Risk Of Recurrent Cardiovascular Disease Research Articles

Changes in Physical Activity and Incidence of Nonfatal Cardiovascular Events in 47 153 Survivors of Myocardial Infarction.

Background The majority of patients survive the acute phase of myocardial infarction (MI) but have an increased risk of recurrent cardiovascular disease (CVD) events. To be regularly physically active or change activity level is associated with a lower risk of all-cause mortality. The objective was to explore to what extent physical activity (PA) levels or change in PA levels during the first year post-MI was associated with any recurrent nonfatal CVD events and specific CVD events (eg, MI, ischemic stroke, and vascular dementia). Methods and Results This cohort study among MI survivors was based on Swedish national registries between 2005 and 2020. PA levels were self-rated at 2 and 12 months post-MI, and patients were classified into remaining physically inactive, increasing, decreasing, or remaining active. A total of 6534 nonfatal CVD events occurred during 6 years of follow-up among the 47 153 included patients. In fully adjusted analyses, the risk of any nonfatal CVD event was lower (P<0.05) among patients remaining active (37%), increasing (22%), or decreasing (18%) PA level compared with remaining inactive. Compared with remaining inactive, the risk of recurring MI and stroke was lower (P>0.05) among remaining active (41% versus 52%, respectively), increasing (20% versus 35%, respectively), or decreasing PA level (24% versus 34%, respectively). For vascular dementia, patients remaining physically active had an 80% lower risk compared with remaining inactive (P<0.05). Conclusions Remaining physically active or change in PA levels during the first year post-MI was associated with a lower risk of recurrent nonfatal CVD events. This emphasizes the importance of supporting patients to continue to be or become physically active.

Trends in low-density lipoprotein cholesterol goal achievement and changes in lipid-lowering therapy after incident atherosclerotic cardiovascular disease: Danish cohort study.

We aimed to investigate trends in low-density lipoprotein cholesterol (LDL-C) goal achievement (LDL-C<1.8 mmol/L, equivalent to 70 mg/dL), initiation of lipid-lowering therapy (LLT) and changes in LLT intensity in individuals with atherosclerotic cardiovascular disease (ASCVD) at very high risk of recurrent cardiovascular disease. A cohort study design was used including individuals with incident ASCVD and LDL-C≥1.8 mmol/L in 2010-2015. Data were obtained from national, population-based registers (patient, prescription, income, and laboratory). We included 11,997 individuals. Acute myocardial infarction, ischemic stroke and stable angina pectoris accounted for 79.6% of the qualifying ASCVD events. At inclusion, 37.2% were in LLT. Mean LDL-C before or during ASCVD hospitalization was 3.1 mmol/L (120 mg/dL). LDL-C goal achievement increased within the first two years after inclusion from 40.5% to 50.6%. LLT initiation within the first 90 days increased from 48.6% to 56.0%. Initiation of intensive LLT increased from 9.6% to 32.8%. The largest change in LLT intensity was seen in the period 180 days before to 90 days after discharge with 2.2% in 2010 to 12.1% in 2015. LDL-C goal achievement within the first 2 years after inclusion increased from 40.5% in 2010 to 50.6% in 2015. LLT initiation within the first year after inclusion increased, especially for intensive LLT, although only one third initiated intensive LLT in 2015. Despite trends show improvements in LDL-C goal achievement, 49.4% of individuals at very high risk of a CV event did not achieve the LDL-C goal within 2 years after ASCVD hospitalization.

Lipid Lowering Agent Prescription and LDL Target Achievement in ACS Patients in Jeddah, Saudi Arabia

