increased over time among HIV+ but not HIV- women. Diabetes treatment was similar among HIV+ and HIV- women (48% vs. 49%) and increased over time in both groups. Diabetes control was greater among HIV+ women (73% vs. 64%, p = 0.03) and did not change over time. The percent of recent smokers who reported no longer smoking was similar between HIV+ and HIV- women (10% vs. 9%), with no differences over time. Virologic suppression was significantly associated with increased hypertension treatment and greater control. HIV+ women have better control of hypertension and diabetes than HIV- women, but many are still not at target levels.

Association between Dietary Patterns and Cardiovascular Risk Factors among Middle-Aged and Elderly Adults in Taiwan: A Population-Based Study from 2003 to 2012.

BackgroundCardiovascular disease (CVD) is one of the leading causes of mortality and loss of disability-adjusted life years in developed countries. This study derived a dietary pattern using an a priori method and additionally derived dietary patterns using a posteriori methods, and assessed the relationship with CVD risk factors in Taiwanese middle-aged and elderly adults.MethodsCross-sectional analyses of 62,965 subjects aged 40 years and above from the Mei Jau (MJ) database collected between 2003 and 2012 in Taiwan. Diet was assessed using a 22 item semi-quantitative food frequency questionnaire. Using this information, three dietary patterns were generated. The a priori diet was labeled the Taiwanese dietary pattern and was derived using hypothesized effect of 22 food groups, while two a posteriori dietary patterns, “vegi-fruits” and “meat-processed”, were derived using principal component analysis. The association between dietary patterns and a range of CVD risk factors (i.e. blood lipids, blood glucose and C-reactive protein) was evaluated using linear regression.ResultsThe results showed that high intake (Q5, quintile 5) of Taiwanese diet was negatively associated with CVD risk factors at (p < 0.001, model 3), but not with triacylglycerol. In addition, high intake of vegi-fruit dietary pattern (Q5) was negatively associated with CVD risk factors (p < 0.001), but not with high-density lipoprotein, while high consumption of meat-processed dietary pattern (Q5) was positively associated with CVD risk factors (p < 0.001), but negatively related with triacylglycerol in Q3 level and no association with C-reactive protein.ConclusionA negative association was observed between Taiwanese or vegi-fruit dietary patterns and CVD risk factors, while a positive association was found between meat-processed dietary pattern and CVD risk factors. The findings suggested that a diet rich in vegetables and fruits has a beneficial effect in the management of CVD risk factors.

Older adult awareness of the influence of cardiovascular disease risk factors on cognitive function.

The aims of the current study were to (i) assess older people's awareness of the association between CVD risk factors and cognitive function; and (ii) examine whether awareness varies as a function of demographic factors. Cardiovascular disease (CVD) risk factors have been linked to subtle deficits in cognitive function. CVD risk factors increase the risk of cognitive decline and dementia. The association between cardiovascular disease (CVD) risk factors and cognitive decrements has been well documented among older people; however, we are unaware of any studies that have measured older people's awareness of this relationship in an effort to assess educational needs. A descriptive, cross-sectional survey design was employed. Community-based older adults aged 60 and older completed a survey that assessed their knowledge of the association between CVD risk factors and cognitive function. One hundred fifty older adults, with a mean age of 72.88years, completed the survey. Results showed that over 75% of the sample was aware that CVD risk factors affect cognitive function. White older adults and older adults with greater perceived financial well-being tended to be more aware of these relationships than non-White participants with less perceived financial well-being. Results suggest that many, but not all older people have awareness of this relationship. As such, there is a need for increased education about the cognitive effects of CVD risk factors, particularly among older people who are already at risk for developing CVD and those with lesser financial well-being. Appropriate educational strategies can expose older patients to the importance of healthy lifestyle and self-care to maintain cognitive function. Nurses can incorporate education into care by identifying patients that would benefit from tailored interventions and providing information to at-risk patients about how to maintain their cognitive function through management of specific CVD risk factors.

