Cardiovascular Disease In High-risk Patients Research Articles

#2610 Low skeletal muscle mass and low skeletal muscle quality are associated with thoracic aorta calcification in dialysis patients

Abstract Background and Aims Cardiovascular disease (CVD) is the leading cause of mortality in dialysis patients. Thoracic aorta calcification (TAC) is a common cardiovascular complication in dialysis patients and is independently associated with CVD. Sarcopenia, particularly low skeletal muscle mass, has been found to be associated with increased cardiovascular risk in dialysis patients. This study aims to explore the relationship between skeletal muscle quality and skeletal muscle mass at the first lumbar vertebra (L1) level determined by opportunistic CT scans (chest CT) and TAC, with the goal of providing valuable opportunities for identifying and intervening in high-risk CVD patients. Method We included 2514 patients for cross-sectional analysis, who underwent dialysis in four centers in China from 2020 to 2023 and all had chest CT scans including the L1 level. Additionally, we conducted a follow-up study on TAC in patients who initiated dialysis between 2014 and 2019 as part of the earlier research, including 215 patients who had undergone at least two chest CT scans for cohort analysis. At the L1 level, we assessed skeletal muscle quality [by skeletal muscle density (SMD), HU] and skeletal muscle mass [by skeletal muscle index (SMI), cm2/m2] in dialysis patients. Measurements of thoracic aorta calcification scores (TACS) and calcification scores for three segments of the thoracic aorta, including ascending aorta calcification score (ATACS), aortic arch calcification score (AoACS), and descending thoracic aorta calcification score (DTACS), were obtained in dialysis patients. Patients were divided based on their annual calcification score growth rate: those with a rate greater than or equal to the average annual increase were classified into the rapid progression group, while those with a rate less than the average were classified into the slow progression group (including those with no progression). Multivariable linear regression models were employed to assess the relationships between SMI and SMD with TACS. Multivariable logistic regression models were used to evaluate the associations of SMl and SMD with the risk of rapid progression of TACS. Results The mean (SD) age of participants was 56 (15) years, with 58.2% being male. The prevalence of TAC was 82.2%, while the prevalence of ascending thoracic aorta calcification (ATAC), aortic arch calcification (AoAC), and descending thoracic aorta calcification (DTAC) was 21.4%, 75.3%, and 68.8%, respectively. Over an average follow-up period of 3.22 years, the progression rate of TAC was 85.6%. Comparing the highest quartile of SMD to the lowest quartile, a significant inverse association was observed with TAC (beta −1.19, 95% CI −1.55— −0.83; P < 0.001). Similarly, comparing the highest quartile of SMI to the lowest quartile, a significant inverse association was found with TAC (beta −0.59, 95% CI −0.92— −0.26; P = 0.001). SMI and SMD, as continuous variables, were both significantly negatively correlated with TAC. Higher SMD was associated with a reduced risk of rapid progression of TAC; after full adjustment, for every 1 SD increase in SMD, the risk of TAC rapid progression decreased by 46% (aOR 0.54, 95% CI 0.32—0.91; P = 0.021). SMI showed no significant association with the rapid progression of TAC. The associations of SMI and SMD with AoAC and DTAC were consistent with their associations with TAC, except for ATAC. The ROC curve analysis indicated that incorporating SMD into the model enhanced the discriminative ability for stratifying the risk of rapid progression of thoracic aorta calcification. Conclusion After adjusting for cardiovascular risk factors and inflammatory markers, higher skeletal muscle quality and higher skeletal muscle mass were significantly associated with lower TAC. Improving skeletal muscle quality in initial dialysis patients may reduce the risk of rapid TAC progression.

