Previous Cardiovascular Events Research Articles

INTENSIVE SYSTOLIC BLOOD PRESSURE TARGET IN OLDER HYPERTENSIVE PATIENTS - IS IT BENEFICIAL?

Objective: The prevalence of hypertension increases with age, and the treatment in older patients is more challenging due to their comorbidities and frailty. The ideal target for systolic blood pressure (SBP) remains unclear. This study analysed how intensive blood-pressure control in older patients reflects cardiovascular events and hypertensive-mediated organ damage (HMOD) reversion. Design and method: We present a descriptive and retrospective study, including patients over 60 years, followed in a central hospital hypertension clinic over two years. One group had an SBP target < 130mmHg (intensive treatment), while the other had a more lenient target. Stroke, acute coronary syndromes, acute decompensated heart failure or death from cardiovascular causes were the evaluated cardiovascular events. The analysed HMOD included microalbuminuria, echocardiographic left ventricular hypertrophy (LVH) and chronic kidney disease (CKD). Results: 150 of 296 patients were selected. 30% were over 80 years old. Cardiovascular events occurred in 9% of patients with SBP < 130mmHg and in 7% of patients with > 130mmHg. More than half of patients (64%) had HMOD. LVH was the most frequent HMOD (78%), followed by microalbuminuria (44,8%) and CKD (37,5%). 61% of patients in intensive treatment had HMOD versus 66% with SBP target > 130mmHg. Reversion of HMOD occurred in 83% of patients with standard treatment compared with 17,6% in the intensive treatment group. Regarding previous cardiovascular events in the studied population, stroke was the most prevalent (56%), followed by acute coronary syndrome (41%). The majority (59%) of these very high cardiovascular risk patients presented an SBP target < 130mmHg. Conclusions: In this study, intensive treatment in older patients did not appear to benefit cardiovascular events prevention and HMOD reversion. However, the HMOD reversion might have been underestimated due to patient discharge prior to further evaluation. In patients with previous cardiovascular events, a tendency to select an intensive treatment seems evident.

EFFECT OF RENAL DENERVATION ON CARDIO ANKLE VASCULAR INDEX IN SUBJECTS WITH RESISTANT HYPERTENSION

Objective: The aim of the study was to determine the clinical characteristics of patients with increased arterial stiffness (AS) undergoing renal sympathetic denervation (RSD) and to examine the role of CAVI measurement as a surrogate for AS in predicting the outcome of RSD. Design and method: Consecutive patients with resistant hypertension who underwent RSD workout at the University Hospital Saint Anna, Sofia, ESH Excellence center of hypertension, between January 2014 and December 2020 were included. RSD was performed on the grounds of resistant hypertension defined as mean daytime systolic BP = > 135 mmHg or diastolic BP = > 85 mmHg in 24-hr ambulatory blood pressure measurement (ABPM) despite the intake of at least three antihypertensive agents, including a diuretic. CAVI was measured using the VaSera system (Fukuda Denshi Co, Japan). RSD was performed with the Symplicity Flex catheter (Medtronic, Minneapolis, MN, USA) according to a standardized protocol. Results: The study included 62 patients with treatment-resistant hypertension, after out of office blood pressure measurement and intensification of therapy, renal denervation was performed in 32 (51.6%). Patients with increased arterial stiffness, defined as CAVI> median of 8.3, were older, with a larger waist circumference and previous cardiovascular events. A long-term effect of the RSD, reported as a reduction in 24-hour systolic blood pressure above 10 mmHg at month 12, was found in 22 patients (68.8%). The median of the observed reduction of the 24-hour systolic blood pressure was -16 mmHg at 95% confidence interval -9.1 to -21 mmHg. Despite similar baseline out-of-office and office blood pressure and concomitant antihypertensive therapy, patients with lower arterial stiffness had a more significant blood pressure effect of renal denervation, a result that persisted within 12 months of follow-up. In contrast, the effect of the procedure was clinically insignificant among patients with baseline CAVI values above 8.3. Conclusions: These findings hold the promise that AS might be used as a selection criterion for RSD, thereby improving outcome following RSD.

