Lifetime Cardiovascular Risk Research Articles

Abstract MP18: Estimating Coronary Mortality Reductions By Shifting The Population Blood Pressure Distribution Or By Improving The Management Of Hypertensive Patients

Introduction: Hypertension is an important risk factor for coronary heart disease (CHD) in the UK and US. Although CHD death rates are falling, a large proportion of hypertensive patients are poorly controlled and population salt intake, a major determinant of hypertension, remains well above the recommended daily maximum of 6g/day. G. Rose identified two strategies to reduce CHD mortality. The first proposes that small, but population-wide, reductions in systolic blood pressure (SBP), achieved by public health measures to reduce salt intake, will deliver large reductions in mortality. The second seeks to reduce mortality by treating hypertensive patients and keeping them below a given risk-threshold. Here we explore the potential to reduce CHD deaths through a combination of these strategies in England and Wales up to 2030. Methods: We used the Stock of Health (SoH) model assuming each individual is born with a SoH, and on an annual basis this stock depreciates due to demographic factors, and fixed and variable risk factors. When the individual’s SoH reaches a critical point, a death from CHD occurs. The model parameters were calibrated using data from the US Cardiovascular Lifetime Risk Pooling Project. Births, deaths and risk factors distributions were estimated using data from England and Wales (ONS). We modelled a baseline scenario, three population-level strategies and two high-risk strategies. The population level strategies to reduce SBP were: (1) a reduction of 0.1 mmHg achievable by health promotion or labelling strategies, (2) a reduction of 1.3 mmHg achievable by mandatory reformulation and (3) matching England and Wales SBP levels to the observed values in the US population (average reduction:7 mmHg). In the high-risk strategies, 30% and 50% of the currently uncontrolled hypertensive patients respectively are treated to keep their SBP under 140 mmHg. Results: In the baseline scenario, the total number of CHD deaths from 2013 to 2030 will be approximately 465,000 (95% CI 460,308 to 469,334). We predict 1,244 (95% CI -3,320 to 5,807) fewer deaths by health promotion; approximately 16,203 (11,691 to 20,718) fewer deaths by mandatory reformulation of foods and some 78,051 (74,016 to 82,087) fewer deaths by reducing SBP levels to the observed levels in US. Conversely, by controlling the SBP of 30% and 50% of uncontrolled hypertensive patients, we predict 4,594 (6 to 9,191) and 7,172 (6,473 to 11,767) fewer deaths respectively. Conclusion: Both risk-targeted treatment strategies and population shifts attributable to salt reduction appear to provide potential substantial contributions to reducing CHD mortality in England and Wales. There remains, however, considerable potential to achieve much greater reductions in mortality by reducing SBP levels to those seen in the US.

Lifetime risk for cardiovascular disease in a Chinese population: the Chinese Multi–Provincial Cohort Study

Lifetime risk estimation is used to predict long-term cardiovascular disease (CVD) risk across the entire life span. However, most of the lifetime risk estimation came from the studies based on western population. This study aimed to assess the lifetime risk of CVD and the impact of risk factors on lifetime risk of CVD in Chinese population. Prospective population-based cohort study. The study sample came from the Chinese Multi-Provincial Cohort Study (CMCS), 21,953 participants aged 35 to 84 years without CVD at the baseline were included. The modified Kaplan-Meier method was used to calculate the lifetime risk of CVD. During follow-up years from 1992 to 2010, 1,280 participants developed acute CVD events and 1,401 died. The lifetime CVD risk, up to age 80 for men and women at age 35, were 24.4% and 20.2% respectively. A very low lifetime risk was found in individuals with an optimal profile of risk factors which modified the effect of aging. By contrast, with two or more high risk factors the lifetime risk up to age 80 reached 51.1% for men and 38.6% for women at age 35. The integrated status of major CVD risk factors can determine lifetime cardiovascular health and CVD risk in Chinese. Early prevention with a goal of all risk factors at optimal levels should become the priority of CVD prevention in the future.

Is Increased Epicardial Adipose Tissue is a Sign of Cardiovascular Disease in Women with Gestational Diabetes Mellitus?

PP-125 Increased epicardial adipose tissue thickness (EATT), a component of body visceral adiposity, has been suggested to increase the likelihood of lifetime cardiovascular disease risk. Women with gestational diabetes mellitus (GDM) have higher risk of developing type 2 diabetes and, consequently

Predictors of cardiovascular risk in women.

