Cardiovascular Disease Risk Estimation Research Articles

Assessing Glycosylated Hemoglobin Thresholds for Development of Cardiovascular Disease by Racial and Ethnic Groups.

Diabetes is the strongest risk factor for cardiovascular disease, and although glycosylated hemoglobin (HbA1c) levels are known to vary by race, no racial and ethnic-specific diagnostic thresholds exist for diabetes in prediction of cardiovascular disease events. The purpose of this study is to determine whether HbA1c thresholds for predicting major adverse cardiovascular events (MACEs) differ among racial and ethnic groups. This is a retrospective cohort study of Kaiser Permanente Northern California adult members (n=309 636) with no history of cardiovascular disease who had HbA1c values and race and ethnicity data available between 2014 and 2019. Multivariable logistic regression was used to evaluate the odds of MACEs by the following racial and ethnic groups: Filipino, South Asian, East Asian, Black, White, and Hispanic. A Youden index was used to calculate HbA1c thresholds for MACE prediction by each racial and ethnic group, stratified by sex. Among studied racial and ethnic groups, South Asian race was associated with the greatest odds of MACEs (1.641 [95% CI, 1.456-1.843]; P<0.0001). HbA1c was a positive predictor for MACEs, with an odds ratio of 1.024 (95% CI, 1.022-1.025) for each 0.1% increment increase in HbA1c. HbA1c values varied between 6.0% and 7.6% in MACE prediction by race and ethnicity and sex. White individuals, South Asian individuals, East Asian women, and Black men had HbA1c thresholds for MACE prediction in the prediabetic range, between 6.0% and 6.2%. Black women, Hispanic men, and East Asian men had HbA1c thresholds of 6.2% to 6.6%, less than the typical threshold of 7.0% that is used as a treatment goal. Findings suggest that the use of race and ethnic- and sex-specific HbA1c thresholds may need to be considered in treatment goals and cardiovascular disease risk estimation.

ASSESSMENT OF CARDIOVASCULAR RISK IN PATIENTS WITH RHEUMATOID ARTHRITIS ACCORDING TO CURRENT HYPERTENSION GUIDELINES

Objective: Patients with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD) by as much as 50% compared to the general population. Considering that disease-specific calculators have failed to provide more accurate CVD risk stratification in RA, CVD risk calculation in RA patients is challenging, especially for those who are not by definition at high risk based on concomitant established CVD or its equivalents. The presence of an immune-mediated inflammatory disease (e.g., RA) has been considered as a CVD risk modifier by the previous 2018 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines. Nevertheless, current 2023 ESH/ESC guidelines recommend assessment in RA using general CVD risk calculators. Design and method: We aimed to calculate CVD risk in RA patients using the most frequently applied CVD risk calculators in the general population. We only stratified patients free from established CVD (heart disease, stroke) or its equivalents (diabetes mellitus, chronic kidney disease) aged 40-74 years. The following algorithms were applied: (i) SCORE2 (Systemic Coronary Risk Estimation-2), (ii) Framingham Risk Score-Adult Treatment Panel (FRS-ATP) CVD risk calculator, and (iii) the American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Equation. We further correlated the estimated CVD risk by each algorithm with surrogate CVD markers, i.e. arterial stiffness and carotid atherosclerosis. For this purpose, carotid-femoral pulse wave velocity (cfPWV) was measured using applanation tonometry (Sphygmocor ®), and carotid intima-media thickness (cIMT) was estimated using carotid ultrasound. Results: A total of 91 patients aged 60.3±8.1 years were included (78% females). Using the FRS-ATP algorithm, more patients were classified as high risk and fewer as low risk compared to the other calculators (Table 1). Moreover, CVD risk calculated with FRS-ATP correlated stronger with both cfPWV and cIMT, compared to CVD risk calculated with the other algorithms (Table 2). Conclusions: In RA patients without established CVD, diabetes, or chronic kidney disease, the FRS-ATP algorithm may be applied as a useful tool for CVD risk stratification. Prospective, large-scale studies are warranted to determine the most reliable CVD risk prediction model for patients with RA.

