Cardiovascular Disease Risk Prediction Score Research Articles

TOTAL CARDIOVASCULAR RISK ASSESSMENT AND CAROTID DAMAGE IN HYPERTENSIVE INDIVIDUALS WITH TYPE-2 DIABETES/PRE-DIABETES: A PILOT STUDY

Objective: This study compared the performance of cardiovascular disease (CVD) risk prediction scores in terms of their association with preclinical carotid damage in patients with type-2 diabetes/pre-diabetes and hypertension without established CVD. Design and method: Adults (> = 18 years) with type-2 diabetes/pre-diabetes and hypertension, without pre-existing CVD were assessed through anthropometric parameters and blood tests. Preclinical carotid damage was assessed by echocardiographic estimation of Carotid Plaque Score (CPS). Carotid damage was defined as CPS higher than the value of the 75th percentile and/or carotid stenosis >50%. Five CVD risk scores were considered (SCORE2/OP2; FRAMINGHAM; UKPDS STR; UKPDS CHD; ASCVD). Results: Fifty-one individuals with complete data on age, sex, smoking, lipid profile and HbA1c were analyzed [mean age (years) 63.7±8.0 (SD), 63% males, body mass index (BMI) (kg/m2) 31.4±5.0 (SD), 44 diabetes, LDL-cholesterol 99.3±32.1 mg/dl, HbA1c 6.4±0.8%]. The C-statistic (ROC curve) in identifying patients with carotid damage was 0.642 [95% CI 0.487, 0.797] for SCORE2/OP2, 0.576 [95% CI 0.408, 0.745] for FRAMINGHAM, 0.696 [95% CI 0.553, 0.839] for UKPDS STR, 0.644 [95% CI 0.491, 0.796] for UKPDS CHD and 0.563 [95% CI 0.396, 0.730] for ASCVD. The UKPDS STR had a significant higher C-statistic value compared to ASCVD (p<0.05), whereas no other score discriminated better than the others in identifying individuals with preclinical carotid damage (p = NS). Conclusions: This pilot analysis suggests that the available CVD risk prediction scores show moderate ability in identifying which patients with type-2 diabetes/pre-diabetes and hypertension have preclinical carotid damage. Although there seems to be no superiority of any of them, the UKPDS STR performed somewhat better.

The comparison of cardiovascular disease risk prediction scores and evaluation of subclinical atherosclerosis in rheumatoid arthritis: a cross-sectional study.

Primary objectives estimated prevalence of traditional cardiovascular disease (CVD) risk factors and compared different CVD risk prediction algorithms in an Indian rheumatoid arthritis (RA) population. Secondary objectives evaluated associations between carotid intima-media thickness (CIMT) and subclinical atherosclerosis (SCA) with CVD risk factors and CVD risk scores. The presence of CVD risk factors were recorded, and 10-year CVD risk was predicted using Framingham risk scoring (FRS) using lipids (FRS-Lipids), FRS using body mass index (FRS-BMI), QRISK-2, SCORE, and the algorithm recommended by ACC/AHA (ASCVD). CIMT was measured on the far-wall of the common carotid artery. Subclinical atherosclerosis was defined as CIMT > 0.9mm or the presence of carotid plaque. A total of 332 patents were enrolled, 12% had diabetes mellitus, 21.4% hypertension, and 6.9% were current/past smokers. Proportions of RA with predicted 10-year CVD risk > 10% varied from 16.2 to 41.9% between scores. Highest magnitude of risk was predicted by FRS-BMI. Agreement between scores in predicting risk was moderate in general. Mean CIMT was 0.70 ± 0.15mm. Age, male sex, and extra-articular manifestations associated with greater CIMT. All risk scores except SCORE moderately correlated with CIMT. About one-seventh had SCA defined as CIMT > 0.9mm or the presence of carotid plaques, associated with increasing age, male gender, or higher ratio of total cholesterol to high-density lipoprotein cholesterol. ASCVD and QRISK-2 scores had maximum area under curve for distinguishing SCA. Individual CVD risk scores predict 10-year CVD risk differently in Indian patients with RA, and require validation for predicting hard end points (CVD events, mortality). Key Points • Diabetes mellitus and hypertension are the most prevalent cardiovascular disease risk factors in Indian patients with RA. • Individual cardiovascular risk prediction scores predict risk differently in Indian patients with RA, highest risk being predicted by the FRS-BMI. • Carotid intima-media thickness in RA associated with increasing age, male sex and extra-articular manifestations. • 14% RA had subclinical atherosclerosis, associated with increasing age, male sex, and higher total cholesterol to HDL-C ratio, best distinguished by ASCVD and QRISK-2 scores.

