Change In Cardiovascular Disease Risk Research Articles

Income inequality and cardiovascular disease risk factors in a highly unequal country: a fixed-effects analysis from South Africa

BackgroundChronic stress associated with high income inequality has been hypothesized to increase CVD risk and other adverse health outcomes. However, most evidence comes from high-income countries, and there is limited evidence on the link between income inequality and biomarkers of chronic stress and risk for CVD. This study examines how changes in income inequality over recent years relate to changes in CVD risk factors in South Africa, home to some of the highest levels of income inequality globally.MethodsWe linked longitudinal data from 9356 individuals interviewed in the 2008 and 2012 National Income Dynamics Study to district-level Gini coefficients estimated from census and survey data. We investigated whether subnational district income inequality was associated with several modifiable risk factors for cardiovascular disease (CVD) in South Africa, including body mass index (BMI), waist circumference, blood pressure, physical inactivity, smoking, and high alcohol consumption. We ran individual fixed-effects models to examine the association between changes in income inequality and changes in CVD risk factors over time. Linear models were used for continuous metabolic outcomes while conditional Poisson models were used to estimate risk ratios for dichotomous behavioral outcomes.ResultsBoth income inequality and prevalence of most CVD risk factors increased over the period of study. In longitudinal fixed-effects models, changes in district Gini coefficients were not significantly associated with changes in CVD risk factors.ConclusionsOur findings do not support the hypothesis that subnational district income inequality is associated with CVD risk factors within the high-inequality setting of South Africa.

Abstract P458: Assessment of Cardiovascular Risk Reduction in Adults With Metabolic Syndrome or Type 2 Diabetes Treated With Lorcaserin: A Pooled Cohort Analysis

Introduction: Obesity is a risk factor for cardiovascular disease (CVD) and even modest weight loss can contribute to its reduction. Lorcaserin, a selective 5HT 2C receptor agonist, is indicated as an adjunct to a reduced-calorie diet and increased physical activity in adults with obesity (BMI≥30 kg/m 2 ) or overweight (BMI 27-29.9 kg/m 2 and at least 1 weight-related comorbidity). Using the 2013 ACC/AHA 10-year CVD risk assessment pooled cohort equation, we examined risk change in patients with metabolic syndrome or type 2 diabetes (T2DM) undergoing treatment with lorcaserin or placebo for weight loss. Methods: We identified patients with metabolic syndrome or T2DM in three randomized, double-blind studies (BLOOM, BLOSSOM, BLOOM-DM) examining the efficacy and safety of lorcaserin 10 mg bid (LOR) vs. placebo (PBO) at one year of treatment. Only patients with lipid values at baseline and one year were included. Once selected, patients were further stratified by weight loss at week 12 of treatment (≥5% vs. <5%). A CVD risk score >5% was classified as high risk, and a 0.5% change in risk over one year was defined as clinically relevant. CVD risk reduction by cohorts, overall and by gender, was compared. Results: Overall, 43% LOR (n=449/1056) and 20% PBO (n=207/1041) patients had > 5% weight reduction at week 12 (p<0.05). Baseline CVD risk was 5.43% and 5.14% in the LOR and PBO cohorts, respectively. At one year, PBO-corrected change in CVD risk compared to LOR treatment was -0.21% (95% CI 0.02, 0.04, p=0.03; LOR -0.55% vs -0.3% PBO) overall and -0.56% (95% CI 0.12, 0.99, p=0.012; LOR -1.08% vs PBO -0.41%) in men. CVD risk in women was <5% at baseline, with no significant change seen at one year. For 12-week responders, both LOR and PBO had a clinically relevant change in CVD risk overall (-0.81% and -0.79%) and for men (-1.71% vs -1.02%). For patients with <5% weight loss, only men in the LOR cohort showed clinically relevant CVD risk changes (-0.57% vs -0.26%, respectively). Conclusion: The analysis suggests that patients with overweight or obesity and metabolic syndrome/T2DM at risk for CVD, and treated with LOR, experienced a significant CVD risk reduction at one year vs PBO, most notably among men. LOR can effectively reduce weight, which is associated with improvements in CVD risk.

Bridging Income Generation with Group Integrated Care for cardiovascular risk reduction: Rationale and design of the BIGPIC study

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance. This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved. This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.