The correlation between liver fibrosis and the 10‐year estimated risk of cardiovascular disease in adults with metabolic‐associated fatty liver disease: A cross‐sectional study in Vietnam

AbstractBackground and AimsMetabolic‐associated fatty liver disease (MAFLD) emerged as a novel term replacing nonalcoholic fatty liver disease (NAFLD) in 2020. While most MAFLD patients are asymptomatic, long‐term hepatic fat accumulation may lead to liver fibrosis and cardiovascular disease (CVD). Nevertheless, the relationship between MAFLD and cardiovascular (CV) risk factors remains unclear. This study aimed to assess the 10‐year estimated CVD risk in individuals diagnosed with MAFLD.MethodsBetween January 2022 and August 2023, this cross‐sectional study enrolled 139 MAFLD patients. We employed the systematic coronary risk evaluation 2 (SCORE2) and the systematic coronary risk evaluation 2–older persons (SCORE2‐OP) scoring systems to evaluate and categorize the 10‐year CV risk. Liver fibrosis was assessed using biochemical parameters (FIB‐4, AST/ALT, and APRI), and their correlation with CV risk was examined.ResultsMost MAFLD patients were categorized as having high or very high CV risk based on the SCORE2 and SCORE2‐OP. Liver fibrosis, measured by the FIB‐4 score, significantly differed among the various CV risk groups. Moreover, FIB‐4 correlated positively with SCORE2 and SCORE2‐OP (r = 0.588, p &lt; 0.001), indicating its substantial predictive ability for identifying individuals at very high CV risk (AUC = 0.765, 95% CI: 0.686–0.845, p &lt; 0.001). A FIB‐4 score of 1.275 demonstrated 81% sensitivity and 64% specificity in predicting very high CV risk among MAFLD patients.ConclusionPatients with MAFLD predominantly face high or very high CV risks, with elevated liver fibrosis associated with increased 10‐year estimated CVD risk. The FIB‐4 score exhibits promising predictive value for identifying MAFLD patients at very high risk of CV disease.

Assessing, communicating and managing cardiovascular disease risk: a practical summary of the 2023 guideline.

The outdated cardiovascular disease risk calculator has been reported to overestimate cardiovascular disease risk for a contemporary Australian population, and does not include relevant variables, such as socioeconomic disadvantage, which has been shown to increase the incidence of both heart attack and stroke. The 2023 Australian Guideline for Assessing and Managing Cardiovascular Disease Risk marks a major milestone as the first update to Australia's cardiovascular disease prevention guideline in over a decade. The new guideline may help to refine and recategorise risk estimates, hence improving the discriminatory and predictive value of the new calculator. The new Australian Cardiovascular Disease Risk Calculator expresses risk scores as a percentage estimate of a person's probability of dying or being hospitalised due to cardiovascular disease within the next 5 years. The new calculator expresses risk scores as low (less than 5%), intermediate (5% to less than 10%), or high (10% or higher) risk over 5 years. Reclassification factors built into the new calculator are designed to help clinicians individualise risk estimates. These factors include ethnicity (e.g. First Nations status), family history of premature cardiovascular disease, severe mental illness, kidney disease and coronary artery calcium score. The new calculator also uses optional diabetes-specific variables (supporting a more granular cardiovascular disease risk assessment of people with type 2 diabetes). People who meet the clinically determined high-risk criteria (chronic kidney disease, familial hypercholesterolaemia) should not progress through the Australian Cardiovascular Disease risk calculator, but move straight to management. For a person with a cardiovascular disease risk score recorded from the outdated calculator, clinicians may want to reassess their risk using the new calculator the next time the person attends.

“They are saying it’s high, but I think it’s quite low”: exploring cardiovascular disease risk communication in NHS health checks through video-stimulated recall interviews with patients – a qualitative study

BackgroundNHS Health Check (NHSHC) is a national cardiovascular disease (CVD) risk identification and management programme. However, evidence suggests a limited understanding of the most used metric to communicate CVD risk with patients (10-year percentage risk). This study used novel application of video-stimulated recall interviews to understand patient perceptions and understanding of CVD risk following an NHSHC that used one of two different CVD risk calculators.MethodsQualitative, semi-structured video-stimulated recall interviews were conducted with patients (n = 40) who had attended an NHSHC using either the QRISK2 10-year risk calculator (n = 19) or JBS3 lifetime CVD risk calculator (n = 21). Interviews were transcribed and analysed using reflexive thematic analysis.ResultsAnalysis resulted in the development of four themes: variability in understanding, relief about personal risk, perceived changeability of CVD risk, and positive impact of visual displays. The first three themes were evident across the two patient groups, regardless of risk calculator; the latter related to JBS3 only. Patients felt relieved about their CVD risk, yet there were differences in understanding between calculators. Heart age within JBS3 prompted more accessible risk appraisal, yet mixed understanding was evident for both calculators. Event-free survival age also resulted in misunderstanding. QRISK2 patients tended to question the ability for CVD risk to change, while risk manipulation through JBS3 facilitated this understanding. Displaying information visually also appeared to enhance understanding.ConclusionsEffective communication of CVD risk within NHSHC remains challenging, and lifetime risk metrics still lead to mixed levels of understanding in patients. However, visual presentation of information, alongside risk manipulation during NHSHCs can help to increase understanding and prompt risk-reducing lifestyle changes.Trial registrationISRCTN10443908. Registered 7th February 2017.