Reduced cerebral vascular fractal dimension among asymptomatic individuals as a potential biomarker for cerebral small vessel disease

Cerebral small vessel disease is a neurological disease frequently found in the elderly and detected on neuroimaging, often as an incidental finding. White matter hyperintensity is one of the most commonly reported neuroimaging markers of CSVD and is linked with an increased risk of future stroke and vascular dementia. Recent attention has focused on the search of CSVD biomarkers. The objective of this study is to explore the potential of fractal dimension as a vascular neuroimaging marker in asymptomatic CSVD with low WMH burden. Df is an index that measures the complexity of a self-similar and irregular structure such as circle of Willis and its tributaries. This exploratory cross-sectional study involved 22 neurologically asymptomatic adult subjects (42 ± 12 years old; 68% female) with low to moderate 10-year cardiovascular disease risk prediction score (QRISK2 score) who underwent magnetic resonance imaging/angiography (MRI/MRA) brain scan. Based on the MRI findings, subjects were divided into two groups: subjects with low WMH burden and no WMH burden, (WMH+; n = 8) and (WMH−; n = 14) respectively. Maximum intensity projection image was constructed from the 3D time-of-flight (TOF) MRA. The complexity of the CoW and its tributaries observed in the MIP image was characterised using Df. The Df of the CoW and its tributaries, i.e., Df (w) was significantly lower in the WMH+ group (1.5172 ± 0.0248) as compared to WMH− (1.5653 ± 0.0304, p = 0.001). There was a significant inverse relationship between the QRISK2 risk score and Df (w), (rs = − .656, p = 0.001). Df (w) is a promising, non-invasive vascular neuroimaging marker for asymptomatic CSVD with WMH. Further study with multi-centre and long-term follow-up is warranted to explore its potential as a biomarker in CSVD and correlation with clinical sequalae of CSVD.

Cardiovascular risk prediction in type 2 diabetes: a comparison of 22 risk scores in primary care setting

Abstract People with type 2 diabetes (T2DM) remain at high risk for cardiovascular disease (CVD) CVD treatment initiation and intensification are guided by risk prediction algorithms. The majority of CVD risk prediction tools have not been validated in T2DM. We compared the performance of general and diabetes specific cardiovascular risk prediction scores for cardiovascular disease (CVD ie coronary heart disease and stroke), CVD+ (including atrial fibrillation and heart failure), and their individual components, in type 2 diabetes patients (T2DM). Scores were identified through a systematic review and included irrespective of the type of predicted CVD, or inclusion of T2DM patients. Performance was assessed in a contemporary sample of 203,172 UK T2DM. We identified 22 scores: 11 derived in the general population, 9 in T2DM patients, and 2 excluded T2DM patients. Over 10 years follow-up, 63,000 events occurred. The RECODE score, derived in people with T2DM, performed best for both CVD (c-statistic 0.731 (0.728,0.734), and CVD+ (0.732 (0.729,0.735)). Calibration slopes (1 indicates perfect calibration) ranged from 0.38 (95% CI 0.37; 0.39) to 1.05 (95% CI 1.03; 1.07). A simple, population specific recalibration process considerably improved performance, now ranging between 0.98 and 1.03. Risk scores performed badly in people with pre-existing CVD (c-statistic ∼0.55). CVD risk prediction scores performed worse in T2DM than in the general population, irrespective of derivation population, and of original predicted outcome. Scores performed especially poorly in patients with established CVD. A simple population specific recalibration markedly improved score performance and is recommended for future use. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): NPIF programme

Response to Comment on Tynjälä et al. Arterial Stiffness Predicts Mortality in Individuals With Type 1 Diabetes. Diabetes Care 2020;43:2266–2271