Traditional Cardiovascular Disease Risk Factor Management in Rheumatoid Arthritis Compared to Matched Nonrheumatoid Arthritis in a US Managed Care Setting.

To compare traditional cardiovascular (CV) risk factor management among patients with rheumatoid arthritis (RA) to that of matched non-RA controls within a large US managed care setting. Adult patients with RA and age- and sex-matched general population (general controls) or osteoarthritis (OA) controls were identified between January 1, 2007 and December 31, 2011. We compared health care utilization, measurement, treatment, and treatment target achievement of traditional CV risk factors among subgroups of CV comorbidity during 1 year of followup between RA and controls. A total of 9,440 RA patients, 31,009 general controls, and 10,352 OA controls were included. The proportions with measurements (blood pressure [BP], low-density lipoprotein [LDL] cholesterol, or hemoglobin A1c ), treatment (antihypertensive, statin, or anti-diabetes mellitus medications), and treatment target achievement were slightly higher in patients with RA compared with general controls. Controlling for other factors, RA patients were more likely to have a measurement of BP (odds ratio [OR] 16.77 [95% confidence interval (95% CI) 10.01-28.08]) or LDL cholesterol (OR 1.25 [95% CI 1.13-1.39]), and to receive antihypertensive (OR 1.84 [95% CI 1.47-2.30]) or anti-diabetic medications (OR 1.26 [95% CI 1.01-1.56]) compared to general controls. RA was not associated with receiving a statin (OR 1.01 [95% CI 0.92-1.12]); however, a target LDL level was more likely to be achieved in RA compared to general controls (OR 1.27 [95% CI 1.17-1.37]) as well as target levels of BP and hemoglobin A1c . These results were consistent with results for OA controls except for a lower probability of receiving a statin in RA compared to OA. Traditional CV risk factors in patients with RA were not less aggressively managed compared to non-RA controls.

Hypertension Among HIV-infected Patients in Clinical Care, 1996-2013.

Persons infected with human immunodeficiency virus (HIV) are at higher risk for major cardiovascular disease (CVD) events than uninfected persons. Understanding the epidemiology of major traditional CVD risk determinants, particularly hypertension, in this population is needed. The study population included HIV-infected patients participating in the UNC CFAR HIV Clinical Cohort from 1996 to 2013. Annual incidence rates of hypertension were calculated. Multivariable Poisson models were fit to identify factors associated with incident hypertension. 3141 patients contributed 21 956 person-years (PY) of follow-up. Overall, 57% patients were black, 28% were women, and the median age was 35 years. Hypertension age-standardized incidence rates increased from 1.68 cases per 100 PYs in 1996 to 5.35 cases per 100 PYs in 2013 (P < .001). In adjusted analyses, hypertension rates were higher among obese patients (incidence rate ratio [IRR] 1.70, 95% confidence interval [CI], 1.43-2.02), and those with diabetes mellitus (IRR 1.44, 95% CI, 1.14-1.83) and renal insufficiency (IRR 1.36, 95% CI, 1.16-1.61), but lower among patients with a CD4 nadir of ≥500 cells/mm(3) (IRR 0.73, 95% CI, .53-1.01). The incidence of hypertension increased from 1996 to 2013, alongside increases in traditional hypertension risk determinants. Notably, HIV-related immunosuppression and ongoing viral replication may contribute to an increased hypertension risk. Aggressive CVD risk factor management, early HIV diagnosis, linkage to care, antiretroviral therapy initiation, and durable viral suppression, will be important components of a comprehensive primary CVD prevention strategy in HIV-infected persons.

Patients' experiences managing cardiovascular disease and risk factors in prison.

