CV Risk Score Research Articles

QRISK2 AND FRAMINGHAM CARDIOVASCULAR RISK SCORES SIGNIFICANTLY CORRELATE WITH IMAGING BIOMARKERS OF PRECLINICAL AD: FINDINGS FROM THE HARVARD AGING BRAIN STUDY

Neuropathological studies suggest many cases of late onset dementia may be due to mixed pathologies, most commonly a combination of Alzheimer's disease (AD) pathology and cerebrovascular disease. The amount of white matter disease (WM hyperintensities, WMH) is often used as a proxy measure for the impact of vascular disease on the brain, but lacks the extensive validation of commonly used vascular risk (CV Risk) scores such as the QRISK2, Framingham Heart Study (FHS) cardiovascular disease (FHS-CVD) and stroke (FHS-Stroke) metrics. Accordingly, we examined the cross-sectional relationship of these CV risk metrics to commonly used imaging biomarkers, including 18F- fludeoxyglucose (FDG) PET, Pittsburgh Compound B (PiB) PET, hippocampal volume, ventricle size, and WMH. MRI, PiB PET, and FDG PET data from 195 clinically normal older participants in the Harvard Aging Brain Study (HABS) were compared to CV risk scores calculated from available demographic, blood pressure, and cholesterol data. Linear regression models (corrected for age and sex) were used to assess relationships between CV Risk and imaging biomarkers and with the Preclinical Alzheimer's Cognitive Composite (PACC). QRISK2 and FHS-CVD risk scores were significantly correlated with AD-typical hypometabolism on FDG PET (Figure 1). Higher QRISK2 was associated with lower hippocampal volume. FHS-CVD and FHS-Stroke risk scores (but not QRISK2) were significantly correlated with WMH. FHS-CVD and FHS-Stroke risk scores also correlated with lateral ventricle size, a measure of central atrophy. Higher FHS-CVD predicted significantly lower scores on the PACC. We observed no significant relationships between any CV risk scores and PET measures of amyloid burden. We observed significant (but modest) cross-sectional relationships between well-validated measures of CV risk and imaging biomarkers commonly used to stratify risk of decline in preclinical AD, but no relationship between elevated CV risk and amyloid burden. Though significant relationships between CV risk scores and WMH were present, these were also relatively weak, suggesting measures of WMH may have limited overlap with vascular risk as assessed in other medical contexts. These results support considering CV risk in studies of preclinical AD, and suggest WMH measures may not completely account for CV risk. Associations Between Cardiovascular Risk Scores and Cross-Sectional AD Biomarkers in the Harvard Aging Brain Study. The heatmap shown depicts partial correlations between cardiovascular risk scores and baseline imaging and cognitive measures, controlling forage and sex. (CVD = Cardiovascular Disease; CHD = Coronary Heart Disease; CVD Death and CHD Death refer to risk of death from CVD or CHD, respectively; *, **, and *** correspond to p < 0.05, < 0.005, and < 0.0005, respectively).

High correlation between Framingham equations with BMI and with lipids to estimate cardiovascular risks score at baseline in HIV-infected adults in the Temprano trial, ANRS 12136 in Côte d'Ivoire.

ContextData on cardiovascular risk (CVR) score among HIV-infected patients in sub-Saharan Africa are scarce. Our first objective was to compare the CVR score of Framingham utilizing BMI and lipids at baseline, and secondary to assess evolution of CVR score over time at Month 30 in the Temprano trial.MethodsHIV-infected adults with CD4 <800/mm3 without criteria for initiating ART were included and followed for 30 months in the Temprano trial, which assessed the benefits and risks of early antiretroviral treatment (ART) vs deferred ART. CVR score was estimated at baseline and Month-30 using Framingham equations with either BMI or lipids and classified as high (>20%), moderate (10–20%), and low risk (<10%). At baseline, we compare these two estimations utilizing the Pearson correlation test and analyze the increasing CV risk score over time by Proportional odds cumulative logit models for people attending the Month-30 (M30) visit.ResultsAmong the 2056 patients, 78% were women, median age was 35 years, and median CD4 count was 464/mm3, 6.8% were obese, 6.3% had hypertension, 7.8% were smokers (1.8% women, 26.8% men), 19% had Total Cholesterol (TC) >5mmol/L, and 1% diabetes at baseline. At baseline the concordance between the two Framingham equations was excellent (r = 0.95; p<0.0001). Among the 1700 patients who attended M30 visit and with available data, 1.3% had a high CV risk score at baseline and 3.1% at M30 visit using Framingham equation with BMI. Adjusted odds ratio (aOR) of being at a higher CV risk score at M30 visit compared to a higher CV risk score at M0 visit was 1.35 (CI 95% 1.17–1.57). Stratified by sex, the increasing CV risk score was OR 1.73 (CI 95%: 1.30–2.29) for women and OR 1.24 (CI 95%: 1.02–1.50) for men. Early ART was not associated with an increasing CV risk score (p = 0.88). Results for the 1422 patients with Framingham equation using lipids were similar.ConclusionIn a large trial evaluating early ART for HIV infection in Côte d’Ivoire, Framingham equation with BMI and lipids were highly correlated and CV risk score increases over time. Early ART was not significantly associated with this increasing CV risk score.

