Relative Risk Of Myocardial Infarction Research Articles

Triglyceride-rich lipoproteins and coronary artery disease risk: new insights from human genetics.

Despite ample success in reducing coronary artery disease (CAD) risk through reduction of low-density lipoprotein cholesterol (LDL-C), there remains substantial residual risk.1–4 Recent prospective studies have demonstrated that elevated triglycerides (TGs) are independent predictors of CAD risk.5–9 Furthermore, TGs are strongly associated with incident CAD events in patients with low LDL-C levels treated with statin.10 Thus, triglyceride-rich lipoproteins (TRLs) offer a potentially orthogonal risk factor to LDL-C for lowering CAD risk, but only if TRLs are causally associated with atherosclerotic disease.11 Human genetics has the potential to reveal the causal relationships of biomarkers found to be associated with disease outcomes.12–15 For example, genetic variants associated with plasma LDL-C levels are consistently associated with CAD risk in the right direction,15–18 consistent with a causal relationship. Importantly, similar studies have causally implicated the key TG-regulating enzyme lipoprotein lipase (LPL) in CAD risk. A common gain-of-function LPL variant, S447X, confers an antiatherogenic lipid profile characterized by low levels of TGs, and in several studies, it has been associated with lower incidence of vascular disease or myocardial infarction (MI).19–25 Conversely, several loss-of-function (LOF) LPL variants associated with elevated TG levels have been reported to be associated with increased CAD risk.21,26 Furthermore, multiple genome-wide association studies in the last 5 years have identified common noncoding variants at the LPL gene locus associated with both TG and CAD risk in the same direction.27–29 Beyond LPL itself, common variants that influence TG levels are significantly associated with CAD risk even after adjusting for their effects on other lipid traits.30 Do et al30 surveyed 185 single-nucleotide polymorphisms (SNPs) that were genome-wide significantly associated with ≥1 plasma lipid trait and identified a subset of …

Risk of coronary heart disease in patients with HIV infection.

The lives of individuals infected with HIV who have access to combination antiretroviral therapy (cART) are substantially prolonged, which increases the risk of developing non-AIDS comorbidities, including coronary heart disease (CHD). In Europe and the USA, individuals with HIV infection have a ∼1.5-fold increased risk of myocardial infarction relative to uninfected individuals. In Africa, the relative risk of myocardial infarction is unknown, but broadened access to life-extending cART suggests that rates of CHD will rise in this and other resource-constrained regions. Atherogenesis in HIV is affected by complex interactions between traditional and immune risk factors. cART has varied, regimen-specific effects on metabolic risk factors. Overall, cART seems to lessen proatherogenic immune activation, but does not eliminate it even in patients in whom viraemia is suppressed. Current strategies to decrease the risk of CHD in individuals infected with HIV include early initiation of cART regimens with the fewest metabolic adverse effects, and careful management of traditional CHD risk factors throughout treatment. Future strategies to prevent CHD in patients with HIV infection might involve the use of HIV-tailored CHD risk-prediction paradigms and the administration of therapies alongside cART that will further decrease proatherogenic HIV-specific immune activation.

Assessing the Effects of Nitrogen Dioxide in Urban Air on Health of West and Southwest Cities of Iran

NO 2 in urban regions is intra-urban public transport system. The annual average of determined air quality for NO 2 is 40 μg/m 3 . Objectives: The present study aimed to estimate and compare epidemiologic indices attributed to the pollutant NO 2 in the urban air of southwest cities of Iran, namely, Ahvaz, Kermanshah, and Bushehr, in 2011. Materials and Methods: In the present study, data relevant to the air-pollutant NO 2 in 2011 was obtained from the Iranian Department of Environment and meteorological organizations of the studied cities. Raw data processing by Excel software included instruction set correction of averaging, coding, and filtering. Then the meteorological parameters were converted as input file to the Air Q model. Finally, by using epidemiologic formulas, relative risk (RR) and attributed part to NO 2 in the three studied cites were estimated. Results: The results showed that in summer, winter, and the whole year, Kermanshah and Bushehr had on average the maximum and minimum NO 2 concentration, respectively, in 2011. In addition, accumulative number of cases attributed to exposure with NO 2 in the studied cities was maximum in Kermanshah (21 cases) and minimum in Bushehr (one case). The results revealed that approximately, the maximum number of death cases attributed to NO 2 were observed in Kermanshah due to heart problems (1.06%), acute infarction (1.8%), and obstructive pulmonary disease (1.9%) with concentration > 20 μg/m 3 . Conclusions: Every 10 μg/m 3 increase in the concentration of the pollutant NO 2 in the studied cities led to increase in the RR of myocardial infarction, cardiovascular diseases, and obstructive pulmonary disease by 0.4%, 0.2%, and 0.4%, respectively, in 2011. Higher RR value can depict mismanagement in urban air quality. The lower level of RR value might be achieved if some control strategies for reducing NO 2 emission were used.

