Lower Atherosclerotic Cardiovascular Disease Research Articles

Cardiovascular risk in elderly persons without established atherosclerotic cardiovascular disease

Abstract Introduction Age is the dominant driver of atherosclerotic cardiovascular disease (ASCVD) risk, and the estimated 10-year ASCVD risk of almost all individuals ≥70 years exceeds conventional risk thresholds. Treatment of risk factors should be considered taking ASCVD risk modifiers, including frailty, lifetime treatment benefit, comorbidities, polypharmacy, socio-economic status, and patient preferences into account. Aim Because of problems with risk prediction in the elderly most ASCVD risk scores do not function well, so there is limited ability to quantify ASCVD risk in persons 70 years of age or older. Therefore, we sought out to estimate ASCVD risk in apparently healthy elderly persons. Methods We enrolled 253 apparently healthy elderly persons ≥70 years without established ASCVD. The Systemic Coronary Risk Estimation 2 - Older Persons (SCORE2-OP) score was used to estimate the 10-year risk of ASCVD. A 10-year risk ≥15% was generally considered ‘very high risk’, and 7.5% to <15% was considered ‘high risk’. Based on age study population was divided into four groups: (1) 70–74 years (N=61), (2) 75–79 years (N=73), 80–84 (N=76), and (4) 85-89 years (N=43). Results The median 10-year ASCVD risk in the entire cohort was 23% (17%–32%). There was no person with low ASCVD risk (<7.5%). 41 out of 253 persons (16.2%) were high-risk and 212 (83.8%) were very high-risk. The number of persons at very high risk of ASCVD increased dramatically with age. Roughly, almost all persons aged ≥75 years were deemed very high risk (Table 1). Multimorbidity defined as the presence of two or more chronic conditions and polypharmacy defined as the use of at least 5 medications were highly prevalent in all four study groups. Hypertension was the most prevalent condition – roughly eight in 10 persons had hypertension. The rate of overweight/obese patients was higher in younger persons. This fact was further reflected by the body composition of study participants and the rate of malnutrition (Table 1). Age ≥75 years was highly predictive for identifying persons at very high risk for ASCVD with a C-statistics of 0.92 (positive predictive value 99%, negative predictive value 53%; P<0.001) (Figure 1). Conclusions Older people without established ASCVD are a heterogeneous group. Most of them were found to be at very high risk of ASCVD. Age and high blood pressure were the dominant drivers of that risk. In addition, ASCVD risk modifiers such as multimorbidity, polypharmacy, and malnutrition were highly prevalent. These findings have important clinical and public health and individualized decisions regarding preventative and therapeutic strategies for elderly persons are needed.Table 1Baseline characteristicsFigure 1.ROC analysis

Abstract 16491: The Relationship Between Cardiovascular Health and 10-year Atherosclerotic Cardiovascular Risk in American Adults

Introduction: Life’s Essential 8 (LE8) is a metric of overall cardiovascular health (CVH) while 10-year atherosclerotic cardiovascular disease (ASCVD) risk is routinely used to guide primary prevention. Yet, the relationship between LE8 and 10-year ASCVD risk is unclear. Hypothesis: CVH has an inverse relationship with 10-year ASCVD risk in adults aged 40–75 years from the National Health and Nutrition Examination Survey 2017-2020 cycle. Methods: Adults with ASCVD and data missing to calculate 10-year ASCVD risk and LE8 scores were excluded. LE8 score was estimated from the mean of LE8 components (scored 0 to 100), with scores ≥80, 79–50, and <49 grouped into ideal, intermediate, and poor CVH, respectively. 10-year ASCVD risk was estimated using pooled cohort equation, with scores <5%, 5–19.9%, and ≥20% grouped as low, borderline/intermediate, and high risk, respectively. The survey weighted chi-square and ANOVA analysis was performed. Results: We included 1,550 adults representing nearly 45 million US adults with a mean age of 57.8 years, 35.3% women. Overall, 35.4%, 42.3%, and 22.3% had low, borderline/intermediate, and high 10-year ASCVD risk, respectively. Low, borderline/intermediate, and high-risk individuals had a mean LE8 score of 68.2, 61.8, and 62.6 (p-value: <0.001) while 18.1%, 7.4%, and 5.6% (p-value: 0.002) had ideal CVH, respectively. Diet, nicotine exposure, body mass index (BMI), and blood lipids metrics were very low across the risk groups (figure). Additionally, the mean blood pressure metric was 41.3 among high-risk and 61.1 among intermediate/borderline-risk individuals. Conclusions: The prevalence of ideal CVH is very low across all 10-year ASCVD risk groups primarily due to poor diet, nicotine exposure, high BMI, and high blood lipids. Since ASCVD risk is predominantly age-dependent and given comparable LE8 scores among borderline/intermediate and high-risk individuals, LE8 may denote an age-independent long-term/lifetime risk.