Abstract MP004: Feasibility of an Appetite Awareness Intervention to Reduce Cardiovascular Disease Risk Factors and Binge Eating in African-American Women with Obesity

Background: Currently, 82.1% of African-American (AA) women are overweight or obese, and 48.9% of AA women have cardiovascular disease (CVD), the leading cause of death. Binge eating disorder (BED) is associated with severe obesity, psychiatric morbidity, and increased risk for CVD. Among AA women, BED is the most common eating disorder and has a 33% prevalence among those seeking weight loss. Since many adults with BED report becoming overweight after binge eating on a regular basis, intervening with individuals at risk to develop BED may be a viable strategy to prevent CVD and further weight gain. Purpose: To investigate the feasibility of an 8-week, community-based Appetite Awareness Training intervention among AA women who are overweight and obese reporting monthly binge eating episodes, and examine preliminary changes in CVD risk, eating self-efficacy, and binge eating between the intervention and control group. Methods: Eligible individuals were randomized to Appetite Awareness Treatment (AAT, n=16) or Wait-List Control (WLC, n=15) with the WLC receiving the AAT after 8-weeks of observation. The goal of Appetite Awareness Treatment is to help participants relearn their biological signals of hunger and satiety. Participants attend group sessions, and receive weekly homework to self-monitor their appetite cues. Assessments were conducted at 0 and 8 weeks at a community-based site. Linear mixed modeling was used to examine the baseline to 8-week changes between AAT and WLC groups on CVD risk factors (body weight, waist circumference, blood pressure) self-efficacy by Weight Efficacy Lifestyle Questionnaire (WEL), and binge eating by the Binge Eating Scale (BES). Results: The sample (N=31), had a mean age of 48.8 (SD±12.8), and a BMI of 33.7 kg/m 2 (SD±3.90). Retention was 87.5%, session attendance 65.9%, and homework completion 55%. There were significant group differences over time in the WEL score (p<.01, d=1.06), and the BES score (p<.001, d=.52) at the end of the intervention. The AAT group had an increase in the WEL score (+25.14±6.67), with no changes in the WLC group (-1.27±4.15). Additionally, the AAT group had a decrease in the BES score (-5.87±0.61), with no changes in the WLC group (0 ±0.01). There were no significant differences within and between groups in CVD risk factors. Conclusions: Our pilot trial results suggest that AAT is feasible in this population, with good retention, attendance, and preliminary evidence of a positive impact on eating self-efficacy, binge eating behaviors, and weight gain prevention. Future research should investigate the effectiveness of AAT to reduce binge eating and CVD risk in a larger sample and study with a longer duration.

Changes in cardiovascular disease risk and behavioural risk factors before the introduction of a health check programme in England

A population-based programme of health checks was introduced for adults in England in 2011 for the primary prevention of cardiovascular diseases (CVD) and risk factors management. The aim was to evaluate changes in cardiovascular risk and behavioural risk factors in a health check eligible population in England from 1994 to 2013, by using repeated cross-sectional design using seven surveys of the Health Survey for England. Measures included traditional CVD risk factors and behavioural risk factors. Linear trends were estimated allowing for sampling design. The surveys comprised 49,805 adults aged 45 to 74years; 30,639 were free from cardiovascular comorbidity; 16,041 (52%) had complete data for quantitative risk factors. Between 1994 and 2013, systolic blood pressure decreased by 3.1 (95% confidence interval 2.5 to 3.6) mmHg per decade in men and 5.0 (4.5 to 5.5) in women. Total cholesterol decreased by 0.20 (0.16 to 0.24) mmol/l per decade in men; 0.23 (0.19 to 0.26) in women. Smoking declined by 6% (5% to 8%) per decade in men; 7% (6% - 8%) in women. The proportion with CVD-risk ≥20% declined by 6.8% per decade in men; 2.4% in women. Multiple behavioural risk factors were strongly associated with estimated CVD-risk, but improving trends in traditional CVD risk factors were inconsistent with increasing indicators of adiposity. Long-term declines in traditional risk factors contributed to reductions in estimated CVD-risk prior to the introduction of a health check programme. Behaviour change interventions for multiple risk factor exposures remain a key area for future research.

Challenges of diabetes prevention in the real world: results and lessons from the Melbourne Diabetes Prevention Study

ObjectiveTo assess effectiveness and implementability of the public health programme Life! Taking action on diabetes in Australian people at risk of developing type 2 diabetes.Research design and methodsMelbourne Diabetes Prevention...

The Impact of Newer Biological Disease Modifying Anti-Rheumatic Drugs on Cardiovascular Risk Factors: A 12-Month Longitudinal Study in Rheumatoid Arthritis Patients Treated with Rituximab, Abatacept and Tociliziumab.

