Risk Stratification In Primary Prevention Research Articles

Polygenic risk score: a new approach to cardiovascular prevention?

Long-lasting epidemiological studies showed that prevention of coronary artery disease (CAD) is highly feasible with the management of several conditions called "risk factors", such as hypertension, cholesterol, smoking, etc. Nevertheless, risk stratification for primary prevention using a statistical combination of risk factors is suboptimal, as conventional risk factors are age-dependent, so that their treatment would be too late to be effective. Genetic risk stratification, built on the genetic variants linked to CAD, has the advantage of being embedded in DNA and then it is independent of age. The rapid advancement of DNA analysis techniques has made it possible to identify many variants and to produce easily a statistical combination of them to obtain a polygenic risk score (PRS). Prospective clinical trials based on risk stratification for CAD using the PRS have shown that statin therapy is associated with a higher reduction in cardiac events in the high genetic risk group compared with the low genetic risk group. A wide clinical use of the PRS, however, is presently not possible, basically due to the lack of a standard in production and validation of the PRS, but genetic risk stratification has the potential to revolutionize primary prevention.

Trimethylamine-N-Oxide and Related Metabolites: Assessing Cardiovascular Risk in the Dallas Heart Study

ObjectiveTo evaluate the association between trimethylamine N-oxide (TMAO) and related metabolites with adverse cardiovascular events in a multiethnic urban primary prevention population. MethodsWe performed a case-control study of 361 participants of the Dallas Heart Study, including 88 participants with an incident atherosclerotic cardiovascular disease (ASCVD) event and 273 controls matched for age, sex, and body mass index without an ASCVD event during 12 years of follow-up (January 1, 2000, through December 31, 2015). Plasma levels of TMAO, choline, carnitine, betaine, and butyrobetaine were measured by mass spectrometry. The differential odds for incident ASCVD by metabolite levels between cases and controls were compared by a conditional logistic regression model adjusted for cardiovascular risk factors. ResultsParticipants with incident ASCVD had higher levels of TMAO and related metabolites compared with those without ASCVD (P<.05 for all). Those with plasma TMAO concentrations in quartile 4 had a more than 2-fold higher odds of ASCVD compared with those in quartile 1 (odds ratio, 2.77 [95% CI, 1.05 to 7.7; P=.04] for hard ASCVD and 2.41 [95% CI, 1.049 to 5.709; P=.04]). Similar trends were seen with the related metabolites choline, betaine, carnitine, and butyrobetaine. ConclusionOur results suggest that TMAO and related metabolites are independently associated with ASCVD events. Although further studies are needed, measurement of TMAO and related metabolites may have a role in ASCVD risk stratification for primary prevention.

Detection of gene mutation in the prognosis of a patient with arrhythmogenic right ventricular cardiomyopathy: a case report

BackgroundArrhythmogenic right ventricular cardiomyopathy (ARVC), or more recently known as arrhythmogenic cardiomyopathy (ACM), is an heritable disorder of the myocardium characterized by progressive fibrofatty replacement the heart muscle and risk of ventricular arrhythmias and sudden cardiac death (SCD). We report a case study to demonstrate the role of gene mutation detection in risk stratification for primary prevention of SCD in a young patient diagnosed with ARVC.Case presentationA 15-year-old Asian (Vietnamese) male patient with no history of documented tachyarrhythmia or syncope and a family history of potential SCD was admitted due to palpitations. Clinical findings and work-up including cardiac magnetic resonance imaging (MRI) were highly suggestive of ARVC. Gene sequencing was performed for SCD risk stratification, during which PKP2 gene mutation was found. Based on the individualized risk stratification, an ICD was implanted for primary prevention of SCD. At 6 months post ICD implantation, the device detected and successfully delivered an appropriate shock to terminate an episode of potentially fatal ventricular arrhythmia. ICD implantation was therefore proven to be appropriate in this patient.ConclusionsWhile gene mutations are known to be an important factor in the diagnosis of ARVC according to the 2010 Task Force Criteria and recent clinical guidelines, their role in risk stratification of SCD remains controversial. Our case demonstrated that when used with other clinical factors and family history, this information could be helpful in identifying appropriate indication for ICD implantation.