Northern Shanghai Study: cardiovascular risk and its associated factors in the Chinese elderly—a study protocol of a prospective study design

IntroductionCardiovascular (CV) diseases are the leading cause of death and disability in the world. Increasing lifespans and ageing populations also contribute to an increasing CV burden. However, in China, there...

Endothelial function assessed by peripheral arterial tonometry is not related to cardiovascular risk score in healthy subjects

&lt;p&gt;&lt;span style="font-size: medium;"&gt;&lt;strong&gt;Background: &lt;/strong&gt;The majority of first cases of myocardial infarction stem from those classified as intermediate- or low-risk in CV risk prediction calculators. Risk prediction models need to be refined in their capacity to discriminate high-risk from low-risk. Peripheral arterial tonometry (PAT) is a non-invasive method to assess peripheral endothelial function that could potentially improve primary prevention of CVD. We investigated the relation of PAT results to CV risk factors and risk score in a healthy cohort.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;span style="font-size: medium;"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;PAT measurements were performed on 102 individuals, with no previous history of CAD, attending a Risk Preventive Clinic.&lt;strong&gt; &lt;/strong&gt;Traditional CV risk factors were evaluated and integrated into a CV risk score calculator. Outcome was expressed as absolute and relative 10-year risk of developing CVD. &lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;span style="font-size: medium;"&gt;Results: &lt;/span&gt;&lt;/strong&gt;&lt;span style="font-size: medium;"&gt;PAT results of reactive hyperemia index (RHI) and augmentation index (AI) had no statistically significant relation to risk score while baseline pulse amplitude was positively correlated with both absolute (&lt;em&gt;p &lt;/em&gt;= 0.02) and relative (&lt;em&gt;p &lt;/em&gt;= 0.02) 10-year risk of developing CVD. Among CV risk factors only heart rate was significantly associated with RHI (r = - 0.24, R&lt;/span&gt;&lt;sup&gt;&lt;span style="font-size: small;"&gt;2&lt;/span&gt;&lt;/sup&gt;&lt;span style="font-size: medium;"&gt; = 0.06, &lt;em&gt;p&lt;/em&gt; = 0.01). AI and baseline pulse amplitude both correlated with several risk factors.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;span style="font-size: medium;"&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Endothelial dysfunction, as measured by PAT, was not associated with an increased 10-year risk of developing CVD. The relation between endothelial dysfunction and established CV risk factors was limited. Further clinical end point studies are needed to fully comprehend the diagnostic and predictive value of PAT measurements in healthy subjects.&lt;/span&gt;&lt;/p&gt;

O41 Serum Vascular Cell Adhesion Molecule 1 Levels are Associated with Vascular Dysfunction and Increased Cardiovascular Risk in an Animal Model and Patients with Rheumatoid Arthritis