ADHERENCE TO THE ANTIHYPERTENSIVE THERAPY – A VIEW FROM THE FAMILY MEDICINE PERSPECTIVE

Objective: To check adherence to the antihypertensive medication in patients with arterial hypertension and a possible impact of fixed-dose drug combinations, cardiovascular event in history, and diabetes on it. Design and method: In this cross-sectional study, every fifth patient with arterial hypertension in two family medicine practices in Zagreb, Croatia (found by Medicus search engine) was analyzed during February 2022. We included medical records of 210 patients (116 males, 94 females) from which we checked the number and type of used antihypertensive medication (single pill or fixed-dose drug combinations), statin use, diabetes type 2 or cardiovascular event in history, and the date of the last lab test results. The patient was considered adherent if she/he regularly ordered hers/his prescribed medication from January to December 2021. Chi-square and Student t-test were used for statistical analysis in Statistica 12. Results: There were no differences between genders. Women were slightly more adherent to the prescribed therapy than men (72.34 vs. 68.11%, P = 0.5076). Statins were prescribed in 65 (30.95%), fixed-dose combination in 139 (66.19%), 39 had diabetes (18.57%), and 28 patients had cardiovascular events in their medical history (13.33%). The adherence was not dependent on the patient’s age (66.75 vs. 66.64 years in adherent patients, P = 0.9509), the existence of diabetes (Chi2 = 1.093, 2, P = 0.2958) or previous cardiovascular event in medical history (Chi2 = 0.384, 2, P = 0.5351). Adherence correlated with the number of prescribed antihypertensive medications (r = 0.263; P < 0.05; and average 2.56 in adherent vs. 1.97 medication per day in non-adherent group, P < 0.001), especially if the therapy was in fixed-dose combination (Chi2 = 11.60, 2, P < 0.001). The age of the lab test results was less in adherent patients (1.25 vs. 1.86 years, P = 0.108). 116 patients (55.24%) had them in 2021, while 16 did not have any result in five and more years (7.14%). Conclusions: The adherence to antihypertensive therapy was similar between genders and correlated with the number of prescribed medications with significantly better results in patients with fixed-dose combinations. The existence of the previous cardiovascular event and type 2 diabetes did not show any benefit on this type of adherence.

REAL WORLD IMPACT OF BLOOD PRESSURE CHANGES ON MORBIDITY AND MORTALITY IN TYPE 2 DIABETES

Objective: To assess the impact of BP changes on the risk of cardiovascular events and mortality in type 2 diabetes. Design and method: The sample was selected using the HER of the Valencian Community. Type 2 diabetics were selected through ICD codes and retrospectively evaluated from January 2012 to December 2016. To evaluate BP changes, the follow-up time was divided in six-month blocks and the average of BP for each interval was considered. SBP was categorized: < 120 mmHg; 120–129 mmHg (reference); 130–139 mmHg; 140–149 mmHg; > 150 mmHg. To evaluate the influence of DBP, the population was stratified according to categories of average DBP: < 60 mmHg; 60–69 mmHg; 70–79 mmHg; > 80 mmHg. Information about cardiovascular events, including Stroke and Acute Coronary Syndrome (ACS) was extracted from the ICD codes. Total mortality was determined by matching records and death certificates. Time-varying Cox regression for SBP stratified by DBP categories was used to assess the risk associated with changes of SBP. The models were adjusted by age, sex, HBA1c, KDIGO, previous cardiovascular events and use of cardiovascular drugs. Results: 156 363 type 2 diabetics patients were included (mean age 69.5(11.5), 48.7% females, mean glycated Hb 7.05 (1.35%) 21% in secondary prevention, 21.4% under insulin treatment). The average number of BP measurements was 14. During an average follow-up of 4.18 y, there were 13399 deaths, 15100 strokes and 6295 ACS. In the fully adjusted time-varying Cox regression, having a SBP< 120 mmHg was a significant risk factor for death across all categories of DBP, whereas SBP> 130 mmHg conferred protection. For the case of ACS and stroke, a J-curve phenomenon was observed with significantly higher risk for those with SBP> 150 mmHg or < 120 mmHg across categories with DBP> 60 mmHg. This J-curve phenomenon was also observed graphically using restricted cubic splines (Figure). Conclusions: Although difficult to achieve in clinical practice, lower boundaries for BP goals in diabetics have to be taking into account.

AB0524 RELATIONSHIP BETWEEN SERUM URIC ACID, CARDIOVASCULAR RISK AND INFLAMMATORY STATUS IN PRIMARY SJÖGREN’S SYNDROME

BackgroundAn unhealthy diet, with or without impaired renal urate excretion, is the most frequent cause of hyperuricemia. Despite its pivotal role in the pathogenesis of gout, the clinical relevance of serum uric acid (SUA) levels goes well beyond the simple association with gout and/or nephrolithiasis. Several studies pointed to hyperuricemia as cardiovascular (CV) risk factor in the general population therefore, the 2018 guidelines of the European Society of Cardiology and the European Society of Hypertension included the assessment of uricemia among the screening tests to be performed in hypertensive patients. Furthermore, in view of the association between hyperuricemia and mortality (both CV and all-cause) and CV events, it is conceivable that cardiovascular damage begins with much lower levels of uricemia. In this context, the first results of the URRAH (Uric Acid Right for Heart Health) study identified a uricemia threshold value of 4.7 mg/dL for all-cause mortality and 5.6 mg/dL for CV mortality1.ObjectivesSince patients with primary Sjögren’s syndrome (pSS) have a higher risk of CV events compared to the general population, we aimed to explore how uricemia correlates with other CV risk factors and previous CV events in patients with pSS and without gout.MethodsA cross sectional study was conducted recruiting consecutive patients with pSS without history of gout. SUA was measured upon recruitment alongside the assessment of disease activity (EULAR Sjögren’s syndrome disease activity index, ESSDAI and ClinESSDAI), patient reported symptoms (EULAR Sjögren’s syndrome patient reported symptoms, ESSPRI), CV risk factors including hypertension and diabetes among others, and previous CV events. Dietary habits were also explored with various food frequency questionnaires.ResultsOne hundred and three patients with pSS were enrolled. SUA levels ranged between 2.9 and 6.8 mg/dl and, according to the cut-off values of the URRAH study, 16 (16%) patients had SUA levels >4.7 mg/dL while 5 (5%) had SUA levels >5.6 mg/dL. Patients with SUA levels >4.7 mg/dL were more likely males (20% vs 3%) with a higher number of CV risk factors compared to patients with SUA levels <4.7mg/dL. No differences were observed regarding dietary habits across groups. Disease activity assessed with both ESSDAI and ClinESSDAI was significantly higher in patients with SUA levels >4.7 mg/dL compared to patients with SUA levels <4.7 (9.3 vs 6.3 p= 0.04 and 9.0 vs 6.0 p=0.03). Conversely, patient reported symptoms (total ESSPRI and individual VAS scales for total dryness, xerostomia, xerophtalmia, pain and fatigue) did not differ across groups. Logistic regression analysis confirmed the association of SUA values >4.7 mg/dL and a higher number of CV risk factors (OR 2.8; 95% CI=1.2-6.5; p=0.016).ConclusionAccumulating evidence highlights the emerging role of hyperuricemia as an independent CV risk factor, but no data are available in pSS patients. This is the first study demonstrating that SUA levels >4.7 mg/dL correlate with both a higher number of CV risk factors and a higher disease activity in pSS patients. Large interventional studies are needed to clarify the possible benefits of urate-lowering treatments in pSS patients.