Prognostic change of adding coronary calcium score and genetic risk score to European SCORE2 in a moderate risk region

Abstract Introduction Cardiovascular disease is a public health issue remaining the leading cause of death worldwide. One of its main contributors is coronary artery disease (CAD), a complex multifactorial disease with the influence of hereditary and environmental factors. It’s crucial to improve cardiovascular risk assessment which is a real challenge in our daily clinical practice. SCORE 2 enhanced the identification of individuals at higher risk of developing CAD, but it remains scanty. Coronary Artery Calcification (CAC) score and Genetic contributions could improve CV risk stratification in primary prevention. Purpose Evaluate the impact of including CAC score and Genetic Risk Score (GRS) to the European SCORE2 in MACE prediction and cardiovascular risk stratification in our asymptomatic population. Methods 945 asymptomatic subjects (mean age 52.9±6.8 years, 74.0% male) selected from the prospective arm of the GENEMACOR study were followed up during 5.4±4.1 years. The population was categorized according to SCORE2 into three risk groups (low-intermediate &amp;lt;5%; high 5-10%; very high &amp;gt;10%). CAC score was performed by cardiac computed tomography and reported as Agatston units according to the Hoff Nomogram in low, moderate and high-risk categories. The GRS was created from 33 genetic variants associated with CAD by GWAS, choosing those with a hazard ratio (HR) higher than 1. Multivariable Cox proportional hazard ratios (HR) with 95% confidence intervals (95% CI) assessed the variables independently associated with CV events occurrence. We evaluated the discriminative ability of the Score2, CAC score and GRS using the Harrel C statistics. Results Cox regression analysis showed that the highest categories of SCORE2, CAC and GRS remained in the equation with an HR of 16.6 (p=0.008), HR of 3.6 (p=0.006) and HR of 3.2 (p=0.022), respectively, when compared with the lowest categories. C-statistic demonstrated that the predictive value for MACE was 0.671 for SCORE2, increased to 0.799 (p=0.002) when adding CAC score and improved to 0.808 (p=0.012) when adding mGRS (Table 1), showing a better discrimination capacity for MACE. Conclusions Our results highlight the importance of adding CAC score and GRS to SCORE2 in primary prevention to improve cardiovascular risk stratification and MACE prediction. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings.

Incremental value of ABI and CAC beyond traditional risk markers in long-term prediction of cardiovascular disease incidence in participants with diabetes and impaired fasting glucose: Multi-Ethnic Study of Atherosclerosis

Background and aimsSubclinical atherosclerosis (SA) diagnosis is key to primary prevention of atherosclerotic cardiovascular disease (ASCVD). SA is common among diabetics. Ankle brachial index (ABI) and coronary artery calcium (CAC) are markers of SA. This study examined whether adding ABI and CAC to diabetic individuals improved ASCVD risk prediction beyond established risk factors. MethodsMESA is an observational cohort of 6814 participants without clinical cardiovascular disease. All participants with diabetes and impaired fasting glucose were included in the analysis. The association between CAC, ABI, and incident ASCVD, and all-cause mortality was examined using Cox proportional hazard regression. The risk prediction models including ABI and/or CAC in addition to standard risk factors alone were compared. ResultsOf the 1719 participants, 55% were male and average age was 64 (±9.6) years old. Participants with diabetes or impaired fasting glucose with higher CAC and lower ABI had higher ASCVD and all-cause mortality. ABI and CAC enhanced ASCVD discrimination over standard risk factors, with C-index (95% CI) of 0.689 (0.66, 0.718) for risk factors alone, 0.696 (0.668, 0.724) for ABI, 0.719 (0.691, 0.747) for CAC, and 0.721 (0.693, 0.749) for CAC + ABI. Similarly, for all-cause mortality, both CAC and ABI improved risk discrimination in addition to standard risk factors alone. ConclusionsIn a large population-based study of individuals with diabetes or impaired fasting glucose, the addition of ABI and CAC to conventional risk factors improved 10-year ASCVD risk prediction. ABI and CAC are non-invasive and cost-effective tests; therefore, these markers should be included into ASCVD risk stratification for primary prevention in the diabetic and impaired fasting glucose population.

Cardiovascular risk stratification in primary prevention of non-communicable diseases

The Journal of the Ceylon College of Physicians (JCCP) is a peer-reviewed, open access journal published bi-annually by the Ceylon College of Physicians (CCP) in the last week of June and December.The objective of the Journal is to promote good clinical practice and influence policy making across the medical world through publication of original research and peer reviewed articles on current issues and to foster responsible and balanced debate on issues that affect medicine and health care in Sri Lanka. Contributions to the JCCP reflect its national and multidisciplinary readership and include current thinking across a range of medical specialties.

