Cardiovascular Risk Categories Research Articles

Assessment of carotid atherosclerosis disease as an incremental predictive value for cardiovascular disease risk

Abstract: Assessment of the carotid atherosclerosis disease can give a prognostication of a patient’s cardiovascular risk. The assessment of carotid atherosclerosis is essential because of the complication of risk factors resulting in severe cardiovascular disease (CVD). This review article aims to summarize systematically the pathophysiology, followed by diagnostic assessment and therapeutic uses of imaging and treatment for carotid atherosclerosis disease. Duplex ultrasound (DUS) of the carotid artery, transcranial Doppler imaging, computed tomographic angiography (CTA), magnetic resonance angiography, and cerebral digital subtraction angiography are diagnostic techniques for carotid stenosis. Currently, DUS of the carotid arteries is the primary screening method for carotid stenosis. Recent interest has focused on carotid intima-media thickness measurements as a possible indicator of early-stage carotid atherosclerosis or CVD risk prediction. Through the growing fields of stress tests and carotid plaque screening, the classification of cardiovascular risk may be improved.

Relationship of Blood Inflammatory Composite Markers with Cardiovascular Risk Factors and Subclinical Atherosclerosis in Patients with Rheumatoid Arthritis.

The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammatory index (SIRI, neutrophils × monocytes/lymphocytes) have been described as potential blood-derived inflammatory biomarkers in several diseases. Rheumatoid arthritis is an inflammatory disease that has been related to an increased risk of cardiovascular (CV) disease. In the present work, we analyze how these hematological composite scores of inflammation are related to classic CV risk factors and subclinical atherosclerosis in patients with RA. In this cross-sectional study that included 430 patients with RA, the NLR, MLR, PLR, and SIRI scores were calculated. Multivariable analysis was performed to examine the relationships of these composite blood scores with subclinical carotid atherosclerosis and with traditional cardiovascular factors, producing a complete profile of lipid molecules and insulin resistance or indices of beta-cell function, and a Systematic Coronary Risk Assessment (SCORE2) calculation. C-reactive protein and disease activity were significantly and positively associated with the four blood composite scores. SCORE2 was significantly associated with higher values of SIRI, NLR, and MLR, but not PLR. These relationships were maintained when SCORE 2 was considered categorical; patients in the very high CV risk category had higher values in all hematological composite scores, except PLR. In the multivariable analysis, SIRI and NLR were independently associated with higher levels of beta cell dysfunction. In conclusion, SCORE2 and the values of the hematological composite scores were positively correlated in patients with RA. In addition, there were some relationships of these scores with traditional CV risk factors, with their association with beta cell dysfunction being the most consistent.

A Jordanian Multidisciplinary Consensus Statement on the Management of Dyslipidemia.

Atherosclerotic cardiovascular disease (ASCVD) is the primary contributor to global mortality rates, which significantly escalates healthcare expenditures. Risk factors for ASCVD (including dyslipidemia) frequently present in clusters rather than separately. Addressing these risk factors is crucial in the early initiation of a comprehensive management plan that involves both lifestyle modifications and pharmacotherapy to reduce the impact of ASCVD. A team of Jordanian professionals from various medical organizations and institutes took the initiative to create a set of guidelines for dyslipidemia screening and therapy. A detailed, comprehensive literature review was undertaken utilizing several databases and keywords. This consensus statement provides recommendations for dyslipidemia management in Jordanians on several issues including cardiovascular risk estimation, screening eligibility, risk categories, treatment goals, lifestyle changes, and statin and non-statin therapies. It is recommended that all Jordanian individuals aged 20 years old or older undergo lipid profile testing. This should be followed by determining the level of cardiovascular risk depending on the presence or absence of ASCVD and cardiovascular risk factors, eligibility for lipid-lowering therapy, and the target low-density cholesterol serum level to be achieved. In conclusion, prioritizing the management of dyslipidemia is of the utmost importance in improving public health and reducing the burden of cardiovascular diseases.

AWARE A novel web application to rapidly assess cardiovascular risk in type 2 diabetes mellitus

AimTo describe the development of the AWARE App, a novel web application for the rapid assessment of cardiovascular risk in Type 2 Diabetes Mellitus (T2DM) patients. We also tested the feasibility of using this App in clinical practice.MethodsBased on 2019 European Society of Cardiology/European Association for the Study of Diabetes criteria for cardiovascular risk stratification in T2DM, the AWARE App classifies patients into very high (VHCVR), high (HCVR) and moderate (MCVR) cardiovascular risk categories. In this retrospective clinical study, we employed the App to assess the cardiovascular risk of T2DM patients, while also collecting data about current glycaemic control and pharmacological treatment.Results2243 T2DM consecutive patients were evaluated. 72.2% of the patients were VHCVR, 8.9% were HCVR, 0.8% were MCVR while 18.2% did not fit into any of the risk categories and were classified as “moderate-to-high” (MHCVR). Compared with the other groups, patients with VHCVD were more frequently ≥ 65 years old (68.9%), with a longer disease duration (≥ 10 years [56.8%]), a history of cardiovascular disease (41.4%), organ damage (35.5%) and a higher numbers of cardiovascular risk factors. Patients with MHCVD generally had disease duration < 10 years (96%), younger age (50–60 years [55%]), no history of cardiovascular disease, no organ damage, and 1–2 cardiovascular risk factors (89%). Novel drugs such as Glucagon Like Peptyde 1 Receptor Agonists or Sodium-Glucose Linked Transporter 2 inhibitors were prescribed only to 26.3% of the patients with VHCVR and to 24.7% of those with HCVR. Glycaemic control was unsatisfactory in this patients population (HbA1c 7.5 ± 3.4% [58.7 ± 13.4 mmol/mol]).ConclusionsThe AWARE App proved to be a practical tool for cardiovascular risk stratification of T2DM patients in real-world clinical practice.