Athérosclérose au cours du lupus érythémateux systémique

Evidence from epidemiological studies demonstrates that patients with systemic lupus erythematosus (SLE) are at increased risk for the development of cardiovascular disease. Traditional cardiovascular risk factors' play an important role in this phenomenon but do not account for the entire risk in lupus patients. The incidence and prevalence of cardiovascular events and infraclinical atherosclerosis are reviewed. Combinations of traditional risk factors with lupus-specific and treatment-related variables are detailed. Atherosclerosis is more prevalent and occurs prematurely in lupus patients. Relative risk of myocardial infarction is between 5 to 8 times greater that of general population, and may exceed 50 in women between 35 and 44years old. SLE was also found as an independent risk factor for subclinical atherosclerosis, and more than one third of lupus patient show evidence of carotid plaques of coronary artery calcifications. Lupus patients have more frequent traditional risk factors compared with general population of similar age and sex. Besides the traditional risk factors, SLE specific risk factors have been identified among witch advanced age at diagnosis, current disease activity, duration of the disease and renal activity. Moreover, lipid abnormalities in patients with SLE are common and likely are one of the major causes of premature atherosclerosis in these patients; the dyslipoprotein associated increased triglycerides and depressed HDL-cholesterol with proinflammatory HDL production. Autoimmunity may have a part of responsibility, but data's in favour of this hypothesis are not strong. Other mechanisms such as vascular inflammation, oxidative stress, immune complexes and complement activation may also elicit endothelial damage and promote atherosclerosis are associated with the pathogenesis of both SLE and atherosclerosis. Steroids may have a true double-edged role with a pro-atherogenic risk regarding the exacerbation of metabolic risk factors and a "beneficial" anti-inflammatory role. It is becoming increasingly apparent that antimalarials treatment in SLE has an atheroprotective and a cardioprotective effect. The other immunosuppressive drugs may reduce progression of atherosclerosis and cardiovascular events but their precise role remains to be elucidated. Despite their role in primary prevention in target general population, for now, systematic prescription of statins does not show a great benefit in the cardiovascular risk in lupus patients. Mechanisms of atherosclerosis in SLE remain elusive. It is partially explained by the interaction of traditional cardiovascular risk factors, lupus-specific factors and therapy specially corticosteroids. Management strategies of lupus should include early all those items.

Cost-utility analysis of genotype-guided antiplatelet therapy in patients with moderate-to-high risk acute coronary syndrome and planned percutaneous coronary intervention.

Prasugrel is recommended over clopidogrel in poor/intermediate CYP2C19 metabolizers with acute coronary syndrome (ACS) and planned percutaneous coronary intervention (PCI), reducing the risk of ischemic events. CYP2C19 genetic testing can guide antiplatelet therapy in ACS patients. The purpose of this study was to evaluate the cost-utility of genotype-guided treatment, compared with prasugrel or generic clopidogrel treatment without genotyping, from the US healthcare provider's perspective. A decision model was developed to project lifetime economic and humanistic burden associated with clinical outcomes (myocardial infarction [MI], stroke and major bleeding) for the three strategies in patients with ACS. Probabilities, costs and age-adjusted quality of life were identified through systematic literature review. Incremental cost-utility ratios (ICURs) were calculated for the treatment strategies, with quality-adjusted life years (QALYs) as the primary effectiveness outcome. Relative risk of developing myocardial infarction and stroke between patients with and without variant CYP2C19 when receiving clopidogrel were estimated to be 1.34 and 3.66, respectively. One-way and probabilistic sensitivity analyses were performed. Clopidogrel cost USD19,147 and provided 10.03 QALYs versus prasugrel (USD21,425, 10.04 QALYs) and genotype-guided therapy (USD19,231, 10.05 QALYs). The ICUR of genotype-guided therapy compared with clopidogrel was USD4,200. Genotype-guided therapy provided more QALYs at lower costs compared with prasugrel. Results were sensitive to the cost of clopidogrel and relative risk of myocardial infarction and stroke between CYP2C19 variant vs. non-variant. Net monetary benefit curves showed that genotype-guided therapy had at least 70% likelihood of being the most cost-effective alternative at a willingness-to-pay of USD100,000/QALY. In comparison with clopidogrel, prasugrel therapy was more cost-effective with <21% certainty at willingness-to-pay of >USD170,000/QALY. Our modeling analyses suggest that genotype-guided therapy is a cost-effective strategy in patients with acute coronary syndrome undergoing planned percutaneous coronary intervention.

