European Systematic Coronary Risk Evaluation Research Articles

European and US Guideline-Based Statin Eligibility, Genetically Predicted Coronary Artery Disease, and the Risk of Major Coronary Events.

A study was designed to investigate whether the coronary artery disease polygenic risk score (CAD-PRS) may guide lipid-lowering treatment initiation as well as deferral in primary prevention beyond established clinical risk scores. Participants were 311 799 individuals from the UK Biobank free of atherosclerotic cardiovascular disease, diabetes, chronic kidney disease, and lipid-lowering treatment at baseline. Participants were categorized as statin indicated, statin indication unclear, or statin not indicated as defined by the European and US guidelines on statin use. For a median of 11.9 (11.2-12.6) years, 8196 major coronary events developed. CAD-PRS added to European-Systematic Coronary Risk Evaluation 2 (European-SCORE2) and US-Pooled Cohort Equation (US-PCE) identified 18% and 12% of statin-indication-unclear individuals whose risk of major coronary events were the same as or higher than the average risk of statin-indicated individuals and 16% and 12% of statin-indicated individuals whose major coronary event risks were the same as or lower than the average risk of statin-indication-unclear individuals. For major coronary and atherosclerotic cardiovascular disease events, CAD-PRS improved C-statistics greater among statin-indicated or statin-indication-unclear than statin-not-indicated individuals. For atherosclerotic cardiovascular disease events, CAD-PRS added to the European evaluation and US equation resulted in a net reclassification improvement of 13.6% (95% CI, 11.8-15.5) and 14.7% (95% CI, 13.1-16.3) among statin-indicated, 10.8% (95% CI, 9.6-12.0) and 15.3% (95% CI, 13.2-17.5) among statin-indication-unclear, and 0.9% (95% CI, 0.6-1.3) and 3.6% (95% CI, 3.0-4.2) among statin-not-indicated individuals. CAD-PRS may guide statin initiation as well as deferral among statin-indication-unclear or statin-indicated individuals as defined by the European and US guidelines. CAD-PRS had little clinical utility among statin-not-indicated individuals.

Predictive value of lung function measures for cardiovascular risk: a large prospective cohort study

IntroductionAlthough lung function measures are associated with cardiovascular disease (CVD), the added predictive values of these measures remain unclear.MethodsFrom the UK Biobank, 308 415 participants free of CVD with spirometry...

Validation of Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons in the EPIC-Norfolk prospective population cohort.

The European Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons (OP) models are recommended to identify individuals at high 10-year risk for cardiovascular disease (CVD). Independent validation and assessment of clinical utility is needed. This study aims to assess discrimination, calibration, and clinical utility of low-risk SCORE2 and SCORE2-OP. Validation in individuals aged 40-69 years (SCORE2) and 70-79 years (SCORE2-OP) without baseline CVD or diabetes from the European Prospective Investigation of Cancer (EPIC) Norfolk prospective population study. We compared 10-year CVD risk estimates with observed outcomes (cardiovascular mortality, non-fatal myocardial infarction, and stroke). For SCORE2, 19 560 individuals (57% women) had 10-year CVD risk estimates of 3.7% [95% confidence interval (CI) 3.6-3.7] vs. observed 3.8% (95% CI 3.6-4.1) [observed (O)/expected (E) ratio 1.0 (95% CI 1.0-1.1)]. The area under the curve (AUC) was 0.75 (95% CI 0.74-0.77), with underestimation of risk in men [O/E 1.4 (95% CI 1.3-1.6)] and overestimation in women [O/E 0.7 (95% CI 0.6-0.8)]. Decision curve analysis (DCA) showed clinical benefit. Systematic Coronary Risk Evaluation 2-Older Persons in 3113 individuals (58% women) predicted 10-year CVD events in 10.2% (95% CI 10.1-10.3) vs. observed 15.3% (95% CI 14.0-16.5) [O/E ratio 1.6 (95% CI 1.5-1.7)]. The AUC was 0.63 (95% CI 0.60-0.65) with underestimation of risk across sex and risk ranges. Decision curve analysis showed limited clinical benefit. In a UK population cohort, the SCORE2 low-risk model showed fair discrimination and calibration, with clinical benefit for preventive treatment initiation decisions. In contrast, in individuals aged 70-79 years, SCORE2-OP demonstrated poor discrimination, underestimated risk in both sexes, and limited clinical utility.