2023 Australian guideline for assessing and managing cardiovascular disease risk.

The 2023 Australian guideline for assessing and managing cardiovascular disease risk provides updated evidence-based recommendations for the clinical assessment and management of cardiovascular disease (CVD) risk for primary prevention. It includes the new Australian CVD risk calculator (Aus CVD Risk Calculator), based on an equation developed from a large New Zealand cohort study, customised and recalibrated for the Australian population. The new guideline replaces the 2012 guideline that recommended CVD risk assessment using the Framingham risk equation. The new guideline recommends CVD risk assessment in people without known CVD: all people aged 45-79 years, people with diabetes from 35 years, and First Nations people from 30 years. The new Aus CVD Risk Calculator should be used to estimate and categorise CVD risk into low (< 5% risk over five years), intermediate (5% to < 10% risk over five years) or high risk (≥ 10% over five years). The following reclassification factors may be applied to recategorise calculated risk to improve accuracy of risk prediction, particularly in individuals close to a risk threshold: Indigenous status/ethnicity, estimated glomerular filtration rate, urine albumin to creatinine ratio measurements, severe mental illness, coronary artery calcium score and family history of premature CVD. A variety of communication formats is available to communicateCVD risk to help enable shared decision making. Healthy lifestylemodification, including smoking cessation, nutrition, physical activity and limiting alcohol, is encouraged for all individuals. Blood pressure-lowering and lipid-modifying pharmacotherapies should be prescribed for high risk and considered for intermediate risk individuals, unless contraindicated or clinically inappropriate. Reassessment of CVD risk should be considered within five years for individuals at low risk and within two years for those with intermediate risk. Reassessment of CVD risk is not recommended for individuals at high risk. CHANGES IN ASSESSMENT AND MANAGEMENT AS A RESULT OF THE GUIDELINE: The updated guideline recommends assessment over a broader age range and uses the Aus CVD Risk Calculator, which replaces the previous Framingham-based equation. It incorporates new variables: social disadvantage, diabetes-specific risk markers, diagnosis of atrial fibrillation and use of blood pressure-lowering and lipid-modifying therapies. Reclassification factors are also a new addition. Updated risk categories and thresholds are based on the new AusCVD Risk Calculator. The proportion of the population in the high risk category (≥ 10% over five years) is likely to be broadly comparable to more than 15% risk from the Framingham-based equation. The full guideline and Aus CVD Risk Calculator can be accessed at www.cvdcheck.org.au.

Comparison of American College of Cardiology/American Heart Association Cardiovascular Risk Score, Framingham Risk Scores, European Society of Cardiology Cardiovascular Disease Risk Calculator, QRISK3-2018 Risk Calculator in Patients Presenting with First Time with Myocardial Infarction: A Step toward the Development of Indian Cardiac Risk Score

Introduction: One of the primary reasons for fatalities and impairments on a global scale is cardiovascular disease (CVD), encompassing a cluster of illnesses impacting the heart and blood vessels. A CVD risk assessment is a screening tool that measures an individual’s risk of developing CVD. Objective: The objective of this study was to compare and evaluate cardiovascular risk using internationally recognized CVD risk scoring systems. Methodology: A prospective, cross-sectional study was carried out for 2 months after the approval of the ethics committee. Naive myocardial infarction (MI) patients presenting to the cardiology department and conforming to the inclusion criteria were enrolled in the study. Patients who are taking statins or any lipid-lowering drugs, as well as patients who are on low-dose aspirin and antidiabetic medications. Using the aforementioned gathered data, the cardiovascular risk scores were computed employing the American College of Cardiology/American Heart Association (ACC/AHA), Framingham risk scores (FRS), European Society of Cardiology (ESC) – CVD risk calculator, and QRISK→3-2018, and subsequently categorized as low risk, intermediate, or high risk based on the individual risk scores. Results: We enrolled 42 patients, with a mean age of 60 years with male dominance. The mean body mass index was 25.5. With a cholesterol/high-density lipoprotein (HDL) ratio of 4.9, the mean systolic blood pressure/diastolic blood pressure was 126/77 mm of Hg. The mean ACC/AHA cardiovascular risk score for 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 11.34%, FRS mean score was 12%, ESC CVD risk calculator mean score was 15.45%, and QRISK3-2018 risk calculator mean score was 20.87% in patients presenting with first time with MI. Conclusion: QRISK3-2018 risk calculator is the most effective out of all the risk calculators with a maximum detection rate of MI in first time presented patients with Naïve MI patients.