We thank Gonzalez-Clemente et al. (1) for presenting an interesting perspective on arterial stiffness as a potential integrative risk factor for cardiovascular disease (CVD) in type 1 diabetes in the light of their findings in a cross-sectional cohort of 179 individuals (2). They demonstrated a strong correlation between aortic pulse wave velocity (PWV) and a CVD risk prediction score obtained from the Steno Type 1 Risk Engine (ST1RE) (3) and determined cutoff values for PWV as a marker of moderate/high (≥10%) and high (≥20%) risk of CVD in individuals with type 1 diabetes. In the FinnDiane Study, we recently showed an independent association between augmentation index (AIx), another marker of arterial stiffness, and all-cause mortality as well as a composite cardiovascular and/or diabetes-related cause of death in a prospective analysis of 906 individuals with type 1 diabetes (4). Although the longitudinal data on PWV in our cohort …

Derivation and internal validation of a multi-biomarker-based cardiovascular disease risk prediction score for rheumatoid arthritis patients

BackgroundRheumatoid arthritis (RA) patients have increased risk for cardiovascular disease (CVD). Accurate CVD risk prediction could improve care for RA patients. Our goal is to develop and validate a biomarker-based model for predicting CVD risk in RA patients.MethodsMedicare claims data were linked to multi-biomarker disease activity (MBDA) test results to create an RA patient cohort with age ≥ 40 years that was split 2:1 for training and internal validation. Clinical and RA-related variables, MBDA score, and its 12 biomarkers were evaluated as predictors of a composite CVD outcome: myocardial infarction (MI), stroke, or fatal CVD within 3 years. Model building used Cox proportional hazard regression with backward elimination. The final MBDA-based CVD risk score was internally validated and compared to four clinical CVD risk prediction models.Results30,751 RA patients (904 CVD events) were analyzed. Covariates in the final MBDA-based CVD risk score were age, diabetes, hypertension, tobacco use, history of CVD (excluding MI/stroke), MBDA score, leptin, MMP-3 and TNF-R1. In internal validation, the MBDA-based CVD risk score was a strong predictor of 3-year risk for a CVD event, with hazard ratio (95% CI) of 2.89 (2.46–3.41). The predicted 3-year CVD risk was low for 9.4% of patients, borderline for 10.2%, intermediate for 52.2%, and high for 28.2%.Model fit was good, with mean predicted versus observed 3-year CVD risks of 4.5% versus 4.4%. The MBDA-based CVD risk score significantly improved risk discrimination by the likelihood ratio test, compared to four clinical models. The risk score also improved prediction, reclassifying 42% of patients versus the simplest clinical model (age + sex), with a net reclassification index (NRI) (95% CI) of 0.19 (0.10–0.27); and 28% of patients versus the most comprehensive clinical model (age + sex + diabetes + hypertension + tobacco use + history of CVD + CRP), with an NRI of 0.07 (0.001–0.13). C-index was 0.715 versus 0.661 to 0.696 for the four clinical models.ConclusionA prognostic score has been developed to predict 3-year CVD risk for RA patients by using clinical data, three serum biomarkers and the MBDA score. In internal validation, it had good accuracy and outperformed clinical models with and without CRP. The MBDA-based CVD risk prediction score may improve RA patient care by offering a risk stratification tool that incorporates the effect of RA inflammation.

Calibration and discrimination of the Framingham Risk Score and the Pooled Cohort Equations.