Abstract 12445: Association of Remnant Cholesterol With Incident Cardiovascular Disease Among Koreans: A National Population-Based Study

Aims: We sought to investigate the association of remnant cholesterol (remnant-C) and low-density lipoprotein cholesterol (LDL-C) levels with incident atherosclerotic cardiovascular disease (ASCVD) in various subgroups among Koreans. Methods: National Health Information Database, collated by Korean National Health Insurance System, was used for analysis. Among the individuals between 40 and 70 years of age and without history of cerebro-cardiovascular disease, those who had twice or more health screenings between 2009 and 2011 were selected. All subjects were divided into 4 groups by LDL-C level of 3.4 mmol/L (130mg/dL) and remnant-C level of 0.8mmol/L (30mg/dL). The primary outcome was defined as the incidence of ASCVD. Results: 3,686,034 individuals (45.6% women) fulfilled the study requirements. By the end of 2017, 144,004 ASCVD events occurred. High remnant-C and low LDL-C group was 19% of total. Compared with low remnant-C and low LDL-C group, the high remnant-C and high LDL-C group had highest ASCVD risk (HR 1.266, CI 1.243-1.289) and the high remnant-C alone group (HR 1.102, CI 1.087-1.118) had similar ASCVD risk to the high LDL-C alone group (HR 1.098, CI 1.083-1.113). The association of high remnant-C (≥0.8 mmol/L) with an increased ASCVD risk was consistent across various strata. Remnant-C levels remained significantly to associate with ASCVD after adjustment for several confounders, including LDL-C levels. Conclusions: Elevated remnant-C values, apart from LDL-C levels, were independently associated with a risk of incident ASCVD. Combination of high LDL-C and high remnant-C levels better predicted ASCVD incidence than each one alone. Therefore, we might take into account remnant-C measurement in risk stratification for primary prevention of ASCVD.

Prognostic role of adding a genetic risk score to the new European SCORE2 in a cardiovascular events prediction, in a moderate-risk region

Abstract Introduction The new SCORE2 provides risk estimates for the combined outcome of fatal and non-fatal cardiovascular disease (CVD) events, in contrast with SCORE's use for CVD mortality only. Genetic predisposition to CVD is not considered in SCORE2 for prevention and treatment. Purpose Evaluate the impact of adding a Genetic Risk Score (GRS) to the new European SCORE2 in MACE prediction and estimate the additional value in cardiovascular risk stratification in an asymptomatic Portuguese population. Methods A prospective study was performed in a population-based cohort of 1,100 individuals without known CVD and diabetes (mean age 53.3±6.9 years). For all included participants, SCORE2 was calculated and three risk categories were considered: low-, moderate- and high-risk. A 33-SNP GRS was constructed and two groups were analyzed: lower and higher than the GRS median. Kaplan-Meier survival curves were created and a Cox regression model was performed with the two scores to assess MACE risk. C-statistic methodology compared the model between SCORE2 solely and SCORE2 plus GRS. Results After Kaplan-Meier analysis for MACE occurrence, the high categories of SCORE 2 and GRS showed worst survival when compared to the lower categories (p&amp;lt;0.0001). Cox regression presented an HR of 8.528 (p=0.001) for high-risk SCORE2 and an HR of 4.520 (p&amp;lt;0.0001) for GRS higher than the median. C-statistic demonstrated that the SCORE2 predictive value was 0.678, increasing to 0.792 when GRS was included (p=0.0005). Conclusions In this work, combining SCORE2 with multiple genetic loci gathered into a GRS, improved the identification of patients with the worst prognosis. This new tool may be of great utility in risk stratification in primary prevention. Larger prospective multicenter cohorts with longer follow-up should reproduce and validate these findings. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): SESARAM EPERAM

Targeted Plasma Proteomics to Predict the Development of Carotid Plaques.