Background: The safety and efficacy of statins administered early to patients after an acute coronary syndrome (ACS) diagnosis have been proven. This study aimed to estimate the prevalence of compliance with guideline recommendations for high-intensity dose statins and achievement of reduced low-density lipoprotein (LDL) levels among patients with ACS in Saudi Arabia. Methods: A cross-sectional study was conducted on 566 patients at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Data on the patient&amp;apos;s demographics, comorbidities, type of ACS, lipid profile at admission, statin type, statin use pattern, side effects, and if the patient achieved the low-density lipoprotein cholesterol (LDL-C) goal (70 mg/dl) or (3.9 mmol/l) after management were collected. Results: At admission, 34.1% had an LDL-C level below 100 mg/dl, 64.5% had total cholesterol below 200 mg/dl, 57.2% had an average triglyceride level, and 53.7% had high-density lipoprotein cholesterol below 40 mg/dl. Moreover, 91% of patients consumed high-potency statins, 99.1% had no statin side effects, and atorvastatin 20 mg was the most commonly used high-potency statin, followed by atorvastatin 40 mg. Approximately 83% of patients achieved the LDL-C goal (70 mg/dl) after management, and patients who had diabetes mellitus, familial hyperlipidemia, or obesity, who experienced no side effects of statins, who had ST-segment elevation myocardial infarction, had an LDL-C level of 160-189 mg/dl at admission and those who had a high total cholesterol level at admission had a significantly higher level of achieving the LDL-C goal. Conclusions: In patients with congenital heart disease, lipid management could be improved to reduce the risk of recurrent cardiovascular disease and recurring episodes.

Inflammation and risk of recurrent cardiovascular events according to prior vascular disease location

Abstract Background In recent years, anti-inflammatory drugs have been shown to reduce the risk of recurrent cardiovascular disease (CVD) events in patients with coronary artery disease (CAD), but have not yet been tested in patients with other vascular disease locations. Whether the relation between inflammation and recurrent CVD is modified by prior vascular disease location is unknown. Purpose This study aimed to establish the relation between low-grade inflammation and recurrent CVD according to prior vascular disease location. Methods Inflammation was measured by plasma concentrations of high-sensitivity C-reactive protein (CRP). Patients from the UCC-SMART cohort with CAD (n=4,517), cerebrovascular disease (CeVD; n=2,154), peripheral artery disease (PAD, n=1,154), or abdominal aortic aneurysm (AAA, n=424), and CRP ≤10 mg/L were included in the main analysis (combined n=8,249). Patients with CRP &amp;gt;10 mg/L (n=756) were analysed separately. The primary outcome was a composite of myocardial infarction, ischemic stroke, or cardiovascular death. Secondary outcomes included the primary outcome components, major adverse limb events (MALE), and all-cause mortality. The relation between CRP and outcomes was assessed using Cox proportional hazard models stratified by prior vascular disease location, and adjusted for potential confounders. Results During a median follow-up of 9.5 years (interquartile range 5.1–13.9) 1,877 CVD events, 887 MALE events, and 2,341 deaths were observed. In the total population, CRP was related to recurrent CVD (hazard ratio [HR] per 1 mg/L 1.08; 95% confidence interval [CI] 1.05–1.10), and all secondary outcomes except for ischemic stroke (HR 1.03; 95% CI 0.99–1.08). Compared to the first quintile of CRP, HRs for recurrent CVD were 1.66 (95% CI 1.41–1.96) for the last quintile ≤10 mg/L, and 1.97 (95% CI 1.64–2.36) for the subgroup with CRP &amp;gt;10 mg/L. CRP was related to recurrent CVD in patients with CAD (HR per 1 mg/L 1.08; 95% CI 1.04–1.11), as well as CeVD (HR 1.05; 95% CI 1.01–1.10), PAD (HR 1.08; 95% CI 1.03–1.13), and AAA (HR 1.08; 95% CI 1.01–1.15; p for interaction 0.815). The relation between CRP and all-cause mortality was stronger for patients with CAD (HR 1.13; 95% CI 1.09–1.16) compared to other locations (HRs 1.06–1.08; p=0.002). Conclusion Inflammation is an independent risk factor of recurrent CVD and mortality, irrespective of prior vascular disease location. Trials of anti-inflammatory drugs in patients with CeVD, PAD, and AAA are warranted. Funding Acknowledgement Type of funding sources: None.

Smoking cessation for secondary prevention of cardiovascular disease.