Abstract 18219: J-Shaped Association Between LDL-Cholesterol Level and Cardiovascular Events: A Longitudinal Follow-Up Study Over 2.4 Million Nationwide Primary Prevention Cohort

Introduction: Low-density lipoprotein (LDL)-cholesterol lowering treatment showed benefits in patients with high atherosclerotic cardiovascular disease (ASCVD) risk. Hypothesis: Although high LDL-cholesterol level is known to increase ASCVD risks, prognostic implications of low LDL-cholesterol level remain elusive. Methods: Using the data from a Korean Nationwide Cohort, we included 2,432,471 subjects without previous ASCVD. From 2009, subjects were followed for myocardial infarction (MI) and ischemic stroke until 2018. Subjects were stratified according to 10-year ASCVD risks (<5%, 5 to <7.5%, 7.5 to <20%, and ≥20%) and LDL-cholesterol level (<70, 70-99, 100-129, 130-159, 160-189, and ≥190 mg/dL). Results: In the overall population (median follow-up: 9.3 years), the relationship between LDL-C level and cardiovascular events showed J-shaped curve. Subjects with LDL-cholesterol <70mg/dL showed increased risk of myocardial infarction compared to those with LDL-cholesterol 70 to <100mg/dL after adjusting covariates in low ASCVD risk group. Similarly, subjects with LDL-cholesterol 70-99 mg/dL and 100-129 mg/dL had lower stroke risks than those with LDL-cholesterol <70mg/dL in low ASCVD risk group. In contrast, LDL-cholesterol level and risks of MI and stroke showed linear association in high ASCVD risk group. Conclusions: High LDL-cholesterol level is associated with increased risk of MI or stroke, while low LDL-cholesterol level does not warrant safety from ASCVD in the primary prevention setting.

Abstract 16424: Comparative Outcomes of Interventions for Peripheral Arterial Disease in Patients With Different Atherosclerotic Cardiovascular Disease Risk Estimates

Introduction: The atherosclerotic cardiovascular disease (ASCVD) Risk Estimator is an effective tool for predicting cardiovascular events. While peripheral arterial disease (PAD) represents an advanced form of atherosclerosis, ASCVD scores have not been studied in this patient population. This study will evaluate ASCVD risk scores in patients undergoing lower extremity revascularization (LER) for PAD and assess their impact on outcomes. Hypothesis: Patients with high ASCVD risk have worse outcomes after LER for PAD compared to those with lower risk. Methods: Electronic medical records of patients undergoing LER for PAD in a single center from 2013-2020 were reviewed. The ACC/AHA ASCVD estimator was used to calculate risk and categorize patients into risk groups before initial LER. Patient characteristics and outcomes were compared between those with high (≥20%) and lower (<20%) risk scores. The lower risk group was composed of patients with intermediate, borderline, and low ASCVD risk. Results: A total of 635 patients were included and 429 (67.6%) had high ASCVD risk scores. Most patients in the lower risk group had intermediate (78%, N=161) risk, followed by low (12%, N=28), and borderline (8%, N=17) risk scores. High risk patients were more commonly males with more severe comorbidities. ( Table) Patients with high ASCVD risk had more long-term mortality (29% vs 19%, P=0.010) and inferior amputation-free survival ( Figure ) compared to those with lower risk. Conclusions: Most patients with PAD undergoing LER have high ASCVD risk. High ASCVD risk scores correlate with outcomes and may be useful for risk stratification in PAD patient populations with advanced atherosclerosis.

Ambient PM2.5 and its components associated with 10-year atherosclerotic cardiovascular disease risk in Chinese adults

BackgroundExposure to particulate matter with aerodynamic diameters less than 2.5 µm (PM2.5) may increase the risk of 10-year atherosclerotic cardiovascular disease (ASCVD) risk. While PM2.5 is comprised of various components, the evidence on the correlation of its components with 10-year ASCVD risk and which component contributes most remains limited. MethodsData were derived from the baseline assessments of China Multi-Ethnic Cohort (CMEC). In total, 69,722 individuals aged 35–74 years were included into this study. The annual average concentration of PM2.5 and its components (black carbon, ammonium, nitrate, sulfate, organic matter, soil particles, and sea salt) were estimated by satellite remote sensing and chemical transport models. The ASCVD risk of individuals was calculated by the equations from the China-PAR Project (prediction for ASCVD risk in China). The relationship between single exposure to PM2.5 and its components and predicted 10-year ASCVD risk was assessed using the logistic regression model. The effect of joint exposure was estimated, and the most significant contributor was identified using the weighted quantile sum approach. ResultsTotally 69,722 participants were included, of which 95.8 % and 4.2 % had low and high 10-year ASCVD risk, respectively. Per standard deviation increases in the 3-year average concentration of PM2.5 mass (odds ratio [OR] 1.23, 95 % confidence interval [CI]: 1.12–1.35), black carbon (1.21, 1.11–1.33), ammonium (1.21, 1.10–1.32), nitrate (1.25, 1.14–1.38), organic matter (1.29, 1.18–1.42), sulfate (1.17, 1.07–1.28), and soil particles (1.15, 1.04–1.26) were related to high 10-year ASCVD risk. The overall effect (1.19, 1.11–1.28) of the PM2.5 components was positively associated with 10-year ASCVD risk, and organic matter had the most contribution to this relationship. Female participants were more significantly impacted by PM2.5, black carbon, ammonium, nitrate, organic matter, sulfate, and soil particles compared to others. ConclusionLong-term exposure to PM2.5 mass, black carbon, ammonium, nitrate, organic matter, sulfate, and soil particles were positively associated with high 10-year ASCVD risk, while sea salt exhibited a protective effect. Moreover, the organic matter might take primary responsibility for the relationship between PM2.5 and 10-year ASCVD risk. Females were more susceptible to the adverse effect.