Low income and education are associated with greater ASCVD risk scores among adults in the US

IntroductionSocial determinants of health (SDOH) are fundamental causes of poor cardiovascular health, yet cardiovascular disease (CVD) risk assessment tools exclude SDOH. Our objective was to determine whether SDOH are independently associated with CVD risk in US adults. MethodsUtilizing the National Health and Nutrition Examination Survey (NHANES), we combined years 1999–2018 and included participants aged 40–79 without history of CVD and with information to calculate CVD risk (n = 21,694). Ten-year risk of atherosclerotic CVD (ASCVD) was calculated using the American Heart Association/American College of Cardiology (AHA/ACC) pooled cohort equations. We used linear regression models to estimate the association between SDOH and ASCVD risk, after adjusting for demographic factors. All analyses accounted for the complex survey design. ResultsMean age was 54.7 years, with 52.7 % female, 73.8 % non-Hispanic White, 9.4 % non-Hispanic Black, and 10.7 % Hispanic. From adjusted models, compared with an income of ≥ $75 K, ASCVD risk was greater by 3.06 (95 % CI: 2.65, 3.47) among those with income < $25 K, by 1.55 (95 % CI: 1.21, 1.89) among those with income $25 K–<$55 K, and by 1.20 (95 % CI: 0.84, 1.56) among those with income $55 K–<$75 K. Compared to college graduates, ASCVD risk was greater by 3.09 (95 % CI: 2.56, 3.62) among those with less than a high school education, by 1.65 (95 % CI: 1.31, 200) among those who were high school graduates, and by 1.41 (95 % CI: 1.11, 1.72) among those with some college education. ConclusionWe found strong graded associations between lower income and lower educational attainment with greater CVD risk.

Cardiovascular Disease Risk in Individuals Following Plant-Based Dietary Patterns Compared to Regular Meat-Eaters.

Plant-based diets (PBDs) have been associated with a lower risk of cardiovascular disease (CVD). The aim was to investigate the predicted 5-year and 10-year risk of developing CVD in individuals following PBDs compared to regular meat-eating diets. This cross-sectional study included n = 240 middle-aged adults habitually consuming dietary patterns for ≥6 months: vegan, lacto-ovo vegetarian (LOV), pesco-vegetarian (PV), semi-vegetarian (SV) or regular meat-eater (RME) (n = 48 per group). Predicted 5-year and 10-year CVD risks were quantified using the Framingham Risk Equation and the Australian Absolute CVD risk calculator, respectively. Multivariable regression analysis was used to adjust for age, sex, smoking status, physical activity, alcohol use and BMI. Over three-quarters of the participants were women, mean age of 53.8 yrs. After adjustments for potential confounders, there was no difference in the predicted risk of CVD between regular-meat diets and PBDs, although crude analyses revealed that vegans had a lower 5-year and 10-year predicted risk of CVD compared to RMEs. SVs, PVs and LOVs had lower CVD risk scores, however, not significantly. Vegans had a favourable cardiometabolic risk profile including significantly lower serum lipid levels, fasting blood glucose and dietary fats and higher dietary fibre intake compared to RMEs. This was the first study to purposefully sample Australians habitually following PBDs. We found that PBDs do not independently influence the predicted risk of CVD, although PBDs tended to have lower risk and vegans had significantly lower cardiometabolic risk factors for CVD.

Predictive performance of machine learning compared to statistical methods in time-to-event analysis of cardiovascular disease: a systematic review protocol

BackgroundGlobally, cardiovascular disease (CVD) remains the leading cause of death, warranting effective management and prevention measures. Risk prediction tools are indispensable for directing primary and secondary prevention strategies for CVD...

Cardiovascular disease risk in Australians following plant-based dietary patterns compared to regular meat eaters

The adoption of dietary patterns emphasising higher intakes of plant foods and lower intakes of animal foods (plant-based diets, PBDs), continue to rise worldwide. PBDs have been associated with a lower risk of cardiovascular morbidity and mortality as well as major risk factors such as overweight/obesity and type 2 diabetes. Evidence regarding the dietary profile and disease risk associated with various PBDs in comparison to traditional meat-eating diets are scarce within the Australian population. The aim of this study is to investigate the 5-year and 10-year risk of developing cardiovascular disease (CVD) among Australians habitually following various PBDs compared to a regular meat diet (RMD). The Plant-based Diet (PBD) Study is a cross-sectional study consisting of healthy adults between aged 30-75 years from the Hunter Region (NSW) between 2021-2023. A validated FFQ was used to assess eligibility and categorise individuals who were habitually consuming one of five dietary patterns for at least 6 months into the following groups: vegan (nil animal products), lacto-vegetarian (LOV, including eggs and dairy), pesco-vegetarian (PV, including seafood with/without dairy and eggs), semi-vegetarian (SV, minimal consumption of animal products) or RMDs (including animal meat daily or multiple times/day)(1). 5-year and 10-year CVD risk was quantified using the Framingham Risk Equation(2) and the Australian Absolute CVD risk calculator, respectively. CVD risk and other quantitative measures was compared using One-way ANOVA or Kruskal Wallis, and Chi-square or Fisher’s Exact for qualitative data. Directed acyclic graphs displayed confounding variables and mediators and a regression model was used to adjust for these. A total of 240 participants (median age 55(16), 77.5% female) with 48 participants in each group showed a significant difference in predicted 5-year risk of CVD (P&lt;0.05), however 10-year risk did not significantly differ across groups. 5-year CVD risk was significantly lower in the vegan group (1%) compared to the RMD, SV, PV, and LOV diet groups (all 2%). In comparison to a vegan diet, crude association showed those consuming a RMD had a 2.4% (95% CI 0.7, 4.1) higher 5-year risk of developing CVD, followed by 1.7% in LOV (95% CI 0.6, 2.9), 1.8% in PV (95% CI 0.5, 3), and 1.1% in SV (95% CI 0.2, 2.1). Significance was lost after adjusting for confounders such as age, gender, smoking status, alcohol intake, physical activity levels and BMI. This is the first study to purposefully sample Australians habitually following PBD, presenting novel population-based evidence for CVD risk. These findings suggest more restrictive PBDs such as vegan diets when compared to RMD may lead to lower CVD risk, however population-based longitudinal studies primary investigating the development of CVDs in the context of PBDs are warranted.