Measurement of Wall Shear Rate Across the Entire Vascular Wall Using Ultrasound Speckle Decorrelation

ObjectiveThe accurate measurement of the wall shear rate (WSR) plays a crucial role in the early diagnosis of cardiovascular disease progression and acute events such as aneurysms and atherosclerotic plaque ruptures. To address this need, the speckle decorrelation (SDC) technique has been used to measure WSR based on the 2-D out-of-plane blood flow speed. This technique is particularly advantageous because it enables the use of a 1-D array transducer to measure WSR over the entire luminal area. This study aims to develop a region-based singular value decomposition (SVD) filtering technique that selectively suppresses clutter noise in the vascular region to measure WSR using SDC. MethodUltrasound simulations, in-vitro flow experiments, and an in-vivo human study were conducted to evaluate the feasibility of this method's clinical application. ResultsThe results demonstrated that WSR can be effectively measured across entire vascular walls using a conventional 1-D array transducer along with the proposed methodology. ConclusionThis study successfully demonstrates a noninvasive and accurate SDC-based method for measuring vital vascular WSR. This approach holds significant promise for assessing vascular WSR in both healthy individuals and high-risk cardiovascular disease patients.

Automatic edge app placement for personalized heart attack predictions

Edge computing brings data processing, analytics and storage closer to the source, but the major limitation of edge devices is that they have limited processing power and storage. Some have argued that cloud can be a solution to overcome the edge computing limitations. However, performing all tasks on the cloud introduces latency issues. Therefore, we need a solution that can use edge and cloud computing intelligently and interchangeable such that the merits of both can be utilized based on the specific scenario. Such a model has not been discussed in the literature so far which poses a very important limitation. We proposed a novel architecture that intelligently switches data processing between the cloud and edge just-in-time based on specific conditions, i.e., if a healthcare scenario demands low latency data are processed at the edge, otherwise data are automatically processed on the cloud. We illustrate this by creating an Automatic edge application to monitor high risk cardiovascular disease patients who are at the risk of heart attacks after a post-operative surgery. Low latency is very important while monitoring such patients and the application is built to automatically detect all such cases and performs heart attack predictions on the edge while other patients data is processing on the cloud. The experimental results have demonstrated that our application can automatically detect high risk cardiovascular disease patients and place their workloads on the edge which is a new and unique invention in the area of automated edge computing. We have also demonstrated that the data retrieval from the edge is 55% faster than the cloud thereby ensuring low latency with edge.

An improved method for estimating low LDL-C based on the enhanced Sampson-NIH equation

BackgroundThe accurate measurement of Low-density lipoprotein cholesterol (LDL-C) is critical in the decision to utilize the new lipid-lowering therapies like PCSK9-inhibitors (PCSK9i) for high-risk cardiovascular disease patients that do not achieve sufficiently low LDL-C on statin therapy.ObjectiveTo improve the estimation of low LDL-C by developing a new equation that includes apolipoprotein B (apoB) as an independent variable, along with the standard lipid panel test results.MethodsUsing β-quantification (BQ) as the reference method, which was performed on a large dyslipidemic population (N = 24,406), the following enhanced Sampson-NIH equation (eS LDL-C) was developed by least-square regression analysis:eSLDL-C=TC1.15-HDL-C1.25-TG6.99-TG×NonHDL-C1120+TG28910+TG×ApoB1240+ApoB4.54-4.73\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$eS\\,LDL-C= \\frac{TC}{1.15}-\\frac{HDL-C}{1.25}-\\frac{TG}{6.99}-\\frac{\\left(TG\ imes NonHDL-C\\right)}{1120}+\\frac{{TG}^{2}}{8910}+\\frac{\\left(TG\ imes ApoB\\right)}{1240}+\\frac{ApoB}{4.54}-4.73$$\\end{document}ResultsThe eS LDL-C equation was the most accurate equation for a broad range of LDL-C values based on regression related parameters and the mean absolute difference (mg/dL) from the BQ reference method (eS LDL-C: 4.51, Sampson-NIH equation [S LDL-C]: 6.07; extended Martin equation [eM LDL-C]: 6.64; Friedewald equation [F LDL-C]: 8.3). It also had the best area-under-the-curve accuracy score by Regression Error Characteristic plots for LDL-C < 100 mg/dL (eS LDL-C: 0.953; S LDL-C: 0.920; eM LDL-C: 0.915; F LDL-C: 0.874) and was the best equation for categorizing patients as being below or above the 70 mg/dL LDL-C treatment threshold for adding new lipid-lowering drugs by kappa score analysis when compared to BQ LDL-C for TG < 800 mg/dL (eS LDL-C: 0.870 (0.853–0.887); S LDL-C:0.763 (0.749–0.776); eM LDL-C:0.706 (0.690–0.722); F LDL-C:0.687 (0.672–0.701). Approximately a third of patients with an F LDL-C < 70 mg/dL had falsely low test results, but about 80% were correctly reclassified as higher (≥ 70 mg/dL) by the eS LDL-C equation, making them potentially eligible for PCSK9i treatment. The M LDL-C and S LDL-C equations had less false low results below 70 mg/dL than the F LDL-C equation but reclassification by the eS LDL-C equation still also increased the net number of patients correctly classified.ConclusionsThe use of the eS LDL-C equation as a confirmatory test improves the identification of high-risk cardiovascular disease patients, who could benefit from new lipid-lowering therapies but have falsely low LDL-C, as determined by the standard LDL-C equations used in current practice.