Background: Mortality is increased in RA patients, mainly due to cardiovascular (CV) disease; however, the biologic mechanisms are unknown. Increased CV risk in RA is attributed to both traditional risk factors and systemic inflammation. CV risk scores, even after modification as recommended by EULAR, underestimate risk in RA and thus there is a need to develop a better means of risk stratification. Murine collagen-induced arthritis (mCIA) is associated with vascular dysfunction, characterized by reduced vascular constriction to 5- hydroxytryptamine (5-HT). This study was undertaken to characterize the relationship between vascular cell adhesion molecule 1 (VCAM-1), which is induced in pro-atherosclerotic conditions in the general population and vascular dysfunction in mCIA and CV risk in RA patients. Methods: mCIA was induced in DBA/1 mice. The severity of arthritis was assessed by the arthritis index score. Constriction responses to 5- HT were used to assess vascular function in isolated sections of thoracic aorta. Serum VCAM-1 was measured with ELISA. Serum VCAM-1, IL-6, ESR and CRP were measured with ELISA in RA patients [182 patients, 4 female:1 male, mean age 60 years (range 21–89), mean disease duration 11.4 years (S.D. 11)]. CV risk was calculated using the Framingham risk calculator and the QRISK2 algorithm. The latter includes RA as an independent CV risk factor. Results: In mCIA, VCAM-1 levels [mean 1500 mg/ml range (929–2528)] correlated with the arthritis index score (r¼0.43, P¼0.03) and negatively correlated with maximal aortic contraction (r¼�0.35, P<0.05). In patients with RA, VCAM-1 was significantly higher in those with a Framingham CV risk score >10% over 10 years [1200 ng/ ml (S.D. 547)] compared with those with <10% risk [937 ng/ml (S.D. 570), P¼0.02]. Similarly, the respective VCAM-1 levels using the QRISK2 were 1179 ng/ml (S.D. 583) vs 949 (S.D. 564), P<0.05]. VCAM-1 was positively correlated with IL-6 levels (r¼0.24, P¼0.008), 28-joint DAS (r¼0.25, P¼0.03) and age (r¼0.26, P¼0.002). There was no statistically significant correlation between VCAM-1 level and disease duration, statin use, BMI, cholesterol, systolic blood pressure, gender or smoking. One of the major differences between QRISK2 and Framingham is inclusion of RA as an independent risk factor in the former. QRISK2 and Framingham CV risk scores were moderately correlated (r¼0.7, P<0.0001). Multivariate analysis using backward stepwise multiple regression found that VCAM-1 (P¼0.002) was a statistically significant independent predictor of QRISK2 score when added to the Framingham score and increased r from 0.6 to 0.62. Conclusion: VCAM-1 levels correlate not only with disease activity and vascular dysfunction in mCIA, but also disease activity and CV risk in RA. VCAM-1 is a potential biomarker for CV disease in RA that warrants further investigation.

Comparison on Statin Use among Hypertensive Patients between Framingham Risk Score and Pooled Cohort Risk Score

Background: Statin is recommended for individuals with an estimated Framingham Risk Score (FRS) of >20%. The 2013 ACC/AHA recommends statins for those with a pooled cohort risk score (PCRS) ≥7.5%. Objectives: To compare statin use in different CV risk categories of FRS and PCRS. Methods: This was a retrospective review study conducted at a primary care clinic in Kuala Lumpur, Malaysia. 883 medical records of hypertensive patients that have attended the clinic for at least one year were selected through systematic random sampling (1:4). CV risk scores were calculated for each individual using FRS and PCRS. FRS has three risk groups: low (<10%), medium (10–20%) and high (>20%). The PCRS is defined as low (<7.5%) and high (≥7.5%). Results: The mean age of the patients was 61.1 ± 10.5 years and 61.7% were females, 658 (74.5%) were on statin. The proportion of statin use in different risk groups was: 74.6% (262) in FRS high risk, 76.1% (526) in the FRS medium and high risk, 78.0% (521) in the pooled cohort high risk. Significant associations were found between statin use and risk category based on PCRS (low versus high) (p < 0.001) as well as FRS (low versus medium and high) (p = 0.038). No significant association was found in FRS (low and medium versus high), p = 0.945. Conclusions: Statins are given in FRS medium and high risk group as well as pooled high risk group. Nearly a quarter of FRS high risk group were not on statin. Emphasis should be placed on treating those in high risk.

SAT0121 Cardiovascular Risk Factors and Outcomes in Patients with Rheumatoid Arthritis across 7 Countries

BackgroundPatients with rheumatoid arthritis (RA) have an increased risk of cardiovascular disease (CVD). CV risk factors and scoring algorithms vary by country but comparisons have not been performed for RA.ObjectivesTo...

FRI0070 High Prevalence of Subclinical Cardiovascular Disease and Abnormal Left Ventricular Geometry Detected by CMR in Asymptomatic Rheumatoid Arthritis Patients

BackgroundCardiac MRI (CMR) has merit in the assessment of cardiovascular disease (CVD) with increased left ventricular mass/end-diastolic volume (LVmass/EDV) associated (ass.) with greater CV risk.[1] CMR-RA studies are few; unclear...