Abstract MP28: Declines in Plasma Levels of Nonnutritive Sweetener Erythritol Are Related to Two-Year Improvements in Atherosclerotic Cardiovascular Disease Risk Estimates Among Adults With Overweight and Obesity

Background: A potential adverse relationship between the consumption of low-calorie sweeteners and cardiovascular disease (CVD) risk has been proposed. High levels of circulating erythritol, a sugar alcohol (polyol) used as one of the non-nutritive sweeteners, have been recently linked to increased risks of major adverse cardiovascular events. However, associations of temporal changes in plasma erythritol and other polyols with cardiometabolic risk remain unclear. Hypothesis: We tested whether changes in plasma levels of non-nutritive sweetener erythritol and other polyols in response to weight-loss dietary interventions were associated with improved atherosclerotic cardiovascular disease (ASCVD) risk estimates and atherogenic lipoproteins among adults with overweight and obesity. Methods: This study included 804 adults (mean BMI: 32.7 [SD 3.9] kg/m 2 ) without diabetes or unstable CVD at baseline who participated in a 2-year intervention of weight-loss diets, the POUNDS Lost trial. Metabolomic profiling was performed to measure plasma erythritol and its precursor erythronate, other sugar alcohols, and low-calorie sweeteners at baseline and 6 months after randomization. The primary outcome was the change in 10-year ASCVD risk scores calculated by the validated pooled cohort equations. Two-year changes in lipid profiles and cholesterol [Chol] in lipoprotein subfractions defined by the presence or absence of apolipoprotein CIII (apoCIII) were analyzed as secondary outcomes. Results: The mean estimated value of the 10-year ASCVD risk was 4.0% at baseline; 16% of the participants were at intermediate or high ASCVD risk (score ≥7.5%). Higher levels of erythritol (per 1 SD increment: β 1.1% [SE 0.2%], p &lt;.0001) and erythronate (β 1.3% [0.2%], p &lt;.0001), as well as other sugar alcohols, such as mannitol-sorbitol, myoinositol, arabitol-xylitol ( p &lt;.0001 for all), and low-calorie sweetener saccharin ( p = 0.02), but not acesulfame ( p =0.8), were related to a higher ASCVD risk at baseline after adjusting for BMI. There was large variability in the changes in metabolite levels across participants; greater decreases in erythritol in response to the interventions were significantly related to greater reductions in ASCVD risk estimates at 6 months (per 1 SD reduction: β -0.2% [SE 0.1%]; p =0.023) and at 2 years (β -0.3% [0.1%]; p = 0.015) after adjusting for covariates, including BMI, the initial metabolite levels, and baseline ASCVD risk. The 6-month decrease in erythritol was associated with long-term (2-year) improvements in atherogenic lipids, including Chol in VLDL+LDL with apoCIII ( p &lt;0.05). Conclusions: Higher plasma levels of erythritol and other sugar alcohols were associated with greater 10-year ASCVD risk scores among adults with overweight and obesity. Weight-loss diet-induced decreases in erythritol levels were related to improved ASCVD risk and atherogenic lipid profiles.