Estimation of 10-year risk of fatal and non-fatal cardiovascular disease in a portuguese population

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiovascular disease (CVD) is the most common noncommunicable disease and actually the leading cause of death globally. Hence, it is important to identify individuals who may benefit from CVD preventive strategies. The European Society of Cardiology (ESC) has recently updated the European Systematic Coronary Risk Evaluation (SCORE) to SCORE2 and SCORE2-OP risk prediction algorithms. Those tools were recalibrated to four groups of countries (low, moderate, high and very high CVD risk) based on national CVD mortality rates published by the WHO, with Portugal being now considered a moderate risk country. Purpose To evaluate the application of SCORE2 and SCORE2-OP in a Portuguese population sample. Methods We conducted a cross-sectional study, including individuals aged 40-90 years, without known established Atherosclerotic Cardiovascular Disease, Diabetes mellitus, Chronic Kidney Disease or Familial Hypercholesterolemia. The sample was recruited at a local cardiovascular screening event in Portugal that took place in May 2022. The 10-year fatal and non-fatal CVD risk was calculated using SCORE2 (for individuals aged < 70 years) and SCORE2-OP (for individuals aged ≥ 70 years) tools. Based on CVD risk category, patients were stratified into 3 categories: low to moderate, high and very high risk according to new SCORE algorithms. Primary outcome was the assessment of 10-year risk of fatal and non-fatal CVD with SCORE2 e SCORE2-OP in a local Portuguese population. According to the data distribution, appropriate statistical tests were conducted to compare independent samples. Multivariable linear regression was used to analyze 10-year CVD risk. Results This cohort included 431 individuals. Median age was 71 years (Q1-Q3: 65-75) and 66.8% of individuals were women. Regarding baseline characteristics of the included individuals, 48.1% had hypertension, 38.3% had dyslipidemia, 25.5% were obese and 6.6% were smokers. Based on the SCORE2 model 92 (26.1%) individuals were classified into low to moderate risk, 162 (46.0%) into high risk and 98 (27.8%) into very high-risk category. SCORE2 median was 3.43 % (Q1-Q3: 5.5-8.0 p< 0.01) and SCORE2-OP median was 12.70 % (Q1-Q3: 9.7-12.7). Active smoking was the only independent predictor of 10-years CVD risk both in SCORE2 (RR 3.28, 95% CI: 1.93-4.66, p=0.001) and SCORE2-OP (RR 6.31, 95% CI: 2.67-9.52, p<0.001). Conclusions Most individuals in this sample were stratified into high or very high risk of developing 10-year fatal and non-fatal cardiovascular events. This data is in accordance with the updated risk category of Portugal based on World Health Organization cardiovascular mortality rates. These results not only validate the application of SCORE to the Portuguese setting, but also reinforce how this easily applicable tool can help to identify patients who will benefit from CVD preventive strategies.

Cardiovascular risk assessment in periodontitis patients and controls using the European Systematic COronary Risk Evaluation (SCORE) model. A pilot study.

Aim: To investigate the use of the European SCORE model in a dental setting by exploring the frequency of a 'high' and 'very high' 10-year CVD mortality risk in patients with and without periodontitis. The secondary aim was to investigate the association of SCORE with various periodontitis parameters adjusting for remaining potential confounders. Material and methods: In this study, we recruited periodontitis patients and non-periodontitis controls, all aged ≥40years. We determined the 10-year CVD mortality risk per individual with the European Systematic Coronary Risk Evaluation (SCORE) model by using certain patient characteristics and biochemical analyses from blood by finger stick sampling. Results: In total, 105 periodontitis patients (61 localized, 44 generalized stage III/IV) and 88 non-periodontitis controls were included (mean age: 54.4years). The frequency of a 'high' and 'very high' 10-year CVD mortality risk was 43.8% in all periodontitis patients and 30.7% in controls (p = .061). In total, 29.5% generalized periodontitis patients had a 'very high' 10-year CVD mortality risk, compared to 16.4% in localized periodontitis patients and 9.1% in controls (p = .003). After adjustment for potential confounders, the total periodontitis group (OR 3.31; 95% CI 1.35-8.13), generalized periodontitis group (OR 5.32; 95% CI 1.90-14.90), lower number of teeth (OR .83; 95% CI .73-1.00) and higher number of teeth with radiographic bone loss ≥33% (OR 1.06; 95% CI 1.00-1.12) were associated with a "very high" SCORE category. In addition, various biochemical risk markers for CVD were more frequently elevated in periodontitis compared to controls (e.g., total cholesterol, triglycerides, C-reactive protein). Conclusion: The periodontitis group as well as the control group had a sizable frequency of a 'high' and 'very high' 10-year CVD mortality risk. The presence and extent of periodontitis, lower number of teeth and higher number of teeth with bone loss ≥33% are significant risk indicators for a 'very high' 10-year CVD mortality risk. Therefore, SCORE in a dental setting can be a very useful tool to employ for primary and secondary prevention of CVD, especially among the dental attenders who have periodontitis.