Risk of ischemic heart disease following occupational exposure to welding fumes: a systematic review with meta-analysis.

Air pollution has been linked to an increased risk of ischemic heart disease (IHD), but less is known about occupational exposure to welding fumes and the risk of IHD. The objective of this paper was to review the epidemiological evidence on causal links between welding fume exposure and risk of IHD and to investigate whether the risk of IHD depends on specific welding characteristics. A systematic search in Medline 1979-2013 and EMBASE 1974-2013 identified 18 epidemiological studies with at least one risk estimate of IHD morbidity or mortality among workers exposed to welding fumes. Following an assessment of completeness of reporting, confounding, and bias, each risk estimate was characterized as more or less reliable. Pooled risk estimates were computed across studies by random effect meta-analyses. The weighted relative risk (RR) for IHD following exposure to welding fumes was 1.09 [95 % confidence interval (CI) 1.00, 1.19]. We calculated a RR of 1.39 (95 % CI 0.96, 2.02) among studies using an internal reference group and 1.08 (95 % CI 0.99, 1.18) for studies using an external reference group. An increased risk was observed for acute myocardial infarction RR = 1.69 (95 % CI 1.18, 2.42) and other IHDs RR = 1.06 (95 % CI 0.98, 1.14). There was too limited evidence to evaluate the risk of IHD related to specific welding characteristics. Several studies indicate that welding is associated with a moderately increased risk of IHD; however, bias and confounding cannot be ruled out with reasonable confidence.

The effect of family stress on risk of myocardial infarction in female population aged 25-64 years in Russia

Objectives: We studied the influence of family stress on relative risk of myocardial infarction (MI) in female population aged of 25-64 years in Russia over 16 years of follow-up.

The effects of calcium supplementation on verified coronary heart disease hospitalization and death in postmenopausal women: a collaborative meta-analysis of randomized controlled trials.

Calcium supplementation, particularly with vitamin D, has been an approved public health intervention to reduce fracture risk. Enthusiasm for this intervention has been mitigated by meta-analyses suggesting that calcium supplementation with or without vitamin D increases myocardial infarction (MI) risk; however, concern has been raised over the design of these meta-analyses. We, therefore, undertook a meta-analysis of randomized controlled trials with placebo or no-treatment control groups to determine if these supplements increase all-cause mortality and coronary heart disease (CHD) risk including MI, angina pectoris and acute coronary syndrome, and chronic CHD verified by clinical review, hospital record, or death certificate in elderly women. The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases were searched from January 1, 1966, to May 24, 2013, for potentially eligible studies, reference lists were checked, and trial investigators were contacted where additional unpublished data were required. The search yielded 661 potentially eligible reports of which 18 met the inclusion criteria and contributed information on 63,563 participants with 3390 CHD events and 4157 deaths. Two authors extracted the data independently with trial data combined using random-effects meta-analysis to calculate the relative risk (RR). Five trials contributed CHD events with pooled relative RR of 1.02 (95% confidence interval [CI], 0.96-1.09; p = 0.51). Seventeen trials contributed all-cause mortality data with pooled RR of 0.96 (95% CI, 0.91-1.02; p = 0.18). Heterogeneity among the trials was low for both primary outcomes (I(2) = 0%). For secondary outcomes, the RR for MI was 1.08 (95% CI, 0.92-1.26; p = 0.32), angina pectoris and acute coronary syndrome 1.09 (95% CI, 0.95-1.24; p = 0.22) and chronic CHD 0.92 (95% CI, 0.73-1.15; p = 0.46). In conclusion, current evidence does not support the hypothesis that calcium supplementation with or without vitamin D increases coronary heart disease or all-cause mortality risk in elderly women.