COMPARING THE CARDIOVASCULAR RISK ESTIMATION IN YOUNG ADULT PATIENTS WITH TYPE 1 DIABETES: STENO F1RISKENGINE VS. ESC-EASD 2019 RISK TABLE

Objective: Adult patients with type 1 diabetes (T1DM) have very high cardiovascular risk, which is typically underestimated in daily clinical practice. The ESC-EASD risk table (2019) for both type 1 and type 2 diabetes is based on categorical variables, ignores specific variables such as HbA1c and yields an imprecise risk estimation (moderate, high or very high). The rarely used Steno T1RiskEngine predicts the 5-year and 10-year risks of a cardiovascular event and of terminal kidney disease, both absolute and relative to the reference population. We undertook to compare the results of both cardiovascular risk calculations in a group of young adult patients with T1DM. Design and method: Retrospective analysis of the data from consecutive patients with a sufficient collection of clinical data was performed. Informed consent was obtained from all patients. The ESC/EASD 2019 risk table is available at doi:10.1093/eurheartj/ehz486; the Steno T1RiskEngine is described in doi:10.1161/CIRCULATIONAHA.115018844 and the calculator is available online: (https://steno.shinyapps.io/T1RiskEngine1) Results: 30 patients were included, 18 women (60%), aged 32±9 years. According to the ESC/EASD table, 2 (6.7%) had moderate risk, 16 (53.3%) had high risk and 12 (40%) had very high risk. With the Steno T1RiskEngine the median risk of cardiovascular event was 6.4% (IQR 2.7-9.3%) at 5 years and 12.4% (IQR 5.9-17.6%) at 10 years, with medians of 1.7% and 3.4% in the reference population (relative risks 376% and 365% at 5 and 10 years); the median risk of terminal kidney disease was 2.9% (IQR 1.2-6.7%) vs. 0.8% in the reference population (relative risk 362%). By cardiovascular risk categories, with the Steno T1RiskEngine we obtained 3 patients (10%) with moderate risk, 13 (43.3%) with high risk and 14 (46.7%) with very high risk, without significant difference vs. the ESC/EASD categorization (Chi2 p = 0.72). Conclusions: The cardiovascular and renal risk of our adult patients with T1DM is very high (&gt;3.5x the reference population risk); the ESC/EASD categorisation of cardiovascular risk does not significantly differ from that of the T1RiskEngine. However, the Steno T1RiskEngine yields a more precise estimation of the individual risks and should be used more frequently.

EXTREME CARDIOVASCULAR RISK IN CARDIOLOGICAL REHABILITATION: PREVALENCE AND IMPACT ON PATIENT'S FUNCTIONAL IMPROVEMENT

Objective: Among patients at very high cardiovascular risk, some are more likely to experience recurrent cardiovascular events. In may 2022, an article was published in the European Heart Journal proposing different definitions of patients at extreme cardiovascular risk. However, the process of defining the patient at extreme cardiovascular risk is still ongoing and more data also on its prevalence are needed. To assess the prevalence of patients at extreme cardiovascular risk in cardiological rehabilitation, to evaluate the clinical features of these patients. Furthermore, we want to establish how the extreme cardiovascular risk condition correlates with the functional improvement obtained during cardiac rehabilitation. Design and method: The study included 938 patients suffering from atherosclerosis who attended the cardiological rehabilitation of Niguarda Hospital in Milan. Patients diagnosed with non-ischemic heart failure or congenital heart disease have been excluded. Patients classified as at extreme cardiovascular risk were compared with the remaining patients and a multivariate linear regression was performed with absolute functional improvement as the dependent variable. Results: Among 938 patients, 26.9% belong to the category of extreme cardiovascular risk. Patients at extreme cardiovascular risk showed a higher average age (67.8 ± 10.4 vs 64.1 ± 11.1 years; p &lt;0.001), a higher prevalence of significant comorbidities (peripheral arterial disease, cerebrovascular disease, chronic kidney disease, dyslipidemia, diabetes, hypertension) and a lower functional improvement during cardiac rehabilitation (102.9 ± 68.6 vs 138.1 ± 86.5 m; p &lt; 0.001). At multivariate analysis extreme cardiovascular risk remains a significant determinant of the absolute functional improvement at Six-Minute Walking Test obtained during cardiac rehabilitation with b = -0.137 and p = 0.035, together with female sex (b = -0.136; p = 0.035). Conclusions: Extreme cardiovascular risk is a widespread condition among patients with chronic coronary syndrome and adversely affects the patient's functional improvement during cardiac rehabilitation. The identification of patients at extreme cardiovascular risk is a goal to be pursued in order to intensify secondary prevention strategies.