The Effectiveness and Safety of Intensive Lipid-Lowering with Different Rosuvastatin-Based Regimens in Patients at High Cardiovascular Disease Risk: A Nonblind, Randomized, Controlled Trial.

A statin alone or non-statins as add-ons have been introduced to intensive low-density lipoprotein cholesterol (LDL-C) -lowering therapy in patients at risk for high cardiovascular disease (CVD). The purpose of this study was to evaluate the effectiveness and safety of different rosuvastatin-based regimens for patients at high risk. Three hundred patients at high CVD risk were randomly assigned to the statin group (rosuvastatin, 20 mg/d), statin_EZ group (statin 10 mg/d + ezetimibe 10 mg/d), statin_pcsk group (statin 10 mg/d + alirocumab 75 mg/2 weeks) or combine3 group (statin 10 mg/d + ezetimibe 10 mg/d + alirocumab 75 mg/2 weeks). The primary outcome measure was cholesterol levels after 24 weeks of follow-up. Secondary outcomes included safety markers and the proportion of patients achieving the 70 mg/dL (1.8 mmol/L) target for LDL-C. A logistic regression model was performed to explore the factors affecting lipid target achievement. The total cholesterol (TC) and LDL-C levels in the four groups after treatment were significantly lower than those before treatment. TC and LDL-C levels after treatment were significantly different among the four groups (p 0.05). The levels in both the combine3 and statin_pcsk9 groups were significantly lower than those in the statin and statin_EZ groups (p 0.05), but there was no significant difference between the combine3 and statin_pcsk9 groups. Fifty-one participants (69%) in the statin_pcsk9 group and 56 participants (78%) in the combine3 group achieved the target. Body mass index (BMI) and hypertensive status were related to LDL-C target achievement. The incidence of adverse events in the four groups was low. The combination of a statin and a PCSK9 inhibitor was safe and more effective for the treatment of high-risk CVD patients, while the addition of ezetimibe was unable to significantly lower lipid levels any further. The rate of achieving the target was higher in patients with hypertension and a low BMI. Chinese Clinical Trial Registry, Identifier: ChiCTR2200058389, Date of Registration: 2022-04-08.