Cardiovascular risk stratification in primary prevention is a clinical challenge. We recently identified a large set of circulating proteins improving the risk prediction for cardiovascular events. We now evaluate which of these proteins predicts the development of subclinical carotid atherosclerosis (SCA) in primary cardiovascular prevention. Three hundred sixty-eight proteins were quantified, by proximity extension assay, from the plasma collected at basal visit from 586 subjects without previous cardiovascular events and without preclinical atherosclerosis. These subjects were reevaluated 11 years after median follow-up (10-12) in a longitudinal observational analysis, to assess the development of SCA, defined as the formation of focal lesion in any carotid tract and detected by carotid ultrasound at basal visit and after follow-up. Common carotid (intima-media thickness [IMT]) was also measured by ultrasound during the same follow-up to identify subjects with faster common carotid intima-media thickness (IMT) progression (increase IMT)>1.3 mm in the common carotid tract). The variation of 68 proteins predicted SCA development and, among them, higher levels of PIgR2 (polymeric immunoglobulin receptor), chemokine (C-C motif) ligand 18, CA1 (carbonic anhydrase 1), Fc gamma receptor IIa and reduced MMP10 (matrix metallopeptidase 10), GT (gastrotropin), IL7R (interleukin 7 receptor) were the most predictive for SCA development. These 7 proteins improved the sensitivity and the specificity for SCA development versus risk factors (age, sex, overweight, hypertension, low HDL-cholesterol, high triglyceride); area under the curve: 0.747 ([0.707-0.784] versus 0.620 [0.577-0.663]; P<0.001). Vice versa, 25 proteins (not in common with the previous 68) predicted faster common carotid IMT progression. Among them, increased IL7D (interleukin 7), chemokine (C-X-C motif) ligand 1, and reduced TNFS13B (TNF superfamily member 13b) significantly increased the sensitivity and the specificity to predict faster common carotid IMT progression as compared with same risk factors (area under the curve: 0.719 [0.680-0.756] versus 0.569 [0.527-0.610]; P<0.001). A new set of circulating proteins have been identified that may be considered as markers of preclinical atherosclerosis development. The difference of the protein identified to predict SCA versus IMT progression may reflect different etiological factors.

Abstract 9703: Prevalence and Outcomes of Low Ankle Brachial Index in ASCVD Risk Categories- from the National Health and Nutrition Examination Survey

Introduction: The utility of Ankle Brachial Index(ABI) as a risk-enhancer to the pooled cohort equations(PCE) in assessing cardiovascular risk for primary prevention of atherosclerotic cardiovascular disease(ASCVD) is uncertain. We aim to assess the prevalence and all-cause mortality of people with low ABI across ASCVD risk categories. Hypothesis: Would the addition of ABI to standard ASCVD risk assessment improve all cause mortality risk stratification? Methods: Participants were recruited as part of the National Health and Nutrition Examination Survey from 1999-2004 and mortality assessed on 12/31/2015. We included participants aged 40-75years with ABI values≤1.3 and data for ASCVD computation using the PCE. Persons with ABI&lt;0.9 and ABI 0.9-1.3 were classified as having low ABI and normal ABI, respectively. Results: The mean follow-up time was 156months(95%CI 154-158). Persons with low ABI were older(61 Vs 53years) and had higher mean systolic blood pressure(135 Vs 126mmHg). There was no difference in mean total cholesterol(mg/dl)[212(95%CI 210-214) vs. 208( 202-215)], LDL(mg/dl) [128 (95%CI 125-130) vs. 121(112-129)] and HDL(mg/dl) [54 (95%CI 53-54) vs. 52(50-55)] between the two ABI categories. The all-cause mortality was higher among persons with low ABI(43.1%) compared to those with normal ABI(12.2%), p&lt;0.001. The all-cause mortality in the normal ABI and low ABI categories was 4.8% and 8.8% in the low risk ASCVD group and 7.8% and 41.6% in the borderline/intermediate ASCVD risk group, respectively. Conclusions: Approximately 67% of participants with low ABI were classified as low, borderline or intermediate risk by PCE. Low ABI was associated with increased all-cause mortality in the intermediate/borderline and high ASCVD risk categories but not in the low ASCVD risk category. Our study supports the use of ABI in risk stratification for primary prevention of ASCVD in individuals with borderline or intermediate risk.