The Clinical Characteristics of Obstructive Sleep Apnea Patients with a Previous Cardiovascular Event

The Clinical Characteristics of Obstructive Sleep Apnea Patients with a Previous Cardiovascular Event

Cost Effectiveness of Inclisiran in Atherosclerotic Cardiovascular Patients with Elevated Low-Density Lipoprotein Cholesterol Despite Statin Use: A Threshold Analysis.

BackgroundInclisiran is a novel, cholesterol-lowering therapy, with a long duration of effect, administered every 6 months (subcutaneously by a healthcare professional). In the ORION-10 trial in US patients with atherosclerotic cardiovascular disease (ASCVD) in addition to maximum tolerated statins, with or without ezetimibe, inclisiran demonstrated statistically significant reductions in low-density lipoprotein cholesterol (LDL-C) of up to 51%. This is the first peer-reviewed publication to investigate the price at which inclisiran is cost effective in the US.ObjectiveThe aim of this study was to determine the maximum price at which inclisiran is cost effective in addition to standard of care, in US patients with ASCVD, versus standard of care alone, at different willingness-to-pay thresholds.Design, Setting and ParticipantsA lifetime Markov model from the US health system perspective, including 15 health states, was used to evaluate the cost effectiveness of inclisiran. The following states were separated by time from a previous cardiovascular event (0–1 years, 1–2 years, 2+ years [‘stable’]): initial, unstable angina, myocardial infarction, and stroke. Additional states included revascularization and death (cardiovascular or non-cardiovascular causes). Baseline risk of cardivoascular events were from US database sources or published literature. Reductions in LDL-C from inclisiran were from the ORION-10 trial. LDL-C reduction was used to adjust baseline risk of cardiovascular events, based on established relationships between 1 mmol/L reduction in LDL-C and decreases in cardiovascular events, from the Cholesterol Treatment Trialists studies. The population included adults with a history of ASCVD, and LDL-C ≥ 70 mg/dL, despite maximum tolerated doses of statin therapy.InterventionsInclisiran as an adjunct to standard of care, compared with standard of care alone.Main Outcomes and MeasuresThe threshold price of inclisiran.ResultsInclisiran as an adjunct to standard of care resulted in threshold annual inclisiran prices of $6383, $9973, and $13,563 at willingness-to-pay thresholds of $50,000, $100,000, and $150,000 per quality-adjusted life-year, respectively. Probabilistic sensitivity analysis showed that at a threshold of $100,000 per QALY, inclisiran had a 100% probability of being cost effective, with an annual price below $9000. At the publicly available price of $3250 per dose, inclisiran was found to have an incremental cost-effectiveness ratio just above the $50,000 per QALY threshold, of $51,686.Conclusions and RelevanceThis study identified the price at which inclisiran is cost effective for the US health system, at generally accepted willingness-to-pay thresholds.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40256-022-00534-9.

P358 THE ROLE OF ADHERENCE TO LIPID–LOWERING THERAPIES IN ACHIEVING LIPID TARGET: FINDINGS FROM REAL–WORLD ANALYSIS IN ITALY

Abstract The objective of the present real–world analysis was to evaluate the impact of adherence to lipid–lowering drugs in reaching the lipid target in settings of clinical practice in Italy. The analysis was based on administrative and laboratory database of selected Healthcare Units in Italy covering approximately 10% of Italian population. Adult patients prescribed with statin and with at least a low–density lipoprotein (LDL) determination were included between 2012 and 2019. The index date was defined as the first prescription for statin within the inclusion period. Patients fell into 4 clusters collectively exhaustive and mutually exclusive based on their characteristics assessed during the year prior index date. Patients were considered as adherent if they had a proportion of days covered (PDC)≥80%. Among overall patients prescribed statin and with a LDL determination, 1% was with familial hypercholesterolemia, 28% with previous cardiovascular events, 21% with diabetes and 50% in primary prevention. Regardless their risk profile, the increasing of adherence was related to a higher achievement of LDL–target, with an increment of + 53.2% among familial hypercholesterolemia, +43.1% in diabetes and +30% in previous cardiovascular events and primary prevention clusters while progressing from low (PDC<40%) to high (PDC≥80%) levels of adherence. However, while in diabetes and primary prevention clusters 80% and 86% of adherent patients, respectively, had their cholesterol level under control, in the familial hypercholesterolemia and previous cardiovascular events clusters only 46% of adherent patients achieve the lipid target. The analysis showed adherence to be a key factor for cholesterol control. However, our findings underline a therapeutic need for patients that, although adherent, fail to achieve the lipid target, especially among patients with previous cardiovascular events (that have low level of LDL to achieve) and with familial hypercholesterolemia (that have high LDL basal level), suggesting therapeutic intensification should be applied.