Treatment gaps in the implementation of LDL cholesterol control among high- and very high-risk patients in Europe between 2020 and 2021: the multinational observational SANTORINI study

European data pre-2019 suggest statin monotherapy is the most common approach to lipid management for preventing cardiovascular (CV) events, resulting in only one-fifth of high- and very high-risk patients achieving the 2019 ESC/EAS recommended low-density lipoprotein cholesterol (LDL-C) goals. Whether the treatment landscape has evolved, or gaps persist remains of interest. Baseline data are presented from SANTORINI, an observational, prospective study that documents the use of lipid-lowering therapies (LLTs) in patients ≥18 years at high or very high CV risk between 2020 and 2021 across primary and secondary care settings in 14 European countries. Of 9602 enrolled patients, 9044 with complete data were included (mean age: 65.3±10.9 years; 72.6% male). Physicians reported using 2019 ESC/EAS guidelines as a basis for CV risk classification in 52.0% (4706/9044) of patients (overall: high risk 29.2%; very high risk 70.8%). However, centrally re-assessed CV risk based on 2019 ESC/EAS guidelines suggested 6.5% (308/4706) and 91.0% (4284/4706) were high- and very high-risk patients, respectively. Overall, 21.8% of patients had no documented LLTs, 54.2% were receiving monotherapy and 24.0% combination LLT. Median (interquartile range [IQR]) LDL-C was 2.1 (1.6, 3.0) mmol/L (82 [60, 117] mg/dL), with 20.1% of patients achieving risk-based LDL-C goals as per the 2019 ESC/EAS guidelines. At the time of study enrolment, 80% of high- and very high-risk patients failed to achieve 2019 ESC/EAS guidelines LDL-C goals. Contributory factors may include CV risk underestimation and underutilization of combination therapies. Further efforts are needed to achieve current guideline-recommended LDL-C goals. ClinicalTrials.gov Identifier: NCT04271280. This study is funded by Daiichi Sankyo Europe GmbH, Munich, Germany.

Mode of delivery and perinatal outcomes by modified World Health Organization classification of maternal cardiovascular risk in pregnancy

Cardiac disease is a leading cause of maternal morbidity and mortality in the United States, and an increasing number of patients with known cardiac disease are reaching childbearing age. Although guidelines indicate that cesarean deliveries should be reserved for obstetrical indications, rates of cesarean delivery among obstetrical patients with cardiovascular disease are higher than those of the general population. This study aimed to evaluate mode of delivery and perinatal outcomes among patients with low-risk and moderate to high-risk cardiac disease as defined by the modified World Health Organization classification of maternal cardiovascular risk. We performed a retrospective cohort study of obstetrical patients with known cardiac disease, as defined by the modified World Health Organization cardiovascular classification categories in pregnancy, who underwent a perinatal transthoracic echocardiogram at a single academic medical center between October 1, 2017 and May 1, 2022. Demographics, clinical characteristics, and perinatal outcomes were collected. Comparisons were made between patients with low- (modified World Health Organization Class I) and moderate to high-risk (modified World Health Organization Class II-IV) cardiac disease using chi-square, Fisher exact, or Student t-tests. Cohen d tests were used to estimate the effect size between group means. Logistic regression models were used to evaluate the odds of vaginal and cesarean delivery in low- and moderate to high-risk groups. A total of 108 participants were eligible for inclusion, with 41 participants in the low-risk cardiac group and 67 in the moderate to high-risk group. Participants had a mean age of 32.1 (±5.5) years at the time of delivery and a mean pregravid body mass index of 29.9 (±7.8) kg/m2. Chronic hypertension (13.9%) and a history of hypertensive disorder of pregnancy (14.9%) were the most common comorbid medical conditions. In total, 17.1% of the sample had a history of a cardiac event (eg, arrhythmia, heart failure, myocardial infarction). Rates of vaginal and cesarean deliveries were similar between the low- and moderate to high-risk cardiac groups. Patients in the moderate to high-risk cardiac group were more likely to be admitted to the intensive care unit during pregnancy (odds ratio, 7.8; P<.05) and experience severe maternal morbidity compared with patients in the low-risk cardiac group (P<.01). Mode of delivery was not associated with severe maternal morbidity in the higher-risk cardiac group (odds ratio, 3.2; P=.12). In addition, infants of mothers with higher-risk disease were more likely to be admitted to the neonatal intensive care unit (odds ratio, 3.6; P=.06) and have longer neonatal intensive care unit stays (P=.005). There was no difference in mode of delivery by modified World Health Organization cardiac classification, and mode of delivery was not associated with risk of severe maternal morbidity. Despite the overall increased risk of morbidity in the higher-risk group, vaginal delivery should be considered as an option for certain patients with well-compensated cardiac disease. However, larger studies are needed to confirm these findings.

