SMART Risk Score Research Articles

Adjustment of the SMART risk score by bioactive adrenomedullin enables a more accurate prediction of mortality in patients with ASCVD

Abstract Background Bioactive adrenomedullin 1-52 (bio-ADM) is a dynamic blood biomarker for real-time assessment of endothelial function. Bio-ADM was recently shown to be a prognostic marker in patients with acute heart failure and cardiogenic shock. The SMART (Second Manifestations of Arterial Disease) score is a validated tool for risk assessment in patients with established atherosclerotic cardiovascular disease (ASCVD). The aim of this study was to assess whether measurement of bio-ADM adds incremental value to the SMART score in stable patients with ASCVD. Methods Circulating bio-ADM levels were assessed in n=695 stable patients with ASCVD in an all-comer cohort. Endpoints evaluated were all-cause mortality and cardiovascular mortality; follow up was 3 years. Results Bio-ADM was higher in non-survivors (all-cause death: n=54, median 33.1 pg/mL) compared to survivors (n=641, median 17.9 pg/mL; p<0.0001). Univariable Cox regression analyses showed bio-ADM to be associated with adverse outcome [standardized hazard ratio (HR) of bio-ADM values: All-cause death: 2.4, 95% confidence interval (CI): 2.0-2.9; p<0.001, cardiovascular death: 2.5, 95% CI: 1.9-3.3; p<0.001]. This association remained significant in various multivariable Cox regression models. Bio-ADM was found to be a strong marker for mortality (c-index: 0.80, Chi²: 54.1) and proved to be superior to other markers including hs-Troponin T (c-index: 0.61, Chi²: 2.0) and eGFR CKD-EPI 2021 (c-index: 0.687, Chi²: 33.5). Addition of bio-ADM to the SMART score significantly improved model performance in predicting mortality (SMART score: c-index: 0.717, Chi²: 24.73; SMART score + bio-ADM: c-index: 0.832, Chi²: 63.24; Delta c-index: 0.115; Delta Chi²: 38.51; all p<0.001) and showed net reclassification improvement in risk categorization with 11.6% in the group of survivors and 9.8% for non-survivors. Conclusion Bio-ADM provides incremental added value (improved discrimination, calibration and reclassification) on top of the SMART risk score in patients with ASCVD.

Abstract 13028: Estimating Cardiovascular Event Rates in US Veterans Using the SMART Risk Score

Background: There is limited data on racial differences in long term cardiovascular (CV) outcomes amongst U.S. veterans. Methods: Utilizing the VA Informatics and Computing Infrastructure and the Corporate Data Warehouse we compared 10-year predicted major adverse CV events [MACE, a composite of all-cause death and non-fatal myocardial infarction] in patients referred for cardiovascular consultation between 2003 and 2009 using the SMART risk score with observed rates across racial groups. The SMART risk score classified patients into low 0-9.9%, intermediate 10-19.9%, high 20-29.9%, and very high >=30% risk groups. Results: 473,136 patients including white (74.7%), African American (15.5%), and other (9.8%) made the study cohort. Observed event rates were significantly higher in African Americans compared with Whites across all SMART risk groups [p<0.001], and highest in the other races, inclusive of Hispanics. These results are depicted in Figure 1 . Conclusion: There is a significantly higher observed 10-year MACE rate in African American veterans compared with their white counterparts across all predicted SMART risk score groups.

The predictive value of the smart risk score in patients referred for coronary angiography

The predictive value of the smart risk score in patients referred for coronary angiography

Excess Mortality for Abdominal Aortic Aneurysms and the Potential of Strict Implementation of Cardiovascular Risk Management: A Multifaceted Study Integrating Meta-Analysis, National Registry, and PHAST and TEDY Trial Data