P126 THE DANGEROUS LINK BETWEEN ECTOPIC ADIPOSITY AND HIGH RISK ATHEROSCLEROSIS: A PARADIGMATIC CASE OF STEMI

Abstract Nowadays CCTA has become the first line diagnostic tool in the clinical management of CAD thanks to its outstanding performance in assessing both the degree of stenosis and coronary plaques features, with crucial prognostic implications. Furthermore, CTCA allows an accurate quantification of epicardial fat, which has been shown to be a metabolic active tissue that by means of inflammatory mediators influences the development of high risk plaques and atrial fibrillation. A 70–years–old man underwent primary PCI for an acute STEMI. He was a former smoker with a history of obesity, hypertension, hypercholesterolemia and type II diabetes, without previous major cardiovascular events or significant comorbidities. The coronary angiography revealed diffuse coronary artery ectasia and a thrombotic total occlusion of the proximal portion of the RCA. After intravenous antiplatelet agent administration, balloon angioplasty was performed and three drug eluting stents were implanted. Furthermore, since the coronary angiography showed a calcific contour travelling parallel to the RCA course, in order to rule out a thrombosed coronary pseudoaneurysm, a CTCA was performed. CTCA unexpectedly revealed an enormous fibro–fatty plaque surrounded by a calcific shell in the RCA ostium–proximal segment, with the stents located at one border of the plaque, well expanded inside the vessel lumen. The post–procedural hospital stay was marked by new onset Atrial Fibrillation, unresponsive to pharmacological cardioversion. In contrast with coronary invasive angiography, CT was able to detect a very high plaque burden and a salient ubiquitary epicardial fat volume. In addition, at the site of the culprit lesion, CT showed huge plaque volume with an extreme eccentrically positive vessel remodeling, large low attenuation areas and spotty calcifications, all features known to predict adverse coronary events. This case shows how the combination of metabolic syndrome and ectopic fat accumulation fosters a milieu conducive for high risk atherosclerosis and its clinical complications.

P17 DOACS EFFECTIVENESS AND SAFETY: FURTHER CONFIRMATIONS FROM REAL WORLD EXPERIENCE

Abstract The present analysis is aimed to evaluate the use and results of direct oral anticoagulants (DOACs) in the past years, in a group of patients presenting with multiple comorbidies and at medium–high thromboembolic risk. In the past years, our outpatient Center followed 929 patients (mean age at admission 76.5 + 9.2 years, range: 29–99 years, 501 men), 848 with non–valvular atrial fibrillation/flutter, and 81 with recent phlebopulmonar thromboembolism (PPTE). An anamnesis of previous cardiovascular events were present in 302 patients (32.5%): coronary artery disease (146), carotid or peripheral atherosclerosis (109), cerebral stroke or ischemia (116). Initial CHA2DS2–VASc and HASBLED score were respectively 3.9 and 2.3 points. Patients were initially treated with Apixaban (A) (301, 89 with reduced dose, according to clinical–prescriptive characteristics), Dabigatran (D) (332, 256 with low dose), Edoxaban (E) (161, 83 with reduced dose), Rivaroxaban (R) (135, 53 with reduced dose). All patients were followed–up periodically (every 6 months) with both clinical and instrumental controls (electrocardiogram, blood tests, etc.), re–evaluating risk factors, in order also to check indication and dosage appropriateness. After a mean follow–up of 3.8 years (range: 6 montsh–9 years), for a total of 3530.2 years*patient, 57 patients (6.1%) had stopped DOAC therapy, because of: severe renal failure (12), repeated bleeding (6), clinical criteria (19), mechanical valve insertion (7), detection of thrombophilia (5), left atrial appendage occlusion (3), frailty (5). In the remaining 872 patients, 33 strokes (7 relapses), 11 PPTE, 17 major bleedings, 24 clinically relevant bleedings, and 71 minor bleedings, occurred. DOAC dose reduction occurred in 101 patients (11.6%: 31on A, 25 on D, 16 on E, 29 on R), because of clinical criteria (28), renal failure (56), bleedings (17). A replacement with other DOACS occurred in 104 patients (11.9%: 7 on A, 71 on D, 5 on E, 21 on R), because of renal failure (29), digestive disorders (27), bleedings (32), thrombotic events (6), lactose intolerance (3), allergic reactions (7). Clinical–and instrumental periodical control of patients treated with DOACs confirmed their effectiveness and safety, even in a population at medium–high thromboembolic risk. Additionally, such a management may allow also a greater prescribing appropriateness, as well as a safer and reliable follow–up over time of these patients.