The effect of vascular risk factors on the efficacy of endolymphatic sac decompression surgery for Meniere's disease: a retrospective cohort study.

This study aimed to investigate the effect of vascular risk factors on the outcomes of endolymphatic sac decompression (ESD) surgery in patients with Meniere's disease. The study included 56 patients with Meniere's disease, who had undergone unilateral ESD surgery. The patients' vascular risk factors were assessed based on the preoperative 10-year atherosclerotic cardiovascular diseases risk classification. Those with no or low risk were defined as the low-risk group, while those with medium, high, or very high risk were defined as the high-risk group. The correlation between the vascular risk factors and ESD efficacy was evaluated by the comparison of vertigo control grade between the two groups. The functional disability score was also assessed to investigate whether ESD improved the quality of life in Meniere's disease patients with vascular risk factors. After ESD, 78.95 and 81.08% of patients from the low-risk and high-risk groups, respectively, demonstrated at least grade B vertigo control; no statistically significant difference was observed (p = 0.96). The postoperative functional disability scores in both groups were significantly lower compared with those before surgery (p < 0.01), with a median decrease of two (1, 2) points in both groups. No statistically significant difference between the two groups was observed (p = 0.65). Vascular risk factors have little effect on the efficacy of ESD in patients with Meniere's disease. Patients with one or more vascular risk factors can still experience a not poor vertigo control and improved quality of life after ESD.

A real-world analysis of adherence and biochemical outcome of patients on rosuvastatin/ezetimibe free vs single-pill combination in italy

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Servier. Background/Introduction One of the most effective strategies for cardiovascular (CV) disease prevention is lipid level control. To achieve this control, a satisfactory level of adherence to effective lipid-lowering medications is required. Purpose To evaluate and compare medication adherence and plasma levels of low-density lipoprotein cholesterol (LDL-C) among 2 cohorts of patients treated with rosuvastatin and ezetimibe (ROS/EZE) as free (FC) or single-pill combination (SPC), in an Italian real-world setting. Methods A retrospective analysis was performed using administrative databases linked to laboratory database, covering approximately 7 million health-assisted subjects. Adults prescribed with ROS/EZE as SPC or FC during January 2018-June 2020 were included and categorized in 2 cohorts. Index date (ID) was the first prescription of SPC or first simultaneous prescription of the 2 drugs (within 30 days interval). Patients were characterized during all available periods prior to ID and followed-up to end of data availability. Propensity score matching (PSM) was applied to minimize selection bias between cohorts; adherence was calculated as proportion of days covered (PDC): PDC&amp;lt;25% non-adherence; PDC=25-75% partial adherence; PDC&amp;gt;75% adherence, after PSM. Based on ESC/EAS 2019 guidelines, patients were stratified by CV risk profile. For a subgroup of patients (n=3,846) with plasma-LDL-C data availability (at ID and during first year of follow-up), the percentages of patients being above 55 mg/dl LDL-C for very-high risk, 70 mg/dl for high risk, and 116 mg/dl for other CV risk patients, and who reached these levels during follow-up were reported. Results The analysis included 25,886 patients in SPC cohort and 7,309 in FC. Post-PSM cohorts were balanced for their characteristics, including CV risk, and comprised 21,927 (SPC) and 7,309 (FC) patients. A higher percentage of patients were adherent to SPC vs FC (56.8% vs 44.5%, p&amp;lt;0.001). A lower percentage of non-adherent patients was found for the SPC vs FC (12.6% vs 27.4%, p&amp;lt;0.001). Among very-high, high and other CV risk patients, respectively, a 30%, 28% and 21% increase in the number of adherent patients was found for SPC vs FC [65.4% vs 50.4%, p&amp;lt;0.001 (very-high); 54.7% vs 42.7%, p&amp;lt;0.001 (high); 43.5% vs 35.9%, p&amp;lt;0.001 (other CV risk)] (Fig. 1). The proportion of very-high-CV risk patients reaching LDL-C ≤55mg/dl in the first year of follow-up was higher in SPC vs FC (35.4% vs 23.8%, p&amp;lt;0.001) (Fig.2). Similarly, among high-risk patients, 46.9% and 23.1% (p&amp;lt;0.001) of SPC and FC, respectively, reached ≤70 mg/dl LDL-C and among other CV-risk patients, 71.6% and 49.5% (p&amp;lt;0.001) of SPC and FC, respectively, reached ≤116 mg/dl LDL-C levels during first year of follow-up. Conclusions This real-world analysis in patients with hypercholesterolemia showed that treatment with ROS/EZE SPC vs FC could be associated with better medication adherence and lower LDL-C levels, whatever the CV risk category.