ObjectivesTo assess whether treatment with one of three novel biological DMARDs; rituximab, abatacept or tocilizumab reduce cardiovascular disease (CVD) risk factors in patients with rheumatoid arthritis (RA).MethodsThis is an open, observational and prospective study with visits at baseline, 3, 6, and 12 months. Patients were assigned to receive rituximab, abatacept or tocilizumab according to clinical indications assessed by an independent rheumatologist. Disease activity was quantified by the disease activity score (DAS28) and extensive ultrasonography. CVD risk was assessed by total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), blood pressure and arterial stiffness measurements [pulse wave velocity (PWV) and augmentation index (AIx)]. Within group change in disease activity and CVD risk over 3 months was explored using paired samples bivariate tests. Predictors of change in CVD risk at 3 months were identified in linear regression models. Changes in CVD risk markers over the 12- month follow-up in patients receiving rituximab were assessed by mixed models repeated analyses.Results24 patients on rituximab, 5 on abatacept and 7 on tocilizumab were included. At 3 months PWV was significantly reduced in the tocilizumab group only, but at 12 months rituximab patients showed a significant reduction in PWV. Reduced inflammation at 3 months was associated with increased TC and HDL-c in the entire cohort.ConclusionTreatment with tocilizumab and rituximab reduces PWV, a marker of CVD risk, in patients with RA.

Framingham ten-year general cardiovascular disease risk: agreement between BMI-based and cholesterol-based estimates in a South Asian convenience sample.

The goal of this analysis was to determine the agreement between body mass index-based and cholesterol-based ten-year Framingham general cardiovascular disease risk scores among a convenience sample of 773 South Asian Canadian adults attending community-based screening clinics. Scores were calculated using age, systolic blood pressure, antihypertensive use, current smoking, diabetes, and total cholesterol and high density lipoprotein (for cholesterol-based risk) or height and weight (for body mass index-based risk). Mean risk score differences (body mass index-based risk minus cholesterol-based risk) were estimated using paired t-tests. Bland-Altman plots were used to assess agreement between scores. Finally, agreement across risk categories (low [<10%], moderate [10% to <20%], high [> = 20%]) was examined using the kappa statistic. Average agreement between the two risk scores was quite good overall (mean differences of 0.6% for men and 0.5% for women), but increased to about 3% among participants 60–74 years of age. However, Bland-Altman plots revealed that the differences between the two scores and the variability of the differences increased with increasing average 10-year risk. In terms of clinical importance, the limits of agreement were reasonable for women < 60 years (95% confidence interval: -3.2% to 3.1%), but of concern for women 60-74 years (95% confidence interval: -6.0% to 12.3%), men < 60 years (95% confidence interval: -7.1% to 7.3%) and men 6-074 years (95% confidence interval: -13.8% to 18.8%). Agreement across categories was moderate for most sex and age groups examined (kappa values: 0.51 for women < 60 years, 0.50 for women 60-74 years, 0.65 for men < 60 years), except for men 60-74 years, where agreement was only fair (kappa = 0.26). In light of these disagreements, evaluation of a participant’s change in cardiovascular disease risk over time will necessitate use of the same risk score (i.e., either body mass index-based or cholesterol-based) at all screening sessions.

Abstract P008: Weight Gain and Cardiovascular Risk Reduction Associated With Tobacco Abstinence in Smokers With Serious Mental Illness

Background: In patients with serious mental illness, high prevalence of smoking and obesity-related risk factors contribute to high rates of cardiovascular disease (CVD) and premature mortality. The impact of smoking cessation on weight gain, obesity-related risk factors, and overall cardiovascular risk among this population is unknown. Methods: We conducted secondary analyses to assess weight gain and change in CVD risk of 87 smokers with serious mental illness (schizophrenia, schizoaffective disorder, and bipolar disorder) who participated in a randomized controlled trial to test the long-term effectiveness of varenicline on smoking cessation. Initially, 203 smokers with serious mental illness were enrolled into an open-label 12-week course of varenicline. Subjects who attained abstinence at the end of the open-label phase were eligible to participate in the randomized phase, and 87 subjects were randomized to continue either varenicline or placebo for the following 40 weeks. Smoking cessation at week 52 (end of treatment) was defined as 21-day point prevalence abstinence. We compared subjects who were abstinent at week 52 (N=33) to subjects who had relapsed to smoking (N=54) on changes in weight and Framingham 10-year CVD risk score over the 52-week trial; outcomes were modeled with repeated measures analyses of variance. Results: At baseline, subjects who achieved week 52 abstinence were older (52 vs. 46 years, p=0.01) and had higher fasting serum glucose (98 vs. 89 mg/dL, p=0.008) than subjects who relapsed, but they did not differ on sex, race, smoking characteristics, blood pressure, lipids, treatment for diabetes, or treatment with antipsychotic medications. Baseline mean body mass index did not differ between abstinent and relapsed subjects (31.4 vs. 32.4, p=0.52), but the baseline mean Framingham risk score was higher for abstinent than relapsed subjects (14.2% vs. 10.8%, p=0.02). Over the 52 week study period, abstinent subjects gained more weight than relapsed subjects (4.8 kg vs. 1.2 kg, p=0.002 for time*abstinence interaction), but the mean Framingham risk score decreased substantially for abstinent subjects and not for relapsed subjects (-7.6% vs. 0.0%, p=0.003 for abstinence effect adjusting for sex, site, varenicline or placebo, and antipsychotic medications). Conclusion: Despite the high prevalence of obesity at baseline and substantial weight gain associated with long-term abstinence, smoking cessation resulted in a large reduction in the Framingham estimated 10-year CVD risk among patients with serious mental illness.