Real World Evidence of Bempedoic Acid on Efficacy and Safety in Patients with Uncontrolled LDL-c and at High Risk of CVD

Background and Objective: Cardiovascular disease (CVD) is a significant cause of morbidity and mortality worldwide, with high-risk patients requiring effective management to reduce their risk of cardiovascular events. Bempedoic acid is a novel therapeutic agent recently approved as an add-on therapy to statins in patients with uncontrolled LDL-c. Bempedoic acid inhibits cholesterol synthesis in the liver, which ultimately reduces the risk of cardiovascular events. Therefore, the present study aims to assess the efficacy and safety of bempedoic acid in patients with uncontrolled LDL-c (Previously on moderate or high-intensity statins) with a high risk of CVD in real-world settings.&#x0D; Methods: This is a multicenter, retrospective, observational study on the data of high-risk-CVD patients collected from Bempedoic Acid on Efficacy and Safety in patients (BEST) Registry. The clinical data of 140 patients who were already on statin therapy and were receiving Bempedoic acid at a dose of 180 mg, along with measurements of the level of LDL-c, HbA1c, HDL, TG, TC, PPPG, FPG, AST, ALT, serum creatinine was taken into consideration. The primary outcome includes a change in LDL-c level, and secondary outcomes involve a change in the level of HbA1c, HDL, TG, TC, PPPG, FPG, AST, ALT, and serum creatinine at week 12 and 24. Adverse events were reported at both time points.&#x0D; Results: A total of 140 patients were included in the present study with a mean age of 51.8 ± 9.2 years and had primary confirmed diagnosis of dyslipidemia with uncontrolled LDL-c. The mean levels of LDL-c decreased from the mean baseline value of 142.67 ± 46.49 mg/dL, to 106.78 ±33.92 mg/d; a statistically significant reduction by 23.23% (p &lt; 0.01) at week 12. Similarly, at week 24, the mean LDL-c value reduced to 90.39 ± 38.89 mg/dL. A 33.38 % decrease was observed (p &lt; 0.01). Other parameters such as non-HDL, FPG, PPPG, AST and serum creatinine also showed statistically significant reduction at week 12 and week 24. &#x0D; Conclusion: The present study demonstrates that bempedoic acid is an effective add-on medication in lowering LDL-c levels in high-risk CVD patients with uncontrolled LDL-c.

Differences in treatment strategies for LDL-cholesterol reduction in a university lipid clinic vs. standard care apart from the use of PCSK9 inhibitors

Lipid-lowering therapy (LLT) in patients with cardiovascular disease (CVD) is insufficient despite clear guideline recommendations. Lipid clinics have specialized in patients with dyslipidemia, but the magnitude and reduction of low-density lipoprotein cholesterol (LDL-C) in lipid clinics has not yet been studied in depth. To assess LDL-C reduction in very high-risk CVD patients achieved in a lipid clinic through different forms of LLT in comparison to standard care without the initiation of PSCK9 inhibitors. Data from 96 lipid clinic patients were analyzed retrospectively and compared to 84 standard care patients. Very high-risk patients were defined according to the European Society of Cardiology (ESC). Different combinations of LLT focusing on statins and ezetimibe were investigated. Achievement of LDL-C treatment goals according to ESC guidelines as well as LDL-C reduction were assessed. Baseline and follow-up data of 180 very high-risk CVD patients (mean age 67.7 (±9.8) y; 60.6% male) were used. Achievement of the LDL-C goal in lipid clinic patients increased significantly from 14.6% at baseline to 41.7% at the latest visit (p<0.001) while standard care patients improved from 21.4% to 33.3% (p=0.08). The largest relative LDL-C reduction via an adjustment in LLT was achieved by initiation of high-intensity statins (50.8 ± 4.9%, n=5, p < 0.05). Treatment in a lipid clinic leads to a superior LDL-C goal achievement in very high-risk CVD patients as compared to standard care with the highest reduction under LLT with high-intensity statins and ezetimibe. Referral algorithms have to be established for high-risk patients.

Evaluating the clinical effectiveness of the NHS Health Check programme: a prospective analysis in the Genetics and Vascular Health Check (GENVASC) study

ObjectiveThe aim of the study was to assess the clinical effectiveness of the national cardiovascular disease (CVD) prevention programme—National Health Service Health Check (NHSHC) in reduction of CVD risk.DesignProspective cohort...