Comparison between the European SCORE and the updated SCORE2 for cardiovascular outcomes

Abstract Introduction The European Systematic Coronary Risk Evaluation (SCORE) has predicted a 10-year risk of CVD since 1986. It included only fatal CVD outcomes, underestimating the total CVD burden, especially for younger people. To counteract this issue, a new score was created (SCORE2) to estimate 10-year fatal and non-fatal CVD risk in Europeans without previous CVD or diabetes aged 40–69 years. Purpose Establish a comparison between SCORE and SCORE2 in terms of CV outcomes in a moderate-risk population. Methods A population of 1,178 individuals without CVD (mean age 53.3±6.9 years; 73.9 male) was stratified into three risk categories for SCORE and SCORE2: low, moderate and high-risk. Using t-test and Chi-square, we compared the two scores in terms of means and risk categories. Kaplan-Meier estimator evaluated MACE occurrence for each category of the two scores during an extended follow-up (mean of 5.2±3.4 years). MACE discriminative capacity of SCORE and SCORE2 was evaluated through C-index methodology. Results The means of the two scores were significantly different (p<0.0001): 2.1±2.4 for SCORE and 6.0±3.3 for SCORE2. 51% of the individuals with high-risk SCORE2 presented the lowest value of SCORE (0–5%). Kaplan-Meier curves showed that the highest category had a worst survival for each score. SCORE2 showed a better discriminative capacity for MACE (C-index 0.678) relatively to SCORE (C-index 0.591), with statistical significance (p<0.0001). Conclusion SCORE2 enhanced the identification of individuals at higher risk of developing CVD and better discriminated MACE occurrence relatively to SCORE. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Dietary Acid Load but Not Mediterranean Diet Adherence Score Is Associated With Metabolic and Cardiovascular Health State: A Population Observational Study From Northern Italy.

Diet plays a pivotal role in shaping the trajectory of chronic diseases. In this regard, the Mediterranean diet has been widely shown to exert beneficial effects on cardiometabolic health. On the contrary, the Western diet, which has also been reported to be an acidogenic dietary pattern, elicits detrimental effects on both metabolic and cardiovascular (CV) health. However, the role of dietary acid load (DAL) as a predictor of cardiometabolic prognosis remains to be elucidated. Thus, this study aims to compare Mediterranean diet adherence (MDA) and DAL focusing on their relationship with metabolic and CV prognosis. A total of 448 individuals aged 55–80 years were grouped depending on their MDA, assessed using food frequency questionnaires, or DAL, evaluated using potential renal load acid (PRAL) and net-endogenous acid production (NEAP). Study participants underwent anthropometric and biochemical measurements. The metabolic syndrome (MetS) prevalence was evaluated according to the National Cholesterol Education Program-Adult Treatment Panel III. Finally, the CV risk was evaluated using three independent algorithms: atherosclerotic cardiovascular disease (ASCVD), European Systematic COronary Risk Evaluation (SCORE), and Cuore risk scores. Mediterranean diet adherence was negatively associated with PRAL and NEAP. Individuals in the higher MDA tertile group had higher HDL cholesterol as well as lower homeostasis model assessment index (HOMA-IR) and fat mass relative to the lowest MDA tertile. However, in the high-MDA tertile group, there was neither a significantly lower MetS prevalence nor CV risk. Instead, both the MetS prevalence and CV risk were higher in individuals in the higher acid PRAL quartile relative to the lower alkaline PRAL quartile. Dietary acid load, especially assessed using PRAL but not MDA, was associated with indices of metabolic and CV prognosis. Thus, DAL assessed by 24-h dietary recalls may represent a better predictor of cardiometabolic health if compared to MDA evaluated using food frequency questionnaires.

Distributions and burden of coronary calcium in asymptomatic Saudi patients referred to computed tomography.