Effectiveness of a team intervention in reducing modifiable cardiovascular disease risk in HIV-infected subjects on antiretroviral therapy.

IntroductionThe increasing age, higher modifiable and inherent cardiovascular disease (CVD) risk of HIV-infected patients [1] necessitates improved approaches to reducing co-morbidities. We aimed to assess the effectiveness of a team intervention in reducing modifiable CVD risk.Materials and MethodsHIV-infected patients ≥50 years attending a large HIV caseload primary-care practice, who were virologically suppressed on antiretroviral therapy (ART), with moderate or severe 10-year CVD Framingham risk (≥10%) were recruited for this prospective case-control study. Intervention participants were provided a team approach to care, which involved treatment by study doctors for lipid, hypertension and ART management, and monthly review by a team of research nurses and dieticians for smoking cessation, exercise and dietary advice over 12 months. Controls were matched on age and smoking status, and were given standard of care (SOC) by non-study doctors. Outcomes included CVD risk factors, body composition and CVD risk assessment, including Framingham 10-yr risk [2] and D:A:D 5-year estimated risk of coronary heart disease (CHD) [3]. Repeated measures analysis of variance was used to examine pre- and post-intervention differences, with p-values used to assess time and main effects of approach to care (Intervention, SOC).ResultsA total of 33 patients completed the intervention, with 33 controls (58.0±6.8 and 59.1±6.9 years, respectively). Smoking cessation occurred in 25% cases versus nil controls. There was a significant change in CVD risk between intervention and control groups, in both Framingham scores (time and group×time interaction) and D:A:D scores (group×time interaction only) (Table 1). There was also a significant difference in change in total cholesterol over the study period (time and group×time interaction). Body composition was only measured in intervention patients, with a significant loss in % body fat observed in pre- and post-intervention.ConclusionsTeam intervention was significantly more effective than standard of care in reducing CVD risk in HIV-infected patients on ART. A team approach to care may be an important component of reducing CVD risk in this population.

A randomized clinical trial to determine the efficacy of manufacturers' recommended doses of omega-3 fatty acids from different sources in facilitating cardiovascular disease risk reduction.

BackgroundOmega-3 fatty acids confer beneficial health effects, but North Americans are lacking in their dietary omega-3-rich intake. Supplementation is an alternative to consumption of fish; however, not all omega-3 products are created equal. The trial objective was to compare the increases in blood levels of omega-3 fatty acids after consumption of four different omega-3 supplements, and to assess potential changes in cardiovascular disease risk following supplementation.MethodsThis was an open-label, randomized, cross-over study involving thirty-five healthy subjects. Supplements and daily doses (as recommended on product labels) were:Concentrated Triglyceride (rTG) fish oil: EPA of 650 mg, DHA of 450 mgEthyl Ester (EE) fish oil: EPA of 756 mg, DHA of 228 mgPhospholipid (PL) krill oil: EPA of 150 mg, DHA of 90 mgTriglyceride (TG) salmon oil: EPA of 180 mg, DHA of 220 mg.Subjects were randomly assigned to consume one of four products, in random order, for a 28-day period, followed by a 4-week washout period. Subsequent testing of the remaining three products, followed by 4-week washout periods, continued until each subject had consumed each of the products. Blood samples before and after supplementation were quantified for fatty acid analysis using gas chromatography, and statistically analysed using ANOVA for repeated measures.ResultsAt the prescribed dosage, the statistical ranking of the four products in terms of increase in whole blood omega-3 fatty acid levels was concentrated rTG fish oil > EE fish oil > triglyceride TG salmon oil > PL krill oil. Whole blood EPA percentage increase in subjects consuming concentrated rTG fish oil was more than four times that of krill and salmon oil. Risk reduction in several elements of cardiovascular disease was achieved to a greater extent by the concentrated rTG fish oil than by any other supplement. Krill oil and (unconcentrated) triglyceride oil were relatively unsuccessful in this aspect of the study.ConclusionFor the general population, the form and dose of omega-3 supplements may be immaterial. However, given these results, the form and dose may be important for those interested in reducing their risk of cardiovascular disease.Trial registrationClinicalTrials.gov: NCT01960660.