Age-dependent and sex-dependent disparity in mortality in patients with adrenal incidentalomas and autonomous cortisol secretion: an international, retrospective, cohort study

The association between cortisol secretion and mortality in patients with adrenal incidentalomas is controversial. We aimed to assess all-cause mortality, prevalence of comorbidities, and occurrence of cardiovascular events in uniformly stratified patients with adrenal incidentalomas and cortisol autonomy (defined as non-suppressible serum cortisol on dexamethasone suppression testing). We conducted an international, retrospective, cohort study (NAPACA Outcome) at 30 centres in 16 countries. Eligible patients were aged 18 years or older with an adrenal incidentaloma (diameter ≥1 cm) detected between Jan 1, 1996, and Dec 31, 2015, and availability of a 1 mg dexamethasone suppression test result from the time of the initial diagnosis. Patients with clinically apparent hormone excess, active malignancy, or follow-up of less than 36 months were excluded. Patients were stratified according to the 0800-0900 h serum cortisol values after an overnight 1 mg dexamethasone suppression test; less than 50 nmol/L was classed as non-functioning adenoma, 50-138 nmol/L as possible autonomous cortisol secretion, and greater than 138 nmol/L as autonomous cortisol secretion. The primary endpoint was all-cause mortality. Secondary endpoints were the prevalence of cardiometabolic comorbidities, cardiovascular events, and cause-specific mortality. The primary and secondary endpoints were assessed in all study participants. Of 4374 potentially eligible patients, 3656 (2089 [57·1%] with non-functioning adenoma, 1320 [36·1%] with possible autonomous cortisol secretion, and 247 [6·8%] with autonomous cortisol secretion) were included in the study cohort for mortality analysis (2350 [64·3%] women and 1306 [35·7%] men; median age 61 years [IQR 53-68]; median follow-up 7·0 years [IQR 4·7-10·2]). During follow-up, 352 (9·6%) patients died. All-cause mortality (adjusted for age, sex, comorbidities, and previous cardiovascular events) was significantly increased in patients with possible autonomous cortisol secretion (HR 1·52, 95% CI 1·19-1·94) and autonomous cortisol secretion (1·77, 1·20-2·62) compared with patients with non-functioning adenoma. In women younger than 65 years, autonomous cortisol secretion was associated with higher all-cause mortality than non-functioning adenoma (HR 4·39, 95% CI 1·93-9·96), although this was not observed in men. Cardiometabolic comorbidities were significantly less frequent with non-functioning adenoma than with possible autonomous cortisol secretion and autonomous cortisol secretion (hypertension occurred in 1186 [58·6%] of 2024 patients with non-functioning adenoma, 944 [74·0%] of 1275 with possible autonomous cortisol secretion, and 179 [75·2%] of 238 with autonomous cortisol secretion; dyslipidaemia occurred in 724 [36·2%] of 1999 patients, 547 [43·8%] of 1250, and 123 [51·9%] of 237; and any diabetes occurred in 365 [18·2%] of 2002, 288 [23·0%] of 1250, and 62 [26·7%] of 232; all p values <0·001). Cortisol autonomy is associated with increased all-cause mortality, particularly in women younger than 65 years. However, until results from randomised interventional trials are available, a conservative therapeutic approach seems to be justified in most patients with adrenal incidentaloma. Deutsche Forschungsgemeinschaft, Associazione Italiana per la Ricerca sul Cancro, Università di Torino.

MO267: Traditional and Disease-Related Cardiovascular Risk Factors in Anca-Associated Vasculitis: A Prospective, Two-Centre, Observational Cohort Study

Abstract BACKGROUND AND AIMS ANCA-associated vasculitis (AAV) has been associated with increased risk of cardiovascular (CV) events. The purpose of the present study was to asses cardiovascular risk determinants and outcomes in a two-centre prospective cohort of AAV patients. METHOD Prevalent patients diagnosed with AAV ≥ 3 months were recruited over a period of 8 months from the Northwest Clinics in the Netherlands and 3 months from the Mount Sinai Hospital in Canada, and followed for 3–5 years. A comprehensive CV risk assessment was performed at inclusion. Subjects were followed up yearly until the first cardiovascular event, death or end of follow-up, whichever came first. Cardiovascular events were assessed by an independent outcome panel. Cox proportional hazards analyses were performed to relate baseline characteristics to the first CV event. RESULTS A total of 144 patients were included (median age 64.6 years, male sex 56%, median BVAS score 0, median Framingham risk score 14.3%). After a median follow-up of 2.91 years, 28 non-fatal and 4 fatal CV events were registered in 16 patients. Twelve patients died of non-cardiovascular causes. The incidence of fatal and non-fatal CV events was 5.5 per 100 patient-years. In a univariable analysis an association was found between traditional risk factors and risk of CV events [hazard ratio (HR) (95% confidence interval)], including age [HR 1.08 (95% CI 1.03–1.14)], HbA1c [HR 1.59 (95% CI 1.15–2.22)], systolic blood pressure [HR 1.04, 1.01–1.06), history of CV event [HR 3.47 (95% CI 1.29–9.32)] and Framingham risk score [HR 1.05 (95% CI 1.03–1.08)]. After adjusting for age and sex, HbA1c [HR 1.70 (95% CI 1.17–2.48)] and previous CV event [HR 2.90 (95% CI 1.02–8.21)] remained significantly associated with CV events. In a multivariable cox regression analysis (adjusted for Framingham risk score), a longer disease duration was associated with CV events [HR 1.08 (95% CI 1.01–1.16)]. CONCLUSION The present study is the largest prospective study on CV risk in patients with AAV and showed that CV risk was driven by both traditional and disease-related risk factors. Disease duration is associated with increased risk of CVE, but which precise disease-related factors accounts for this finding, and whether it can be acted upon remain to be determined.