BackgroundDespite greater risk of cardiovascular disease (CVD) mortality in patients with a history of incarceration, little is known about how prisons manage CVD risk factors (CVD-RF) to mitigate this risk.MethodsWe conducted in-depth interviews with individuals with CVD-RF who had been recently released from prison (n = 26). These individuals were recruited through community flyers and a primary care clinic in Connecticut. Using a grounded theory approach and the constant comparative method, we inductively generated themes about CVD-RF care in prisons. Data collection and analysis occurred iteratively to refine and unify emerging themes.ResultsFour themes emerged about care in prison: (1) Participants perceive that their CVD-RFs are managed through acute, rather than chronic, care processes; (2) Prison providers’ multiple correctional and medical roles can undermine patient-centered care; (3) Informal support systems can enhance CVD-RF self-management education and skills; and (4) The trade-off between prisoner security and patient autonomy influences opportunities for self-management.ConclusionsPatients develop self-management skills through complex processes that may be compromised by the influence of correctional policies on medical care. Our findings support interventions to engage peers, medical providers, care delivery systems, and correctional staff in cultivating effective self-management strategies tailored to prison settings.

Abstract P267: Geographic Patterns of Cardiovascular Disease Risk Factor Prevalence in the Continental US

Objectives: Our understanding of geographic variation in cardiovascular disease (CVD) risk factors is based upon self-reported variables or geographically limited coverage. Our objective was to explore geographic variation in measured hypertension, measured diabetes, measured dyslipidemia, and self-reported current smoking prevalence. Methods: We used baseline data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, whose community-dwelling participants were recruited nationally between 2003 and 2007. Participants underwent a telephone interview and in-home examination. Hypertension, diabetes, and dyslipidemia were based on physiologic measures or reported medication use. Current cigarette smoking was self-reported. Using participants’ residential latitude and longitude, we tested for clustering of each risk factor using the difference in Ripley’s K functions test and, when we found evidence of clustering, used thin plate regression splines (TPRS) in a logistic regression framework to create age- race-, and sex-adjusted maps of risk factor prevalence. Results: Risk factor status and location data were available for 27,787 of the 30,239 participants (92%). Mean (±SD) age of these participants was 65(±9) years, 41% were black, 55% were women, 59% had hypertension, 22% had diabetes, 54% had dyslipidemia, and 15% were current smokers. We found statistically significant geographic clustering of hypertension, diabetes, and smoking prevalence, but not dyslipidemia. The regions with the highest prevalence varied across risk factors (Figure 1). Conclusions: Louisiana and Mississippi might require the most intense management of CVD risk factors. These maps show variation across and within administrative units, providing an accurate representation of geographic variation in risk factor prevalence. High resolution maps could be put to use by healthcare organizations to justify requests for higher reimbursement rates based upon local population health.

Factors Influencing Physician Counseling on Cardiovascular Risk.

A significant reduction in cardiovascular disease (CVD) mortality is related to aggressive management of modifiable CVD risk factors. Therefore, patients at increased risk for CVD should not only benefit from standard pharmacotherapy but also from counseling regarding lifestyle behavioral changes. To determine the patient factors that influence provision of cardiovascular risk reduction counseling from physicians, as well as the frequencies of counseling. Secondary analysis of a prospective, randomized trial among an underserved inner-city and rural population (n = 388) with a 10% or greater CVD risk (Framingham 10-year risk score). Subjects were followed for 1 year and were seen for quarterly assessments, which included evaluation of weight, blood pressure, lipid, and glucose status. At each of the 4 quarterly visits, subjects were asked if their physician had discussed or made recommendations regarding lifestyle behaviors, specifically diet, weight loss, and exercise. The average patient age was 61.3 ± 10.1 years, average A1c was 6.7 ± 1.6%, average total cholesterol was 201 ± 44 mg/dL. The average body mass index (BMI) was 31.8 ± 6.4 kg/m2, and the average blood pressure was 146 ± 18/82 ±11 mm Hg. Using binary logistic regression analysis, BMI (P < .025) was the only clinical factor related to physician lifestyle counseling. All other risk factors showed no statistical relationship. The data indicate that BMI is the major factor associated with whether or not physicians provide counseling regarding nutrition and weight loss. Physicians may be missing important opportunities to influence behavior in patients at high risk for CVD by limiting their focus to obese patients.