BackgroundUnlike Western and Asian populations, the prevalence and severity of coronary artery calcification (CAC) have not been adequately examined in Saudi Arabia and other nearby Arab Gulf countries.ObjectivesTo estimate the age and gender specific percentiles of coronary calcium score (CCS) and to study the severity of CAC in relation to patient risk in a large sample of asymptomatic Saudi patients.MethodsRetrospective cross-sectional study was conducted between July 2007 and December 2017 at a large Cardiac Centre in Riyadh, Saudi Arabia. The target was adult patients without pre-existing CAD referred to (64 multidetector spiral) computed tomography for standard indications.ResultsA total 2863 patients were included in the current analysis. The 90th percentile of CCS was 95.0 in males compared with 53.2 in females and was 823.95 in patients aged ≥ 75 years compared with zero in patients < 40 years. Extensive CAC (CCS > 400) were 3.1% in males compared with 1.6% in females and 14.0% in patients aged ≥ 75 years compared with 0.0% in patients < 40 years. CCS was steadily higher with increasing European systematic coronary risk evaluation; 3.1 ± 22.5 in mild risk, 37.1 ± 201.9 in moderate risk, 116.1 ± 256.1 in high risk, and 131.0 ± 222.0 in very high risk.ConclusionsAs expected, the findings confirm the higher burden of CAC in males, older age, and higher CAD risk. The burden of CAC in current patients is much lower than reported in US and other Western patients. Local cardiologist should consider using local rather than US percentiles of CCS.

A prospective, multicenter, epidemiological study of the prevalence of cardiovascular risk factors in hypertensive patients in Greece, the WIN-HAZARD study

Abstract Background/Introduction Arterial hypertension (AH) is a major, common, modifiable, risk factor for cardiovascular disease. It is strongly associated with cardiovascular disease (CVD), the leading cause of death globally, according to World Health Organization. In addition to elevated blood pressure (BP), many hypertensive patients have other risk factors that increase the overall cardiovascular risk. The calculation of the total cardiovascular (CV) risk is necessary for selecting the proper treatment strategy and guide timely treatment decisions and interventions. Purpose This prospective, multicenter, epidemiological, non-interventional, nationwide study aimed to evaluate the type and number of total CVD risk factors in hypertensive patients in Greece, according to the 2013 guidelines of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC), applicable at the time of the study conduct. Methods Overall, 3 Cardiology Hospital sites and 167 private Cardiologists, Internists, Endocrinologists and General Practitioners nationwide participated in the study, enrolling consecutive adult patients with hypertension under treatment. Total CV risk was assessed by 2013 ESH/ESC criteria, and the European Systematic Coronary Risk Evaluation (SCORE) algorithm. It involved a single visit, with no screening period for the patients. The study has been conducted in compliance with ICH/GCP standards, from March 2017 to April 2019. Results In total 1309 patients with AH under treatment were enrolled (59% male, mean age 60.6 years, mean BMI 28.2). The median time from AH diagnosis was 3.7 years. The most common CV risk factors were dyslipidaemia (76.4%), male gender (59%), advanced age (58.1%) and abdominal obesity (46.1%). The incidence of the remaining total CV risk factors per category was asymptomatic target organ damage (20.8%), diabetes (11.3%) and established CV or renal disease (5.8%). The majority of the study patients (71.6%) had concomitantly ≥3 total CV risk factors (table 1 and table 2). The mean (±SD) systolic arterial pressure was 143.5±14.7 mmHg and the mean (±SD) diastolic 85.5±8.6 mmHg. More than half of the patients (51.8%) received one antihypertensive drug, with angiotensin II receptor blockers (ARBs) being the most commonly reported drug class (23.9%), followed by calcium channel blockers (15.8%). Conclusion This real-world study with its broad geographical coverage and phycisians' specialty range, contributed significant epidemiological data pertaining to prevalence of cardiovascular risk factors in adult hypertensive patients and their current treatment status in Greece. The value of this observational study lies in supporting the proper deployment of current guidelines, as well as, the implementation of future preventive healthcare programmes. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): WIN MEDICA S.A. Table 1Table 2

Cardiovascular risk assessment in people living with HIV compared to the general population