Investigating genes associated with heart failure, atrial fibrillation, and other cardiovascular diseases, and predicting disease using machine learning techniques for translational research and precision medicine

Cardiovascular disease (CVD) is the leading cause of mortality and loss of disability adjusted life years (DALYs) globally. CVDs like Heart Failure (HF) and Atrial Fibrillation (AF) are associated with physical effects on the heart muscles. As a result of the complex nature, progression, inherent genetic makeup, and heterogeneity of CVDs, personalized treatments are believed to be critical. Rightful application of artificial intelligence (AI) and machine learning (ML) approaches can lead to new insights into CVDs for providing better personalized treatments with predictive analysis and deep phenotyping. In this study we focused on implementing AI/ML techniques on RNA-seq driven gene-expression data to investigate genes associated with HF, AF, and other CVDs, and predict disease with high accuracy. The study involved generating RNA-seq data derived from the serum of consented CVD patients. Next, we processed the sequenced data using our RNA-seq pipeline and applied GVViZ for gene-disease data annotation and expression analysis. To achieve our research objectives, we developed a new Findable, Accessible, Intelligent, and Reproducible (FAIR) approach that includes a five-level biostatistical evaluation, primarily based on the Random Forest (RF) algorithm. During our AI/ML analysis, we have fitted, trained, and implemented our model to classify and distinguish high-risk CVD patients based on their age, gender, and race. With the successful execution of our model, we predicted the association of highly significant HF, AF, and other CVDs genes with demographic variables.

Real-World Data on Comparison of Lipid-Lowering Effects between Alirocumab and Evolocumab in Patients with Hypercholesterolemia.

Even though the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, have been approved to reduce plasma low-density lipoprotein cholesterol (LDL-C) and the risk of atherosclerotic cardiovascular disease in high-risk patients, real-world data showing comparisons of the lipid-lowering effects between alirocumab and evolocumab are scarce because of the low prescription rates of PCSK9 inhibitors in clinical practice. Between Feb 2018 and Sep 2021, 22 patients who received alirocumab and 22 patients who received evolocumab at a tertiary medical center were enrolled. The patients' baseline characteristics, prescribed medications, plasma LDL-C levels, and percentages of reduction in LDL-C were compared between alirocumab users and evolocumab users. The alirocumab users more frequently received ezetimibe treatment (72.7% vs. 40.9%, p = 0.03) and had higher baseline LDL-C (165.6 ± 63.2 mg/dL vs. 130.8 ± 56.3 mg/dL, p = 0.04) compared with the evolocumab users. At 6 months of follow-up, the plasma LDL-C levels in the alirocumab users were similar to those in the evolocumab users (79.3 ± 64.0 mg/dL vs. 63.5 ± 44.1 mg/dL, p = 0.48). Additionally, the percentages of LDL-C reduction following treatment were similar between the alirocumab users and evolocumab users (-47.0% ± 45.0% vs. -49.8 ± 24.9%, p = 0.66). The LDL-C lowering effects of alirocumab are similar to those of evolocumab in clinical practice.

Overcoming High Cardiovascular Disease Burden in Indonesia: The Importance of Massive Cardiovascular Disease Risk Factor Screening, Aggressive Guideline-Directed Treatment, and Community-Based Programs

Indonesia is a developing country with a large number of populations. Cardiovascular disease (CVD) is a serious public health concern in Indonesia because of its high burden. Moreover, the high-risk CVD patients were under treatment. Optimal CVD prevention can be the solution to this issue. In this paper, we are talking mainly about the role of massive CVD risk factor screening, precise risk stratification, aggressive guideline-directed treatment, and community-based programs in reducing the CVD burden.

Real-world data on the comparison of LDL-C lowering effects between alirocumab and evolocumab

Background and Aims : Despite proprotein convertase subtilisin/Kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, have been approved to further reduce serum low-density lipoprotein cholesterol (LDL-C) levels and significantly reduce the risk of atherosclerotic cardiovascular disease in high-risk patients, there are still few studies to compare the LDL-C lowering effects between alirocumab and evolocumab in clinical practice. The present study was aimed to report a real-world data on the comparison of LDL-C lowering effects between the abovementioned 2 PCSK9 inhibitors.