Although accurate risk prediction is essential in guiding treatment decisions in primary prevention of atherosclerotic cardiovascular disease, the accuracy of the Framingham Risk Score (recommended by a Canadian guideline) and the Pooled Cohort Equations (recommended by US guidelines) has not been assessed in a large contemporary Canadian population. Our primary objective was to assess the calibration and discrimination of the Framingham Risk Score and Pooled Cohort Equations in Ontario, Canada. We conducted an observational study involving Ontario residents aged 40 to 79 years, without a history of atherosclerotic cardiovascular disease, who underwent cholesterol testing and blood pressure measurement from Jan. 1, 2010, to Dec. 31, 2014. We compared predicted event rates generated by the Framingham Risk Score and the Pooled Cohort Equations with observed event rates at 5 years using linkages from validated administrative databases. Our study cohort included 84 617 individuals (mean age 56.3 yr, 56.9% female). Over a maximum follow-up period of 5 years, we observed 2162 (2.6%) events according to the outcome definition of the Framingham Risk Score, and 1224 (1.4%) events according to the outcome definition of the Pooled Cohort Equations. The predicted event rate of 5.78% by the Framingham Risk Score and 3.51% by the Pooled Cohort Equations at 5 years overestimated observed event rates by 101% and 115%, respectively. The degree of overestimation differed by age and ethnicity. The C statistics for the Framingham Risk Score (0.74) and Pooled Cohort Equations (0.73) were similar. The Framingham Risk Score and Pooled Cohort Equations significantly overpredicted the actual risks of atherosclerotic cardiovascular disease events in a large population from Ontario. Our finding suggests the need for further refinement of cardiovascular disease risk prediction scores to suit the characteristics of a multiethnic Canadian population.

Role of cardiorespiratory fitness in lifetime cardiovascular risk prediction models: a cross-sectional analysis

BackgroundDespite well-established associations between cardiorespiratory fitness (CRF) and long-term cardiovascular disease risk, CRF remains underused in clinical practice. With a growing emphasis on longer-term risk, developments to UK cardiovascular disease risk equations such as the Joint British Societies' 3 (JBS3) calculator now see the prediction of both lifetime and short-term risk. However, unlike the US LifetimeRisk model, the JBS3 algorithm does not include CRF as a risk variable. The aim of this study was to examine whether differences in CRF values are reflected in long-term cardiovascular disease risk prediction scores using a risk equation that includes CRF in the design (LifetimeRisk) and one that does not (JBS3). MethodsA retrospective, cross-sectional analysis was performed on 81 male steelworkers who participated in the second phase of the Prosiect Sir Gâr workplace-based cardiovascular disease risk assessment initiative in Carmarthenshire, Wales. CRF was calculated with a validated and reliable submaximal protocol based on heart rate responses (Chester Step Test). Between-group CRF differences (excellent or good vs average or below average) were determined by independent sample t test or Mann-Whitney U test, and any association between CRF and individual risk scores investigated by Pearson's correlation. FindingsMen in the lower CRF categories had greater body-mass index scores than men in the higher CRF categories (p=0·001); and less desirable blood lipid profiles with higher total cholesterol (p=0·041) and non-HDL cholesterol (p=0·019) concentrations. The predicted long-term cardiovascular disease risk in the LifetimeRisk model was also greater in the lower fitness group than higher fitness group (mean 13·6% [SD 2·9] vs 7·2 [1·9], p<0·0001), and a negative correlation was evident between individual CRF values and predicted risk scores (r=–0·603, p<0·0001). However, there were no differences between CRF groups in predicted JBS3 lifetime risk (median 79 years [IQR 77–80] vs 79 [78–80], p=0·354). InterpretationThese preliminary observations demonstrate that the LifetimeRisk prediction scores more accurately represent the current literature between CRF and longer-term cardiovascular disease risk in a group of white men. Although, more research is required, this study raises an important question as to whether CRF should be considered in the design of future UK long-term cardiovascular disease risk equations. FundingThis work was part funded by the European Social Fund through the European Union's Convergence programme administered by the Welsh Government.

'Should we reconsider the role of age in treatment allocation for primary prevention of cardiovascular disease?' No, but we can improve risk communication metrics.

The opinion piece published in this edition of the European Heart Journal by Leening and colleagues1 represents one of the two main opposing views on the role of age in cardiovascular disease (CVD) risk prediction scores and for determining risk-reducing treatment thresholds. Leening et al . raise concerns about the dominance of age in CVD risk prediction scores and propose the use of two new risk metrics that do not rely on age. In contrast Wald and colleagues have advocated that for simplicity, age, rather than multivariable predicted risk, should be the sole criterion used to determine eligibility for treatment.2 In our opinion both positions are problematic. We agree with Wald et al . that age is the single best predictor of a patient's short-term (e.g. 5- or 10-year) CVD risk and is also the single best predictor of the short-term benefits of CVD risk reduction.2 However, we disagree that the simplicity of an age-only treatment threshold would outweigh the incremental improvement in predictive power and the greater acceptability (to patients and clinicians) of risk prediction scores that include the standard modifiable CVD risk factors alongside age. We also disagree with Leening and colleagues that the dominant role of age in CVD risk prediction calculators is a problem because, as stated above, age is best single predictor of future CVD risk and treatment benefit. We acknowledge the concerns that they and many others have regarding the apparent dominance of age in CVD risk prediction, but we disagree with their assumptions about the role of age in CVD risk prediction and about how predicted CVD risk should be used to inform management decisions. …