Abstract Background Effective cardiovascular preventive strategies are crucial among people living with HIV (PLWH), who are facing a high burden of atherosclerotic cardiovascular disease (ASCVD). However, it remains unclear which cardiovascular risk score is the most appropriate in clinical practice. Purpose We aimed to prospectively assess and compare the accuracy of widely used cardiovascular risk scores in PLWH and individuals from the general population. Methods We used data from the Swiss HIV Cohort Study (SHCS), a longitudinal study involving 20,802 HIV-infected adults aged over 18 years, and from the CoLaus|PsyCoLaus study, a Swiss population-based cohort including 6,733 individuals aged 35–75 years. The European Systematic Coronary Risk Evaluation Score (SCORE), the North American Pooled Cohort Equation (PCE) and the HIV-specific Data Collection o-n Adverse events of Anti-HIV Drugs (D:A:D) score were calculated for all participants free from ASCVD between January 1, 2003 and December 31, 2009. Accuracy of the scores was assessed based on discrimination and calibration metrics for each cohort separately using incident ASCVD as outcome. The value of adding HIV-specific factors to the model presenting the best predictive capacities between SCORE and PCE was evaluated using the net reclassification index (NRI). Results 6,373 PLWH (28.4% women; aged 40.6 [SD, 9.9]; 57.2% on antiretroviral therapy) and 5,403 individuals from the general population (53.5% women, aged 52.8 [SD, 10.7]) were included in the analysis with a mean follow-up time of 13.5 (SD, 4.1) and 9.9 (SD, 2.3) years, respectively. 533 (8.4%) participants in the SHCS and 374 (6.9%) in the CoLaus|PsyCoLaus study experienced an incident ASCVD translating into age-adjusted incidence rates of 12.9 vs. 7.5 per 1,000 person-year, respectively. In SHCS, PCE and D:A:D presented discriminative capacities with AUROC of 0.757 (95% CI, 0.736–0.777) and 0.763 (95% CI, 0.743–0.783), respectively, compared to SCORE (0.704 [95% CI, 0.681–0.728]). Calibration of all scores was suboptimal in SHCS, with under-prediction of ASCVD in the higher deciles of risk compared to the CoLaus|PsyCoLaus study. Adding CD4 nadir (&amp;lt;200 cells/mm3) and abacavir exposure as categorical variables to PCE resulted in a marginal improvement in discrimination and in a global NRI of 2.7% (95% CI, 0.3–5.1, p-value = 0.03). Conclusions PLWH presented a two-fold higher rate of incident ASCVD compared to individuals of the same age from the general population. The accuracy of PCE score to predict ASCVD in PLWH is equivalent to the D:A:D score and may represent a better alternative due to its reduced set of variables and its widespread use. Adding HIV-specific factors to PCE did not improve its predictive performance. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation

Liver fibrosis marker is an independent predictor of cardiovascular morbidity and mortality in the general population

BackgroundA growing body of evidence suggests that Non-alcoholic fatty liver disease (NAFLD) and liver fibrosis are associated with cardiovascular disease (CVD). However, the independent role of liver fibrosis markers in the prediction of CVD in the general population is seldom tested. AimsTo assess whether a marker of liver fibrosis predicts the first occurrence of a CVD event in a large sample of community-based general population. MethodsHistorical cohort using data from a large health provider that operates a centralized computerized medical record. The level of liver fibrosis was measured by the fibrosis-4 (FIB-4) score, and the association with CVD was adjusted for the European Systematic Coronary Risk Evaluation calculator (SCORE). ResultsThe study included 8,511 individuals, 3,292 with inconclusive fibrosis and 195 with advanced fibrosis (FIB-4 ≥ 2.67). People with advanced fibrosis had higher risk for CVD, after adjustment for sociodemographic characteristics, the SCORE, use of statins and aspirin (HR [95%CI], 1.63 [1.29–2.06]). The association persisted in both women and men. Using age-specific cut-offs, there was a dose-response association between inconclusive and advanced fibrosis and CVD (HR [95%CI], 1.15 [1.01–1.31]) and HR [95%CI], 1.60 [1.27–2.01], respectively, P for trend<0.001). ConclusionsA simple fibrosis score is independently associated with CVD, suggesting that fibrosis markers should be considered in primary-care risk assessment.

Cardiorespiratory fitness improves prediction of mortality of standard cardiovascular risk scores in a Latino population.