Cluster randomized controlled trial of a peer support program for people with diabetes: study protocol for the Australasian peers for progress study

BackgroundWell managed diabetes requires active self-management in order to ensure optimal glycaemic control and appropriate use of available clinical services and other supports. Peer supporters can assist people with their daily diabetes self-management activities, provide emotional and social support, assist and encourage clinical care and be available when needed.MethodsA national database of Australians diagnosed with type 2 diabetes is being used to invite people in pre-determined locations to participate in community-based peer support groups. Peer supporters are self-identified from these communities. All consenting participants receive diabetes self-management education and education manual prior to randomization by community to a peer support intervention or usual care. This multi-faceted intervention comprises four interconnected components for delivering support to the participants. (1) Trained supporters lead 12 monthly group meetings. Participants are assisted to set goals to improve diabetes self-management, discuss with and encourage each other to strengthen linkages with local clinical services (including allied health services) as well as provide social and emotional support. (2) Support through regular supporter-participant or participant-participant contact, between monthly sessions, is also promoted in order to maintain motivation and encourage self-improvement and confidence in diabetes self-management. (3) Participants receive a workbook containing diabetes information, resources and community support services, key diabetes management behaviors and monthly goal setting activity sheets. (4) Finally, a password protected website contains further resources for the participants. Supporters are mentored and assisted throughout the intervention by other supporters and the research team through attendance at a weekly teleconference. Data, including a self-administered lifestyle survey, anthropometric and biomedical measures are collected on all participants at baseline, 6 and 12 months. The primary outcome is change in cardiovascular disease risk using the UKPDS risk equation. Secondary outcomes include biomedical, quality of life, psychosocial functioning, and other lifestyle measures. An economic evaluation will determine whether the program is cost effective.DiscussionThis manuscript presents the protocol for a cluster randomized controlled trial of group-based peer support for people with type 2 diabetes in a community setting. Results from this trial will contribute evidence about the effectiveness of peer support in achieving effective self-management of diabetes.Trial registration numberAustralian New Zealand Clinical Trials Registry (ANZCTR); ACTRN12609000469213

Endothelial Function Is Impaired across the Stages of the Menopause Transition in Healthy Women

The stages of the menopause transition are characterized by changes in ovarian hormones and increased cardiovascular disease (CVD) risk factors and vasomotor symptoms that may adversely affect vascular health. We tested the hypothesis that endothelial function, a predictor of CVD, would be reduced across the stages of the menopause transition, independent of CVD risk factors and vasomotor symptoms. This was a cross-sectional study of 132 healthy women from the general community aged 22-70 yr, categorized as premenopausal (n = 33, 32 ± 6 yr; mean ± SD), early perimenopausal (n = 20, 49 ± 3 yr) or late perimenopausal (n = 22, 50 ± 4 yr), or early (n = 30, 55 ± 3 yr) or late postmenopausal (n = 27, 61 ± 4 yr). Endothelial-dependent vasodilation was measured by brachial artery flow-mediated dilation (FMD) using ultrasound. Brachial artery FMD was significantly different among the groups (P < 0.001). It was highest in premenopausal women (9.9 ± 2.1%) with progressive decrements in perimenopausal (early: 8.2 ± 2.5%; late: 6.5 ± 1.9%) and postmenopausal women (early: 5.5 ± 1.9%; late: 4.7 ± 1.7%). Adjustment for risk factors, vasomotor symptoms, and sex hormones did not alter the association (P < 0.001). In subgroup analyses of women aged 50-59 yr, brachial artery FMD was lower in late peri- and early and late postmenopausal compared with early perimenopausal women (P < 0.001) but was not different between late perimenopausal and either early or late postmenopausal women. Our findings suggest that a decline in endothelial function begins during the early stages of menopause (perimenopause) and worsens with the loss of ovarian function and prolonged estrogen deficiency. These data add to the accumulating evidence that the perimenopausal window is a critical time period for adverse changes in CVD risk.