Smoking is a leading cause of cardiovascular disease (CVD), particularly coronary heart disease (CHD). However, quitting smoking may prevent secondary CVD events in people already diagnosed with CHD. OBJECTIVES: To examine the impact of smoking cessation on death from CVD and major adverse cardiovascular events (MACE), in people with incident CHD. We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the trials registries clinicaltrials.gov and the International Clinical Trials Registry Platform. We ran all searches from database inception to 15 April 2021. SELECTION CRITERIA: We included cohort studies, and both cluster- and individually randomised controlled trials of at least six months' duration. We treated all included studies as cohort studies and analysed them by smoking status at follow-up. Eligible studies had to recruit adults (> 18 years) with diagnosed CHD and who smoked tobacco at diagnosis, and assess whether they quit or continued smoking during the study. Studies had to measure at least one of our included outcomes with at least six months' follow-up. Our primary outcomes were death from CVD and MACE. Secondary outcomes included all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, new-onset angina and change in quality of life. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods for screening and data extraction. We assessed the risk of bias for the primary outcomes using the ROBINS-I tool. We compared the incidence of death from CVD and of MACE (primary outcomes) between participants who quit smoking versus those who continued to smoke for each included study that reported these outcomes. We also assessed differences in all-cause mortality, incidence of non-fatal myocardial infarction, incidence of non-fatal stroke and new onset angina. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI). For our outcome, change in quality of life, we calculated the pooled standardised mean difference (SMD) and 95% CI for the difference in change in quality of life from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using the I²statistic. We assessed the certainty of evidence for our primary outcomes using the eight GRADE considerations relevant to non-randomised studies. We included 68 studies, consisting of 80,702 participants. For both primary outcomes, smoking cessation was associated with a decreased risk compared with continuous smoking: CVD death (HR 0.61, 95% CI 0.49 to 0.75; I² = 62%; 18 studies, 17,982 participants; moderate-certainty evidence) and MACE (HR 0.57, 95% CI 0.45 to 0.71; I² = 84%; 15 studies, 20,290 participants; low-certainty evidence). These findings were robust to our planned sensitivity analyses. Through subgroup analysis, for example comparing adjusted versus non-adjusted estimates, we found no evidence of differences in the effect size. While there was substantial heterogeneity, this was primarily in magnitude rather than the direction of the effect estimates. Overall, we judged 11 (16%) studies to be at moderate risk of bias and 18 (26%) at serious risk, primarily due to possible confounding. There was also some evidence of funnel plot asymmetry for MACE outcomes. For these reasons, we rated our certainty in the estimates for CVD death as moderate and MACE as low. For our secondary outcomes, smoking cessation was associated with a decreased risk in all-cause mortality (HR 0.60, 95% CI 0.55 to 0.66; I² = 58%; 48 studies, 59,354 participants), non-fatal myocardial infarction (HR 0.64, 95% CI 0.58 to 0.72; I² = 2%; 24 studies, 23,264 participants) and non-fatal stroke (HR 0.70, 95% CI 0.53 to 0.90; I² = 0%; 9 studies, 11,352 participants). As only one study reported new onset of angina, we did not conduct meta-analysis, but this study reported a lower risk in people who stopped smoking. Quitting smoking was not associated with a worsening of quality of life and suggested improvement in quality of life, with the lower bound of the CI also consistent with no difference (SMD 0.12, 95% CI 0.01 to 0.24; I² = 48%; 8 studies, 3182 participants). AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that smoking cessation is associated with a reduction of approximately one-third in the risk of recurrent cardiovascular disease in people who stop smoking at diagnosis. This association may be causal, based on the link between smoking cessation and restoration of endothelial and platelet function, where dysfunction of both can result in increased likelihood of CVD events. Our results provide evidence that there is a decreased risk of secondary CVD events in those who quit smoking compared with those who continue, and that there is a suggested improvement in quality of life as a result of quitting smoking. Additional studies that account for confounding, such as use of secondary CVD prevention medication, would strengthen the evidence in this area.

Life's Simple 7 at Midlife and Risk of Recurrent Cardiovascular Disease and Mortality after Stroke: The ARIC study