BackgroundCardiorespiratory fitness (CRF) is a powerful predictor of mortality. This study evaluated the predictive value of CRF for mortality in Chilean subjects without atherosclerotic disease compared with the Framingham, European Systematic Coronary Risk Evaluation (SCORE), and 2013 ACC/AHA risk scores and determined the incremental predictive value of CRF when added to these scores.HypothesisCRF improves prediction of all‐cause and cardiovascular disease (CVD)‐related mortality of the standard international risk scores.MethodsCross‐sectional study, which evaluated 4064 subjects between 2002 and 2016. Cardiovascular (CV) risk factors, anthropometric and biochemical parameters, and blood pressure were measured. CRF was determined by metabolic equivalents during maximum stress test. The Framingham, SCORE, and ACC/AHA risk scores were calculated for all subjects. After a median follow‐up of 9 years, all‐cause and CVD‐related mortality were assessed. Receiver operating curves were built to determine mortality prediction for CRF, the risk scores, and CRF added to the scores.ResultsAs of August 2016, 99 deaths were reported, 33 of which were CVD‐related. All risk scores and CRF predicted CVD‐related mortality, with CRF identified as the best predictor: CRF: C = 0.88 (95% CI: 0.82‐0.93) vs Framingham: C = 0.68 (95% CI: 0.60‐0.76), SCORE: C = 0.76 (95% CI: 0.70‐0.83), and ACC/AHA: C = 0.79 (95% CI: 0.73‐0.85). Predictive power of the three scores improved when CRF was added to the model, but this was only significant for the Framingham score.ConclusionsCRF is a good predictor of both, all‐cause and CV mortality and a better predictor of CVD‐related deaths than standard risk scores in this population.

Systematic Coronary Risk Evaluation estimated risk and prevalent subclinical atherosclerosis in coronary and carotid arteries: A population-based cohort analysis from the Swedish Cardiopulmonary Bioimage Study.

It is not clear if the European Systematic Coronary Risk Evaluation algorithm is useful for identifying prevalent subclinical atherosclerosis in a population of apparently healthy individuals. Our aim was to explore the association between the risk estimates from Systematic Coronary Risk Evaluation and prevalent subclinical atherosclerosis. The design of this study was as a cross-sectional analysis from a population-based study cohort. From the general population, the Swedish Cardiopulmonary Bioimage Study randomly invited individuals aged 50-64 years and enrolled 13,411 participants mean age 57 (standard deviation 4.3) years; 46% males between November 2013-December 2016. Associations between Systematic Coronary Risk Evaluation risk estimates and coronary artery calcification and plaques in the carotid arteries by using imaging data from a computed tomography of the heart and ultrasonography of the carotid arteries were examined. Coronary calcification was present in 39.5% and carotid plaque in 56.0%. In men, coronary artery calcium score >0 ranged from 40.7-65.9% and presence of carotid plaques from 54.5% to 72.8% in the age group 50-54 and 60-65 years, respectively. In women, the corresponding difference was from 17.1-38.9% and from 41.0-58.4%. A doubling of Systematic Coronary Risk Evaluation was associated with an increased probability to have coronary artery calcium score >0 (odds ratio: 2.18 (95% confidence interval 2.07-2.30)) and to have >1 carotid plaques (1.67 (1.61-1.74)). Systematic Coronary Risk Evaluation estimated risk is associated with prevalent subclinical atherosclerosis in two major vascular beds in a general population sample without established cardiovascular disease or diabetes mellitus. Thus, the Systematic Coronary Risk Evaluation risk chart may be of use for estimating the risk of subclinical atherosclerosis.

Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk.

Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors. Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy - the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated. About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28-1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results. Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.

Usefulness of carotid ultrasonography in the assessment of coronary artery disease extension in patients undergoing exercise echocardiography