Differences in 10-year cardiovascular risk estimation using SCORE and SCORE2 risk prediction tools: a moderate risk country population analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiovascular disease (CVD) risk assessment plays a central role in nowadays clinical practice given its burden in morbidity and mortality worldwide. In the 2021 European Society of Cardiology Guidelines on cardiovascular disease prevention a new CVD risk prediction algorithm was presented, the SCORE2. This tool overcomes some of old SCORE limitations by predicting 10-year fatal and non-fatal CVD risk in individuals without previous CVD or diabetes aged 40-65 years and by including contemporary data from epidemiological data of 13 European countries. Differences on 10-year cardiovascular risk category prediction between SCORE and SCORE2 is still scarce. Purpose We aimed to compare differences in 10-year cardiovascular disease risk prediction in a Portuguese population using SCORE and SCORE2. Methods We conducted a cross-sectional study in a Portuguese population sample. Individuals aged 40-65 years old without known Atherosclerotic Cardiovascular Disease, Diabetes, Chronic Kidney Disease or Familial Hypercholesterolemia were included. The 10-year CVD risk was calculated using SCORE and SCORE2. Based on CVD risk category, patients were stratified into 4 categories - low, moderate, high and very high risk – according to SCORE and in 3 categories - low to moderate, high and very high risk - according to SCORE2 model. Primary outcome was 10-year CVD risk prediction difference between above mentioned models. According to the data distribution, appropriate statistical tests were conducted. Results 117 individuals were included in the study cohort, 79 (67.5%) of which were women. In our study, the 10-year risk prediction of fatal and non-fatal cardiovascular events was significantly different between SCORE and SCORE2. When assessing 10-year risk of CVD through SCORE model, 97.1% (n= 100) of the individuals were classified into low and moderate risk categories. On the other hand, when evaluating CVD risk with SCORE2 only 66% (n=62) of the participants were classified into those risk categories, meaning that 30.9% (n=29) of patients were in high and very high-risk categories with SCORE2 (vs. 2.9% with SCORE). Correlation between SCORE and SCORE2 was verified (R=0.572; p&amp;lt; 0.0001). Regarding cardiovascular risk factors, active smoking was the only independent predictor for 10-year CVD risk in SCORE2 (RR: 3.28, 95% CI: 1.93-4.66, p=0.001). There were no independent predictors for CVD risk in SCORE. Conclusions Ten-year cardiovascular risk assessment may be underestimated by SCORE model. In the present study, through SCORE CVD risk classification most of patients were classified into lower risk categories than those obtained through updated SCORE2. SCORE2 is a more up-to-date and more calibrated CVD risk assessment tool than old SCORE, so SCORE2 may contribute to a better reclassification of patients and hereafter allow intensification of CVD protection measures.

P496 EXTREME CARDIOVASCULAR RISK IN CARDIOLOGICAL REHABILITATION: PREVALENCE AND IMPACT ON PATIENT’S FUNCTIONAL IMPROVEMENT

Abstract Background Among patients at very high cardiovascular risk, some are more likely to experience recurrent cardiovascular events. In may 2022, an article was published in the European Heart Journal proposing different definitions of patients at extreme cardiovascular risk. However, the process of defining the patient at extreme cardiovascular risk is still ongoing and more data also on its prevalence are needed. Aims: To assess the prevalence of patients at extreme cardiovascular risk in cardiological rehabilitation, to evaluate the clinical features of these patients. Furthermore, we want to establish how the extreme cardiovascular risk condition correlates with the functional improvement obtained during cardiac rehabilitation. Methods The study included 938 patients suffering from atherosclerosis who attended the cardiological rehabilitation of Niguarda Hospital in Milan. Patients diagnosed with non–ischemic heart failure or congenital heart disease have been excluded. Patients classified as at extreme cardiovascular risk were compared with the remaining patients and a multivariate linear regression was performed with absolute functional improvement as the dependent variable. Results Among 938 patients, 26.9% belong to the category of extreme cardiovascular risk. Patients at extreme cardiovascular risk showed a higher average age (67.8 ± 10.4 vs 64.1 ± 11.1 years; p ≤ 0.001), a higher prevalence of significant comorbidities (peripheral arterial disease, cerebrovascular disease, chronic kidney disease, dyslipidemia, diabetes, hypertension) and a lower functional improvement during cardiac rehabilitation (102.9 ± 68.6 vs 138.1 ± 86.5 m; p ≤ 0.001). At multivariate analysis extreme cardiovascular risk remains a significant determinant of the absolute functional improvement at Six–Minute Walking Test obtained during cardiac rehabilitation with b = –0.137 and p = 0.035, together with female sex (b = –0.136; p = 0.035). Conclusion Extreme cardiovascular risk is a widespread condition among patients with chronic coronary syndrome and adversely affects the patient’s functional improvement during cardiac rehabilitation. The identification of patients at extreme cardiovascular risk is a goal to be pursued in order to intensify secondary prevention strategies.