Cardiovascular disease is the leading cause of death in women, contributing to one in three female deaths. Despite improvements in overall cardiovascular outcomes, substantial gender and ethnic disparities remain. In order to improve outcomes among women, we recommend the following: every woman should undergo risk stratification for short-term and lifetime cardiovascular risk given the substantial long-term risk of cardiovascular disease; modifiable cardiovascular risk factors in women should be modified to the greatest extent possible; and these factors include lipid abnormalities, hypertension, smoking, diabetes, obesity, physical inactivity and, possibly, inflammatory markers. The rate of decline in heart disease is slower for women than men, highlighting the need for gender-specific interventions to address the outcomes gap.

Elevated Blood Pressure in Pregnancy and Subsequent Chronic Disease Risk

Preeclampsia, a new-onset hypertensive disorder of pregnancy, is associated with lifetime cardiovascular disease risk, but less is known about risk after other pregnancy-related hypertension. The Northern Finland Birth Cohort 1966 included all expected births from 1 year (N=12 055 women). Blood pressure measurements and other prospective data were determined from prenatal care records and questionnaires for 10 314 women. Subsequent diagnoses were ascertained from Finnish registries (average follow-up, 39.4 years). Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) estimate risks in hypertensive women compared with normotensive women. Hypertension during pregnancy was associated with increased risk of subsequent cardiovascular disease and arterial hypertension. Women with chronic hypertension and superimposed preeclampsia/eclampsia had high risk for future diseases. Gestational hypertension was associated with increased risk of ischemic heart disease (HR, 1.44 [95% CI, 1.24-1.68]), myocardial infarcts (HR, 1.75 [95% CI, 1.40-2.19]), myocardial infarct death (HR, 3.00 [95% CI, 1.98-4.55]), heart failure (HR, 1.78 [95% CI, 1.43-2.21]), ischemic stroke (HR, 1.59 [95% CI, 1.24-2.04]), kidney disease (HR, 1.91 [95% CI, 1.18-3.09]), and diabetes mellitus (HR, 1.52 [95% CI, 1.21-1.89]). Isolated systolic hypertension was associated with increased risk of myocardial infarct death (HR, 2.15 [95% CI, 1.35-3.41]), heart failure (HR, 1.43 [95% CI, 1.13-1.82]), and diabetes mellitus (HR, 1.42 [95% CI, 1.13-1.78]), whereas isolated diastolic hypertension was associated with increased risk of ischemic heart disease (HR, 1.26 [95% CI, 1.05-1.50]). Results were similar in nonsmoking women aged <35 years with normal weight and no diabetes mellitus during pregnancy. Elevated blood pressure during pregnancy, regardless of type and even without known risk factors, signals high risk of later cardiovascular disease, chronic kidney disease, and diabetes mellitus. Clinical monitoring, risk factor evaluation, and early intervention could benefit women with hypertension in pregnancy.

OP81 Estimating the Potential of Population Level Changes in Cholesterol and Blood Pressure for Reducing UK Coronary Heart Disease Mortality Rates: A Novel Modelling Approach

BackgroundCoronary heart disease (CHD) mortality is declining. However, population ageing and increasing obesity and diabetes might reverse this trend. Strategies to reduce salt and saturated fat intake could substantially decrease...

Multi-Ethnic Study of Atherosclerosis Arterial Age Versus Framingham 10-Year or Lifetime Cardiovascular Risk

Methods to improve coronary heart disease (CHD) risk prediction include incorporation of coronary artery calcium (CAC) within risk models and considering longer time horizons such as evaluation of lifetime cardiovascular risk (LTR). We compared the accuracy of 10-year Framingham risk score (FRS), LTR, and Multi-Ethnic Study of Atherosclerosis (MESA) arterial age-adjusted 10-year risk for prediction of incident CHD events in men in the Prospective Army Coronary Calcium Project. We studied 1,633 healthy men (mean age 43 years, range 40 to 50 years, mean FRS 4.6%) with electron-beam computed tomography for CAC. Events (CHD death, myocardial infarction, acute coronary syndrome with nonelective coronary revascularization) were prospectively assessed over 5.6 ± 1.5 years. Predicted risk using 10-year FRS for CHD and cardiovascular disease, LTR, and MESA arterial age were evaluated in relation with CAC and CHD events. CAC prevalence was strongly related to LTR, increasing in a graded fashion from 10.1% to 66.7% across 8 categories of increasing LTR. On receiver operating characteristic analysis, MESA arterial age (area under curve 0.78, 95% confidence interval 0.64 to 0.93) had the largest area under the curve but similar areas under the curve were observed for 10-year risk (CHD 0.74, 0.61 to 0.86; cardiovascular disease 0.70, 0.59 to 0.82), LTR (0.68, 0.49 to 0.76), and LTR with CAC as a covariate (0.76, 0.63 to 0.89). Inclusion of family history of CHD or body mass index did not improve model accuracy. In conclusion, increasing LTR was associated with increasingly prevalent CAC in this low-risk cohort and inclusion of CAC improved the accuracy of LTR for short-term event prediction.