BackgroundStroke is a leading cause of morbidity and mortality among adults in the U.S. Ideal levels of the Life's Simple 7 (LS7) are associated with lower cardiovascular disease (CVD) and all-cause mortality. However, the association of LS7 with CVD, recurrent stroke, and all-cause mortality after incident stroke is unknown. MethodsWe used data from the ARIC study, a cohort of 13,508 adults from four US communities, 45–64 years old at baseline (1987–1989). Cardiovascular hospitalizations and mortality were ascertained in follow-up through December 31st, 2017. We defined cardiovascular health (CVH) based on AHA definitions for LS7 (range 0-14) and categorized CVH into four levels: LS7 0-3, 4-6, 7-9, and ≥10 (ideal LS7), according to prior studies. Outcomes included incident stroke, CVD, recurrent stroke, all-cause mortality, and a composite outcome including all the above. Adjusted hazard ratios (95% CI) were estimated with Cox proportional hazards regression models. ResultsMedian (25%-75%) follow-up for incident stroke was 28 (18.6-29.2) years. Participants with incident stroke were 55.7 (SD 5.6) years-old at baseline, 53% were women and 35% Black. Individuals with LS7 score ≥10 had 65% lower risk (HR: 0.35; 95% CI: 0.29-0.41) of incident stroke than those with LS7 4-6 (reference group). Of 1,218 participants with incident stroke, 41.2% (n=502) had composite CVD and 68.3% (n=832) died during a median (25%-75%) follow-up of 4.0 (0.76-9.95) years. Adjusted HR (95% CI) for stroke survivors with LS7≥10 at baseline were 0.74 (0.58-0.94) for the composite outcome, 0.38(0.17-0.85) for myocardial infarction, 0.60 (0.40-0.90) for heart failure, 0.63 (0.48-0.84) for all-cause mortality, and 0.65 (0.39-1.08) for recurrent stroke. ConclusionsGood and excellent midlife cardiovascular health are associated with lower risks of incident stroke and CVD after stroke. Clinicians should stress the importance of a healthy lifestyle for primary and secondary CVD prevention.

Use of lipid-lowering therapy after ischaemic stroke and expected benefit from intensification of treatment

ObjectivesElevated low-density lipoprotein cholesterol (LDL-C) increases the risk of recurrent cardiovascular disease (CVD) events. We examined use of lipid-lowering therapy (LLT) following ischaemic stroke, and estimated benefits from guideline-based up-titration...

Genetic variants associated with low-density lipoprotein cholesterol and systolic blood pressure and the risk of recurrent cardiovascular disease in patients with established vascular disease

Background and aimsPolygenic risk scores (PRSs) can be used to quantify the effect of genetic contribution to LDL-cholesterol (LDL-C) and systolic blood pressure (SBP). Several PRSs for LDL-C and SBP have been shown to be associated with cardiovascular disease (CVD) in the general population. This study aimed to evaluate the effect of an LDL-C PRS and an SBP PRS on the risk of recurrent CVD in patients with CVD. MethodsGenotyping was performed in 4,416 patients included in the UCC-SMART study. Weighted LDL-C PRS (279 LDL-C-related SNPs) and SBP PRS (425 SBP-related SNPs) were calculated. Linear regression models were used to evaluate the relation between both PRSs and LDL-C and SBP. The effects of the LDL-C PRS and SBP PRS, and its combination on the risk of recurrent CVD (stroke, myocardial infarction, and vascular death) were analyzed with Cox proportional-hazard models. ResultsPer SD increase in LDL-C PRS, LDL-C increased by 0.18 mmol/L (95%CI 0.15–0.21). Per SD increase in SBP PRS, SBP increased by 3.19 mmHg (95%CI 2.60–3.78). During a follow-up of 11.7 years (IQR 9.2–15.0) 1,198 recurrent events occurred. Neither the LDL-C nor the SBP PRS were associated with recurrent CVD (HR 1.05 per SD increase in LDL-C PRS (95%CI 0.99–1.11) and HR 1.04 per SD increase in SBP PRS (95%CI 0.98–1.10)). The combination of both scores was neither associated with recurrent CVD (HR 1.09; 95%CI 0.93–1.28). ConclusionsIn patients with vascular disease, LDL-C PRS and SBP PRS, both separately and in combination, were not significantly associated with recurrent CVD.

Achieving lipid targets within 12 months of an acute coronary syndrome: an observational analysis.