Abstract MP22: Age-Varying Implications of Recalibration of Cardiovascular Disease Risk Prediction in a New England-Based Healthcare System

Introduction: Atherosclerotic cardiovascular disease (ASCVD) risk estimation via the 2013 Pooled Cohort Equations (PCE) overestimates risk in population-based cohorts. We evaluated its recalibration performance in a contemporary healthcare cohort. Methods: We identified 160,926 patients in the Mass General Brigham healthcare system aged 40-79 years and without prior ASCVD or lipid-lowering medication use between 2010 and 2012. Recalibration was achieved using sex- and race-specific baseline survival and risk factor distributions of the derivation (80%) set. Internal validation compared Kaplan-Meier-adjusted observed and predicted risk based on original versus recalibrated PCE. Changes in sensitivity and specificity were calculated across various treatment thresholds for each age decile. Results: Of the 160,926 patients (mean [SD] age: 54.6 [8.6] years; 61.4% female; 82.7% non-Hispanic White), 20,373 (12.7%) underwent ASCVD over 10 years. The original PCE underestimated ASCVD risk (observed vs. predicted incidence rate: 0.13 vs. 0.05) globally and across all sex, race, and risk categories. After recalibration (observed vs. predicted incidence rate: 0.13 vs. 0.18), the prediction closely mirrored the actual ASCVD incidence in low-to-borderline risk but overestimated risk in the high risk. At ≥7.5% treatment threshold, patients aged 40-49 years derived the greatest net relative benefit (sensitivity: +42.9%; specificity: -26.6%) whereas the extent of specificity loss surpassed that of sensitivity gain beyond age 50 years with minimal reclassification by seventh decade in life. Treatment threshold yielding the greatest net benefit was incrementally higher with older age from ≥7.4% in age 40-49 years to ≥24.1% in 60-69 years. Conclusion: In healthcare setting, PCE significantly underestimated risk. Recalibration recovered sensitivity at the expense of reduced specificity in age-differential manner, highlighting the need for individualized prediction and clinical decision-making.

Abstract P282: Pooled Cohort Equation Performance at Quantile Thresholds of African and European Ancestry Among Hispanic/Latino: Findings From Multi-Ethnic Study of Atherosclerosis (MESA)

Background: Current recommendations include using the non-Hispanic White (NHW) pooled cohort equation (PCE) for 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation among Hispanic individuals and the non-Hispanic Black (NHB) PCE when African ancestry is present. We studied PCE performance at thresholds of African and European ancestry among US Hispanics. Methods: Hispanic participants from the Multi-Ethnic Study of Atherosclerosis (MESA), ages 44-75 years without diabetes mellitus or prior cardiovascular disease were included. ADMIXTURE software was used to estimate quantile thresholds of continental genetic ancestry (African and European). We compared 10-year survival Kaplan-Meier estimates among Mexican Hispanics, Caribbean Hispanics and Other Hispanics using a log-rank analysis. We calculated the predicted-to-observed (P/O) ASCVD event ratios using the NHW and NHB PCE across quantile threshold of African and European ancestry. Results: 966 MESA Hispanics were stratified into: Mexican (n=504), Caribbean (n=284) or Other Hispanic (n=178). At 10-years, there were 179 ASCVD events [Mexicans (n=107), Caribbean (n=49), Other Hispanic (n=23)]. We observed overestimation using the NHW and NHB PCE as evidenced by P/O ratios &gt;1. Both PCEs performed better (P/O ratios converge toward 1) with increasing quantiles of European Ancestry and performed worse (P/O ratios diverge from 1) with increasing quantiles of African Ancestry. At a greater than 0.7 quantile of African ancestry, a sharp increase in overestimation was recorded for both PCEs. (Fig1A). Though Mexican Hispanics had the lowest ASCVD-free survival probability at 10 years’ time mark, results were not statistically significant. (Fig 1B) Conclusion: We observed overestimation in the 10-year ASCVD risk estimation using the NHW and NHB PCE among Hispanics as evidenced by P/O ratios &gt;1. Both PCEs performed better with increasing quantiles of European ancestry and performed poorly with increasing quantiles of African ancestry.

Role Played by Biochemical and Hematological Parameters in the Prediction of Cardiovascular Risk

Introduction: The term “cardiovascular diseases” (CVDs) refers to any disease affecting the heart or blood vessels. CVDs are the most common cause of death worldwide and the most responsible reason for 10% of deaths in the early 20th century. These CVDs can emerge as myocardial infarction or ischemic heart disease, stroke, and congestive heart failure. For diagnosing CVDs, physical, radiological investigations, and laboratory investigations for cardiac enzymes and lipid profile are used. In clinical practices, cardiovascular risk prediction models are very important in the identification, prevention, and staging of the severity of CVDs. Framingham Risk Score-coronary heart disease, Framingham Risk Score-cardiovascular disease, QRESEARCH-cardiovascular risk algorithm, Joint British Society risk-calculator-3, WHO/ISH CVD risk prediction charts, and Atherosclerotic Cardiovascular Disease risk-estimator are some of the available CVD risk estimators. However, many of these estimators can be used only to evaluate individuals more than 40 years and to assess the risk for 10-years. Therefore, new risk estimators are needed to overcome the deficiencies of the available risk estimators. Research have been done in novel directions; on ratios of routinely performing hematological and biochemical laboratory parameters such as Neutrophil to Lymphocyte Ratio (NLR), Platelet to Lymphocyte Ratio (PLR), and Aspartate aminotransferase to Alanine aminotransferase ratio (AST/ALT). The outcomes indicate a relationship between the above-said ratios and the risk for CVDs. &#x0D; Conclusion: On such grounds, this review describes the importance of developing a CVD risk estimator by amalgamating some of the biochemical and hematological parameters, including NLR, PLR, and AST/ALT ratios, aiming to overcome the existing shortcomings.