Abstract 16746: Cardiovascular Disease Outcomes After Breast Cancer in Postmenopausal Women: Results From the Women’s Health Initiative

Introduction: A growing population of older breast cancer (BC) survivors may be at risk of cardiovascular disease (CVD). Pre-existing CVD risk factors may impact on subsequent development of CVD after BC among postmenopausal women. Objectives: (1) To describe baseline CVD risk factors among postmenopausal women with and without BC prior to diagnosis of BC; and (2) To examine independent associations of BC with individual and composite CVD events (i.e., the first occurrence of coronary heart disease [CHD], angina, coronary revascularization, congestive heart failure, peripheral arterial disease, and stroke) and mortality outcomes (i.e., all-cause, CVD, and CHD death) after BC adjusting for baseline characteristics and CVD risk factors. Methods: This prospective cohort study included 101,916 women in the Women’s Health Initiative (WHI) (including 4,340 women with invasive BC) aged 50-79 years without CVD at baseline (1993-1998) through December 2010. Over a period of 10 years after BC, CVD morbidity and mortality outcomes were identified and age-adjusted rates per 1,000 person-years and hazard ratios (HRs) with 95% confidence intervals (CIs) from Cox models were determined for women who did and did not develop BC. Results: Regardless of BC status, baseline CVD risk factors prior to BC, such as smoking, hypertension, diabetes and hypercholesterolemia, were strong predictors of CVD outcomes in postmenopausal women. Multivariable Cox models revealed that women who developed BC (n = 4,340) had a similar risk of composite CVD (HR = 0.91, 95% CI, 0.82-1.02), but a higher risk of CHD (HR=1.33, 95% CI, 1.12-1.58), compared with women without BC (n = 97,576). Women aged 70-79 and on hormonal therapy at the WHI entry with localized BC during follow-up period had the highest CHD death rate. The results were similar after excluding women with baseline cancer at the WHI study entry. Conclusions: These results emphasize the great need for identification and timely management of pre-existing CVD risk factors for postmenopausal women with BC. CVD accounts for almost as many deaths as BC among women with localized disease, indicating that improved effort to prevent and treat CVD risk factors could improve survival of postmenopausal BC survivors.

Effect of consuming novel foods consisting high oleic canola oil, barley β-glucan, and DHA on cardiovascular disease risk in humans: the CONFIDENCE (Canola Oil and Fibre with DHA Enhanced) study – protocol for a randomized controlled trial

BackgroundMetabolic syndrome (MetS) has been identified as a major contributor to the development of cardiovascular disease (CVD). Current recommendations for dietary management of people with MetS involve quantitative and qualitative modifications of food intake, such as high consumption of vegetables, fruits, and whole grain foods. The results from our previous human trials revealed the potential of the dietary components high-oleic acid canola oil (HOCO)-docosahexaenoic acid (DHA) and high molecular weight barley β-glucan individually in managing CVD risk factors. Foods with a combination of HOCO-DHA and barley β-glucan have never been tested for their effects on CVD risk. The objective is to determine the effects of consuming novel foods HOCO-DHA, and barley β-glucan on managing CVD risk factors in people with MetS.Methods/DesignWe are conducting a randomized, single-blind crossover trial with four treatment phases of 28 days each separated by a 4-week washout interval. Participants (n=35) will be provided with weight-maintaining, healthy balanced diet recommendations according to their energy requirements during the intervention periods. Participants will receive muffins and cookies as treatment foods in a random order and will consume at least one meal per day at the research center under supervision. The four treatments include muffins and cookies consisting of (1) all-purpose flour and HOCO-DHA (50 g/day); (2) barley flour (4.36 g/day of β-glucan) and a blend of sunflower oil, safflower oil, and butter as control oil (50 g/day); (3) barley flour (4.36 g/day of β-glucan) and HOCO-DHA (50 g/day; dosage of DHA would be 3 g/day); and (4) all-purpose flour and control oil (50 g/day). At the beginning and end of each phase, we will evaluate anthropometrics; systolic and diastolic blood pressure; blood lipid profile; low-density lipoprotein subfractions and particle size; 10-year Framingham CVD risk score; inflammatory status; and plasma and red blood cell fatty acid profiles, fecal microbiome, and body composition by dual-energy X-ray absorptiometry.ConclusionCholesterol synthesis will also be studied, using a stable isotope approach. The proposed study will lead to innovation of novel food products, which may result in improvement in the overall cardiovascular health of humans.Trial registrationClinical trials.gov identifier: NCT02091583. Date of registration: 12 March 2014.