Extreme cardiovascular risk in cardiological rehabilitation: prevalence and impact on patient’s functional improvement

Background and Aims: Among patients at very high cardiovascular risk, some are more likely to experience recurrent cardiovascular events. In May 2022, an article was published in the European Heart Journal proposing different definitions of patients at extreme cardiovascular risk. However, the process of defining such patient is still ongoing and more data on its prevalence are needed. Our aims consisted in assessing the prevalence of patients at extreme cardiovascular risk in cardiological rehabilitation and in evaluating the clinical features of such patients. Furthermore, we wanted to establish how the extreme cardiovascular risk condition correlates with the functional improvement obtained during cardiac rehabilitation. Methods: The study included 938 patients suffering from atherosclerosis who attended the cardiological rehabilitation of Niguarda Hospital in Milan. Patients classified as at extreme cardiovascular risk were compared with the remaining patients and a multivariate linear regression was performed with absolute functional improvement as the dependent variable. Results: Among 938 patients, 26.9% belong to the category of extreme cardiovascular risk. Patients at extreme cardiovascular risk showed a higher average age (67.8 ± 10.4 vs 64.1 ± 11.1 years; p ≤ 0.001), a higher prevalence of significant comorbidities (peripheral arterial disease, cerebrovascular disease, dyslipidemia, diabetes, chronic kidney disease, hypertension) and a lower functional improvement during cardiac rehabilitation (102.9 ± 68.6 vs 138.1 ± 86.5 m; p ≤ 0.001). At multivariate analysis extreme cardiovascular risk remains a significant determinant of the absolute functional improvement at Six-Minute Walking Test obtained during cardiac rehabilitation with b = -0.137 and p = 0.035, together with female sex (b = -0.136; p = 0.035). Conclusions: Extreme cardiovascular risk is a widespread condition among patients with chronic coronary syndrome and adversely affects the patient’s functional improvement during cardiac rehabilitation. The identification of patients at extreme cardiovascular risk is a goal to be pursued in order to intensify secondary prevention strategies.

C-reactive Protein, Glomerular Filtration Rate, and Echocardiographic Parameters in Individuals With Different Cardiovascular Risk Categories

Despite the emergence of modern biomarkers, innovative methods of examination and treatment, the problems of cardiovascular risk in clinical medicine are still quite relevant. Widespread cardiovascular risk factors and high mortality from diseases of the circulatory system are observed in all countries of the world, including the Kyrgyz Republic thicknesses, relative LV wall thickness, LV myocardial mass, LV myocardial mass index, r. Aim of the study. To study the clinical and functional values of CRP and its relationship with cardiovascular risk factors in patients with chronic non-communicable diseases. Material and methods. The single-center open study included 290 people with different categories of cardiovascular risk, of which 150 men (51.7%), women - 140 (48.3%). All participants were analyzed hemodynamic parameters, indicators of clinical and biochemical parameters. The excretory function of the kidneys was assessed by the level of serum cystatin C. The glomerular filtration rate (GFR) was calculated according to the method of F. Hoek. The size of the left atrium (LA), the linear dimensions of the left ventricle (LV) were taken into account with an assessment of the structural modification of the myocardium. Depending on the concentration of CRP, two groups were formed: 1A and 1B. Results. In patients with high CRP levels, mean age, body mass index, heart rate, platelet, leukocyte, glucose, and cystatin C blood levels were significantly higher, and mean HDL cholesterol and GFR were significantly lower. Left atrial size, LV end-diastolic size, ventricular septal and posterior wall right ventricular E/A ratio, DT (deceleration time) LV, DT (deceleration time) of the right ventricle were significantly higher in the group of individuals with high levels of blood CRP. In patients with normal (1A) and elevated (1B) levels of CRP in the structure of changes in LV geometry, an eccentric variant of LV hypertrophy was significantly more often detected (74.9% and 66.0%, respectively). The blood CRP concentration was positively associated with the size of the left atrium and LV wall thickness, and negatively with the rate of GFR. Conclusion. In individuals with high and very high cardiovascular risk, elevated CRP levels are associated with more pronounced cardiovascular risk factors. In the group of patients with a high level of CRP, structural modification of the myocardium is represented significantly more often by an eccentric variant of LV hypertrophy.

Limitations of Cardiovascular Risk Scores in Primary Prevention. An Opportunity for Risk Modulators?

Background: Cardiovascular risk scores have limitations related to calibration, discrimination, and low sensitivity. Different "risk modulators" have been identified to improve cardiovascular risk stratification: carotid atherosclerotic plaque (CAP), coronary artery calcium (CAC) score and lipoprotein(a) [Lp(a)]. Objectives: The aims of this study were: 1) to determine the prevalence of risk modulators mentioned in a primary prevention population; 2) determine the concordance between the 2 methods of detecting subclinical atherosclerosis; and 3) establish which proportion of patients should receive statins according to the initial risk stratification and after being recategorized by screening for risk modulators. Methods: Individuals aged 18 to 79 years who consulted for cardiovascular risk assessment and who were not receiving lipid-lowering treatment were included. The risk score was calculated in each patient using ASCVD Risk Estimator. The presence of CAP, CAC score and Lp(a) level were evaluated. Results: The cohort was made up of 348 patients; mean age was 55.6 ± 12.2 years and 45.4% were men. In the total population, 29.8%, 36.8%, and 53.2% of patients showed Lp(a) value ≥ 50 mg/dL, CAP, or a CAC score &gt; 0, respectively. The prevalence of CAP and CAC score was progressively higher according to the cardiovascular risk category; however, the proportion of low-risk subjects who had risk modulators was considerable (Lp(a) ≥ 50 mg/dl: 25.7%; CAP: 22%; CAC score &gt; 0: 33%). In the 60 subjects &lt;45 years , the prevalence of CAC score &gt; 0 and CAP was 18.3% and 10%, respectively. The agreement between the two methods for quantifying subclinical atheromatosis was fair (kappa= 0.33). The indication for statin treatment increased by 31.6% after evaluating the presence of modulators. Conclusion: The presence of risk modulators was common in this population in primary prevention, even in low-risk subjects or &lt;45 years. Detection of risk modulators could improve initial stratification and lead to reconsideration of statin treatment.