To assess lipid levels in people six or 12 months after hospitalisation with acute coronary syndrome (ACS); to identify factors associated with not achieving lipid level targets. Retrospective cohort study; analysis of data from CONCORDANCE, an Australian ACS registry, 2009-2018. Adult patients who had experienced confirmed ACS of cardiovascular origin, for whom serum lipid levels had been assessed on admission and six or 12 months after discharge. Not achieving lipid targets by most recent follow-up (in order of priority: low-density lipoprotein cholesterol [LDL-C] ≤1.8mmol/L or total cholesterol ≤4mmol/L); factors associated with not achieving target lipid levels. Lipid levels measured at 6- or 12-month follow-up were available for 2671 of 10578 people discharged from hospital alive; 1194 (45%) had not achieved lipid targets at their most recent follow-up, including 876 (73%) who had been prescribed intensive lipid-lowering therapy at discharge. People under 65 years of age, those using lipid-lowering therapy or with higher cholesterol levels on admission, patients prescribed fewer than four evidence-based therapies or not prescribed intensive lipid-lowering therapy on discharge, and women were more likely to not reach lipid level targets. Almost half the patients did not achieve target lipid levels within 12 months of an admission to hospital with ACS. These people are at elevated risk of recurrent cardiovascular disease, and therapy could be optimised (eg, dose escalation, drug combinations, novel therapies) to improve outcomes.

Heart Failure and the Risk of Recurrent Cardiovascular Events in Patients Attending Outpatient Clinics in the United Arab Emirates.

Heart failure (HF) prognosticates a death sentence, and despite recent advances in treatment, long-term outcomes for patients with advanced HF are very poor, with only a 50%-60% survival rate at 5 years. This is alarming for the approximately 26 million people worldwide living with HF. This study aimed to investigate the relationship between HF and the risk of recurrent cardiovascular disease (CVD) events or CVD death among the national population in the United Arab Emirates (UAE). A retrospective study was conducted from April 2008 to September 2019 including 240 patients ≥18 years with a previous vascular event. Patient outcomes such as CVD death, the occurrence of a recurrent vascular event, or until the end of the study period, whichever occurred first. Twenty-three patients (9.6%) had a concomitant diagnosis of HF and this doubled the risk of recurrent CVD events or death over 9 years. HF, age, lower body mass index, and atrial fibrillation were significant predictors of recurrent CVD or mortality. The mean age was 65 years and the risk of a CVD event or death increased at a rate of 3% for every increasing year of age. Patients with HF have approximately a 65% likelihood of survival at 5 years, whereas those without HF have about an 85% at 5-year survival. HF is a strong predictor of recurrent CVD events or mortality in UAE patients with established CVD. Thus, aggressive management of modifiable risk factors for vascular disease through multidisciplinary teams guides clinicians toward meticulous control of CVD risk factors to improve disease prognosis and premature death.

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

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

Abstract 13852: Socioeconomic Status is Associated With Recurrent Cardiovascular Disease Events in People With Prevalent Cardiovascular Disease

Introduction: While low socioeconomic status (SES) is an established risk factor for incident cardiovascular disease (CVD), there is scarce data regarding the association between SES and recurrent CVD events. Hypothesis: SES measures are associated with recurrent CVD events and mortality among those with prevalent CVD. Methods: We examined 3,031 individuals in the ARIC Study who developed CVD (either myocardial infarction [MI], heart failure [HF] or stroke) from the baseline visit (1987-1989) through 2013 to allow 5 years follow-up for recurrent CVD. SES was defined using baseline measures of income, education and area deprivation index (ADI), modeled individually and combined in a cumulative SES score. We used adjusted Cox proportional hazard regression to evaluate the associations of SES with composite and individual outcomes of first recurrent CVD and mortality. Results: Median age was 69 years, 49% were female, 29% Black. Over a median follow up of 4.6 years, 2,033 participants (67%) had a recurrent CVD event, and 2,202 (73%) died. Relative to the highest income group, being in the lowest income group was associated with higher risk for recurrent CVD (HR 1.27; 95% CI: 1.07-1.51) and mortality (HR 1.32; 95% CI: 1.12-1.56) ( Table ). Similarly, less than high school education was associated with increased risk of recurrent CVD (HR 1.25; 95% CI: 1.04-1.51) and mortality (HR 1.21; 95% CI: 1.01-1.45). No significant outcome associations were seen for ADI. Low cumulative SES was associated with approximately 20% higher risk of recurrent CVD, total mortality and the composite of recurrent CVD and mortality. Similar patterns were seen for individual subtypes of CVD, with the strongest SES-mortality associations for MI and stroke. Conclusions: In the high-risk group of individuals with existing CVD, low SES was linked to greater likelihood of recurrent CVD events and death. SES should be a focus in the design of secondary prevention efforts to improve outcomes in CVD.