113-OR: The OPTIFAST (OP) Total and Partial Meal Replacement Program Improves Cardiometabolic Risk in Adults With Obesity—Secondary and Exploratory Analysis of the OPTIWIN Study

The effects of weight loss on atherosclerotic cardiovascular disease (ASCVD) risk factors using a partial or total meal replacement program (MRP) are not fully understood. We performed secondary and exploratory analyses of changes in blood pressure (BP), lipids, and global ASCVD risk in a randomized, controlled MRP trial using OP (n=135) compared with a low-calorie food-based (FB) dietary plan (n=138) that resulted in significant weight loss at week (W) 26 (reduction phase) and W52 (maintenance). Baseline characteristics were well balanced (mean [standard deviation] age OP/FB 47 [11]/47 [11] years, BMI 38.4 [5.5]/39.2 [6.2] kg/m2, females 86/79%, 10-year ASCVD risk <5% 87/74%, dysglycemia 52/50%). Changes in risk factors were estimated by a linear mixed model. At W26, systolic/diastolic BP were significantly reduced with OP vs FB (table), and a greater proportion achieved ≤ 130/80 mmHg (66.7% vs 53.6%, OR 2.11 [95% CI 1.10, 4.03], p=0.024). All lipid parameters significantly improved, as did the global ASCVD risk. A similar, but slightly attenuated pattern was observed at W52. In subgroup analysis by age (<40, 40-59, ≥ 60 years), SBP (</≥ 130 mmHg) and sex, greater treatment effects were generally seen with higher SBP and age, and in men. In people with obesity at low ASCVD risk, OP significantly improved CV risk factors and global ASCVD risk. Disclosure J.D.Ard: Advisory Panel; Novo Nordisk, Consultant; Eli Lilly and Company, Intuitive Surgical, Regeneron, Other Relationship; Optum Labs, Weight Watchers International, Research Support; Nestlé Health Science, Boehringer Ingelheim Inc., Epitomee, KVK Tech. I.Neeland: Consultant; Nestlé Health Science, Speaker's Bureau; Boehringer Ingelheim and Eli Lilly Alliance, Bayer Inc. A.E.Rothberg: None. R.Chilton: None. D.De luis: None. A.H.Hawkinson: Employee; Nestlé Health Science. S.S.Cohen: Consultant; Nestlé Health Science. O.Johansen: Employee; Nestlé Health Science. Funding Nestlé Health Science

IMPACT OF CARDIOVASCULAR RISK AND HYPERTENSION ON SUBCLINICAL CORONARY ATHEROSCLEROSIS IN ASYMPTOMATIC DIABETIC INDIVIDUALS

Objective: This study sought to evaluate the effect of 10-year ASCVD (Atherosclerotic Cardiovascular Disease) risk and blood pressure (BP) on subclinical coronary atherosclerosis in asymptomatic diabetic individuals. Design and method: We analyzed 739 asymptomatic diabetic individuals (mean age 55.5 ± 7.3 years; 541 [73.2%] men) with no prior history of coronary artery disease who voluntarily underwent coronary computed tomography angiography (CCTA) as part of a general health examination. The classification of BP was adapted from the American College of Cardiology/American Heart Association 2017 guideline. Study participants were categorized as low (<15%) and high ASCVD risk (> = 15%) groups, respectively. Subclinical coronary atherosclerosis was defined as the presence of any coronary plaque by CCTA. Results: In subjects with low ASCVD risk (n = 498), after adjustment for cardiovascular risk factors, subclinical coronary atherosclerosis was not associated with elevated BP, stage 1, and stage 2 hypertension groups compared with normal BP group (P for all > 0.05). On the other hand, in subjects with high ASCVD risk (n = 241), there was no statistically difference in the adjusted odds ratios of both elevated BP (adjusted odds ratio [aOR] 2.068; 95% confidence interval [CI], 0.703–6.080; P = 0.187) and stage 1 hypertension groups (aOR, 1.533; 95% CI, 0.679–3.459; P = 0.304) for the presence of any coronary plaque. However, the stage 2 hypertension group had a significant association with subclinical coronary atherosclerosis (aOR, 4.127; 95% CI, 1.592–10.696; P = 0.004). Conclusions: In asymptomatic diabetic individuals with low ASCVD risk, BP levels were not associated with an increased risk of subclinical coronary atherosclerosis. However, in those with high ASCVD risk, stage 2 hypertension was only associated with an increased risk of subclinical coronary atherosclerosis. These results suggest that hypertension management may be different in diabetic individuals according to the their ASCVD risk.