Left atrial dimension and traditional cardiovascular risk factors predict 20-year clinical cardiovascular events in young healthy adults: the CARDIA study.

We investigated whether the addition of left atrial (LA) size determined by echocardiography improves cardiovascular risk prediction in young adults over and above the clinically established Framingham 10-year global CV risk score (FRS). We included white and black CARDIA participants who had echocardiograms in Year-5 examination (1990-91). The combined endpoint after 20 years was incident fatal or non-fatal cardiovascular disease: myocardial infarction, heart failure, cerebrovascular disease, peripheral artery disease, and atrial fibrillation/flutter. Echocardiography-derived M-mode LA diameter (LAD; n = 4082; 149 events) and 2D four-chamber LA area (LAA; n = 2412; 77 events) were then indexed by height or body surface area (BSA). We used Cox regression, areas under the receiver operating characteristic curves (AUC), and net reclassification improvement (NRI) to assess the prediction power of LA size when added to calculated FRS or FRS covariates. The LAD and LAA cohorts had similar characteristics; mean LAD/height was 2.1 ± 0.3 mm/m and LAA/height 9.3 ± 2.0 mm(2)/m. After indexing by height and adjusting for FRS covariates, hazard ratios were 1.31 (95% CI 1.12, 1.60) and 1.43 (95% CI 1.13, 1.80) for LAD and LAA, respectively; AUC was 0.77 for LAD and 0.78 for LAA. When LAD and LAA were indexed to BSA, the results were similar but slightly inferior. Both LAD and LAA showed modest reclassification ability, with non-significant NRIs. LA size measurements independently predict clinical outcomes. However, it only improves discrimination over clinical parameters modestly without altering risk classification. Indexing LA size by height is at least as robust as by BSA. Further research is needed to assess subgroups of young adults who may benefit from LA size information in risk stratification.

Awareness and use of cardiovascular risk scores by family physicians in southeastern Ontario

Background: Our objective was to determine the assessment of cardiovascular risk by family physicians. Methods: A questionnaire was sent by mail or fax regarding both awareness and use of the various CV risk scores in southeastern Ontario. Results: Of 181 family physicians surveyed, 96% were aware of at least one CV risk score and 40% were aware of the JUPITER study. Despite this awareness, 72% simply counted risk factors to assess risk, rather than to calculate risk using established scoring methods. Only 23% used the JUPITER study criteria. This suggests an under-estimated of overall CV risk by family physician’s practicing in southeastern Ontario. Interpetation: Cardiovascular risk in primary care is being underestimated in southeastern Ontario. Additional knowledge translation strategies are required to enhance the family physician’s awareness and use of established risk scoring methods if we are to reduce the burden of CV disease.

Cardiovascular risk assessment of South Asians in a religious setting: a feasibility study

South Asians in the UK have high cardiovascular disease (CVD) mortality. Therefore, this population is likely to benefit from screening programmes. To address this issue, an initiative was set up between the Royal Free Hampstead NHS Trust, H.E.A.R.T. UK and two Hindu temples in North London to provide screening for CVD risk factors in the community. A total of 434 individuals of Gujarati Indian origin were screened. Measurements included anthropometry, blood pressure and lipid profiles. Three different scoring systems: Framingham, Joint British Societies' 2 and QRISK2 were used to estimate CVD risk. At least one modifiable CVD risk factor was present in 92% of the individuals screened; 52% were hypertensive, 40% were obese, 75% had central adiposity and 10% had total cholesterol/high density lipoprotein cholesterol ratio > 6. In addition, 37% of a subset of 104 individuals with a fasting sample fulfilled the diagnostic criteria for metabolic syndrome. Overall, 15% of participants screened had a 10-year CV risk score > 20% using QRISK2. The three risk score calculators showed moderate agreement: QRISK2 and JBS2 (kappa 0.61, 95% CI 0.54-0.67), QRISK2 and Framingham (kappa 0.63, 95% CI 0.57-0.70) and JBS2 and Framingham (kappa 0.70, 95% CI 0.64-0.75). A high prevalence of modifiable risk factors for CVD was detected in the population screened.