Reducing lifetime cardiovascular risk

Reducing lifetime cardiovascular risk

Abstract MP044: Prediction of 10-year and Lifetime Risk for Cardiovascular Disease in Mexico: Results from a National Representative Survey in 2006

Introduction: Mexico is undergoing a fast-paced epidemiologic transition, yet little is known about its cardiovascular risk. In the absence of Mexican prediction tools algorithms developed for other populations may be informative and a first step in the development of risk calculation tools specific to this population. Methods: We applied two US-based algorithms based on the Framingham Heart Study data to stratify 5,074 cardiovascular disease-free Mexican adults by 10-year and lifetime cardiovascular risk. We used data from the 2006 Mexican National Health and Nutrition Survey (ENSANUT), a publicly available complex multistage, stratified nationally representative survey. Participants were aged 20 to 82 years and represent 42 million Mexican adults. Ten-year and lifetime predicted risks were combined to define the following groups: low 10-year (&lt;10%)/low lifetime (&lt;39%) predicted risk, low 10-year (&lt;10%)/high lifetime (≥39%) predicted risk and high 10-year (≥10%) predicted risk or diagnosed diabetes. Results: While we estimated that according to these tools a slight majority of Mexican adults (56% or 24 million) are at low short-term/low lifetime predicted risk for cardiovascular disease, there are 10 million Mexican adults (24%) that despite a low short-term risk have a high lifetime predicted cardiovascular risk, while 20% (8 million) are at a high short-term risk for cardiovascular disease. Women had a higher prevalence of low short-term/low lifetime predicted risk (64 vs 46%), while men had a high short term predicted risk that was twice that of women (26 vs 14%). The prevalence of low short-term either with low or high lifetime predicted cardiovascular risk was somewhat higher in rural areas, but there was no substantial difference between participants from urban and rural areas in the prevalence of high short-term risk for cardiovascular disease. Conclusion: Half of Mexican adults have an elevated risk for developing cardiovascular disease during their lifetimes, but less than a half of those are identified using traditional short-term risk calculation tools only. This is the first exercise of this kind in Mexico, risk stratification was based on algorithms that may not be entirely applicable to Mexican population and require refinement.

Lifetime cardiovascular risk of childhood obesity

An increase in the incidence and an earlier onset of coronary artery disease is expected because of the increased prevalence of childhood obesity. Comorbidities of obesity, such as dyslipidemia, insulin resistance syndrome, hypertension, associated nutritional deficiencies, and a sedentary lifestyle or associated lifestyle factors such as tobacco smoke exposure, are likely to account for this increase because these are all independent risk factors for accelerated atherosclerosis. Because clinical atherosclerotic cardiovascular disease does not manifest in obese children, assessment of the subclinical markers of atherosclerosis may help in the evaluation of the progression of atherosclerosis, in further stratification of risk, and in monitoring the effects of intervention. Furthermore, because multiple risk factors with poorly understood interplay might be present in obese children, assessment of the vasculature directly, and perhaps the assignment of a "vascular age," may be a useful method to quantify the "end organ" effect of exposure to these various risks. Obese children may show favorable changes in their behaviors that result in an improvement in clinically measurable risk factors with various clinic-based and behavior modification therapies, but the vascular benefits of such interventions need to be studied further. Broad social, cultural, legislative, and policy changes that support healthy lifestyles within families and communities need to be implemented to decrease the prevalence of childhood obesity and its cardiovascular consequences in communities. The effect of risk factor modification on the vasculature will continue to be a resource for the direction of evidence-based therapy in obese children.