A191 NONALCOHOLIC FATTY LIVER DISEASE AND LIVER FIBROSIS INCREASE CARDIOVASCULAR RISK IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Abstract Background Non-alcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both NAFLD and cardiovascular diseases seem more frequent in patients with inflammatory bowel disease (IBD). Purpose We aimed to assess the effect of NAFLD and associated liver fibrosis on the cardiovascular risk in people with IBD. Method We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP >275 dB/m and liver stiffness measurement (LSM) by TE ≥8 kPa, respectively. Nonalcoholic steatohepatitis (NASH) with liver fibrosis was defined as Fibroscan-aspartate aminotransferase (AST) score (FAST) >0.35. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator proposed by the American Heart Association and computed from age, sex, race, lipid pattern, blood pressure, diabetes treatment and smoking. Based on the American Heart Association guidelines, the 10-year cardiovascular risk by ASCVD was categorized as low if <5%, borderline if 5%–7.4%, intermediate if 7.5%–19.9% and high if ≥20% or if previous cardiovascular event.Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis. Result(s) We included 405 patients with IBD (54% female; mean age 45+15 years; mean BMI 26+5 Kg/m; 31% with ulcerative colitis; 7% with diabetes; 14% with hypertension). Overall, 278 (68%), 23 (6%), 47 (12%) and 57 (14%) were categorized as at low, borderline, intermediate and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (32%) and 35 (9%) patients, respectively. NASH with fibrosis was found in 11 (3%) patients. Patients with NAFLD and with significant liver fibrosis diagnosed by TE with CAP had higher proportion of intermediate-high ASCVD risk category (see Figure). These findings were confirmed also in young IBD patients <55 years old with NAFLD. No difference in ASCVD risk was detected for FAST score. After adjusting for IBD disease activity, significant liver fibrosis and BMI, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% confidence interval [CI] 1.56–5.68), IBD duration (aOR 1.55 per 10 years, 95% CI 1.22–1.97), and ulcerative colitis (aOR 2.32, 95% CI 1.35–3.98). Only 30% of IBD patients classified as intermediate-high ASCVD risk were on statin treatment, with no difference between patients with and without NAFLD. Image Conclusion(s) NAFLD increases cardiovascular risk, independently of age, IBD-related factors and BMI. A potential implication of our finding is the targeted cardiovascular assessment in IBD patients with NAFLD and appropriate initiation of statin, particularly if they have longer IBD duration and ulcerative colitis. Please acknowledge all funding agencies by checking the applicable boxes below CAG Disclosure of Interest None Declared

A34 NONALCOHOLIC FATTY LIVER DISEASE AND LIVER FIBROSIS INCREASE CARDIOVASCULAR RISK IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Abstract Background Non-alcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both NAFLD and cardiovascular diseases seem more frequent in patients with inflammatory bowel disease (IBD). Purpose We aimed to assess the effect of NAFLD and associated liver fibrosis on the cardiovascular risk in people with IBD. Method We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP >275 dB/m and liver stiffness measurement (LSM) by TE ≥8 kPa, respectively. Nonalcoholic steatohepatitis (NASH) with liver fibrosis was defined as Fibroscan-aspartate aminotransferase (AST) score (FAST) >0.35. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator proposed by the American Heart Association and computed from age, sex, race, lipid pattern, blood pressure, diabetes treatment and smoking. Based on the American Heart Association guidelines, the 10-year cardiovascular risk by ASCVD was categorized as low if <5%, borderline if 5%–7.4%, intermediate if 7.5%–19.9% and high if ≥20% or if previous cardiovascular event.Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis. Result(s) We included 405 patients with IBD (54% female; mean age 45+15 years; mean BMI 26+5 Kg/m2; 31% with ulcerative colitis; 7% with diabetes; 14% with hypertension). Overall, 278 (68%), 23 (6%), 47 (12%) and 57 (14%) were categorized as at low, borderline, intermediate and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (32%) and 35 (9%) patients, respectively. NASH with fibrosis was found in 11 (3%) patients. Patients with NAFLD and with significant liver fibrosis diagnosed by TE with CAP had higher proportion of intermediate-high ASCVD risk category (see Figure). These findings were confirmed also in young IBD patients <55 years old with NAFLD. No difference in ASCVD risk was detected for FAST score. After adjusting for IBD disease activity, significant liver fibrosis and BMI, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% confidence interval [CI] 1.56–5.68), IBD duration (aOR 1.55 per 10 years, 95% CI 1.22–1.97), and ulcerative colitis (aOR 2.32, 95% CI 1.35–3.98). Only 30% of IBD patients classified as intermediate-high ASCVD risk were on statin treatment, with no difference between patients with and without NAFLD. Image Conclusion(s) NAFLD increases cardiovascular risk, independently of age, IBD-related factors and BMI. A potential deliverable of our finding is the targeted cardiovascular assessment in IBD patients with NAFLD and appropriate initiation of statin, particularly if they have longer IBD duration and ulcerative colitis. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Associationbetweenpulse wave velocityand the10-year risk of atherosclerotic cardiovascular disease in the Chinese population: Acommunity-based study.