Use of Guideline-Directed Medical Therapy in Patients With ST-Elevation Myocardial Infarction.

IntroductionST-elevation myocardial infarction (STEMI) is a serious manifestation of coronary artery disease and remains a significant contributor to morbidity and mortality worldwide. To reduce the risk of recurrent cardiovascular disease (CVD) events, the American College of Cardiology (ACC) and American Heart Association (AHA) recommend the use of five classes of medications after acute coronary syndrome (ACS). The purpose of this study was to evaluate whether STEMI patients admitted to our community hospital were discharged on optimal medical therapy based on the latest AHA/ACC guidelines.MethodsA retrospective, single-center electronic medical records review was conducted at our community hospital between July 2017 and December 2018. Patients included in the study were admitted to our hospital through the emergency department as STEMI alerts. We reviewed the discharge prescriptions and assessed compliance with the medication regimen endorsed by AHA/ACC, which includes aspirin, P2Y12 inhibitors, β-blockers, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and statins.ResultsA total of 147 patients were included in our study. The mean age of our study population was 62 ± 12.48 years. 97.2% of all patients with STEMI underwent coronary angiography. Hypertension (65.9%) was the most common comorbidity followed by hyperlipidemia (54.42%), diabetes mellitus (29.25%), and history of coronary artery disease (CAD) (24.48%). Among patients with successful reperfusion, 87.4% of the patients received the combination of four guideline-directed medical therapy (GDMT) (comprising dual antiplatelet therapy, a β-blocker, and a statin) and 57% were discharged on five guideline-directed medical treatment (the combination of dual antiplatelet therapy, a β-blocker, an ACEIs or an ARB, and a statin).ConclusionOptimal secondary prevention medications are known to be effective in reducing the risk of repeat ischemic events in ACS. This study demonstrated that adherence to GDMT in our community-based hospital study is better compared to prior studies but remained suboptimal. Potential strategies to improve adherence to guidelines are necessary.

Abstract P256: Better Mid-life Life’S Simple 7 Status is Associated With Lower Risk of Recurrent Cardiovascular Disease and All-cause Mortality After Stroke: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Cardiovascular disease (CVD), including stroke, is a leading cause of morbidity and mortality. Ideal levels of the American Heart Association’s Life’s Simple 7 (LS7) metric are associated with lower stroke risk. However, the association between LS7 and recurrent CVD and mortality after incident stroke is unclear. Hypothesis: Stroke survivors with higher LS7 scores before incident stroke would have lower risk of recurrent CVD and mortality than those with lower scores. Methods: From 14715 individuals free of stroke at ARIC baseline (1987-1989), we analyzed data on 1380 participants who had an incident stroke between 1987-2017. A summary baseline LS7 score (range: 0-14) was derived by assigning 2 points for ideal, 1 point for intermediate, and 0 points for poor on each of the following: smoking, adiposity, physical activity, diet, total cholesterol, blood pressure and fasting glucose at baseline. We calculated adjusted hazard ratios (HR) for a composite and individual CVD outcomes of recurrent stroke, myocardial infarction, heart failure, and all-cause mortality after incident stroke, per a priori categories in baseline LS7 score. Results: At baseline, the mean age of participants with incident stroke was 55.7 ± 5.6 years (53% women, 36% black). Participants with the highest LS7 scores (≥10, n= 3287) had 66% lower risk (HR: 0.34, 95% CI: 0.29-0.40) of incident stroke than those with intermediate cardiovascular (CV) health (4-6, n=4166) ( Table ). During a median (SE) follow-up of 7.5 (0.45) years, 42.5% (587/1380) had recurrent composite CVD after incident stroke. LS7 score at baseline (before incident stroke) was inversely associated with recurrent CV outcomes (composite, myocardial infarction, heart failure) and all-cause mortality after incident stroke but not recurrent stroke (Table) . Conclusions: Better CV health in mid-life before incident stroke was associated with lower risk of recurrent CVD after stroke, suggesting that good CV health is essential for secondary prevention among stroke patients.