Change Heart and Vascular Risk with Attitude, Nutrition, Goals, and Exercise (CHANGE)

Synopsis: Cardiovascular disease is the number one cause of death in the United States. Traditional risk factors account for more than 90% of the risk of an initial heart attack. Forty-four percent of the reduction in death from heart disease in recent decades is attributed to risk factor modification. Many individuals are aware of their risk factors; however, they are not aware of their treatment goals. Low-risk individuals identified by the Framingham risk score account for the majority of cardiovascular events. Identification of lifetime risk rather than Framingham risk identifies individuals appropriate for early aggressive risk factor management. Purpose: A Cardiovascular Prevention Program was developed by Christiana Care Health System in January 2008 with the goal of improving management of cardiovascular risk factors and reducing the lifetime cardiovascular risk of community members. Methods: The multidisciplinary team included the Medical Director, Advanced Practice Nurse, Cardiovascular Nurses, Behavioral Health Specialist, Vascular Lab, Marketing, and Heart and Vascular Administration. Through a promotional campaign, community members were invited to visit the Christiana Care Website to complete an online cardiovascular risk assessment. Individuals identified with any cardiovascular risk were invited to come for a free comprehensive on-site screening with a cardiovascular nurse. This included a full lipid profile, blood sugar, body mass index, waist circumference, blood pressure, carotid auscultation, assessment of sex-specific and psychosocial risk factors, and triple vascular screening. Personalized risk factor counseling was provided with an emphasis on patient goals and educating and empowering patients with knowledge. In addition to Framingham risk, the patient's lifetime risk for cardiovascular disease was determined during a multidisciplinary team review, and best-practice recommendations provided to the patient and Primary Care Physician. Results: Key outcomes from 289 patients seen in 2008 reflected risk factor profiles consistent with national statistics. Although 70% met traditional lipid goals, only 18% met lipid goals for lifetime risk of cardiovascular disease. A total of 48% had undiagnosed hypertension. Of patients surveyed 6 months following their visit (n=83), 94% had taken steps to achieve their health goals, and 65% had discussed the results and recommendations with their doctor. Approximately one-third of these patients stated they had changes to their treatment plan by their Primary Care Physician based on the screening results! Conclusions: Educating and empowering patients to take an active role in their cardiovascular prevention, in conjunction with educating their providers on best-practice recommendations based on lifetime risk, results in improved management of cardiovascular risk factors.

Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database

Objective To develop, validate, and evaluate a new QRISK model to estimate lifetime risk of cardiovascular disease.Design Prospective cohort study with routinely collected data from general practice. Cox proportional hazards...

Prevalence and Progression of Subclinical Atherosclerosis in Younger Adults With Low Short-Term but High Lifetime Estimated Risk For Cardiovascular Disease

Background— We hypothesized that individuals with low 10-year but high lifetime cardiovascular disease risk would have a greater burden of subclinical atherosclerosis than those with low 10-year but low lifetime risk. Methods and Results— We included 2988 individuals ≤50 years of age at examination year 15 from the Coronary Artery Risk Development in Young Adults (CARDIA) study and 1076 individuals ≤50 of age at study entry from the Multi-Ethnic Study of Atherosclerosis (MESA). The 10-year risk and lifetime risk for cardiovascular disease were estimated for each participant, permitting stratification into 3 groups: low 10-year (&lt;10%)/low lifetime (&lt;39%) risk, low 10-year (&lt;10%)/high lifetime risk (≥39%), and high 10-year risk (≥10%) or diagnosed diabetes mellitus. Baseline levels and change in levels of subclinical atherosclerosis (coronary artery calcium or carotid intima-media thickness) were compared across risk strata. Among participants with low 10-year risk (91% of all participants) in CARDIA, those with a high lifetime risk compared with low lifetime risk had significantly greater common (0.83 versus 0.80 mm in men; 0.79 versus 0.75 mm in women) and internal (0.85 versus 0.80 mm in men; 0.80 versus 0.76 mm in women) carotid intima-media thickness, higher coronary artery calcium prevalence (16.6% versus 9.8% in men; 7.1% versus 2.3% in women), and significantly greater incidence of coronary artery calcium progression (22.3% versus 15.4% in men; 8.7% versus 5.3% in women). Similar results were observed in MESA. Conclusions— Individuals with low 10-year but high lifetime risk have a greater subclinical disease burden and greater incidence of atherosclerotic progression compared with individuals with low 10-year and low lifetime risk, even at younger ages.