Increased risk of cardiovascular disease (CVD) with age in HIV-positive men: a comparison of the D:A:D CVD risk equation and general population CVD risk equations.

The aim of the study was to statistically model the relative increased risk of cardiovascular disease (CVD) per year older in Data collection on Adverse events of anti-HIV Drugs (D:A:D) and to compare this with the relative increased risk of CVD per year older in general population risk equations. We analysed three endpoints: myocardial infarction (MI), coronary heart disease (CHD: MI or invasive coronary procedure) and CVD (CHD or stroke). We fitted a number of parametric age effects, adjusting for known risk factors and antiretroviral therapy (ART) use. The best-fitting age effect was determined using the Akaike information criterion. We compared the ageing effect from D:A:D with that from the general population risk equations: the Framingham Heart Study, CUORE and ASSIGN risk scores. A total of 24 323 men were included in analyses. Crude MI, CHD and CVD event rates per 1000 person-years increased from 2.29, 3.11 and 3.65 in those aged 40-45 years to 6.53, 11.91 and 15.89 in those aged 60-65 years, respectively. The best-fitting models included inverse age for MI and age + age(2) for CHD and CVD. In D:A:D there was a slowly accelerating increased risk of CHD and CVD per year older, which appeared to be only modest yet was consistently raised compared with the risk in the general population. The relative risk of MI with age was not different between D:A:D and the general population. We found only limited evidence of accelerating increased risk of CVD with age in D:A:D compared with the general population. The absolute risk of CVD associated with HIV infection remains uncertain.

Microbial Translocation and Cardiometabolic Risk Factors in HIV Infection

The widespread access to antiretroviral treatment during the past decades has transformed HIV infection from a lethal disease to a chronic condition, in which the relative burden of non-AIDS-related chronic disorders such as cardiovascular disease, malignancy, renal, liver, and bone disease has increased. The adjusted relative risk for myocardial infarction is reported to be around 2-fold compared to that of the general population, which over time is likely to translate into increased absolute risk in an aging population. Thus, delineating potentially HIV-specific pathogenetic mechanisms is crucial in order to tailor novel strategies for prophylaxis and treatment. This review will focus on advances in the field that possibly link HIV-induced alterations of the gut mucosa and consequent microbial translocation to cardiometabolic risk factors in HIV infection. Recent work suggests that markers of microbial translocation are closely associated with several cardiovascular risk factors such as dyslipidemia, insulin resistance, hypertension, coagulation abnormalities, endothelial dysfunction, and carotid atherosclerosis. Future studies should investigate whether associations between microbial translocation and cardiovascular risk factors will translate into increased risk of acute events, and whether strategies to target gut microbiota and microbial translocation might reduce such a risk.

THE RELATION OF PERSONAL ANXIOUSNESS AND SELF-AWARENESS ABOUT THE HEALTH CONDITION, AND ITS INFLUENCE ON 16-YEAR RISK OF ACUTE CARDIOVASCULAR DISEASES DEVELOPMENT IN WOMEN 25-64 YEARS OLD

Aim. To evaluate the influence of personal anxiousness (PA) on the relative risk of myocardial infarction and stroke development in the open cohort of women 25-64 years old during 16 years. Material and methods. As a part of MONICA-psychosocial in 1994 the random representative group of women was studied in the age of 25-64 y. (n=870), living in one of the districts of Novosibirsk. PA was assessed by Spielberg test. During 16-year period (1994-2010) in this cohort, all cases of primary myocardial infarction and stroke cases were studied. Results. The prevalence of higher PA in open population among women of 25-64 y.o. was 60%. Higher PA was related to lower self-assessment about health. During 16 years the relative risk of myocardial infarction development was 4.2 (p=0,05), stroke 3.5 (p&lt;0,05) times higher in women with higher PA. The rate of myocardial infarction and stroke development was higher in married women with PA in social frame "senior manager" and "strenuous labour" with higher or lower level of education. Conclusion. The studied prevalence of higher PA risk in open population of 25-64 y.o. women reached 60%. Women with higher PA had higher relative risk of myocardial infarction and stroke during 16 years follow-up, low self-awareness about the health; risk of infarction is related to social gradient.