Gender-based cardiometabolic risk evaluation in minority and non-minority men grading the evidence of non-traditional determinants of cardiovascular risk

To the Editor: We read with interest the review entitled ‘Gender-based cardiometabolic risk evaluation in minority and non-minority men grading the evidence of non-traditional determinants of cardiovascular risk’ (1). This review highlights the relevance of surrogate markers for the evaluation of vascular risk. South Asians formed 4% of the UK population in 2001 and they are at a high risk of vascular events (2,3). We screened 1027 Gujrati Indians (both genders) in faith based settings. Our preliminary analysis (n = 434) shows that at least one modifiable risk factor was present in 92% of those screened, 15% of the participants screened had a 10 year CV risk score >20% using QRISK2. Central adiposity (according to the 2009 consensus definition of metabolic syndrome) (4) was present in 75% of subjects. Therefore, this population has a high prevalence of metabolic syndrome and central obesity which are discussed in the Billups et al. review (1). In line with the review of Billups et al. (1), we will include some of the surrogate markers of vascular risk in our screening programme. For example, we will measure arterial stiffness, ankle-brachial index and carotid intima media thickness. We will also be using Point of Care Testing (5) to measure glycated haemoglobin and microalbuminuria. Hopefully, increasing the number of markers of vascular risk will help to estimate risk better in primary prevention as well as to potentially monitor the success of treatment in both primary and secondary prevention. AJ, DH, LR have no competing interests to disclose. DRN has received grants from Pfizer (Pfizer Foundation award 2008), Abbott, Merck Sharp & Dohme, and Astra Zeneca for this service. DRN has advisory board membership for Merck Sharp & Dohme and Roche. DRN is a speaker for Merck Sharp & Dohme, Abbott and Pfizer. DPM has advisory board membership and is a speaker for Merck Sharp & Dohme and Genzyme.

Target organ damage in a population at intermediate cardiovascular risk, with adjunctive major risk factors: CArdiovascular PREvention Sacco Study (CAPRESS)

The objective of the study is to assess the prevalence of target organ damage (TOD) at carotid, cardiac, renal and peripheral vascular levels in a population at intermediate cardiovascular risk, with adjunctive major risk factors (AMRF). From March 2007 to July 2009 we examined 979 subjects at intermediate cardiovascular risk, as indicated by the Italian algorithm "Progetto Cuore"; the patients were aged 40-69years, sensitized by one or more AMRF such as family history for cardiovascular disease (CVD), being overweight or obese, and smoking habit (more than 10 cigarettes/day). We measured common carotid intima-media thickness (cc-IMT) and plaque at any level, left ventricular mass index (LVMI), urine albumin/creatinine ratio (UACR), and ankle-brachial index (ABI). The prevalence of at least one TOD was 63% (617 subjects), cc-IMT was high in 48.2% (472), UACR abnormal in 14.1% (138), LVMI high in 12.6% (117) and ABI pathological in 9.1% (89). In those with carotid damage 423 had a plaque, amounting to 43.2% of the total population. Of note, carotid damage was present in all subjects with 3 TODs, and in 92% of subjects with 2 TODs. A multivariate logistic regression model including conventional factors and AMRF indicated that age 50-69years, systolic blood pressure, relevant smoking and CV risk score ≥15 were independently and significantly associated with at least one TOD, and at least, with carotid damage. Among the AMRF, peripheral arterial disease was associated with relevant smoking, with an odds ratio (OR) of 3 [confidence interval (CI) 1.80-4.97, p<0.0001]; overweight and obesity both had selective associations with cardiac damage with OR 2.75 (CI 1.2-6.3, p<0.01) and OR 3.89 (CI 1.61-9.73, p<0.01). A substantial proportion of people at intermediate risk, with at least one AMRF have at least one TOD, a major predictor of cardiovascular outcomes.

Joint and distinct risk factors associated with micro- and macrovascular complications in a cohort of type 2 diabetic patients cared through disease management