Validation of the Framingham general cardiovascular risk score in a multiethnic Asian population: a retrospective cohort study

ObjectiveThis study aims to examine the validity of the Framingham general cardiovascular disease (CVD) risk chart in a primary care setting.DesignThis is a 10-year retrospective cohort study.SettingA primary care clinic...

Assessment of diet quality improves the classification ability of cardiovascular risk score in predicting future events: The 10-year follow-up of the ATTICA study (2002-2012).

In past years the prediction of cardiovascular disease (CVD) risk has received special attention; however, the presented risk models have so far not been very successful or appreciated. The aim of the present work was to examine whether the inclusion of a diet quality evaluation in a CVD risk prediction model is associated with the accuracy of estimating future events. The working sample consisted of the 2009 ATTICA study participants (aged 18-89 years). The HellenicSCORE (a calibration of the European Society of Cardiology SCORE, based on age, gender, smoking habits, systolic blood pressure and total cholesterol) was calculated as a proxy of heart disease risk, while assessment of diet quality was based on the MedDietScore, which evaluates adherence to a Mediterranean diet. Fatal or non-fatal incidence of CVD (i.e., development of acute coronary syndromes, stroke or other CVD according to WHO-ICD-10 criteria) was calculated using the 10-year follow-up (2002-2012) data of the ATTICA study participants. The MedDietScore and the HellenicSCORE were significant predictors of CVD events (p < 0.05). The estimating bias (i.e., misclassification rate of cases) of the model that included only the HellenicSCORE was significantly reduced by the inclusion of MedDietScore in the risk model (Harrell's C = 0.027, p = 0.012), improving the classification ability of the risk model by 56%. The inclusion of dietary evaluation increased the accuracy of HellenicSCORE risk estimation and, thus, its incorporation into CVD risk prediction scores might help clinicians and public health professionals to better allocate future CVD candidates.

Association between high-sensitivity cardiac troponin T levels and the predicted cardiovascular risk in middle-aged men without overt cardiovascular disease

A slight elevation of cardiac troponin T (TnT) levels in the circulating blood can be detected by the recently developed, high-sensitivity TnT (hsTnT) assay. However, it remains unclear whether a slight elevation of hsTnT is associated with an increased cardiovascular risk in subjects without overt cardiovascular disease (CVD). The serum hsTnT levels were measured in a work site-based population of 1,072 middle-aged males (mean age 44 years) without any history or presence of CVD. The lower detection limit of the hsTnT assay used in the present study was 0.002 ng/mL. The association of the hsTnT levels with cardiovascular risk factors and the predicted CVD risk, as determined by the Framingham CVD risk prediction score, were examined. Detectable hsTnT levels were seen in 867 subjects (80.9%). The highest value of the hsTnT was 0.020 ng/mL. Among various cardiovascular risk factors, age, blood pressure, estimated glomerular filtration rate, current smoking, and left ventricular hypertrophy were independent determinants of hsTnT levels. The odds ratio for a high predicted CVD risk (10-year risk > or =20%) in the highest tertile of hsTnT (> or =0.005 ng/mL) in comparison to the lowest tertile (< or =0.002 ng/mL) was 3.98 (95% CI 1.72-9.24, P = .001) after adjusting for multiple potential confounders. The present study showed the hsTnT levels to be significantly associated with several cardiovascular risk factors and the predicted CVD risk in middle-aged men without overt CVD, thus suggesting the usefulness of measuring hsTnT to identify high-risk subjects in the primary prevention of CVD.

Stroke in a young woman.

<h3>Objective</h3> This study aims to examine the validity of the Framingham general cardiovascular disease (CVD) risk chart in a primary care setting. <h3>Design</h3> This is a 10-year retrospective cohort study....