To evaluate whether carotid disease is associated with coronary artery disease (CAD) extension in patients undergoing treadmill exercise stress echocardiography (EE). We retrospectively studied 156 patients without previous vascular disease who underwent EE, carotid ultrasonography, and coronary angiography between 2002 and 2013. Low-, intermediate-, and high-risk EE were defined as negative, localized ischemia, and multivessel/extensive ischemia EE respectively; carotid disease according to Mannheim and American Society of Echocardiography Consensus and CAD extension from zero to three vessel disease as stenosis ≥50% by visual assessment. Of the 156 patients, 67 (42.9%), 43 (27.6%), 22 (14.1%), and 24 (15.4%) had zero, one, two, and three vessel disease respectively. Age (P=0.047), male sex (P=0.010), diabetes mellitus (P=0.039), smoking habit (P=0.015), fasting plasma glucose (P=0.021), European Systematic COronary Risk Evaluation (P=0.003), pretest CAD probability (P=0.003), high-risk EE (P<0.001), and carotid plaque presence (CP) (P<0.001) were associated in univariate analysis with more extensive CAD. Predictors of CAD extension in multivariate analysis were high-risk EE (odds ratio [OR] 2.42, P<0.001), CP presence (OR 1.75, P=0.004), and pretest CAD probability >65% (OR 1.49, P=0.023). CP was also associated with multivessel CAD in the 53 patients with low- or intermediate-risk EE (P=0.001). CP is associated with CAD extension in patients with ischemic heart disease suspicion undergoing EE. Patients with CP could benefit from a more aggressive therapeutic strategy regarding patients without carotid disease and similar risk EE, especially in intermediate- and/or low-risk test where guidelines recommend initially optimal medical treatment.

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial

Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention. Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575. 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]). This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification. Västerbotten County Council, the Swedish Research Council, the Heart and Lung Foundation, the Swedish Society of Medicine, and Carl Bennet Ltd, Sweden.

Sleep study-guided multidisciplinary therapy (SGMT) for patients with acute coronary syndrome: Trial rationale and design.

Obstructive sleep apnea (OSA) is an emerging risk marker for acute coronary syndrome (ACS). This randomized trial aims to determine the effects of sleep study-guided multidisciplinary therapy (SGMT) comprising overnight sleep study, continuous positive airway pressure, and behavioral therapy for OSA during the subacute phase of ACS. We hypothesize that SGMT will reduce (1) the plasma levels of N-terminal pro brain natriuretic peptide and suppression of tumorigenicity 2; (2) the estimated 10-year risk of cardiovascular mortality as measured by the European Systematic Coronary Risk Evaluation (SCORE) algorithm; and (3) the cardiovascular event rate during a 3-year follow-up, compared with standard therapy. In the SGMT trial, 180 patients presenting with ACS will be randomly assigned to SGMT (n = 90) and standard therapy (n = 90) groups. Both groups will receive guideline-mandated treatment for ACS. Those assigned to SGMT will additionally undergo a sleep study and, if OSA is diagnosed, attend a multidisciplinary OSA clinic where they will receive personalized treatment including continuous positive airway pressure and behavioral/lifestyle counseling. The primary endpoint is the plasma N-terminal pro brain natriuretic peptide concentration at 7-month follow-up. This report presents the baseline characteristics of 117 patients (SGMT group: n =54; standard therapy group: n =63) who had been enrolled into the study as of August 31, 2017. The results of this trial will help us to understand whether active OSA diagnosis and treatment will improve the physiologic and clinical cardiovascular outcomes of this group of patients.

Electrocardiographic unrecognized myocardial infarction does not improve prediction of cardiovascular events beyond traditional risk factors. The Tromsø Study.

Background Unrecognized myocardial infarction (MI) is a frequent and intriguing entity associated with a similar risk of death as recognized MI. Previous studies have not fully addressed whether the poor prognosis is explained by traditional cardiovascular risk factors. We investigated whether electrocardiographically detected unrecognized MI was independently associated with cardiovascular events and death and whether it improved prediction for future MI in a general population. Design Prospective cohort study. Methods We studied 5686 women and men without clinically recognized MI at baseline in 2007-2008. We assessed the risk of future MI, stroke and all-cause mortality in persons with unrecognized MI compared with persons with no MI during 31,051 person-years of follow-up. Results In the unadjusted analyses, unrecognized MI was associated with increased risk of future recognized MI (hazard ratio 1.84, 95% confidence interval (CI) 1.15-2.96) and all-cause mortality (hazard ratio 1.78, 95% CI 1.21-2.61), but not stroke (hazard ratio 1.09, 95% CI 0.56-2.17). The associations did not remain significant after adjustment for traditional risk factors (hazard ratio 1.25, 95% CI 0.76-2.06 and hazard ratio 1.38, 95% CI 0.93-2.05) for MI and all-cause mortality respectively. Unrecognized MI did not improve risk prediction for future recognized MI using the Framingham Risk Score ( p = 0.96) or the European Systematic COronary Risk Evaluation ( p = 0.65). There was no significant sex interaction regarding any of the endpoints. Conclusion Electrocardiographic unrecognized MI was not significantly associated with future risk of MI, stroke or all-cause mortality in the general population after adjustment for the traditional cardiovascular risk factors, and it did not improve prediction of future MI.