We analysed the risk factors associated with diabetic complications in the cohort of patients assisted by a type 2 diabetes mellitus (T2DM) shared-care program. We analysed registry data from 16,136 T2DM patients. Of them, 4,781 had microangiopathy, 3,469 CV events. They were 70.5 ± 17.1 years old, 50% were male, disease duration 13.3 ± 7.8 years, BMI 28.7 ± 4.9 kg/m², HbA1c 7.08 ± 1.23%, FBG 134.7 ± 35.7 mg/dl, 2hPPBG 163.9 ± 47.8 mg/dl, 12.5% smokers. Cholesterol 202.5 ± 37.6 mg/dl, HDL 51.4 ± 20.4 mg/dl, LDL 126.5 ± 36.0 mg/dl, triglyceride 146.2 ± 72.4 mg/dl, SBP 137.8 ± 14.2 mmHg, DBP 80.7 ± 10.8 mmHg, 10-year CV risk score 13.7 ± 9.1; 70.4% had no microangiopathy-i.e. renal, retinal, peripheral nerve disease-and 78.5% of patients had no CV events. Age-adjusted risk factors associated with diabetic complications were male gender, HbA1c, 2hPPBG, HDL, and triglyceride. FBG and SBP were associated with microangiopathy, whereas smoking with cardiovascular events. Optimal targets were reached in: FBG 17%, 2hPPBG 8%, HbA1c 21%, cholesterol 17%, HDL 8%, LDL 5%, triglyceride 20%, SBP 13%, DBP 30%. Drug profiles showed 13% using metformin, 28% sulphonilureas, 26% bitherapy, 4% insulin; 12% statins, 16% anti-platelets, 27% anti-hypertensives, 2% anti-coagulants. T2DM patients showed an acceptable CV risk profile. Joint risk factors for diabetic complications were male gender, HbA1c, 2hPPBG, HDL, and triglyceride. Distinct risk factors were FBG and SBP for micro- and smoking for macrovascular disease. A targeted-to-treat approach needs more attention in the care of T2DM patients.

Stemming the tide: reducing cardiovascular disease and renal failure in Australian Aborigines*

An epidemic of cardiovascular disease (CVD) and end stage renal disease (ESRD) has developed among Aborigines in the Northern Territory; CVD deaths increased over the 1980s (tripling among women!), and are now more than five times those of non-Aboriginal people, while ESRD rates are increasing more than 20-fold and are doubling every three to four years. Dialysis costs (>$75,000 per person/year) pose a crisis for health care budgets, but premature mortality is the greater human catastrophe. Health services are not meeting the challenge of timely diagnosis, prevention and containment. We screened 90% of adults (20+ years) in one community, with CVD mortality among the highest in Australia, and ESRD rates increased 60-fold. Seventy-five per cent of persons were smokers. Central obesity was common, but BMIs only modestly increased by Caucasian standards, 23% had hypertension (>140/90), 29% had diabetes or impaired glucose tolerance (IGT) (peaking at 65% of persons aged 40-49 years), high triglyceride and insulin levels were common, and 55% had albuminuria (albumin/creatinine ratio (ACR), >3.4 gm/moL). Progressive albuminuria predicted renal failure. ACR was correlated with age, BMI, blood pressure, lipid, glucose and insulin levels, heavy drinking and past and current skin infections, and, inversely with birth weight. ACR correlated strongly with a composite CV risk score, and in a two to five year follow-up, microalbuminuria (ACR 3.4-33) and overt albuminuria (ACR 34+) have both predicted increased rate of premature death from natural causes of lower ACRs. Thus albuminuria marks CV risk/disease. This implies that renal and CV disease share common risk factors, and should respond to the same interventions, and that this response might be monitored through ACR levels. Robust public health programmes could reduce all these reversible risk factors, lowering disease rates over the intermediate term, however, few such programmes are in place. Modification of disease in persons already afflicted is a parallel responsibility. To this end, in November 1995, we introduced a treatment programme with Coversyl (perindopril, Servier) for all persons in the study community with hypertension (>140/90), for all diabetics with ACR 3.4+ and for all nondiabetic, non-hypertensive persons with progressive overt albuminuria (ACR 34+). One-quarter of all adults, or 224 persons have enrolled; 162 have reached one year of treatment and 100 have passed two years. Compliance is reasonable and enthusiasm high. Average SBP has fallen 12 mmHg (24 mmHg in hypertensive persons), while average ACR and estimated glomerular filtration rate (GFR) have stabilised. This contrasts favourably with the pretreatment course (average 2.7 years) in the same persons, when SBP had increased by 3 mmHg, ACR had increased by 15% and GFR had decreased by 3.5 mL/min each year. Cautious estimates suggest a >50% fall in ESRD, and a reduction in all-cause and CV deaths, even at this early stage, although more extended observation is needed. These data predict a dramatic and rapid fall in morbidity, premature deaths and health care costs if these basic principles of medical care are extended to all Aboriginal people. A national, concerted, multi-disciplinary effort to implement a coherent, effective strategy to this end is of great urgency.