Menopause status explains large individual variation in cardiovascular disease risk marker response to different dietary choline intake levels

Excess dietary choline has been implicated in increased cardiovascular disease (CVD) risk, a process mediated by bacterial catabolism of choline to trimethylamine N‐oxide (TMAO). To determine whether variation in dietary choline leads to differences in plasma TMAO and CVD risk in human subjects, we enrolled twenty female participants in a two‐month, controlled dietary intervention study where they were exposed to three different intake levels of choline‐equivalents (choline, phosphatidylcholine and other choline‐containing compounds). Plasma samples collected at the end of each exposure were analyzed using liquid chromatography time‐of‐flight mass spectrometry to determine TMAO levels. Plasma oxidized low density lipoprotein (oxLDL), a marker for CVD risk, was measured using sandwich ELISA to establish whether changes in dietary choline levels were associated changes in CVD risk. Our analysis identified significant dose‐response relationships between choline equivalent intake and both plasma TMAO response (P=2.15e‐05 – MANOVA) and plasma oxLDL levels (P=0.0285). TMAO and oxLDL response variation were largely explained by menopause status (P=0.0003 and P=0.0014 respectively). These results suggest the possibility that bacteria‐mediated TMAO production may be important in the increased CVD risk observed in post‐menopausal women. NIH DK055895, DK056350 and RR00046 supported this work.

Abstract P40: The Impact of a COSEHC Physician Education Program on Patient Cardiovascular Disease Risk Variables in a Large South Carolina Medical Practice

COSEHC is conducting an 18-month prospective nested cohort design study, COSMIC [ CO SEHC Cu S tomized Model of Intervention and Care], which evaluates the effectiveness of a physician process improvement education program to reduce gaps in physicians’ application of cardiovascular disease (CVD) guidelines in a primary care South Carolina (SC) practice. The COSMIC project evaluates patient CVD risk variable outcomes as a measure of physician improvement. This study evaluates changes in patient CVD risk between baseline (BL) and 6 months (6-mo) among physician cohort 1 (CH1; n=1200 patient records) receiving COSMIC physician education and the control group (cohort 2 (CH2); n=1200 patient records). The COSMIC program involves educational modules that promote clinical care systems changes using JNC 7 and ATP III revised guidelines followed by a repeat process based on reassessed outcomes. At 6-mo, there was statistically more improvement in diastolic blood pressure (DBP) for CH2 than CH1. However, no other CVD outcomes changes were noted between CH1 and CH2 for systolic blood pressure (SBP) total, LDL, or HDL cholesterol (TC, LDL-C, HDL-C), triglycerides, hemoglobin A1c (HgA1c), creatinine, or body mass index (BMI)] using the last observation carried forward method ( Table 1 ). While improvements in TC, triglycerides, and HgA1c increased for both groups at 6-mo, CH1 tended to have smaller increases than CH2, respectively. Changes in LDL-C showed improvement for CH1 at 6-mo while CH2 did not improve. Additionally, CH1 had a higher percentage of total patients with return values/visits for each CVD risk factor. This project, while showing no statistically significant changes over 6-mo other than DBP, reveals a trend for modest improvements with physician education for 6-mo in a SC primary care practice. Continuation of this program inclusive of improved clinical care systems will determine the ultimate impact on improving CVD risk in the Southeast United States. Table 1. A comparison of changes in CVD risk factors between BL and 6-mo among CH1 and CH2. * p &lt; 0.05 Cohort 1 (mean ± SD) Cohort 2 (mean ± SD) Changes in Systolic Blood Pressure (mm Hg) -0.91 ± 15.56 -1.79 ± 15.11 Chanegs in Diastolic Blood Pressure (mm Hg) -0.76 ± 9.47 * -1.74 ± 8.63 Changes in Total Cholesterol (mg/dL) 0.92 ± 22.79 1.57 ± 22.39 Changes in LDL Cholesterol (mg/dL) -0.34 ± 19.58 0.08 ± 18.15 Changes in HDL Cholesterol (mg/dL) 1.04 ± 5.87 1.01 ± 5.34 Changes in Triglycerides (mg/dL) 0.55 ± 37.01 0.74 ± 37.81 Changes in Hemoglobin A1c (%) 0.003 ± 0.59 0.062 ± 0.68 Changes in Creatinine (mg/dL) -0.03 ± 0.16 -0.03 ± 0.13 Changes in Body Mass Index (BMI) 0.07 ± 2.12 0.08 ± 1.69

Independent effects of age-related changes in waist circumference and BMI z scores in predicting cardiovascular disease risk factors in a prospective cohort of adolescent females