Higher oral porphyromonas gingivalis abundance is associated with the presence of atherosclerotic cardiovascular disease in high-risk patients and in patients with Heterozygous Familial Hypercholesterolemia

Background and Aims : Low-grade chronic inflammation, promoted by dysbiosis of gut and oral microbiota, may contribute to individual susceptibility to ASCVD. High oral Porphyromonas gingivalis (PG) and lower Fusobacterium nucleatum (FN) concentrations have been associated with clinical and experimental atherosclerosis. We assessed oral PG and FN abundance in very high-risk patients with previous ASCVD and with or without heterozygous FH and in healthy control subjects.

Resumption of Antiplatelet Therapy after Major Bleeding.

Major bleeding is a common threat in patients requiring antiplatelet therapy. Timing and intensity with regard to resumption of antiplatelet therapy represent a major challenge in clinical practice. Knowledge of the patient's bleeding risk, defining transient/treatable and permanent/untreatable risk factors for bleeding, and weighing these against thrombotic risk are key to successful prevention of major adverse events. Shared decision-making involving various disciplines is essential to determine the optimal strategy. The present article addresses clinically relevant questions focusing on the most life-threatening or frequently occurring bleeding events, such as intracranial hemorrhage and gastrointestinal bleeding, and discusses the evidence for antiplatelet therapy resumption using individual risk assessment in high-risk cardiovascular disease patients.

Post-transplant Diabetes Mellitus: What Physicians Need to Know.

Post-transplant diabetes mellitus (PTDM) is a common problem among solid organ transplant recipients contributing to morbidity and affecting patient as well as graft survival adversely. It can occur at any period following transplantation, but maximum incidence is observed in the first few months, with a second peak after a few years after transplantation. The pathogenesis is complex and poorly understood, however, it is associated with both dysfunctional beta-cells and insulin resistance. Both nonpharmacologic and antidiabetic therapies are important for adequate glycemic control. This point of view article provides a short review on PTDM in solid organ transplantation (SOT) recipients from a general physician's perspective.

Cardiovascular risks and primary interventions among treated rheumatoid arthritis patients: Experience from a tertiary care centre in Kuala Lumpur, Malaysia

Purpose: To investigate the cardiovascular risk among treated rheumatoid arthritis (RA) patients to predict the factors associated with high cardiovascular risk and to determine the presence of pharmacotherapy primary prevention among treated RA patients with high cardiovascular disease (CVD) risk.Methods: The study was a prospective cross-sectional study on adult patients diagnosed and treated for RA and without established heart disease/stroke. Cardiovascular risk scoring was based on Framingham Cardiovascular Disease 10-year risk prediction model (BMI model) x 1.5 factor while descriptive and inferential analyses were done using SPSS.Results: High CVD risk was defined as FRS-CVD cardiovascular risk categories (&gt;20%) and 55.9% of patients were at high CVD risk. Use of Hydroxychloroquine (OR: 0.44; 95 % CI: 0.21- 0.92; p= 0.028) and COX-2 inhibitors (OR: 0.31; 95% CI:0.10- 0.95; p = 0.039) were found to be significantly associated with high CVD risk among treated RA patients. Significant number of high CVD risk patients did receive pharmacotherapy primary prevention (p = 0.001).Conclusion: Hydroxychloroquine and COX-2 inhibitors are independent negative risk predictors associated with high CVD risk among treated RA patients. Baseline cardiovascular risk data may be useful in rational use of medications to treat RA, considering that cardiovascular related mortality is the leading cause of death in RA.