Accumulated evidence has shown that carotid-femoral and brachial-ankle PWV well predict cardiovascular events but it is still unclear if the predictability is same or not. In this cross-sectional study based on a community atherosclerosis cohort in Beijing, China, a total of 5282 participants without previous coronary heart disease and stroke were enrolled from a community atherosclerosis cohort in Beijing, China. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk were calculated by the China-PAR model, and<5%, 5%-10% and>10% were defined as low, intermediate, and high risk, respectively. The average baPWV and cfPWV values were 16.63±3.35m/s and 8.45±1.78m/s, respectively. The mean 10-year ASCVD risk was 6.98% (interquartile range: 3.90%-12.01%). The patients with low, intermediate, and high 10-year ASCVD risk accounted for 34.84% (1840), 31.94% (1687),, and 33.23% (1755) respectively. Multivariate analysis showed that for every 1m/s increase in baPWV and cfPWV, the 10-year ASCVD risk increased by 0.60% (95% confidence interval: 0.56%-0.65%, p<.001) and 1.17% (95% confidence interval: 1.09%-1.25%, p<.001), respectively. The diagnostic ability of the baPWV was comparable to the cfPWV (area under the curve: 0.870 [0.860-0.879] vs. 0.871 [0.861-0.881], p=.497). In conclusion, baPWV and cfPWV are positively associated with the 10-year risk of ASCVD in the Chinese community-based population, with a nearly identical association with a high 10-year risk of ASCVD.

Abstract 58: ASCVD Risk Score Trajectories During 25 Years Of Follow-up And Risk Of Ischemic Stroke And Cognitive Impairment

Background: An individual’s atherosclerotic burden is associated with the cumulative exposure to vascular risk factors across the lifespan. We used the ARIC study to identify trajectories of atherosclerotic cardiovascular disease (ASCVD) risk over time and to evaluate their association with risk of stroke and cognitive impairment. Methods: We included cardiovascular disease-free ARIC participants with low or borderline ASCVD risk at the baseline study visit (10-year ASCVD Risk Score &lt;7.5%) and those who attended all 5 ARIC study visits (~25 years of follow-up). We used group-based trajectory modelling to define ASCVD trajectories. We report baseline characteristics of individuals in the four trajectories and the incidence of stroke (ischemic and hemorrhagic) and cognitive impairment (either MCI or dementia) during follow-up. Results: We included 3,470 ARIC participants. The four trajectories of ASCVD risk during follow-up are in Figure 1. The low and high increase trajectories comprised 46.5% and 7.0% of participants. Vascular risk factors such as hypertension, diabetes, hyperlipidemia, and obesity were more common in trajectories with higher ASCVD risk (Table 1). The rate of ARIC-adjudicated stroke during follow-up increased from 1.6% in the low trajectory to 4.6% in the high trajectory (p&lt;0.001), of self-reported stroke from 8.6% to 16.6% (p&lt;0.001), and of ARIC-adjudicated cognitive impairment from 16.0% to 35.0% (p&lt;0.001). Conclusions: We found four main trajectories of ASCVD risk over 25 years of follow-up in individuals with baseline low or borderline ASCVD risk, which are associated with the risk of incident stroke and cognitive impairment. assessment.

Prognostic value of CT-derived coronary artery disease characteristics varies by ASCVD risk: insights from the PROMISE trial.