Burden of myocardial infarction attributable to road-traffic noise: a pilot study in Belgrade.

The aim of this pilot study was to calculate the disability-adjusted life years (DALY) as a quantification of the burden of myocardial infarction (MI) attributable to road-traffic noise in Belgrade, Serbia. Exposure to road-traffic noise was estimated on a sample of almost 6000 adult inhabitants living in the central municipality Stari Grad in Belgrade, Serbia. Each participant was assigned to daytime noise levels for 16 h exposure measured on the street of current residence. Population-attributable fraction of MI due to road-traffic noise was calculated based on the distribution of the population in different noise exposure categories and the respective relative risk of MI compared to the reference level. DALYs due to noise-related MI were calculated as the sum of years of life lost and years with disability. The contribution of road traffic noise to the occurrence of MI for the population of the municipality Stari Grad in Belgrade equals 2.518%. Total DALY for MI due to road-traffic noise results in 176 years, that is, 115 years for men and 61 years for women. When adjusted for the present size of the population in Belgrade, total DALY due to road-traffic noise equals 107 years/million inhabitants that is, 70/million inhabitants for men and 37/million inhabitants for women. The burden of disease due to road-traffic noise in Belgrade is relatively small but noteworthy from the public health point of view.

The influence of social support on risk of acute cardiovascular diseases in female population aged 25–64 in Russia

ObjectiveTo study the prevalence of social support (SS) and its influence on the relative risk (RR) of myocardial infarction (MI) and stroke in the female population aged 25–64 in Russia.Materials and methodsUnder the third screening of the WHO “MONICA-psychosocial” programme, a random representative sample of women aged 25–64 (n=870) were surveyed in Novosibirsk. SS was measured according to the methods of the Berkman–Sym test [indices of close contacts (ICC) and index of social network (SNI)]. From 1995 to 2010, women were followed for 16 years to observe the incidence of MI and stroke.ResultsThe prevalence of low levels of ICC and SNI in women aged 25–64 was 57.1 and 77.7%, respectively. Low levels of ICC and SNI were associated with poor self-rated health and awareness about their health, adverse behavioural habits, high job strain and family stress.Rates of MI and stroke development were higher in married women with low ICC and SNI who were being in class “hard manual work”. Over a 16-year study period, the RR of MI in women with low ICC compared to those with high ICC was 4.9 times higher, and the risk of stroke was 4.1 times higher. Low level of SNI increased MI risk in 2.9 times, risk of stroke in 2.7 times.ConclusionMajority of women aged 25–64 years in Russia have low social support which is associated with poor self-rated health, low awareness about the health that increases the risk of MI and stroke in 2.7–4.9 times in groups of “married” and “hard physical work”.

1718 – Depression and risk development of acute cardiovascular diseases in female population aged 25–64 in Russia

To explore the effect of depression (D) on relative risk of myocardial infarction (MI) and stroke and its relation with awareness and attitude towards the health in female population of 25–64 years in Russia. Under the third screening of the WHO “MONICA-psychosocial” (MOPSY) program random representative sample of women aged 25–64 years (n=870) were surveyed in Novosibirsk. D was measured at the baseline examination by means of test “MOPSY”. From 1995 to 2010 women were followed for 16 years for the incidence of MI and stroke. The prevalence of D in women aged 25–64 years was 55.2%. With growth of D levels positive self-rated health reduced and almost 100% of those women have health complaints. Women with major D significantly extended negative behavioral habits: smoking and unsuccessful attempts to give it up, low physical activity, they are less likely to follow a diet. Major D associated with high job strain and family stress. Risk of MI development in women with D during 16 years of study was higher in 2.53 times (95%CI=1.26-24.34; p< 0.05), risk of stroke was higher in 4.63 times (95%CI=1.03-20.89; p< 0.05 MI and stroke rates were more likely in married women having D with average educational level who being in both “managers” and “physical labor” social classes. The prevalence of D in women aged 25–64 years more than 50%. Women with D had 2.53-fold risk of MI and 4.63-fold risk of stroke over 16 years of follow-up.