Changes in bile acid subtypes and improvements in lipid metabolism and atherosclerotic cardiovascular disease risk: the Preventing Overweight Using Novel Dietary Strategies (POUNDS Lost) trial

BackgroundDistinct circulating bile acid (BA) subtypes may play roles in regulating lipid homeostasis and atherosclerosis. ObjectivesWe investigated whether changes in circulating BA subtypes induced by weight-loss dietary interventions were associated with improved lipid profiles and atherosclerotic cardiovascular disease (ASCVD) risk estimates. MethodsThis study included adults with overweight or obesity (n = 536) who participated in a randomized weight-loss dietary intervention trial. Circulating primary and secondary unconjugated BAs and their taurine-/glycine-conjugates were measured at baseline and 6 mo after the weight-loss diet intervention. The ASCVD risk estimates were calculated using the validated equations. ResultsAt baseline, higher concentrations of specific BA subtypes were related to higher concentrations of atherogenic very low-density lipoprotein lipid subtypes and ASCVD risk estimates. Weight-loss diet-induced decreases in primary BAs were related to larger reductions in triglycerides and total cholesterol [every 1 standard deviation (SD) decrease of glycocholate, glycochenodeoxycholate, or taurochenodeoxycholate was related to β (standard error) –3.3 (1.3), –3.4 (1.3), or –3.8 (1.3) mg/dL, respectively; PFDR < 0.05 for all]. Greater decreases in specific secondary BA subtypes were also associated with improved lipid metabolism at 6 mo; there was β –4.0 (1.1) mg/dL per 1-SD decrease of glycoursodeoxycholate (PFDR =0.003) for changes in low-density lipoprotein cholesterol. We found significant interactions (P-interaction < 0.05) between dietary fat intake and changes in BA subtypes on changes in ASCVD risk estimates; decreases in primary and secondary BAs (such as conjugated cholate or deoxycholate) were significantly associated with improved ASCVD risk after consuming a high-fat diet, but not after consuming a low-fat diet. ConclusionsDecreases in distinct BA subtypes were associated with improved lipid profiles and ASCVD risk estimates, highlighting the importance of changes in circulating BA subtypes as significant factors linked to improved lipid metabolism and ASCVD risk estimates in response to weight-loss dietary interventions. Habitual dietary fat intake may modify the associations of changes in BAs with ASCVD risk.This trial was registered at clinicaltrials.gov as NCT00072995

Age-dependent association of central blood pressure with cardiovascular outcomes: a cohort study involving 34 289 participants using the UK biobank.

It remained unclear whether central blood pressures (BP) was more closely associated with cardiovascular disease (CVD) than brachial BP in different age groups. To investigate the age-stratified association of CVD with brachial and central BPs, and to evaluate corresponding improvement in model performance. This cohort study included 34 289 adults without baseline CVD from the UK Biobank dataset. Participants were categorized into middle-aged and older aged groups using the cut-off of age 65 years. The primary endpoint was a composite cardiovascular outcome consisting of cardiovascular mortality combined with nonfatal coronary events, heart failure and stroke. Multivariable-adjusted hazard ratios expressed CVD risks associated with BP increments of 10 mmHg. Akaike Information Criteria (AIC) was used for model comparisons. In both groups, CVD events were associated with brachial or central SBP ( P ≤ 0.002). Model fit was better for central SBP in middle-aged adults (AIC 4427.2 vs. 4429.5), but model fit was better for brachial SBP in older adults (AIC 10 246.7 vs. 10 247.1). Central SBP remained significantly associated to CVD events [hazard ratio = 1.05; 95% confidence interval (CI) 1.0-1.1] and improved model fit (AIC = 4426.6) after adjustment of brachial SBP only in the middle-aged adults. These results were consistent for pulse pressure (PP). In middle-aged adults, higher central BPs were associated with greater risks of CVD events, even after adjusting for brachial BP indexes. For older adults, the superiority of central BP was not observed. Additional trials with adequate follow-up time will confirm the role of central BP in estimating CVD risk for middle-aged individuals.

A polygenic risk score added to a QRISK®2 cardiovascular disease risk calculator demonstrated robust clinical acceptance and clinical utility in the primary care setting.