Previous studies imply a profound residual mortality risk following successful abdominal aorta aneurysm (AAA) repair. This excess mortality is generally attributed to increased cardiovascular risk. The aim of this study was (1) to quantify the excess residual mortality for patients with AAA, (2) to evaluate the cross sectional level of cardiovascular risk management, and (3) to estimate the potential of optimised cardiovascular risk management to reduce the excess mortality in these patients. Excess mortality was estimated through a systematic review and meta-analysis, and through data from the Swedish National Health Registry. Cardiovascular risk profiles were individually assessed during eligibility screening of patients with AAA for two multicentre pharmaceutical AAA stabilisation trials. The potential of full implementation of cardiovascular risk management was estimated through the validated Second Manifestations of ARTerial disease (SMART) risk scores algorithm. The meta-analysis showed a similarly impaired survival for patients who received early repair (small AAA) or regular repair (≥ 55 mm), and a further impaired survival for patients under surveillance for a small AAA. Excess mortality was further quantified using Swedish population data. The data revealed a more than quadrupled and doubled five year mortality rate for women and men who had their AAA repaired, respectively. Evaluation of the level of risk management of 358 patients under surveillance in 16 Dutch hospitals showed that the majority of patients with AAA did not meet therapeutic targets set for risk management in high risk populations, and indicated a more pronounced prevention gap in women. Application of the SMART risk score algorithm predicted that optimal implementation of risk management guidelines would reduce the 10 year risk of major adverse cardiovascular events from 43% to 14%. Independent of the rupture risk, AAA is associated with a worryingly compromised life expectancy with a particularly poor prognosis for women. Optimal implementation of cardiovascular risk prevention guidelines is predicted to profoundly reduce cardiovascular risk.

Long-term prognostic value of vasodilator stress cardiac magnetic resonance in patients with atrial fibrillation.

AimsAlthough the prevalence of coronary artery disease (CAD) is high among patients with atrial fibrillation (AF), studies on stress perfusion cardiac magnetic resonance (CMR) imaging frequently exclude patients with AF, and its prognostic and diagnostic value in high‐risk patients with suspected or known CAD remains unclear.Methods and resultsIn this longitudinal cohort study, we included 164 consecutive patients with AF during vasodilator perfusion CMR. Diagnostic value was evaluated regarding invasive coronary angiography in a subset of patients. We targeted a follow‐up of >5 years and used CMR results as stratification, and the primary outcome was major adverse cardiac events [MACE, cardiovascular (CV) death and myocardial infarction (MI)]. Secondary outcomes included late coronary revascularization or stroke and the components of the primary outcome. Of the whole cohort (73.8% male, mean age 72.2 years ± 7.8 SD), 99.4% were successfully scanned (163/164 patients). Median CHA2DS2‐VASc score was 4 [interquartile range (IQR) 3–5], and median 10‐year risk for CV events based on SMART risk score was high (24%, IQR 16–32%). Thirty‐two patients (19.6%) presented with ischaemia and 52 patients (31.9%) with late gadolinium enhancement (LGE). A combination of LGE and inducible ischaemia was present in 20 patients (12.3%). Diagnostic accuracy was 86.2% [confidence interval (CI) 68.3–96.1%]. The median follow‐up was 6.6 years (IQR 3.6–7.8). Ischaemia in vasodilator perfusion CMR was significantly associated with the occurrence of MACE [P < 0.01; hazard ratio (HR) 2.65, CI 1.39–5.08], as well as LGE (P = 0.03; 1.74, CI 1.07–3.64) and the combination of both (P < 0.01; HR 2.67, CI 1.59–5.62). After adjustment by age, left ventricular ejection fraction, and the presence of diabetes, ischaemia in vasodilator perfusion CMR remained significantly associated with the occurrence of MACE (2.10, CI 1.08–4.10; P = 0.03). In secondary endpoint analysis, there was a significant association of ischaemia in CMR with CV death (P < 0.05; HR 1.93, CI 0.95–3.9) and MI (P < 0.01; HR 13, CI 1.35–125.4), while no significant association was found regarding the occurrence of revascularization (P = 0.45; HR 1.43, CI 0.57–3.58) or stroke (P = 0.99; HR 0.99, CI 0.21–2.59).ConclusionsVasodilator stress perfusion CMR demonstrated an excellent diagnostic and significant prognostic value at long‐term follow‐up in high‐risk patients with persistent AF and suspected or known CAD.