To compare the prognostic value of individual CT-derived coronary artery disease (CAD) characteristics across categories of clinical cardiovascular risk. The central core laboratory assessed coronary artery calcium (CAC), obstructive CAD (stenosis ≥ 50%), and high-risk plaque (HRP) in stable outpatients with suspected CAD enrolled in the PROMISE trial. Multivariable Cox regression models (endpoint: unstable angina, nonfatal myocardial infarction, or all-cause mortality; median follow-up: 2years) were used to compare hazard ratios (HR) of the CT measures between low-borderline (< 7.5%) and moderate-high (≥ 7.5%) atherosclerotic cardiovascular disease (ASCVD) risk based on the pooled cohort equation. Among 4356 included patients (aged 61 ± 8years, 52% women), 67% had ASCVD risk ≥ 7.5%. Stratified by ASCVD risk, CAD ≥ 50% had nearly threefold greater HR in individuals with ASCVD < 7.5% (aHR, 6.85; 95% CI, 2.33-20.15; p < 0.001) vs. ASCVD ≥ 7.5% (aHR: 2.66, 95% CI: 1.67-4.25, p < 0.001; interaction p = 0.041). CAC predicted events solely in ASCVD ≥ 7.5% patients (aHR: 1.92, 95% CI: 1.01-3.63, p = 0.045; interaction p = 0.571), while HRP predicted events only in ASCVD < 7.5% (aHR: 3.11, 95% CI: 1.09-8.85, p = 0.034; interaction p = 0.034). Prognostic values of CT-derived CAD characteristics differ by ASCVD risk categories. While CAD ≥ 50% has the highest prognostic value regardless of ASCVD risk, CAC is prognostic in high and HRP in low ASCVD risk. These findings suggest that CAD ≥ 50% and HRP detection rather than CAC scoring may better risk-stratify symptomatic low-risk patients and thus potentially improve downstream care. • Prognostic value of individual CT-derived CAD characteristics differs by categories of cardiovascular risk. • Presence of obstructive coronary artery stenosis ≥ 50% has the highest prognostic value regardless of cardiovascular risk. • Coronary artery calcium is independently prognostic in high and high-risk plaque features in low cardiovascular risk.

Nonalcoholic Fatty Liver Disease Increases Cardiovascular Risk in Inflammatory Bowel Diseases.

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both conditions seem more frequent in patients with inflammatory bowel disease (IBD). We aimed to assess the effect of NAFLD and liver fibrosis on intermediate-high cardiovascular risk in IBD. We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP ≥275 dB m-1 and liver stiffness measurement by TE ≥8 kPa, respectively. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator and categorized as low if <5%, borderline if 5%-7.4%, intermediate if 7.5%-19.9%, and high if ≥20% or if previous cardiovascular event. Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis. Of 405 patients with IBD included, 278 (68.6%), 23 (5.7%), 47 (11.6%), and 57 (14.1%) were categorized as at low, borderline, intermediate, and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (31.9%) and 35 (8.6%) patients, respectively. After adjusting for disease activity, significant liver fibrosis and body mass index, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% CI, 1.56-5.68), IBD duration (aOR 1.55 per 10 years, 95% CI, 1.22-1.97), and ulcerative colitis (aOR 2.32, 95% CI, 1.35-3.98). Assessment of cardiovascular risk should be targeted in IBD patients with NAFLD, particularly if they have longer IBD duration and ulcerative colitis.

Performance of the pooled cohort equation in South Asians: insights from a large integrated healthcare delivery system

South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a “risk enhancer” in the 2018 American College of Cardiology/American Heart Association Guidelines. Risk estimation and statin eligibility in South Asians is not well understood; we studied the accuracy of 10-years ASCVD risk prediction by the pooled cohort equation (PCE), based on statin use, in a South Asian cohort. This is a retrospective cohort study of Kaiser Permanente Northern California South Asian members without existing ASCVD, age range 30–70, and 10-years follow up. ASCVD events were defined as myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use during the study period: never; at baseline and during follow-up; and only during follow-up. Predicted probability of ASCVD, using the PCE was calculated and compared to observed ASCVD events for low < 5.0%, borderline 5.0 to < 7.5%, intermediate 7.5 to < 20.0%, and high ≥ 20.0% risk groups. A total of 1835 South Asian members were included: 773 never on statin, 374 on statins at baseline and follow-up, and 688 on statins during follow-up only. ASCVD risk was underestimated by the PCE in low-risk groups: entire cohort: 1.8 versus 4.9%, p < 0.0001; on statin at baseline and follow-up: 2.58 versus 8.43%, p < 0.0001; on statin during follow-up only: 2.18 versus 7.77%, p < 0.0001; and never on statin: 1.37 versus 2.09%, p = 0.12. In this South Asian cohort, the PCE underestimated risk in South Asians, regardless of statin use, in the low risk ASCVD risk category.

Cardiovascular risk-enhancing factors and coronary artery calcium in South Asian American adults: The MASALA study