Challenges and Opportunities in the Management of Cardiovascular Risk Factors in Youth With Type 1 Diabetes: Lifestyle and Beyond.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in persons with type 1 diabetes (T1D). Specific risk factors associated with diabetes, such as hyperglycemia and kidney disease, have been demonstrated to increase the incidence and progression of CVD. Nevertheless, few data exist on the effects of traditional risk factors such as dyslipidemia, obesity, and hypertension on CVD risk in youth with T1D. Improvements in understanding and approaches to the evaluation and management of CVD risk factors, specifically for young persons with T1D, are desirable. Recent advances in noninvasive techniques to detect early vascular damage, such as the evaluation of endothelial dysfunction and aortic or carotid intima-media thickness, provide new tools to evaluate the progression of CVD in childhood. In the present review, current CVD risk factor management, challenges, and potential therapeutic interventions in youth with T1D are described.

Clinical Decision Support Systems and Prevention: A Community Guide Cardiovascular Disease Systematic Review.

Clinical decision support systems (CDSSs) can help clinicians assess cardiovascular disease (CVD) risk and manage CVD risk factors by providing tailored assessments and treatment recommendations based on individual patient data. The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors, practices for CVD-related preventive care services such as clinical tests and prescribed treatments, and management of CVD risk factors. An existing systematic review (search period, January 1975-January 2011) of CDSSs for any condition was initially identified. Studies of CDSSs that focused on CVD prevention in that review were combined with studies identified through an updated search (January 2011-October 2012). Data analysis was conducted in 2013. A total of 45 studies qualified for inclusion in the review. Improvements were seen for recommended screening and other preventive care services completed by clinicians, recommended clinical tests completed by clinicians, and recommended treatments prescribed by clinicians (median increases of 3.8, 4.0, and 2.0 percentage points, respectively). Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol, and hemoglobin A1C levels. CDSSs are effective in improving clinician practices related to screening and other preventive care services, clinical tests, and treatments. However, more evidence is needed from implementation of CDSSs within the broad context of comprehensive service delivery aimed at reducing CVD risk and CVD-related morbidity and mortality.

Abstract 584: The Association of Psychosocial Risk Factors with Subclinical Atherosclerosis in South Asians

Objective: South Asians (individuals from India, Pakistan, Bangladesh, Nepal, and Sri Lanka) are at higher risk of cardiovascular disease (CVD) than other ethnic groups, however this increased risk cannot be explained by traditional risk factors. We investigated the association of psychosocial risk factors with carotid intima media thickness (cIMT), a measure of subclinical CVD, in a community-based cohort of South Asians living in the United States. Methods: A total of 906 individuals from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study, aged 40-83, were included in this cross-sectional analysis. High resolution B-mode ultrasonography was used to measure right and left common cIMT (CCA) and internal cIMT (ICA). Linear regression analyses were done to test the associations of the following psychosocial variables: anger, anxiety, depressive symptoms, current and prior 6-month life stress, social support, and everyday hassles with CCA and ICA. In a multivariable model, results were adjusted for the following traditional CVD risk factors: age, sex, systolic blood pressure, hypertension medication use, education, physical activity, diabetes, BMI, smoking, and total/HDL cholesterol ratio. Interaction effects between sex and psychosocial variables were also tested. Results: In age- and sex- adjusted analyses, current life stress and life stress over the past 6 months were positively associated with CCA [mean difference per 1-SD increase (CI) was 0.014 (0.001-0.028; p=0.042) and 0.015 (0.001-0.029; p=0.031), respectively], but were no longer significant after adjusting for other CVD covariates. There was a significant sex interaction with anxiety (p=0.044). Among men, anxiety was positively associated with CCA [mean difference per 1-SD increase (CI) was 0.021 (0.001-0.041; p=0.04) in age-adjusted analyses, and 0.022 (0.002-0.042; p=0.031) in a fully adjusted model]. ICA was not associated with any psychosocial factor. Conclusion: Compared to results in other ethnic groups, there was no significant association between trait anger and cIMT in South Asians. Anxiety was associated with CCA independent of traditional CVD risk factors in men alone.