Mobile Clinic In Massachusetts Associated With Cost Savings From Lowering Blood Pressure And Emergency Department Use

Mobile health clinics are in increasingly wide use, but evidence of their clinical impact or cost-effectiveness is limited. Using a unique data set of 5,900 patients who made a total of 10,509 visits in 2010-12 to the Family Van, an urban mobile health clinic in Massachusetts, we examined the effect of screenings and counseling provided by the clinic on blood pressure. Patients who presented with high blood pressure during their initial visit experienced average reductions of 10.7 mmHg and 6.2 mmHg in systolic and diastolic blood pressure, respectively, during their follow-up visits. These changes were associated with 32.2 percent and 44.6 percent reductions in the relative risk of myocardial infarction and stroke, respectively, which we converted into savings using estimates of the incidence and costs of these conditions over thirty months. The savings from this reduction in blood pressure and patient-reported avoided emergency department visits produced a positive lower bound for the clinic's return on investment of 1.3. All other services of the clinic-those aimed at diabetes, obesity, and maternal health, for example-were excluded from this lower-bound estimate. Policy makers should consider mobile clinics as a delivery model for underserved communities with poor health status and high use of emergency departments.

1701 – Association of personal anxiety with attitude towards the health and risk of acute cardiovascular diseases over 16-years in female population aged 25–64 in Russia

The aim To study the effect of personal anxiety on relative risk of myocardial infarction (MI) and stroke and its relation with awareness and attitude towards the health in female population of 25–64 years in Russia. Material and methods Under the third screening of the WHO “MONICA-psychosocial” program random representative sample of women aged 25–64 years (n=870) were surveyed in Novosibirsk. Levels of personal anxiety were measured at the baseline examination by means of Spilberger’s test. From 1995 to 2010 women were followed for 16 years for the incidence of MI and stroke. Results High level of anxiety (HLA) in studied cohort revealed in 60% of women. Women with HLA had 1.5-3-fold growth of negative self-rated health (87.5%), about 90% had health complaints, more likely had negative behavioral habits and higher levels of job and family stress compared to those with lower levels of anxiety. Risk of MI development in women with HLA over 16 years of study was higher in 4.2 times (95%CI=1.946-18.583; p=0.05), risk of stroke was higher in 3.5 times (95%CI=1.020-12.015; p Conclusions There is high prevalence of HLA in female population aged of 25–64 years. Women with HLA had poor selfrated health and awareness about their health and it associated with higher risk of MI and stroke over 16 years of follow-up.

THE INFLUENCE OF PERSONAL ANXIETY ON RISK OF MYOCARDIAL INFARCTION AND STROKE DURING 16 YEARS (1995–2010) IN WOMEN AGED 25–64 IN CONDITION OF WESTERN SIBERIA MEGAPOLIS (NOVOSIBIRSK)

ObjectivesTo study the influence of personal anxiety (PA) on relative risk of myocardial infarction (MI) and stroke in women aged of 25–64 years during 16 years of follow up in...

DEPRESSION AND RISK OF MYOCARDIAL INFARCTION AND STROKE DURING 16 YEARS

ObjectivesTo study the influence of depression (D) on relative risk of myocardial infarction (MI) and stroke in women aged of 25–64 years during 16 years of follow up in Novosibirsk.MethodsWithin...

The Health Impact of Getting to Glucose, Systolic Blood Pressure (SBP), and Serum Cholesterol Goals in Patients Newly Diagnosed with Type 2 Diabetes Mellitus (T2DM) in Canada

Good management of T2DM requires not only control of blood glucose, but control of SBP and serum cholesterol levels as well. Unfortunately, goal attainment is difficult and many patients in Canada and elsewhere do not meet these targets. The objective of this research was to estimate the potential health benefits (reduced incidence of micro- and macrovascular events and increased survival) of two treatment scenarios attributable to treating newly-diagnosed patients to the glucose, SBP and cholesterol goals specified in the CDA guidelines (7.0 percent (%), 130 mmHg and 77 mg/dL, respectively) versus levels observed in a T2DM population tailored to the Canadian setting (8.0%, 140 mmHg and 112 mg/dL, respectively) using a validated simulation tool, the Economic and Health Outcomes (ECHO)-T2DM model over 25 years. Pharmacotherapy for hyperglycemia, hypertension, and hypercholesterolemia in line with CDA guidelines were applied to both treatment scenarios. Treating patients to CDA goals was estimated to reduce the relative risk of myocardial infarction by 31%, congestive heart failure by 12%, stroke by 24%, ischemic heart disease by 25%, macular edema by 34%, end stage renal disease by 26.9%, and macroalbuminuria by 56.5% over 25 years. Estimated survival was on average, approximately 4 months longer for patients treated to CDA goals. These results suggest that intensifying therapy to achieve key biomarker goals in patients newly diagnosed with T2DM can lead to meaningful gains in long-term health outcomes in Canada.