ObjectivesThe 2018 and 2019 U.S. guidelines for the management of cholesterol and primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of cardiovascular risk-enhancing factors (REFs), including South Asian ancestry, to refine ASCVD risk estimation. However, the associations of REFs with atherosclerosis are unclear in South Asian American adults, who have a disproportionately elevated premature coronary heart disease risk. In the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort, we investigated associations of individual REFs, or the number of REFs, with coronary artery calcium (CAC). MethodsUsing baseline and follow-up data from MASALA, we evaluated the association of REFs (family history of ASCVD, low-density lipoprotein cholesterol ≥160 mg/dL, triglycerides ≥175 mg/dL, lipoprotein(a) >50 mg/dL, high-sensitivity C-reactive protein [hsCRP] ≥2.0 mg/dL, ankle-brachial index <0.9, chronic kidney disease, metabolic syndrome), individually and combined, with baseline prevalent CAC, any CAC progression (including incident CAC and CAC progression), and annual CAC progression rates using multivariable logistic regression and generalized linear models. ResultsAmong 866 adults, mean age was 55 [SD 9] years and 47% were female. There were no significant associations of REFs with baseline prevalent CAC or any CAC progression (incident CAC and CAC progression at Exam 2) after adjustment. Among the 56% of participants who had any CAC progression, having 3+ REFs was associated with a significantly higher annual CAC progression rate (adjusted rate ratio [aRR] 1.94, 95% CI 1.39–2.72) vs. having 0 REFs. The annual CAC progression rate was 20% higher per additional REF (aRR 1.20, 95% CI 1.09–1.32). Findings were similar after excluding statin users, and among those with low 10-year ASCVD risk (<5%). ConclusionsAmong South Asian American adults, we found no association of REFs with prevalent CAC at baseline or having any CAC progression. Among those with any CAC progression, a higher number of REFs was associated with higher annual CAC progression rates.

Abstract 9539: Risk of Earlier Atherosclerotic Cardiovascular Disease in Women With Low Bone Mineral Density

Background: The potential association between lower bone mineral density (BMD) and atherosclerotic cardiovascular disease (ASCVD) has been suggested in women. We investigated whether the association between low BMD and ASCVD differs according to the age of ASCVD occurrence. Methods: We retrospectively analyzed 7,932 women aged 50-65 years who underwent dual-energy X-ray absorptiometry to measure total hip BMD. The primary outcome of interest was ASCVD, defined as a composite of ASCVD death, myocardial infarction, and ischemic stroke. Participants were classified into no event (n=7,803), early ASCVD (occured before 70 years of age) (n=97), and late ASCVD (occured at or after 70 years of age) (n=32) groups. The association of low BMD with early and late ASCVD was estimated using multivariate Cox hazard modeling after adjustment for clinical risk factors (age, body mass index, hypertension, diabetes, hyperlipidemia, current smoking, and previous fracture). Results: The median age increased across no event, early ASCVD, and late ASCVD groups (58, 60, and 63 years, respectively). However, the estimated BMD T-score at the age of 65 years was lowest in the early ASCVD group (median -0.9, -1.1, and -0.5, respectively). Lower BMD was an independent predictor for early ASCVD (adjusted hazard ratio [HR]: 1.34 per 1-SD decrease in T-score, 95% confidence interval [CI] 1.08-1.67), but not late ASCVD (adjusted HR: 0.88, 95% CI 0.60-1.30) (Figure). The inverse trend between early ASCVD risk and BMD T-score was consistent regardless of the number of accompanied clinical risk factors. Conclusions: Low BMD is an independent predictor for earlier ASCVD occurrence in women. BMD evaluation can provide prognostic benefit for risk stratification for earlier ASCVD occurrence.

Do statins benefit low-risk population for primary prevention of atherosclerotic cardiovascular disease: A retrospective cohort study.

The reported beneficial effects of statins on cardiovascular outcome based on risk assessment are inconsistent. Therefore, we investigated statin therapy effectiveness for the primary prevention of cardiovascular disease (CVD), according to the Korean Risk Prediction Model (KRPM). Subjects aged 40-79 years with low density lipoprotein cholesterol (LDL-C) of < 190 mg/dL and without CVD history were categorized as statin users or non-users using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database, Korea, 2002-2015. The 10-year atherosclerotic CVD (ASCVD) risk was calculated using the validated KRPM and categorized as low, borderline, intermediate, or high-risk groups; the incidence of major adverse cardiovascular events (MACEs) was compared over a mean follow-up period of 5.7 years using Cox proportional hazard models. The MACE incidence risk was decreased in statin users [hazard ratio (HR) 0.90, 95% confidence interval (CI) (0.84-0.98)]. However, there was an increased risk of MACE incidence in low-risk statin users [HR 1.80, 95% CI (1.29-2.52)], and no significant relationship was identified between statin use and MACE in the borderline [HR 1.15, 95% CI (0.86-1.54)] and intermediate-risk [HR 0.94, 95% CI (0.85-1.03)] groups. The risk of MACE incidence decreased only in the high CVD risk group among statin users. Statin use is not associated with MACE reduction in low- to intermediate-risk participants. Therefore, individuals with LDL-C level of < 190 mg/dL and low ASCVD risk should consider statin therapy only when CVD risk is proved obvious using an appropriate ASCVD risk tool.

Heterogeneity in the Association Between the Presence of Coronary Artery Calcium and Cardiovascular Events: A Machine-Learning Approach in the MESA Study.