Sex differences in cardiovascular risk factors and disease prevention

Cardiovascular disease (CVD) has been seen as a men's disease for decades, however it is more common in women than in men. It is generally assumed in medicine that the effects of the major risk factors (RF) on CVD outcomes are the same in women as in men. Recent evidence has emerged that recognizes new, potentially independent, CVD RF exclusive to women. In particular, common disorders of pregnancy, such as gestational hypertension and diabetes, as well as frequently occurring endocrine disorders in women of reproductive age (e.g. polycystic ovary syndrome (PCOS) and early menopause) are associated with accelerated development of CVD and impaired CVD-free survival.With the recent availability of prospective studies comprising men and women, the equivalency of major RF prevalence and effects on CVD between men and women can be examined. Furthermore, female-specific RFs might be identified enabling early detection of apparently healthy women with a high lifetime risk of CVD.Therefore, we examined the available literature regarding the prevalence and effects of the traditional major RFs for CVD in men and women. This included large prospective cohort studies, cross-sectional studies and registries, as randomised trials are lacking. Furthermore, a literature search was performed to examine the impact of female-specific RFs on the traditional RFs and the occurrence of CVD.We found that the effects of elevated blood pressure, overweight and obesity, and elevated cholesterol on CVD outcomes are largely similar between women and men, however prolonged smoking is significantly more hazardous for women than for men. With respect to female-specific RF only associations (and no absolute risk data) could be found between preeclampsia, gestational diabetes and menopause onset with the occurrence of CVD.This review shows that CVD is the main cause of death in men and women, however the prevalence is higher in women. Determination of the CV risk profile should take into account that there are differences in impact of major CV RF leading to a worse outcome in women. Lifestyle interventions and awareness in women needs more consideration. Furthermore, there is accumulating evidence that female-specific RF are of influence on the impact of major RF and on the onset of CVD. Attention for female specific RF may enable early detection and intervention in apparently healthy women. Studies are needed on how to implement the added RF's in current risk assessment and management strategies to maximize benefit and cost-effectiveness specific in women.

The potential impact of new national guidance on primary prevention of cardiovascular disease in people living with HIV.

IntroductionCardiovascular disease (CVD) is the leading cause of death in England and Wales. As people living with HIV (PLWH) age, proactive management of CVD risk factors is crucial. The long-awaited draft guidelines for CVD from the National Institute of Clinical Excellence (NICE) propose lipid modification (with statins) and lifestyle modification for 40–74 year olds with >10% (previously >20%) 10-year risk of CVD using QRISK2. We currently use Framingham so compared 3 CVD risk calculators in our cohort and analyzed the impact of a change in CVD threshold on the proportion of our patients who would need intervention.Materials and MethodsFramingham, QRISK2 and JBS3 cardiovascular risk calculators were compared in a group of randomly selected patients. Then, to analyze the impact of a change in primary prevention threshold on our cohort, we interrogated a prospectively collected database to identify all individuals who had a documented Framingham risk assessment and applied the current/proposed thresholds accordingly. We performed the same analysis for the three calculator subgroup (recalculating Framingham risk). Finally we surveyed HIV services in England & Wales regarding their choice of calculator.ResultsWe compared the 3 CVD risk calculators in 100 patients, see Table 1.In terms of eligibility for primary prevention 20.9% (916/4383) had documented Framingham risk assessment as part of routine care. Using a 20% threshold, 8.8% (81/916) would require intervention, increasing to 35.2% (322/916) with a threshold for intervention of 10%. Restricting analysis to the 100 patients to whom we applied all three calculators resulted in the following proportion requiring intervention with a 20%/10% threshold, respectively: Framingham 28%/76%, QRISK2 20%/53%, JBS3 15%/42% (four patients were excluded due to incomplete data).ConclusionsReducing the threshold for cardiovascular preventative measures to 10% vastly increases the number of patients requiring primary intervention, from two- to fourfold depending on risk calculator used. This may have significant implications, including cost, drug–drug interactions and patient experience, that HIV physicians and general practitioners will need to address, ideally in a coordinated and patient-focused manner.