Effect of PCSK9 Inhibitor on Blood Lipid Levels in Patients with High and Very-High CVD Risk: A Systematic Review and Meta-Analysis

Objectives We aimed to investigate the effects of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor on blood lipid levels in patients with high and very-high cardiovascular risk. Design 14 trials (n = 52,586 patients) comparing treatment with or without PCSK9 inhibitors were retrieved from PubMed and Embase updated to 1st Jun 2021. The data quality of included studies was assessed by two independent researchers using the Cochrane systematic review method. All-cause mortality, cardiovascular mortality, and changes in serum low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), apolipoprotein B (ApoB), lipoprotein (a) (LP (a)), non-high-density lipoprotein cholesterol (non-HDL-C), high-density lipoprotein cholesterol (HDL-C), and apolipoprotein A1 (ApoA1) from baseline were analyzed using Rev Man 5.1.0 software. Results Compared with treatments without PCSK9 inhibitor, addition of PCSK9 inhibitors (evolocumab and alirocumab) had obvious decreasing effects on the levels of LDL-C [MD = −46.86, 95% CI (−54.99 to −38.72), P < 0.00001], TC [MD = −31.92, 95% CI (−39.47 to −24.38), P < 0.00001], TG [MD = −8.13, 95% CI (−10.48 to −5.79), P < 0.00001], LP(a) [MD = −26.69, 95% CI (-27.93 to −25.44), P < 0.00001], non-HDL-C [MD = −42.86, 95% CI (−45.81 to −39.92), P < 0.00001], and ApoB [MD = −38.44, 95% CI (−42.23 to -34.65), P < 0.00001] in high CVD risk patients. Conversely, changes of HDL-C [MD = 6.27, CI (5.17 to 7.36), P < 0.00001] and ApoA1 [MD = 4.33, 95% CI (3.53 to 5.13), P < 0.00001] from baseline were significantly more in high cardiovascular disease risk patients who received PCSK9 inhibitors treatment. Conclusion Addition of PCSK9 inhibitors to standard therapy resulted in definite improvement in blood lipid levels compared with therapies that did not include them.

Risk Factor Clusters and Cardiovascular Disease in High-Risk Patients: The UCC-SMART Study.

Background:Clustering of vascular risk factors, i.e., the co-existence of two or more risk factors, has been associated with a higher risk of cardiovascular disease (CVD) in the general population. This study aims to firstly, examine patterns of clustering of major cardiovascular risk factors in high-risk patients and their relation with the risk of recurrent cardiovascular disease and all-cause mortality. Secondly, to assess which combinations are associated with the highest risk of CVD and all-cause mortality and to study population attributable fractions.Methods:A total of 12,616 patients from the Utrecht Cardiovascular Cohort – Second Manifestations of ARTerial diseases (UCC-SMART) study consisting of patients with or a high risk to develop cardiovascular disease were studied. We constructed sixteen clusters based on four individual modifiable risk factors (hypertension, dyslipidemia, current smoking, overweight). Patients were followed from September 1997 to March 2017. Cox proportional hazard models were used to compute adjusted hazard ratios for CVD risk and all-cause mortality and 95% confidence intervals for clusters, with patients without any risk factor as reference group. The population attributable fractions (PAFs) were calculated. Subgroup analyses were conducted by age and sex.Results:During a mean follow-up period of 8.0 years, 1836 CVD events were registered. The prevalence of patients with zero, one, two, three, and four risk factors was 1.4, 11.4, 32.0, 44.8 and 10.4%. The corresponding hazard ratios (HR) for CVD risk and all-cause mortality were 1.65 (95% CI 0.77; 3.54) for one risk factor, 2.61 (1.24; 5.50) for two, 3.25 (1.55; 6.84) for three, and 3.74 (1.77; 7.93) for four risk factors, with patients without any risk factor as reference group. The PAFs were 6.9, 34.0, 50.1 and 22.2%, respectively. The smoking-hypertension-dyslipidemia combination was associated with the highest HR: 4.06 (1.91; 8.63) and the hypertension-dyslipidemia combination with the highest PAF: 37.1%.Conclusion:Clusters including smoking and hypertension contributed to the highest risk of CVD and all-cause mortality. This study confirms that risk factor clustering is common among patients at high-risk for CVD and is associated with an increased risk of CVD and all-cause mortality.