5131Unmet need for secondary prevention in individuals from the general population with increased lipoprotein(a): a contemporary population-based study

Abstract Background There is strong evidence linking high lipoprotein(a) (Lp(a)) to development of incident cardiovascular disease (CVD), but it is not clear whether Lp(a) is associated with risk of recurrent CVD events in individuals from the general population with preexisting CVD. This is of importance as the first drugs specifically aimed at lowering Lp(a) are currently in development, and these would likely be used primarily in individuals with established CVD for secondary prevention of recurrent CVD events. Purpose We tested the hypothesis that high concentrations of Lp(a) are associated with high risk of recurrent CVD in individuals from the general population with preexisting CVD. Methods From the Copenhagen General Population Study (CGPS) (2003–2015) of 58,527 individuals with measurements of Lp(a) at baseline, 2,527 aged 20–79 with a history of CVD were studied. The primary endpoint was major adverse cardiovascular event (MACE). We also studied 1,115 individuals with CVD at baseline from the Copenhagen City Heart Study (CCHS) (1991–1994) and the Copenhagen Ischemic Heart Disease Study (CIHDS) (1991–1993). Results During a median follow-up of 5 years (range: 0–13, 13,974 person-years), 493 individuals (20%) experienced a MACE in the CGPS. MACE incidence rates per 1,000 person-years were 29 (95% CI: 25–34) for individuals with Lp(a) &lt;10mg/dL (&lt;18nmol/L), 35 (30–41) for 10–49mg/dL (18–104nmol/L), 42 (34–51) for 50–99mg/dL (105–213nmol/L), and 54 (42–70) for ≥100mg/dL (≥214nmol/L) (see Figure). Compared to individuals with Lp(a) &lt;10mg/dL (&lt;18nmol/L), the MACE incidence rate ratios were 1.21 (0.98–1.50) for 10–49mg/dL (18–104nmol/L), 1.43 (1.12–1.82) for 50–99mg/dL (105–213nmol/L), and 1.85 (1.38–2.49) for ≥100mg/dL (≥214nmol/L). Independent confirmation was obtained in individuals from the CCHS and CIHDS with MACE incidence rates per 1,000 person-years of 94 (95 CI: 84–106) for individuals with Lp(a) &lt;10mg/dL (&lt;18nmol/L), 115 (103–129) for 10–49mg/dL (18–104nmol/L), 134 (115–156) for 50–99mg/dL (105–213nmol/L), and 140 (116–169) for ≥100mg/dL (≥214nmol/L). Conclusion High concentrations of Lp(a) are associated with high risk of recurrent CVD in individuals from the general population with preexisting CVD. This points to a possible unmet need for secondary prevention in individuals with increased Lp(a), and such individuals could be a target group for upcoming randomized cardiovascular outcome trials. Acknowledgement/Funding The Novo Nordisk Foundation, Herlev and Gentofte Hospital, Chief Physician Johan Boserup and Lise Boserup's Fund

EVALUATION OF MEDICATION PERSISTENCE IN THE IMPROVE-IT TRIAL

Cholesterol-lowering medications reduce the risk of recurrent cardiovascular disease, though medication discontinuation limits effectiveness. We evaluated medication persistence in the IMPROVE-IT trial: a long-term, placebo-controlled, randomized trial of simvastatin vs simvastatin/ezetimibe in

Association between CETP gene polymorphism, insulin resistance and risk of diabetes mellitus in patients with vascular disease