Comparison between a genetic risk score and the European SCORE in cardiovascular events prediction in a primary prevention population

Abstract Background The risk for Coronary Artery Disease (CAD) can be estimated using different scores, such as the European SCORE (Systematic Coronary Risk Evaluation) scale or genetic risk score (GRS). The addition of GRS to the European SCORE may increase the precision of predicting MACE (Major Adverse Cardiovascular Events). Purpose This study aims to compare the European SCORE and the multiplicative genetic risk score (mGRS) in predicting MACE. Methods and results The study included 1110 asymptomatic individuals without known CAD from GENEMACOR prospective registry. We defined the primary endpoint of all-cause cardiovascular events. The study population had mean age of 51.6 years, 74.1% male and had risk factors of diabetes (11.6%), dyslipidemia (67.5%), hypertension (48.1%) and smoking (22.9%). Using C-index methodology, mGRS score was superior to SCORE in predicting MACE (mGRS = 0.832 Vs SCORE = 0.615; p=0.014). Conclusions The mGRS score was superior to SCORE in predicting MACE in an asymptomatic and free of CAD population. Genetic information may improve cardiovascular risk stratification in primary prevention. Funding Acknowledgement Type of funding sources: None.

Left ventricular hypertrophy and sudden cardiac death

Sudden cardiac death (SCD) is among the leading causes of death worldwide, and it remains a public health problem, as it involves young subjects. Current guideline-directed risk stratification for primary prevention is largely based on left ventricular (LV) ejection fraction (LVEF), and preventive strategies such as implantation of a cardiac defibrillator (ICD) are justified only for documented low LVEF (i.e., ≤ 35%). Unfortunately, only a small percentage of primary prevention ICDs, implanted on the basis of a low LVEF, will deliver life-saving therapies on an annual basis. On the other hand, the vast majority of patients that experience SCD have LVEF > 35%, which is clamoring for better understanding of the underlying mechanisms. It is mandatory that additional variables be considered, both independently and in combination with the EF, to improve SCD risk prediction. LV hypertrophy (LVH) is a strong independent risk factor for SCD regardless of the etiology and the severity of symptoms. Concentric and eccentric LV hypertrophy, and even earlier concentric remodeling without hypertrophy, are all associated with increased risk of SCD. In this paper, we summarize the physiology and physiopathology of LVH, review the epidemiological evidence supporting the association between LVH and SCD, briefly discuss the mechanisms linking LVH with SCD, and emphasize the need to evaluate LV geometry as a potential risk stratification tool regardless of the LVEF.

The Indices of Cardiovascular Magnetic Resonance Derived Atrial Dynamics May Improve the Contemporary Risk Stratification Algorithms in Children with Hypertrophic Cardiomyopathy.

Introduction: The most efficient risk stratification algorithms are expected to deliver robust and indefectible identification of high-risk children with hypertrophic cardiomyopathy (HCM). Here we compare algorithms for risk stratification in primary prevention in HCM children and investigate whether novel indices of biatrial performance improve these algorithms. Methods and Results: The endpoints were defined as sudden cardiac death, resuscitated cardiac arrest, or appropriate implantable cardioverter-defibrillator discharge. We examined the prognostic utility of classic American College of Cardiology/American Heart Association (ACC/AHA) risk factors, the novel HCM Risk-Kids score and the combination of these with indices of biatrial dynamics. The study consisted of 55 HCM children (mean age 12.5 ± 4.6 years, 69.1% males); seven had endpoints (four deaths, three appropriate ICD discharges). A strong trend (DeLong p = 0.08) was observed towards better endpoint identification performance of the HCM Risk-Kids Model compared to the ACC/AHA strategy. Adding the atrial conduit function component significantly improved the prediction capabilities of the AHA/ACC Model (DeLong p = 0.01) and HCM Risk-Kids algorithm (DeLong p = 0.04). Conclusions: The new HCM Risk-Kids individualised algorithm and score was capable of identifying high-risk children with very good accuracy. The inclusion of one of the atrial dynamic indices improved both risk stratification strategies.

Should Lipoprotein(a) be Measured in Youth?

Should Lipoprotein(a) be Measured in Youth?

Cardiovascular risk scoring and magnetic resonance imaging detected subclinical cerebrovascular disease.