MO760: Cardiovascular Score Risk Calculators in Dialysis Patients: Can We Use Them?

Abstract BACKGROUND AND AIMS Cardiovascular disease is the most significant cause of morbidity and mortality in dialysis patients. Despite significant information regarding the utility of cardiovascular risk score charts in the general population for prediction of major cardiovascular events, their usefulness in dialysis patients was rarely analysed. These scores may underestimate the risk since they were not validated in chronic kidney disease and non-traditional risk factors are also involved in this population. A J-relationship was demonstrated between total cholesterol and cardiovascular death in dialysis, and some data suggest that these charts are useless in dialysis since total cholesterol is included in calculators. The aim of the study was to assess the predictive capacity of risk scores for developing a major cardiovascular event, myocardial infarction or cardiovascular death, in dialysis. METHOD We performed a prospective study in which we evaluated 2 score charts, the Framingham risk score (FRS) for hard coronary heart disease and the new SCORE 2, in haemodialysis (HD) and peritoneal dialysis (PD) patients. We excluded patients with diabetes because FRS is not recommended in these patients. Predictive power for myocardial infarction (MI) and cardiovascular death (CvD) of both scores was evaluated using receiver operating characteristic curve analysis by SPSS ver. 20.0. RESULTS We included 232 PD patients (114 F), mean age 58.4 + 7.2 years, and 260 HD patients (137 F), mean age 59.7 + 3.9 years. Mean follow-up was 5.5 years. Majority of these patients were classified as high cardiovascular risk (CvR) by both charts: 65% by FRS and 54% by SCORE2 in PD, 69% by FRS and 58% by SCORE2 in HD. Both scores were significantly higher in patients with renal hypertensive disease compared with other causes of kidney disease (Table 1). We found no significant differences regarding these scores in HD versus PD. The best predictive value for developing MI during follow up was obtained by FRS (AUC 0.885 for HD, AUC 0.887 for PD) compared with SCORE2 (AUC 0.776 for HD, AUC 0.724 for PD). FRS had also the best predictive value for CvD (AUC 0.812 for HD, 0.808 for PD) compared with SCORE2 (AUC 0.701 for HD, 0.694 for PD). Regarding MI, all events occurred in high-CvR patients during follow-up according to these two risk scores: 22 events (9.5%) occurred in PD and 26 events (10%) in HD. All CvD events also occurred in high-CvR category, with 36 events (15.5%) in PD and 39 events (15%) in HD. After adjustment for age, gender and previous cardiovascular events, both scores were independent predictors for MI and CvD- FRS had an adjusted HR 4.3 [95% confidence interval (95% CI) 1.8–8.6; P = 0.005] for HD, HR 3.7 (95% CI 1.5–6.6; P = 0.001) for PD; SCORE2 had an adjusted HR 4.9 (95% CI 2.8–9.3; P = 0.003) for HD, HR 5.1 (95% CI 1.4–7.7; P = 0.001) for PD. CONCLUSION We found that both risk scores, the Framingham risk score and SCORE2, are useful to predict major heart events (MI and CvD) in dialysis, both HD and PD. These charts may be used as a tool in order to improve patients’ management. Our results need to be investigated and validated in larger prospective studies.

The relationship between mortality and daily number of steps in type 2 diabetes.

Physical activity (PA) is an established modifiable factor for the prevention of cardiovascular disease. Our objective was to assess the association of PA with mortality rates in a national sample of patients with diabetes. We analyzed a nationally representative sample from The National Health and Nutrition Examination Survey (NHANES, periods 2003-2004 and 2005-2006) that used PA Monitors. Individuals were matched for BMI, number of steps/per day and age. Three groups were created: subjects with less than 5000/steps per day (low), 5000-7500/steps per day (moderate) and more than 7500/steps per day (high levels of physical activity). All-cause mortality was ascertained through December 2015. A sample of 3072 individuals (1018 with diabetes) was analyzed. Patients with diabetes had 30% increased risk of mortality of all causes (RR: 1.298, 95% CI [1.162-1.451], P<0.001), higher levels of PA (>7500 steps/day) provided similar relative risk for subjects with diabetes compared to their controls (RR:1.256 [95% CI 0.910-1.732]). In a Poisson model adjusted for sex, history of previous cardiovascular event or cancer, ethnicity, Hb1ac, SBP, and total cholesterol to HDL ratio, patients with diabetes and moderate or high PA had an associated 44% to 80% lower risk of all-cause mortality compared to those with low PA. The subgroup of patients with diabetes and high PA had no excess of mortality compared to the general population. PA can reduce the gap for all-cause mortality, used as an index of cardiovascular fitness and a clinical tool for the assessment of mortality risk.