Hemorrhagic Complications Associated With Aspirin

ASPIRIN IS WIDELY USED FOR PRIMARY AND SECONDary prevention of cardiovascular events. Substantial scientific evidence supports the beneficial role of aspirin in reducing the risk of cardiovascular events in secondary prevention. In a meta-analysis including 135 000 patients considered to be at high risk for vascular events (90% with known coronary artery disease, cerebral artery disease, or peripheral artery disease), aspirin was associated with a reduced relative risk of vascular events (myocardial infarction, stroke, and vascular death) by 22% (absolute risk reduction [ARR], 2.5%) but also was associated with an increased relative risk of major extracranial bleeding events by 60% (absolute risk increase [ARI], 0.42%). In another meta-analysis, aspirin used for secondary prevention was associated with a reduced relative risk of myocardial infarction by 31%, ischemic stroke by 22%, and cardiovascular death by 13%. For a hypothetical group of 10 000 patients, aspirin used for secondary prevention would be expected to prevent approximately 250 major vascular events (number needed to treat [NNT], 40) but would be expected to cause approximately 40 major extracranial bleeding events (number needed to harm [NNH], 240). Thus, the net benefit of aspirin for secondary prevention would substantially exceed the bleeding hazard. For 6 major vascular events prevented, approximately 1 major bleeding event would occur; therefore, the value of aspirin for secondary prevention is not disputed. In contrast, there is an ongoing debate surrounding use of aspirin for primary prevention. Published evidence does not support the assumption that the balance of benefits and harms of aspirin use is clearly favorable for primary prevention. In a meta-analysis using individual patient data from 6 randomized trials including 95 000 patients, aspirin was associated with a reduced relative risk of vascular events by 12% (ARR, 0.07%), but also was associated with an increased relative risk of extracranial bleeding events by 54% (ARI, 0.03%). Although aspirin was associated with reduced relative risk of myocardial infarction by 23% (ARR, 0.05%), there was no association between aspirin use and risk of stroke or vascular death. The proportional reduction of vascular events by aspirin in primary prevention was not affected by the predicted risk of coronary heart disease, age, sex, hypertension, or diabetes. For a hypothetical group of 10 000 patients, aspirin use for primary prevention would be expected to prevent 7 major vascular events (NNT, 1430) and cause 1 hemorrhagic stroke and 3 major extracranial bleeding events (NNH, 2500). This suggests that for 2 major vascular events prevented, approximately 1 major bleeding event would occur. A meta-analysis that focused on primary prevention suggested that the effects of aspirin were sex-related: aspirin was associated with a reduced relative risk of stroke by 24% among women and reduced relative risk of myocardial infarction by 32% among men, but these risk reductions were offset by an increase in the relative risk of major bleeding events by 68% among women and 72% among men. Another meta-analysis and a randomized trial support the findings that the magnitude of benefit with aspirin in primary prevention is small and at least partially balanced by the magnitude of harm. Before these clinical trial data were available, the US Preventive Services Task Force recommended use of aspirin for men aged 45 to 79 years and for women aged 55 to 79 years when the potential benefit due to a reduction in myocardial infarction outweighs the potential harm due to an increase in gastrointestinal hemorrhage. These recommendations seem to be mainly based on evidence extrapolated from large trials of populations at high risk of vascular events, under the assumption that age confers an elevated risk of cardiovascular disease. In light of more recent reports, the new European guidelines on cardiovascular disease prevention do not recommend aspirin for primary prevention because of its unfavorable risk-to-benefit profile. In this issue of JAMA, findings from the study by De Berardis et al reinforce the European recommendations for aspirin use. The authors performed a population-based co-