OP.3C.01] COMPARISON BETWEEN EUROPEAN SYSTEMATIC CORONARY RISK EVALUATION AND ITALIAN CUORE ALGORITHMS IN ADULT OUTPATIENTS FOLLOWED BY GENERAL PRACTITIONERS AND SPECIALISED CENTRES

Objective: Global cardiovascular (CV) risk stratification based on either European Systematic Coronary Risk Evaluation (SCORE) or Italian CUORE algorithms should be performed in all adult outpatients by both general practitioners (GPs) and specialised physicians (SPs). Design and method: To compare individual CV risk profile by using either European SCORE and Italian CUORE algorithms in adult outpatients followed by GPs and SPs in Italy. All available data were centrally analysed for global CV risk assessment and rates of control of major CV risk factors, including blood pressure (BP), serum cholesterol, triglycerides and glucose levels. CV risk profile characterization was based on both SCORE and CUORE algorithms. Study population was stratified according to referring physicians (GPs, cardiologists, diabetologists, other SPs). Results: We analysed data from an overall population sample of 10,404 adult outpatients (age 60.76.5 years, BMI 28.34.9 kg/m2, BP 136.714.4/82.18.2 mmHg, total cholesterol 212.240.7 mg/dl, HDL cholesterol 50.812.3 mg/dl), among whom 7,767 (74.7%) were followed by GPs, 1,239 (11.9%) by cardiologists, 1,006 (9.7%) by diabetologists and 392 (3.8%) by other SPs. Systolic/diastolic BP, total/LDL cholesterol and triglycerides levels were higher and HDL cholesterol was lower in patients followed by GPs and cardiologists compared to other groups. Conversely, BMI and fasting glucose levels were higher in patients followed by diabetologists than in other groups. All major CV risk factors and comorbidities were more frequently reported and controlled in patients followed by cardiologists than in the other groups, with the only exception of diabetes. Both European SCORE (4.74.5) and Italian CUORE (13.711.5) were significantly higher in outpatients followed by cardiologists than in those followed by GPs (4.03.6 and 11.59.7) and diabetologists (3.73.5 and 10.39.2) or other SPs (3.32.8 and 9.47.4; P < 0.001 for all comparisons). Conclusions: Despite proper use of drugs and better pharmacological control of major risk factors, both European SCORE and Italian CUORE algorithms reported higher CV risk profile in patients followed by cardiologists than in patients followed by diabetologists, GPs, and other SPs.

Simple screening tools predict death and cardiovascular events in patients with rheumatic disease

Objectives: Patients with rheumatic disease (RD) have an increased mortality risk compared with the general population, mainly due to cardiovascular disease (CVD). We aimed to identify patients at high risk of CVD and mortality by comparing three screening tools suitable for clinical practice.Method: In this prospective, single-centre study, consecutive patients with rheumatoid arthritis (RA), systemic autoimmune disease (SAI), or spondyloarthritides (SpA) including psoriatic arthritis underwent a comprehensive cardiovascular risk assessment. Patients were predefined as being at high risk for cardiovascular events or death if any of the following were present: European Systematic COronary Risk Evaluation (SCORE) ≥ 3%, N-terminal pro-brain natriuretic peptide (NT-proBNP) ≥ 200 pg/mL, or any pathological electrocardiogram pattern.Results: The patient population (n = 764) comprised 352 patients with RA, 260 with SAI, and 152 with SpA. After a median follow-up of 5.2 years, 6.0% of RD patients had died (7.0%, 7.2%, and 1.4% of patients in the RA, SAI, and SpA subgroups), and 5.0% had experienced a cardiovascular event (5.0%, 6.4%, and 2.8%, respectively). For all RD patients and the RA and SAI subgroups, NT-proBNP ≥ 200 pg/mL and SCORE ≥ 3% identified patients with a 3.5–5-fold increased risk of all-cause death and cardiovascular events. Electrocardiogram pathology was associated with increased mortality risk, but not with cardiovascular events.Conclusion: NT-proBNP ≥ 200 pg/mL or SCORE ≥ 3% identifies RA and SAI patients with increased risk of cardiovascular events and death. Both tools are suitable as easy screening tools in daily practice to identify patients at risk for further diagnostics and closer long-term follow-up.