IntroductionGenetic inhibition of Cholesteryl Ester Transfer Protein (CETP) might be associated with insulin resistance and incident type 2 diabetes mellitus (T2DM). This study investigated the relation between a genetic variant in the CETP gene and measures of insulin resistance and incident T2DM in patients with manifest cardiovascular disease (CVD). Furthermore the effect on risk of recurrent cardiovascular events was investigated. MethodsSMART is a prospective cohort study performed in 5601 patients with clinically manifest CVD. We selected a variant (rs3764261) associated with reduced CETP activity and increased levels of HDL cholesterol (HDL-C). Patients were divided in three groups: 2640 wild type patients (GG), 2420 heterozygotes for rs3764261 (GT) and 541 homozygotes for rs3764261 (TT). Regression analyses were performed using an additive model. ResultsThe study population consisted of 4656 patients without T2DM and 945 patients with T2DM at baseline. Presence of rs3764261 was associated with increased HDL-C in patients without T2DM (β 0.106, 95%CI 0.083–0.128) and with T2DM (β 0.043, 95%CI 0.007–0.078). During a median follow up of 7.2 years (IQR 4.7–10.2) 427 incident T2DM occurred. Presence of rs3764261 was not related to incident T2DM (HR 0.96, 95%CI 0.83–1.11) in patients without T2DM at baseline. Furthermore, presence of rs3764261 was not related to insulin resistance (glucose, insulin, HOMA-IR, HbA1c) or recurrent CVD (HR 0.92, 95%CI 0.84–1.02). ConclusionPresence of CETP SNP rs3764261 is not associated with insulin resistance and incident T2DM in patients with clinically manifest vascular disease. Furthermore, no effect of rs3764261 on the risk of recurrent CVD was observed.

Homocysteine Lowering and Cardiovascular Events after Acute Myocardial Infarction

Homocysteine is a risk factor for cardiovascular disease. We evaluated the efficacy of homocysteine-lowering treatment with B vitamins for secondary prevention in patients who had had an acute myocardial infarction. The trial included 3749 men and women who had had an acute myocardial infarction within seven days before randomization. Patients were randomly assigned, in a two-by-two factorial design, to receive one of the following four daily treatments: 0.8 mg of folic acid, 0.4 mg of vitamin B12, and 40 mg of vitamin B6; 0.8 mg of folic acid and 0.4 mg of vitamin B12; 40 mg of vitamin B6; or placebo. The primary end point during a median follow-up of 40 months was a composite of recurrent myocardial infarction, stroke, and sudden death attributed to coronary artery disease. The mean total homocysteine level was lowered by 27 percent among patients given folic acid plus vitamin B12, but such treatment had no significant effect on the primary end point (risk ratio, 1.08; 95 percent confidence interval, 0.93 to 1.25; P=0.31). Also, treatment with vitamin B6 was not associated with any significant benefit with regard to the primary end point (relative risk of the primary end point, 1.14; 95 percent confidence interval, 0.98 to 1.32; P=0.09). In the group given folic acid, vitamin B12, and vitamin B6, there was a trend toward an increased risk (relative risk, 1.22; 95 percent confidence interval, 1.00 to 1.50; P=0.05). Treatment with B vitamins did not lower the risk of recurrent cardiovascular disease after acute myocardial infarction. A harmful effect from combined B vitamin treatment was suggested. Such treatment should therefore not be recommended. (ClinicalTrials.gov number, NCT00266487.).

Risk factors for cardiovascular event recurrence in the Atherosclerosis Risk in Communities (ARIC) study

Numerous studies have identified risk factors and markers associated with incidence of cardiovascular disease (CVD). However, few studies have examined whether established risk factors, novel blood markers, carotid ultrasonography, or ankle-brachial index can predict recurrent CVD events. We analyzed the relation of established risk factors and markers of atherosclerosis with the risk of recurrent CVD in 766 participants. Over a mean of 8.7 years of follow-up, 70 women and 243 men had a recurrent CVD event (85.3% coronary heart disease and 23.7% stroke). Adjusting for age and sex, this study found that established risk factors were associated with recurrent CVD events in the anticipated direction. Being in the highest (vs lowest) quartiles of lipoprotein (a), fibrinogen, white blood cells, and creatinine at baseline were associated with 47%, 69%, 65%, and 81%, respectively, greater risk of a CVD event, and being in the highest quartile of albumin was associated with 39% lower risk. Being in the highest (vs lowest) quartile of carotid intima-media thickness (IMT) was associated with a doubling of risk, and having carotid plaque with acoustic shadowing (vs having no plaque) was associated with 83% increased risk of a CVD event. After adjustment for established risk factors, creatinine, albumin, and carotid IMT in the highest quartile (vs lowest quartile) and carotid plaque with acoustic shadowing (vs no plaque) were independently associated with recurrent CVD events. Established risk factors, but only a few of novel risk factors and markers, were independent predictors of recurrent CVD events.