Does Mediterranean Adequacy Index Correlate with Cardiovascular Events in Patients with Advanced Chronic Kidney Disease? An Exploratory Study.

The Mediterranean Diet (MD) is a healthy dietary pattern, demonstrated to reduce the risk of cancer, diabetes, cardiovascular and neurodegenerative diseases, and early death. The Mediterranean Adequacy Index (MAI) is used to measure adherence to the MD in perspective studies in the general population and correlates with cardiovascular events. The aim of this study was to calculate the MAI among patients with advanced chronic kidney disease (CKD) and correlate it with traditional uremic, microbiota-derived, and proatherogenic toxins as well as nutritional status, quality of life, and cardiovascular events. A total of 60 adult patients with advanced CKD were enrolled and their MAI was calculated. According to the median value, patients were divided into lower (l-MAI, <1.80) and higher (h-MAI, ≥1.80) MAI groups. Biochemical parameters, microbiota-derived and proatherogenic toxins (p-Cresyl sulphate, Indoxyl-sulphate, and Lipoprotein-associated phospholipase A2), nutritional status, quality of life, and cardiovascular events that occurred in the previous three years were recorded. The mean value of the MAI was 2.78 ± 2.86. The MAI was significantly higher in foreigners (median (IQR) 6.38 (8.98) vs. 1.74 (1.67), p < 0.001) and diabetic patients. The l-MAI and h-MAI groups had similar routinary blood, p-Cresyl-sulphate, Indoxyl-sulphate, and Lp-PLA2 as well as nutritional status and quality of life parameters. The MAI was not associated with previous cardiovascular events and did not correlate with cardiovascular events in CKD patients. New and nephro-tailored indexes are warranted to evaluate nutritional therapy in CKD patients.

Registro Argentino de Medición de la Presión Arterial en Consultorio. Estudio RAMPAC

IntroductionHypertension (HTN) is the leading cause of mortality and disability in the world. In Argentina, almost 44% of hypertensives do not know about their condition and this may be due to the low rate of blood pressure (BP) measurements during the office visit. Our hypothesis is that the measurement and electronic recording of BP (BPMR) is not a routine practice in Argentina. ObjectiveTo describe the rate of office BP measurement in Argentina. MethodsThis is a retrospective, multicentre, point prevalence study. We analysed all office visits on 9/19/2019 at 9 medical institutions in 6 provinces of Argentina. ResultsTwo thousand and eighty-two office visits were analysed. The patients’ mean age was 52.1 years (18-103), 1790 (59.7%) were female, and 702 (36.1%) were hypertensives. BP was measured in 420 visits (14.1%; 95% CI 12.8-15.4). In a multivariate logistic regression model, history of HTN (OR 1.91, P<.001) and previous cardiovascular event (OR 1.76, P<.001) were associated with more odds of BPMR. The presence of cancer was associated with fewer odds of BPMR (OR .51, P<.01). Cardiology measured BP up to 49.5% (144/291 visits), followed by internal medicine 30% (152/507 visits). ConclusionBPMR during office visits is deficient in Argentina and represents a missed healthcare opportunity. Different strategies are needed to detect hypertensive patients and reduce cardiovascular events.

Direct Healthcare Costs by Level of Adherence of a Real-World Population of Statin Users in Italy.

PurposeThis real-world study investigates the direct healthcare costs from the perspective of the Italian Healthcare National Service of experienced statin users according to their level of adherence to therapy and to their cardiovascular (CV) profile in Italian settings of outpatients clinical practice.Patients and MethodsA retrospective observational analysis was performed based on administrative databases covering approximately 6 million health-assisted individuals. Adult patients with statins prescription between January 2014 and December 2016 were screened, and first prescription within this period was the index date. Follow-up lasted 1 year after index date. Only patients receiving statins prior index date (experienced statin users) were included and distributed in clusters based on their CV profile. Adherence was calculated during follow-up as proportion of days covered (PDC) and classified in low adherence (PDC<40%), partial adherence (PDC=40–79%) and adherence (PDC≥80%). Mean direct healthcare costs of drugs, hospitalizations, and outpatient services were evaluated during follow-up.ResultsA total of 436,623 experienced statin users were included and distributed as follows: 5.5% in the previous CV events, 22.6% in diabetes, 55.7% in CV treatments and 16.2% in the no comorbidity cluster. Total mean annual cost/patient decreased from low adherent to adherent patients from €4826 to €3497 in previous CV events, from €2815 to €2360 in diabetes cluster, from €2077 to €1863 for patients with CV treatments. Same trend was reported for the cost item related to hospitalizations, which was the major determinant of the total costs. In previous CV event cluster, adherence was associated to a saving of €879 on total costs.ConclusionThe study highlighted a decrease in overall mean costs as adherence levels increase, particularly for patients with previous CV events, showing how improving adherence could be associated to cost savings and suggesting suited strategy based on CV profile should be undertaken for adherence optimization.

"Dangerous liaisons: NAFLD and liver fibrosis increase cardiovascular risk in HIV".