High-density lipoprotein cholesterol, triglycerides, andcharacteristics of coronary atherosclerosis in patients with significant coronary artery disease newly diagnosed bycomputed tomography coronary angiography.

The Current European Society of Cardiology guidelines indicate specific target low-density lipoprotein cholesterol (LDL-C) levels for different cardiovascular risk categories in terms of prevention. However, the target for high-density lipoprotein cholesterol (HDL-C) and triglycerides has not been established. The study aims to investigate the associations betweenHDL-C,triglycerides, andcoronary plaque characteristics. This was a prospective single-center study with enrolled consecutive patients with newly diagnosed significant (≥1stenosis ≥50%) CAD on computed tomography coronary angiography (CTCA). Patients had lipids andCTCA analysis, including high-risk plaque (HRP) features: low-attenuation plaque (LAP), napkin-ring sign (NRS), positive remodeling (PR), and spotty calcium (SC), type of the plaque (calcified, noncalcified, mixed), and their composition (calcified, fibrous, fibro-fatty, necrotic core). The study included 300 patients (191 men, 66 [8] years). Sixty-six percent of them had lipid-lowering therapy. HRPwas found in 208 patients. There was no association between LDL-C, plaque composition, and HRP presence. There was a negative correlation between HDL-C, fibro-fatty and necrotic core plaque components (P = 0.0002, P = 0.0009). There was a positive correlation between triglycerides and necrotic core (P = 0.038). There were differences in HDL-C and triglycerides in patients with and without NRS (47 vs. 53 mg/dl, P = 0.0002 and 128 vs. 109 mg/dl, P = 0.02). In logistic regression, HDL-C (odds ratio [OR], 0.95;95% confidence interval [CI], 0.93-0.98; P <0.001), triglycerides (OR, 1.00; 95% CI, 1.00-1.01; P = 0.02), and male sex (OR, 3.04; 95% CI, 1.41-6.52; P = 0.004) were NRS predictors. In multivariable regression, only HDL-C (OR, 0.96; 95% CI, 0.93-0.99; P = 0.02) was an independent predictor of NRS. Lower HDL-C and higher triglycerides were associated with NRS presence and more necrotic core plaque components in coronary plaques in patients with newly diagnosed CAD.

Nonexercise machine learning models for maximal oxygen uptake prediction in national population surveys.

Nonexercise algorithms are cost-effective methods to estimate cardiorespiratory fitness (CRF), but the existing models have limitations in generalizability and predictive power. This study aims to improve the nonexercise algorithms using machine learning (ML) methods and data from US national population surveys. We used the 1999-2004 data from the National Health and Nutrition Examination Survey (NHANES). Maximal oxygen uptake (VO2 max), measured through a submaximal exercise test, served as the gold standard measure for CRF in this study. We applied multiple ML algorithms to build 2 models: a parsimonious model using commonly available interview and examination data, and an extended model additionally incorporating variables from Dual-Energy X-ray Absorptiometry (DEXA) and standard laboratory tests in clinical practice. Key predictors were identified using Shapley additive explanation (SHAP). Among the 5668 NHANES participants in the study population, 49.9% were women and the mean (SD) age was 32.5years (10.0). The light gradient boosting machine (LightGBM) had the best performance across multiple types of supervised ML algorithms. Compared with the best existing nonexercise algorithms that could be applied to the NHANES, the parsimonious LightGBM model (RMSE: 8.51 ml/kg/min [95% CI: 7.73-9.33]) and the extended LightGBM model (RMSE: 8.26 ml/kg/min [95% CI: 7.44-9.09]) significantly reduced the error by 15% and 12% (P < .001 for both), respectively. The integration of ML and national data source presents a novel approach for estimating cardiovascular fitness. This method provides valuable insights for cardiovascular disease risk classification and clinical decision-making, ultimately leading to improved health outcomes. Our nonexercise models provide improved accuracy in estimating VO2 max within NHANES data as compared to existing nonexercise algorithms.

Evaluation of hypercholesterolemia management in at-risk patients by cardiologists in France: a case vignette-based study.