Aims Cardiovascular risk factors are used for risk stratification in primary prevention. We sought to determine if simple cardiac risk scores are associated with magnetic resonance imaging (MRI)-detected subclinical cerebrovascular disease including carotid wall volume (CWV), carotid intraplaque haemorrhage (IPH), and silent brain infarction (SBI).Methods and resultsA total of 7594 adults with no history of cardiovascular disease (CVD) underwent risk factor assessment and a non-contrast enhanced MRI of the carotid arteries and brain using a standardized protocol in a population-based cohort recruited between 2014 and 2018. The non-lab-based INTERHEART risk score (IHRS) was calculated in all participants; the Framingham Risk Score was calculated in a subset who provided blood samples (n = 3889). The association between these risk scores and MRI measures of CWV, carotid IPH, and SBI was determined. The mean age of the cohort was 58 (8.9) years, 55% were women. Each 5-point increase (∼1 SD) in the IHRS was associated with a 9 mm3 increase in CWV, adjusted for sex (P < 0.0001), a 23% increase in IPH [95% confidence interval (CI) 9–38%], and a 32% (95% CI 20–45%) increase in SBI. These associations were consistent for lacunar and non-lacunar brain infarction. The Framingham Risk Score was also significantly associated with CWV, IPH, and SBI. CWV was additive and independent to the risk scores in its association with IPH and SBI.Conclusion Simple cardiovascular risk scores are significantly associated with the presence of MRI-detected subclinical cerebrovascular disease, including CWV, IPH, and SBI in an adult population without known clinical CVD.

GENECHOC study: A study designed to identify the genetic variants involved in appropriate shock in primary prevention. Clinical description of the patients

Arrhythmic risk stratification for primary prevention in patients with severe cardiomyopathy (CM) remains difficult. We established a large database of patients implanted for primary prevention with the aim to identify genetic modifiers involved in the occurrence of arrhythmic events. We described the clinical characteristics of patients included in the study. Patients were included in 22 French centers over a 9 year-period. Only patients implanted for primary prevention (no previous arrhythmias at the time of implantation in patients who had an EF less than 35%). Patients implanted with a resynchronization therapy were not included in the study. 1079 patients were enrolled (mean age 59 ± 11, 86.3% male). Ischemic CM was found in 77.1% and 20.5% had a non-ischemic CM. The mean EF was 27 ± 7%. The population was well treated with beta-blockers treatment in 89.9% and angiotensin converting enzyme inhibitors in 90.7%. VVI ICD was implanted in 721 patients (67%) and DDD ICD in 357 (33%). After a mean follow-up of 5.5 ± 2.5 years appropriate ICD therapy occurred in 388 (35.9%) patients. Predictive factors for appropriate therapy were male gender (38.2% in male vs. 21.6% in women, P = 9.10 −5 ). There was no significant difference for EF, 27.2 ± 5.3 in patients without ICD therapy vs. 26.8 ± 5 in patients with ICD therapy. The etiology of CM (ischemic vs. non ischemic) didn’t change the rate of appropriate therapy (respectively 34.9% vs. 37.7%, P = 0.4). 61 patients (5.6%) received inappropriate therapies mainly because of supraventricular tachycardia ( n = 24, 39.3%), T wave oversensing ( n = 11, 18%) and lead failure ( n = 14, 22.9%). Our population is similar in term of arrhythmic risk and clinical presentation to the usual population implanted for primary prevention. As for the first time this population is homogenous in term of geographic origin, it will allow using a GWAS analysis to identify genetic modifiers involved in SCD.

What imaging techniques should be used in primary versus secondary prevention for further risk stratification?

Background and aimsAn accurate assessment of the cardiovascular (CV) risk of an individual is key for guiding the appropriate treatment strategy for cardiovascular disease (CVD). Although conventional risk factors for CVD are well established, there can be substantial variation in the extent of atherosclerosis between patients. The use of a variety of imaging modalities can be beneficial in the primary prevention stage and in the classification of an individual's CV risk. Therefore, appropriate implementation of these imaging techniques for risk assessment purposes, in line with clinical guidelines, can influence the outcomes of CVD prevention. MethodsThe expert working group collaborated to review current invasive and non-invasive imaging techniques available to healthcare practitioners and how they can be used in the measurement of preclinical vascular damage and CV risk assessment. ResultsAfter evaluation of the current guideline recommendations and clinical data available, the expert working group collaborated to produce recommendations regarding the use of imaging in the risk stratification in primary prevention, CV risk in peri-acute coronary syndrome and CV risk assessment in secondary prevention. ConclusionsOverall, a variety of both invasive and non-invasive imaging modalities were highlighted by the expert working group as having the potential to assist in the risk assessments of patients at risk of CVD. These imaging techniques can be utilised in both primary and secondary prevention strategies and have the potential to be important risk modifiers, improving the outcome of CV risk assessment.