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. We aimed to assess the impact of NAFLD and liver fibrosis on intermediate-high cardiovascular risk in people living with HIV. We included people living with HIV from three cohorts. NAFLD and significant liver fibrosis were defined using transient elastography: controlled attenuation parameter ≥288 dB/m and liver stiffness measurement ≥7.1 kPa, respectively. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator in patients aged between 40 and 75years and categorised as low if <5%, borderline if 5%-7.4%, intermediate if 7.5%-19.9% and high if ≥20% or with the presence of a previous cardiovascular event. Patients with hepatitis B and/or hepatitis C virus co-infection, alcohol abuse and unreliable transient elastography measurements were excluded. Predictors of intermediate-high cardiovascular risk were investigated in multivariable analysis by logistic regression and also by stratifying according to body mass index (BMI; cut-offs of 25 and 30kg/m2 ) and age (cut-off of 60years). Of 941 patients with HIV alone included, 423 (45%), 128 (13.6%), 260 (27.6%) and 130 (13.8%) were categorised as at low, borderline, intermediate and high ASCVD risk, respectively. Predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.11; 95% confidence interval [CI] 1.40-3.18; p<0.001), liver fibrosis (aOR 1.64; 95% CI 1.03-2.59; p=0.034), duration of HIV (aOR 1.04; 95% CI 1.02-1.06; p<0.001), and previous exposure to thymidine analogues and/or didanosine (aOR 1.54; 95% CI 1.09-2.18; p=0.014). NAFLD was also associated with higher cardiovascular risk in normoweight patients (aOR 2.97; 95% CI 1.43-6.16; p=0.003), in those with BMI <30kg/m2 (aOR 2.30; 95% CI 1.46-3.61; p<0.001) and in those aged <60 years (aOR 2.19; 95% CI 1.36-3.54; p=0.001). Assessment of cardiovascular disease should be targeted in people living with HIV with NAFLD and/or significant liver fibrosis, even if they are normoweight and young.

Indole-3-acetic acid correlates with monocyte-to-high-density lipoprotein (HDL) ratio (MHR) in chronic kidney disease patients.

Indole-3-acetic acid is a protein-bound indolic uremic toxin deriving from tryptophan metabolism. Increased levels are associated with higher thrombotic risk and both cardiovascular and all-cause mortality. An emerging biomarker of cardiovascular disease is the monocyte-to-high-density lipoprotein ratio (MHR). The main purpose of this study was to investigate the association of indole-3-acetic acid with MHR and other markers of cardiovascular risk in patients with chronic kidney disease (CKD). We enrolled 61 non-dialysis CKD patients and 6 dialysis patients. Indole-3-acetic acid levels were measured with ELISA technique. In the whole cohort of 67 patients, indole-3-acetic acid was directly related to Ca × P (ρ = 0.256; P = 0.0365) and MHR (ρ = 0.321; P = 0.0082). In the 40 patients with previous cardiovascular events, indole-3-acetic acid correlated with uric acid (r = 0.3952; P = 0.0116) and MHR (ρ = 0.380; P = 0.0157). MHR was related with fibrinogen (ρ = 0.426; P = 0.0010), arterial hypertension (ρ = 0.274; P = 0.0251), C-reactive protein (ρ = 0.332; P = 0.0061), gender (ρ = -0.375; P = 0.0017; 0 = male, 1 = female), and CKD stage (ρ = 0.260; P = 0.0337). A multiple regression analysis suggested that indole-3-acetic acid might be an independent predictor of MHR. This study shows a significant association between indole-3-acetic acid and MHR. Prospective studies are required to evaluate if decreasing indole-3-acetic acid concentrations may reduce MHR levels and cardiovascular events and improve clinical outcomes.

Obesity, chronic kidney disease progression and the role of the adipokine C1q/TNF related protein-3

Introduction and aimsObesity is a risk factor for incident chronic kidney disease (CKD). C1q/TNF related protein 3 (CTRP3) is an adipokine with multiple effects and may modulate the association between obesity and vascular diseases. The aim of the study is to explore potential links between obesity, CTRP3 levels and CKD progression. MethodsPatients with stage 3 and 4 CKD without previous cardiovascular events were enrolled and divided into groups according to body mass index (BMI) and sex. Demographic, clinical, analytical data and CTRP3 levels were collected at baseline. During follow-up, renal events (defined as dialysis initiation, serum creatinine doubling or a 50% decrease in estimated glomerular filtration rate were registered). Results81 patients were enrolled. 27 were obese and 54 non-obese. Baseline CTRP3 was similar between both groups (90.1±23.8 vs 84.5±6.2; p=0.28). Of the sum, 54 were men and 27 women, with higher CTRP3 in women (81.4±24.7 vs 106±24.7;p<0.01). During a mean follow-up of 68 months, 15 patients had a renal event. Patients in the higher CTRP3 tertile had less events but without statistical significance (p=0.07). Obese patients in the higher CTRP3 tertile significantly had less renal events (p=0.049). By multiple regression analysis CTRP3 levels could not predict renal events (HR 0.98; CI95% 0.96–1.06). ConclusionsCTRP3 levels are higher in woman than men in patients with CKD, with similar levels between obese and non obese. Higher CTRP3 levels at baseline were associated with better renal outcomes in obese patients.