Coronary artery calcium (CAC) has been widely recognized as an important predictor of cardiovascular disease (CVD). Given the finite resources, it is important to identify individuals who would receive the most benefit from detecting positive CAC by screening. However, the evidence is limited as to whether the burden of positive CAC on CVD differs by multidimensional individual characteristics. We sought to investigate the heterogeneity in the association between positive CAC and incident CVD. This cohort study included adults from MESA (Multi-Ethnic Study of Atherosclerosis) ages ≥45 years and free of cardiovascular disease. After propensity score matching in a 1:1 ratio, we applied a machine learning causal forest model to (1) evaluate the heterogeneity in the association between positive CAC and incident CVD, and (2) predict the increase in CVD risk at 10-years when CAC>0 (versus CAC=0) at the individual level. We then compared the estimated increase in CVD risk when CAC>0 to the absolute 10-year atherosclerotic CVD (ASCVD) risk calculated by the 2013 American College of Cardiology/American Heart Association pooled cohort equations. Across 3328 adults in our propensity score-matched analysis, our causal forest model showed the heterogeneity in the association between CAC>0 and incident CVD. We found a dose-response relationship of the estimated increase in CVD risk when CAC>0 with higher 10-year ASCVD risk. Almost all individuals (2293 of 2428 [94.4%]) with borderline risk of ASCVD or higher showed ≥2.5% increase in CVD risk when CAC>0. Even among 900 adults with low ASCVD risk, 689 (69.2%) showed ≥2.5% increase in CVD risk when CAC>0; these individuals were more likely to be male, Hispanic, and have unfavorable CVD risk factors than others. The expected increases in CVD risk when CAC>0 were heterogeneous across individuals. Moreover, nearly 70% of people with low ASCVD risk showed a large increase in CVD risk when CAC>0, highlighting the need for CAC screening among such low-risk individuals. Future studies are needed to assess whether targeting individuals for CAC measurements based on not only the absolute ASCVD risk but also the expected increase in CVD risk when CAC>0 improves cardiovascular outcomes.

Risk of earlier atherosclerotic cardiovascular disease in women with low bone mineral density.

Low bone mineral density (BMD) is associated with higher risk of atherosclerotic cardiovascular disease (ASCVD) in women. We investigated whether the association between low BMD and ASCVD differs according to the age at ASCVD occurrence. We retrospectively analyzed 7932 women aged 50–65 years who underwent dual-energy X-ray absorptiometry. ASCVD was defined as a composite of ASCVD death, myocardial infarction, and ischemic stroke. When we classified participants into no event (n = 7803), early ASCVD (< 70 years) (n = 97), and late ASCVD (≥ 70 years) (n = 32) groups, age gradually increased across groups (median, 58, 60, and 63 years, respectively). However, the estimated BMD T-score at the age of 65 years was lowest in the early ASCVD group (median − 0.9, − 1.1, and − 0.5, respectively). Lower BMD was an independent predictor for early ASCVD (adjusted hazard ratio [95% confidence interval]: 1.34 [1.08–1.67] per 1-SD decrease in T-score), but not for late ASCVD (0.88 [0.60–1.30]). The inverse trend between early ASCVD risk and BMD T-score was consistent regardless of the number of accompanied clinical risk factors. Thus, low BMD is an independent predictor for early ASCVD in women. BMD evaluation can provide prognostic benefit for risk stratification for early ASCVD.

Prevalence and outcomes of low ankle brachial index by atherosclerotic cardiovascular disease risk level: Insights from the National Health and Nutrition Examination Survey (NHANES)

BackgroundAnkle brachial index (ABI) as a risk-enhancing factor in addition to the pooled cohort equation (PCE) in assessing cardiovascular risk for primary prevention of atherosclerotic cardiovascular disease (ASCVD) is uncertain. MethodsWe analyzed data from the 1999–2004 National Health and Nutrition Examination Survey (NHANES), for 5130 participants, aged 40 and older, without known cardiovascular disease or diabetes, with available data on standard ASCVD risk and ABI. Prevalence of low ABI (ABI<0.9) and all-cause mortality in persons with low, borderline and intermediate ASCVD risk categories using PCE was assessed. ResultsThe overall prevalence of low ABI was 3.1%. The participants with low ABI were predominantly clustered in the intermediate (33%) and high (33%) ASCVD risk categories while most participants with a normal ABI were in the low (56%) and intermediate (23%) risk categories. All-cause mortality was higher among participants with low ABI compared to those with a normal ABI in both the intermediate/borderline and high-risk categories, p<0.001 but not in the low-risk ASCVD category, p = 0.323. ConclusionsUsing the PCE, two-third of the participants with low ABI were classified as having a low, borderline or intermediate risk of ASCVD. Low ABI was associated with an increased all-cause mortality in the overall cohort and specifically among those with a borderline/intermediate or high risk of ASCVD but not in those with a low risk of ASCVD. Our study supports consideration of ABI as a risk enhancer for primary prevention among patients classified as borderline or intermediate risk of ASCVD.