Assessing the feasibility and acceptability of a financial versus behavioural incentive-based intervention for community health workers in rural Indonesia

BackgroundThe World Health Organization recommends that community health workers (CHWs) receive a mix of financial and non-financial incentives, yet notes that there is limited evidence to support the use of one type of incentive (i.e. financial or non-financial) over another. In preparation for a larger scale trial, we investigated the acceptability and feasibility of two different forms of incentives for CHWs in Malang District, Indonesia.MethodsCHWs working on a cardiovascular disease (CVD) risk screening and management programme in two villages were assigned to receive either a financial or non-financial incentive for 6 months. In the financial incentives village, CHWs (n = 20) received 16,000 IDR (USD 1.1) per patient followed up or 500,000 IDR (USD 34.1) if they followed up 100% of their assigned high-risk CVD patients each month. In the non-financial incentive village, CHWs (n = 20) were eligible to receive a Quality Care Certificate for following up the highest number of high-risk CVD patients each month, awarded in a public ceremony. At the end of the 6-month intervention period, focus group discussions were conducted with CHWs and semi-structured interviews with programme administrators to investigate acceptability, facilitators and barriers to implementation and feasibility of the incentive models. Data on monthly CHW follow-up activity were analysed using descriptive statistics to assess the preliminary impact of each incentive on service delivery outcomes, and CHW motivation levels were assessed pre- and post-implementation.ResultsFactors beyond the control of the study significantly interrupted the implementation of the financial incentive, particularly the threat of violence towards CHWs due to village government elections. Despite CHWs reporting that both the financial and non-financial incentives were acceptable, programme administrators questioned the sustainability of the non-financial incentive and reported CHWs were ambivalent towards them. CHW service delivery outcomes increased 17% for CHWs eligible for the non-financial incentive and 21% for CHWs eligible for the financial incentive. There was a statistically significant increase (p < 0.0001) in motivation scores for the performance domain in both villages.ConclusionIt was feasible to deliver both a performance-based financial and non-financial incentive to CHWs in Malang District, Indonesia, and both incentive types were acceptable to CHWs and programme administrators. Evidence of preliminary effectiveness also suggests that both the financial and non-financial incentives were associated with improved motivation and service delivery outcomes. These findings will inform the next phase of incentive design, in which incentive feasibility and preliminary effectiveness will need to be considered alongside their longer-term sustainability within the health system.

Understanding Accelerated Atherosclerosis in Systemic Lupus Erythematosus: Toward Better Treatment and Prevention.

Systemic lupus erythematosus (SLE) carries a significant risk of cardiovascular disease (CVD). The prevalence of premature CVD is especially noteworthy because it occurs in premenopausal women with SLE who would otherwise have very low rates of CVD. While traditional risk factors likely play a role in development of CVD in the setting of SLE, they do not fully explain the excess risk. The pathogenesis of CVD in SLE is not fully understood, but the inflammatory nature of SLE is believed to be a key factor in accelerating atherosclerosis. Systemic inflammation may lead to an abnormal lipid profile with elevated triglycerides, total cholesterol, and low-density lipoprotein cholesterol and dysfunctional high-density lipoprotein cholesterol. Additionally, the inflammatory milieu of SLE plasma promotes endothelial dysfunction and vascular injury, early steps in the progression of atherosclerotic CVD. Despite the overall headway that has been achieved in treating lupus, innovative therapeutics specifically targeting the progression of atherosclerosis within the lupus population are currently lacking. However, there have been advancements in the development of promising modalities for diagnosis of subclinical atherosclerosis and detection of high CVD risk patients. Due to the significant impact of CVD on morbidity and mortality, research addressing prevention and treatment of CVD in SLE needs to be prioritized. This review explores the intricate interplay of SLE-specific properties that contribute to atherosclerosis and CVD within this population, as well as screening methods and possible therapies.