Aim: This online interactive survey investigated lipid-lowering approaches of French cardiologists in high- and very high-cardiovascular risk patients with hypercholesterolemia. Materials & methods: Physicians assessed three hypothetical patients at three clinic visits, and selected the patients'cardiovascular risk category, target low-density lipoprotein cholesterol (LDL-C)and treatment. Results: A total of162 physicians completed 480 risk assessments; 58% of assessments correctly categorized the hypothetical patients. Most physicians chose the correct LDL-C target for one of the very high-risk patients, but higher-than-recommended targets were selected for the other very high-risk patient and the high-risk patient. Statins were the most commonly chosen treatment. Conclusion: French cardiologists often underestimate cardiovascular risk in patients with hypercholesterolemia, select a higher-than-recommended LDL-C target and prescribe less intensive treatment than that recommended by guidelines.

Evaluation of vascular risk in patients with migraine with and without aura treated with erenumab: Post hoc analysis of pooled long‐term clinical trial data

To assess cardiovascular (CV) safety of erenumab in clinical trial patients associated with degree of CV risk. Hypertension has been considered a theoretical risk associated with the inhibition of the calcitonin gene-related peptide pathway in migraine management, particularly in a patient population with pre-existing CV risk factors. Data pooled from four double-blind, randomized trials were used to assess blood pressure (BP) changes and CV safety in patients grouped based on 10-year risk of cardiac, cerebrovascular, and peripheral artery disease as no-risk-factors, low-risk (>0% to ≤10%), moderate-risk (>10% to ≤20%), and high-risk (>20%) categories. CV safety was assessed as ischemic cardiovascular and cerebrovascular adverse events (ICCAE). There was no apparent difference between placebo- (N=1032) and erenumab-treatment groups (70 mg, N=885; 140 mg, N=504) in clinical worsening of BP category from baseline to Months 1-3 (14% [143/1032] placebo vs. 13% [114/885] and 14% [71/504] for erenumab 70 and 140 mg, respectively) regardless of baseline BP category. The adverse event (AE) profile of erenumab was similar across CV risk categories throughout the long-term analysis. Erenumab-treated patients with high and moderate 10-year CV risk (N=107) did not experience any ICCAEs during the double-blind treatment period; there was a single ICCAE (a cerebral dural venous sinus thrombosis) observed in the low-risk erenumab group (N=273). There were no increases in AEs during the long-term extensions of up to 5 years (N= 2499; 3482 patient-years of exposure to erenumab) with exposure-adjusted incidence rates of cardio/cerebrovascular disorder AEs of 0.4, 0.5, 0.0, and 1.1 (per 100 patient-years) for no risk factor (N= 1805), low (N= 492), moderate (N= 121), and high (N= 81) 10-year CV risk groups, respectively. Ischemic CV and cerebrovascular AEs were uncommon and the incidence rates were similar across the 10-year CV risk categories. This analysis helps provide more detail on the CV safety of erenumab.

Prognostic value of CT-derived coronary artery disease characteristics varies by ASCVD risk: insights from the PROMISE trial.

To compare the prognostic value of individual CT-derived coronary artery disease (CAD) characteristics across categories of clinical cardiovascular risk. The central core laboratory assessed coronary artery calcium (CAC), obstructive CAD (stenosis ≥ 50%), and high-risk plaque (HRP) in stable outpatients with suspected CAD enrolled in the PROMISE trial. Multivariable Cox regression models (endpoint: unstable angina, nonfatal myocardial infarction, or all-cause mortality; median follow-up: 2years) were used to compare hazard ratios (HR) of the CT measures between low-borderline (< 7.5%) and moderate-high (≥ 7.5%) atherosclerotic cardiovascular disease (ASCVD) risk based on the pooled cohort equation. Among 4356 included patients (aged 61 ± 8years, 52% women), 67% had ASCVD risk ≥ 7.5%. Stratified by ASCVD risk, CAD ≥ 50% had nearly threefold greater HR in individuals with ASCVD < 7.5% (aHR, 6.85; 95% CI, 2.33-20.15; p < 0.001) vs. ASCVD ≥ 7.5% (aHR: 2.66, 95% CI: 1.67-4.25, p < 0.001; interaction p = 0.041). CAC predicted events solely in ASCVD ≥ 7.5% patients (aHR: 1.92, 95% CI: 1.01-3.63, p = 0.045; interaction p = 0.571), while HRP predicted events only in ASCVD < 7.5% (aHR: 3.11, 95% CI: 1.09-8.85, p = 0.034; interaction p = 0.034). Prognostic values of CT-derived CAD characteristics differ by ASCVD risk categories. While CAD ≥ 50% has the highest prognostic value regardless of ASCVD risk, CAC is prognostic in high and HRP in low ASCVD risk. These findings suggest that CAD ≥ 50% and HRP detection rather than CAC scoring may better risk-stratify symptomatic low-risk patients and thus potentially improve downstream care. • Prognostic value of individual CT-derived CAD characteristics differs by categories of cardiovascular risk. • Presence of obstructive coronary artery stenosis ≥ 50% has the highest prognostic value regardless of cardiovascular risk. • Coronary artery calcium is independently prognostic in high and high-risk plaque features in low cardiovascular risk.