Cross-sectional data indicate that central adiposity is associated with cardiovascular disease risk, independent of total adiposity. The use of longitudinal data to investigate the relation between changes in fat distribution and the emergence of risk factors is limited. We tested the hypothesis that age-related change in waist circumference (to reflect central adiposity) during adolescence is a significant predictor of longitudinal change in cardiovascular disease risk, after adjustment for change in body mass index (BMI) z score (to reflect total adiposity) in a cohort of postmenarcheal adolescent females. We also tested whether race modified this relation. We analyzed publicly available data from the National Heart, Lung, and Blood Institute Growth and Health Study. Longitudinal regression models were fitted to investigate the independent effects of changes in waist circumference on cardiovascular disease risk factors. Steeper age-related increases in waist circumference over time were associated with a greater increase in LDL-cholesterol concentrations, systolic blood pressure, diastolic blood pressure, and homeostasis model assessment of insulin resistance, after adjustment for BMI z score, in white but not in black females. Change in waist circumference was not a statistically significant predictor of age-related changes in HDL-cholesterol, triglyceride, insulin, and glucose concentrations, after adjustment for changes in BMI z score, in either white or black females. Our research suggests that monitoring waist circumference in addition to BMI z score has the potential to identify adolescents at risk of the emergence of cardiovascular disease risk factors, at least in white females. The data also suggest that race may modify the relation between fat distribution pattern and cardiovascular disease risk factors.

Effects on cardiovascular disease risk of a web-based health risk assessment with tailored health advice: a follow-up study

Introduction:A large proportion of the cardiovascular disease (CVD) burden can potentially be prevented by primary prevention programs addressing major causal risk factors. A Web-based health risk assessment (HRA) with tailored feedback for individual health promotion is a promising strategy. We evaluated the effect on CVD risk of such a program among employees of a Dutch worksite.Methods:We conducted a prospective follow-up study among 368 employees who voluntarily participated in a Web-based HRA program at a single Dutch worksite in 2008. The program included a multicomponent HRA through a Web-based electronic questionnaire, biometrics, and laboratory evaluation. The results were combined with health behavior change theory to generate tailored motivational and educational health advice. On request, a health counseling session with the program physician was available. Follow-up data on CVD risk were collected 1 year after initial participation. The primary outcome was a change in Framingham CVD risk at 6 months relative to baseline. We checked for a possible background effect of an increased health consciousness as a consequence of program introduction at the worksite by comparing baseline measurements of early program participants with baseline measurements of participants who completed the program 6 months later.Results:A total of 176 employees completed follow-up measurements after a mean of 7 months. There was a graded relation between CVD risk changes and baseline risk, with a relative reduction of 17.9% (P = 0.001) in the high-risk category (baseline CVD risk ≥20%). Changes were not explained by additional health counseling, medication, or an increase in health consciousness within the company.Conclusions:Voluntary participation in a Web-based HRA with tailored feedback at the worksite reduced CVD risk by nearly 18% among participants at high CVD risk and by nearly 5% among all participants. Web-based HRA could improve CVD risk in similar populations. Future research should focus on the persistence of the effects underlying the CVD risk reduction.

Community Programs for the Prevention of Cardiovascular Disease: A Systematic Review

In this systematic review, the authors aimed to assess the effectiveness of community programs for prevention of cardiovascular disease (CVD). They searched numerous electronic databases (CDSR, DARE, HTA, EED, and CENTRAL via the Cochrane Library, MEDLINE, MEDLINE In Process, EMBASE, CINAHL, PsycINFO, HMIC, and ASSIA) and relevant Web sites from January 1970 to mid-July 2008. Controlled studies of community programs for the primary prevention of CVD were included. Net changes in CVD risk factors were used to generate an overall index for net change in 10-year CVD risk. The authors identified 36 relevant community programs that took place between 1970 and 2008. These programs were multifaceted interventions employing combinations of media, screening, and counseling activities and environmental changes and were primarily evaluated using controlled before-after studies. In 7 studies, investigators reported changes in CVD/total mortality rates, and in 5 they reported net changes. In all cases, these net changes were positive but were largely nonsignificant. In 22 studies, investigators reported changes in physiologic CVD risk factors, and there was a positive trend in the calculated CVD risk score. The average net reduction in 10-year CVD risk was 0.65%. Community programs for CVD prevention appear to have generally achieved favorable changes in overall CVD risk and, with adaptation to current circumstances, deserve continued consideration as possible approaches to preventing CVD.