Optimal method of measuring the T-peak to T-end interval for risk stratification in primary prevention

Several published investigations demonstrated that a longer T-peak to T-end interval (Tpe) implies increased risk for ventricular tachyarrhythmia (VT/VF) and mortality. Tpe has been measured using diverse methods. We aimed to determine the optimal Tpe measurement method for screening purposes. We evaluated 305 patients with LVEF ≤ 35% and an implantable cardioverter-defibrillator implanted for primary prevention. Tpe was measured using seven different methods described in the literature, including six manual methods and the automated algorithm '12SL', and was corrected for heart rate. Endpoints were VT/VF and death. To account for differences in the magnitude of Tpe measurements, results are expressed in standard deviation (SD) increments. We evaluated the clinical utility of each measurement method based on predictive ability, fraction of immeasurable tracings, and intra- and interobserver correlation. >Over 31 ± 23 months, 82 (27%) patients had VT/VF, and over 49 ± 21 months, 91 (30%) died. Several rate-corrected Tpe measurement methods predicted VT/VF (HR per SD 1.20-1.34; all P < 0.05), and nearly all methods (both corrected and uncorrected) predicted death (HR per SD 1.19-1.35; all P < 0.05). Optimal predictive ability, readability, and correlation were found in the automated 12SL method and the manual tangent method in lead V2. For the prediction of VT/VF, the utility of Tpe depends upon the measurement method, but for the prediction of mortality, most published Tpe measurement methods are similarly predictive. Heart rate correction improves predictive ability. The automated 12SL method performs as well as any manual measurement, and among manual methods, lead V2 is most useful.

Biomarkers for risk stratification in secondary cardiovascular prevention. A role of red blood cell distribution width and calcium score

BackgroundPatients with coronary artery disease (CAD) are considered as high risk in terms of secondary cardiovascular prevention. However, obviously the risk is not homogenous across the whole group. Red blood cell distribution width (RDW) has been recently related to adverse outcomes in patients with atherosclerosis. Calcium score (CaS) may be used for risk stratification in primary prevention. The value of these biomarkers for prediction of cardiovascular outcomes in patients with CAD is unknown. MethodsThe study group comprised 269 consecutive patients with significant stable CAD. The primary endpoint was a composite of death or nonfatal myocardial infarction. ResultsMedian post-discharge follow up was 43.2 months (IQR39.2–48.6). The primary outcome was observed in 27 patients including 13 deaths and 14 nonfatal myocardial infarction. According to ROC analysis the best cut-off value for RDW for prediction of the primary event was 14% [(AUC) = 0.69; 95%CI:0.63–0.75; p = 0.0002] and for CaS was 603 [(AUC) = 0.66; 95%CI:0.60–0.72; p = 0.001]. According to multivariable Cox regression analysis both RDW>14% (HR 2.6; 95%CI:1.1–5.9) and CaS>603 (HR 2.3; 95%CI:1.1–5.1) were independently correlated to the primary outcome. Subsequently, patients were categorized into three risk subgroups: LOW: CaS≤603 and RDW≤14–124(46.1%), MID: either CaS>603 or RDW>14–104(38.7%), and HIGH - CaS>603 and RDW>14–41(15.2%) patients. The respective risk of events according to Kaplan–Meier analysis were 4.03%, 9.62%, and 29.27% (p < 0.0001). ConclusionsRDW and calcium score may be predictors of future cardiovascular events in patients with significant CAD. They may be useful tools for risk stratification and may indicate patients suitable for more aggressive secondary prevention measures.

Risk Stratification for Primary Prevention of Coronary Artery Disease: Roles of C-Reactive Protein and Coronary Artery Calcium.

Risk stratification of individuals at risk for atherosclerotic cardiovascular disease (ASCVD) plays an important role in primary prevention of cardiovascular disease. In addition to risk scores derived from conventional cardiovascular risk factors, high sensitivity C-reactive protein (hs-CRP) and coronary artery calcium (CAC) have emerged as two of the widely accepted non traditional risk factors for atherosclerotic disease that have shown incremental prognostic value in predicting cardiovascular events. This review systematically assesses the role of hs-CRP and CAC in various studies and demonstrates meta-analyses of the incremental prognostic value of hs-CRP and CAC in identifying patients at risk of future CVD events. Compared with this, CAC showed better incremental prognostic value and might be a better indicator of ASCVD risk in asymptomatic adults.