The aim of the study was to assess the real-world feasibility, acceptability, and impact of an integrated risk tool for cardiovascular disease (CVD IRT, combining the standard QRISK®2 risk algorithm with a polygenic risk score), implemented within routine primary practice in the UK National Health Service. The Healthcare Evaluation of Absolute Risk Testing Study (NCT05294419) evaluated participants undergoing primary care health checks. Both QRISK2 and CVD IRT scores were returned to the healthcare providers (HCPs), who then communicated the results to participants. The primary outcome of the study was feasibility of CVD IRT implementation. Secondary outcomes included changes in CVD risk (QRISK2 vs. CVD IRT) and impact of the CVD IRT on clinical decision-making. A total of 832 eligible participants (median age 55 years, 62% females, 97.5% White ethnicity) were enrolled across 12 UK primary care practices. Cardiovascular disease IRT scores were obtained on 100% of the blood samples. Healthcare providers stated that the CVD IRT could be incorporated into routine primary care in a straightforward manner in 90.7% of reports. Participants stated they were 'likely' or 'very likely' to recommend the use of this test to their family or friends in 86.9% of reports. Participants stated that the test was personally useful (98.8%) and that the results were easy to understand (94.6%). When CVD IRT exceeded QRISK2, HCPs planned changes in management for 108/388 (27.8%) of participants and 47% (62/132) of participants with absolute risk score changes of >2%. Amongst HCPs and participants who agreed to the trial of genetic data for refinement of clinical risk prediction in primary care, we observed that CVD IRT implementation was feasible and well accepted. The CVD IRT results were associated with planned changes in prevention strategies.

Novel Prediction Equations for Absolute Risk Assessment of Total Cardiovascular Disease Incorporating Cardiovascular-Kidney-Metabolic Health: A Scientific Statement From the American Heart Association.

Cardiovascular-kidney-metabolic (CKM) syndrome is a novel construct recently defined by the American Heart Association in response to the high prevalence of metabolic and kidney disease. Epidemiological data demonstrate higher absolute risk of both atherosclerotic cardiovascular disease (CVD) and heart failure as an individual progresses from CKM stage 0 to stage 3, but optimal strategies for risk assessment need to be refined. Absolute risk assessment with the goal to match type and intensity of interventions with predicted risk and expected treatment benefit remains the cornerstone of primary prevention. Given the growing number of therapies in our armamentarium that simultaneously address all 3 CKM axes, novel risk prediction equations are needed that incorporate predictors and outcomes relevant to the CKM context. This should also include social determinants of health, which are key upstream drivers of CVD, to more equitably estimate and address risk. This scientific statement summarizes the background, rationale, and clinical implications for the newly developed sex-specific, race-free risk equations: PREVENT (AHA Predicting Risk of CVD Events). The PREVENT equations enable 10- and 30-year risk estimates for total CVD (composite of atherosclerotic CVD and heart failure), include estimated glomerular filtration rate as a predictor, and adjust for competing risk of non-CVD death among adults 30 to 79 years of age. Additional models accommodate enhanced predictive utility with the addition of CKM factors when clinically indicated for measurement (urine albumin-to-creatinine ratio and hemoglobin A1c) or social determinants of health (social deprivation index) when available. Approaches to implement risk-based prevention using PREVENT across various settings are discussed.

Correlation of Atherogenic Index of Plasma and Atherogenic Coefficient with Cardiovascular Disease Risk assessed by ASCVD Risk Calculator

Introduction: Cardiovascular disease (CVD) is the leading cause of approximately one-third deaths worldwide. Absolute lipid parameters are inadequate in predicting CVD risk and several lipid indices have been introduced namely “Atherogenic index of plasma” (AIP) and “Atherogenic coefficient” (AC). CVD risk of a patient for the upcoming 10 years can be calculated using atherosclerotic cardiovascular disease (ASCVD) risk calculator. Though, this method currently accepts as the gold standard, certain drawbacks have been reported. Therefore, the aim of this study was to investigate the correlation of AIP and AC with CVD risk estimation for the upcoming 10 years calculated by ASCVD risk calculator. Methods: Hundred and fifty-three patients were recruited for the study. Socio-demographic data were collected through interviewer-based questionnaire. Total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides values were obtained from the lipid profile test results of the study participants. AIP and AC were calculated using formulas while 10-year ASCVD risk was calculated by ASCVD risk calculator. Results: There was no significant correlation between AIP and 10-year ASCVD risk (p&gt;0.05) and AC and 10-year ASCVD risk (p&gt;0.05), but a significant correlation was observed between AIP and AC (Pearson’s correlation r=0.425, p&lt;0.05). Conclusions: CVD risk of patients should be assessed routinely especially as it is overlooked in most patients presenting normal lipid profile variables, hence the actual risk remains silent unless it is properly investigated using laboratory investigations