Interventions to Reduce Clinical Inertia in Cardiac Risk Factor Management in Renal Transplant Recipients

Cardiovascular disease (CVD) is the leading cause of death in renal transplant recipients (RTRs). Clinical inertia (CI) is defined as "recognition of the problem, but failure to act." The effect of educational interventions in minimizing CI in CVD risk factor management was assessed. Educational sessions were conducted among 201 RTRs to inform them about their goals for blood pressure (BP), low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (HbA1c). Physicians were reminded about treatment goals using checklists. Pre-intervention and post-intervention CI was measured as "no action" or "appropriate action" by the physicians. Post-intervention percentage of RTRs with "no clinical action" for BP, LDL-C, and HbA1c control decreased from 10.8% to 3.8% (P=.02), 28.2% to 11.1% (P=.008), and 10.3% to 4.5% (P=.05), respectively, while those with "appropriate action" increased from 66.2% to 83.3% (P<.001), 68.7% to 79.4% (P=.008), and 85.1% to 93.2% (P=.03), respectively. Educational interventions and patient participation were shown to reduce CI.

Aortic Pulse Wave Velocity Improves Cardiovascular Event Prediction: An Individual Participant Meta-Analysis of Prospective Observational Data From 17,635 Subjects

The goal of this study was to determine whether aortic pulse wave velocity (aPWV) improves prediction of cardiovascular disease (CVD) events beyond conventional risk factors. Several studies have shown that aPWV may be a useful risk factor for predicting CVD, but they have been underpowered to examine whether this is true for different subgroups. We undertook a systematic review and obtained individual participant data from 16 studies. Study-specific associations of aPWV with CVD outcomes were determined using Cox proportional hazard models and random effect models to estimate pooled effects. Of 17,635 participants, a total of 1,785 (10%) had a CVD event. The pooled age- and sex-adjusted hazard ratios (HRs) per 1-SD change in loge aPWV were 1.35 (95% confidence interval [CI]: 1.22 to 1.50; p < 0.001) for coronary heart disease, 1.54 (95% CI: 1.34 to 1.78; p < 0.001) for stroke, and 1.45 (95% CI: 1.30 to 1.61; p < 0.001) for CVD. Associations stratified according to sex, diabetes, and hypertension were similar but decreased with age (1.89, 1.77, 1.36, and 1.23 for age ≤50, 51 to 60, 61 to 70, and >70 years, respectively; pinteraction <0.001). After adjusting for conventional risk factors, aPWV remained a predictor of coronary heart disease (HR: 1.23 [95% CI: 1.11 to 1.35]; p < 0.001), stroke (HR: 1.28 [95% CI: 1.16 to 1.42]; p < 0.001), and CVD events (HR: 1.30 [95% CI: 1.18 to 1.43]; p < 0.001). Reclassification indices showed that the addition of aPWV improved risk prediction (13% for 10-year CVD risk for intermediate risk) for some subgroups. Consideration of aPWV improves model fit and reclassifies risk for future CVD events in models that include standard risk factors. aPWV may enable better identification of high-risk populations that might benefit from more aggressive CVD risk factor management.