Low-dose hydrocortisone in the evening modulates symptom severity in restless legs syndrome

Circadian symptom manifestation in the evening and night is one of the main characteristics of restless legs syndrome (RLS). Although the inverse temporal course of corticosteroid rhythm and RLS symptom severity is obvious, this relationship has yet to be studied. We investigated the effect of late-evening application of exogenous cortisol (hydrocortisone) on sensory leg discomfort (SLD), one of the main complaints of patients with RLS. Ten untreated patients with idiopathic RLS participated in the study. Change of SLD was rated on a visual analogue scale during the 60 minutes resting period of the so-called Suggested Immobilization Test. Patients received either hydrocortisone 40 mg or placebo (saline) IV in random order in a double-blind crossover design, with 1 week between the experiments. Severity of SLD was lower during hydrocortisone infusion than during placebo (p = 0.032). Though blind to the experimental condition, 5 of the 10 patients experienced improvement in symptoms during hydrocortisone administration, but no patient felt an amelioration during the placebo condition. Our data indicate a probable physiologic relationship between evening and early night hour restless legs syndrome symptom increase and low cortisol level.

Obesity, Metabolic Syndrome, and Cardiovascular Disease

Early childhood overweight and obesity have alarmingly increased over the years. Adulthood obesity is a well demonstrated significant independent predictor of cardiovascular risk (CVR) and/or mortality, which predisposes to the major components of metabolic syndrome (MS). Evidence of MS in obese children has been also reported associated with biochemical and inflammatory factors that affect vascular physiologic function. Assessment of vascular function can be measured noninvasively in children allowing early detection of endothelial dysfunction and severe increase of arterial stiffness before clinical manifestations of atherosclerosis. Impairment of endothelial function related to the severity of obesity and to the degree of insulin resistance is considered as a condition that confers a premature atherogenicity status and is linked to adult conventional cardiovascular risk factors. Adipose tissue factors that interfere with insulin action and endothelial cell function have also been identified as major precursors of CVR factors. The metabolic and cardiovascular consequences of childhood obesity are well demonstrated and have a major impact on the development of atherosclerosis and lifetime CVR. The development of programs involving both diet and exercise for children with overt overweight/obesity appears to be essential to improve vascular function and metabolic disorders. Such interventions should be complemented by a primary prevention against childhood obesity.

Megaloblastic Madness

<h3>Background</h3> Coronary heart disease (CHD) mortality is declining. However, population ageing and increasing obesity and diabetes might reverse this trend. Strategies to reduce salt and saturated fat intake could substantially decrease population-wide cholesterol and blood pressure levels and consequently reduce CHD events. Our aim was to explore the potential reduction in CHD mortality burden that might be achieved by population shifts in these risk factors. <h3>Methods</h3> The novel Stock of Health (SoH) modelling approach integrates demographic and risk factor data from the Office for National Statistics and the Health Survey for England, and risk factor effects from the US Cardiovascular Lifetime Risk Pooling Project. The SoH approach estimates the latent “stock” of CHD-related health for each individual within the entire population of England and Wales (51 million). It then computes failure times for CHD mortality, allowing for multiplicative risk factor effects and competing mortality risks. We first simulated CHD deaths for England and Wales over the period 2000-2010. We then extended the simulations to 2030, and compared “FEASIBLE” and “IDEAL” population intervention scenarios, targeted to systolic blood pressure (SBP) and cholesterol under two future trend assumptions: I) assuming mortality rates in 2010 remain stable through to 2030, or II) assuming CHD mortality continue falling. <h3>Results</h3> The mean simulated failure times closely mirrored those actually observed(1993–2004: men=72 vs. 71 years; women=74 vs. 75 years). In 2030, about 81200 CHD deaths are expected to occur under trend assumption I (+14% compared to 2010, reflecting population ageing) and 47600 under trend assumption II (–18% compared to 2010). SBP: For trend I, a FEASIBLE SBP reduction of 1mmHg and IDEAL reduction of –5mmHg could result in approximately 77300 (+9%, baseline: 2010)and 64500 (–9%, baseline: 2010) deaths respectively in 2030. Assuming falling trends (II), about 45500 (–22%, baseline: 2010) and 38300 (–34%, baseline: 2010) deaths would result in 2030 under the feasible and ideal scenarios respectively. Total cholesterol (TC): Under trend I, a FEASIBLE TC reduction of 0.1 mmol/l and IDEAL reduction of 0.5 mmol/l could result in about 74800 and 57000 deaths (5% and –20%) by 2030. Assuming trend II, the resulting deaths would be approximately 43900 and 33400 (–25% and –43%, baseline: 2010) respectively. <h3>Conclusion</h3> Under both trend assumptions, the adoption of evidence-based dietary policies to reduce salt and saturated fat intake, resulting in population-wide decreases in blood pressure and cholesterol could result in substantial declines in forecasted CHD mortality.