The Influence of Baseline Plasma Fibrinogen on Responses to an Accumulative Brisk Walking Intervention

Plasma fibrinogen (PF) is a commonly used marker of coagulation and inflammation, particularly in physical activity (PA) interventions, to assess change in cardiovascular disease risk. However, such studies have shown equivocal results. Since many physiological factors" baseline measures influence the potential for change due to exercise intervention, few of these studies have considered PF baseline measures. PURPOSE Therefore, the purpose of this study was to determine whether 24 weeks of accumulative brisk walking could decrease plasma fibrinogen and whether baseline PF affects the outcomes. METHODS 52 non-smoking sedentary males (54 ± 8.1 years), who were asymptomatic of cardiovascular disease and diabetes completed a 24-week randomised controlled walking trial. Participants were randomly allocated into one of the following three groups: control (CON); single bout of brisk walking per day (SBW); or accumulative bouts of brisk walking (ABW). Each walking group performed 30 minutes of walking ≥65% HRmax per day on 5 days of the week, with ABW accumulating their walking in 3×15 or 2×15 minute bouts. Pre- and post-intervention fasting blood samples were collected. The samples were assessed using a clotting technique and analysed using a one-way ANOVA and also two-way ANCOVA, with baseline plasma fibrinogen as a co-variate. One-way ANOVA was employed to assess differences between groups at baseline and Pearson"s correlations were used to assess the relationships. RESULTS There was a main effect of walking compared to CON on PF using one-way ANOVA (P=0.027) and ANCOVA (P=0.039). PF increased by 0.18 ± 0.66 g·L-1 in CON, but decreased by -0.34 ± 0.57 g·L-1 in SBW (P=0.268) and -0.30 ± 0.62 g·L-1 in ABW. However, when applying one-way ANOVA to the delta scores, the decrease in PF observed in SBW (P=0.052) approached significance, but not ABW (P=0.077), whereas applying an ANCOVA determined that ABW (P=0.040) significantly decreased PF but not SBW (P=0.268). Despite there being no significant differences between groups at baseline, Pearson"s correlation demonstrate that those with higher baseline PF generally reduced PF greater than those with lower baseline PF. CONCLUSION The data suggest that baseline PF affects changes in PF and baseline PF should be considered when investigating the effect of interventions on PF.

Which risk engines are best to assess CVD risk in diabetes?

the news and views article by ray and sattar (Diabetes: which risk engines should be used to assess patients with diabetes? Nat. Rev. Endocrinol. 5, 302–303; 2009)1 raises a number of interesting points regarding the role of cardiovascular disease (CvD) risk assessment tools in the prevention of CvD among people with type 2 diabetes mellitus (t2DM). the authors suggest that the uK Prospective Diabetes study (uKPDs) risk engine has several advantages over the Framingham risk score (Frs), particularly as it incorporates a measure of glycemia and duration of diabetes mellitus, alongside other traditional risk factors. However, our systematic review demonstrates that scant evidence exists to suggest that diabetesspecific risk tools estimate CvD risk more accurately than those developed in the general population.2 validation studies comparing the predictive performance of the Frs and the uKPDs risk engine report conflicting results.3–5 Furthermore, adding a measure of glycemia to the Frs improves discrimination slightly in men but not in women, without significant improvement in reclassification of risk category.6 the authors’ conclusion that 2% of patients with t2DM might be below a treatment threshold, and hence denied medication (depending on choice of risk scores) is an oversimplification of the issue. while the total proportions with a modeled 10-year CvD risk ≥20% may be similar, two different scores may identify completely different individuals, thus statistics such as the net reclassification improvement are more informative. ray and sattar advocate measurement of lifetime CvD risk in order to circumvent problems related to changes in CvD risk over time. Modeling lifetime risk is prone to many sources of uncertainty. Changes in the distribution of CvD risk factors and treatments over time, both within and between populations, could limit the predictive accuracy. Furthermore, it might be more clinically relevant and also more persuasive for patients to know CvD risk and treatment benefits over a shorter period. ray and sattar conclude by suggesting that future studies on t2DM should incorporate data on emerging prognostic biomarkers to help improve CvD risk prediction and thus risk reduction. However, very few novel biomarkers improve risk prediction models over and above the inclusion of traditional risk factors, and any improvement is likely to be marginal.7,8 there may be little to gain from developing novel CvD risk scores, incorporating expensive biomarkers, in historical cohorts including individuals dissimilar to patients in whom the risk score would be used.9 More precise risk prediction by itself will not improve health outcomes. indeed, there is no strong evidence that a CvD risk assessment performed by a clinician improves CvD-related health outcomes.10 Further research might address other potential uses of risk scores, for example, to better understand the interaction between clinicians and patients when CvD risk has been assessed, and the effects on physician prescribing and patient health behaviors such as diet, smoking, physical activity and medication adherence. in summary, diabetes-specific risk scores do not predict CvD in people with t2DM more accurately than risk scores developed in the general population. Future research might focus on exploring patient–provider perceptions and responses to information about CvD risk. MRC Epidemiology Unit, Institute of Metabolic Science, Box 285, Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK (P. Chamnan, R. K. Simmons, S. J. Griffin)