Risk for recurrent cardiovascular events and expected risk reduction with optimal treatment one year after an acute coronary syndrome

Abstract Background According to the latest ESC Guidelines for chronic coronary syndromes (CCS), patients who suffered an acute coronary syndrome (ACS) pass to a chronic stable phase after one year. In these patients the estimated 10-year risk for recurrent cardiovascular (CV) events varies considerably. We estimated this risk and the expected risk reduction after optimal control. Methods We applied the SMART risk score in 211 patients one year after an ACS to estimate the 10-year risk for recurrent CV events (subsequent non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death). We assessed the distribution of the estimated risk and the potential risk reduction that might be achieved with an optimal guideline-directed management of modifiable risk factors (systolic blood pressure, low-density lipoprotein cholesterol, smoking and body mass index). Results In our cohort, the median SMART score was 16% [interquartile range (IQR), 9.5–26]. If all modifiable risk factors met guideline-recommended targets, median SMART risk score would be 9.4% (IQR, 5.9–17.1), with 52% of the patients at a 10-year risk &amp;lt;10%, while 10% and 11% at 20–30% and &amp;gt;30% risk respectively. The total median reducible risk was 4.7% (IQR, 1.7–8.8). Conclusions The SMART score had a wide distribution among patients with CCS. Noteworthy, one out of five patients will remain at a &amp;gt;20% 10-year risk, even with optimal risk factors management, clearly underlining that residual risk is an unmet clinical issue, which demands individualized patient care. Baseline and total residual risk score Funding Acknowledgement Type of funding source: None

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

DA VINCI study: Change in approach to cholesterol management will be needed to reduce the implementation gap between guidelines and clinical practice in Europe

Predicting 10-year risk of recurrent cardiovascular events andcardiovascular interventions in patients with established cardiovascular disease: results from UCC-SMART and REACH

BackgroundExisting cardiovascular risk scores for patients with established cardiovascular disease (CVD) estimate residual risk of recurrent major cardiovascular events (MACE). The aim of the current study is to develop and externally validate a prediction model to estimate the 10-year combined risk of recurrent MACE and cardiovascular interventions (MACE+) in patients with established CVD. MethodsData of patients with established CVD from the UCC-SMART cohort (N = 8421) were used for model development, and patient data from REACH Western Europe (N = 14,528) and REACH North America (N = 19,495) for model validation. Predictors were selected based on the existing SMART risk score. A Fine and Gray competing risk-adjusted 10-year risk model was developed for the combined outcome MACE+. The model was validated in all patients and in strata of coronary heart disease (CHD), cerebrovascular disease (CeVD), peripheral artery disease (PAD). ResultsExternal calibration for 2-year risk in REACH Western Europe and REACH North America was good, c-statistics were moderate: 0.60 and 0.58, respectively. In strata of CVD at baseline good external calibration was observed in patients with CHD and CeVD, however, poor calibration was seen in patients with PAD. C-statistics for patients with CHD were 0.60 and 0.57, for patients with CeVD 0.62 and 0.61, and for patients with PAD 0.53 and 0.54 in REACH Western Europe and REACH North America, respectively. ConclusionsThe 10-year combined risk of recurrent MACE and cardiovascular interventions can be estimated in patients with established CHD or CeVD. However, cardiovascular interventions in patients with PAD could not be predicted reliably.

Risk for Recurrent Cardiovascular Events and Expected Risk Reduction With Optimal Treatment 1 Year After an Acute Coronary Syndrome

According to the latest European Society of Cardiology Guidelines for the diagnosis and management of chronic coronary syndromes, patients who suffered an acute coronary syndrome fall into a chronic stable phase after 1 year. In these patients, the estimated 10-year risk for recurrent cardiovascular events varies considerably. We applied the SMART (Second Manifestations of Arterial Disease) risk score in 281 patients 1 year after an acute coronary syndrome to estimate the 10-year risk for recurrent cardiovascular events (subsequent nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death). We assessed the distribution of the estimated risk and the potential risk reduction that might be achieved with optimal guideline-directed management of modifiable risk factors (systolic blood pressure, low-density lipoprotein cholesterol, smoking, and body mass index). In our cohort, the median SMART score was 16.1% (interquartile range [IQR] 9.7 to 27.3), particularly increased in patients with older age, diabetes, polyvascular disease or chronic kidney disease (median 28.6%, IQR 20.8 to 52.9; 23.8%, 4.8 to 41.6; 29.4%, 18.8 to 49.7; 53.8%, 26.5 to 71.6, respectively). If all modifiable risk factors met guideline-recommended targets, the median SMART risk score would be 9.6% (IQR 6.3 to 20.9), with 51% of the patients at a 10-year risk <10%, while 11% and 15% at 20% to 30% and >30% risk, respectively. In conclusion, the SMART score had a wide distribution in patients with chronic coronary syndromes. A quarter of patients remained at a >20% 10-year risk, even with optimal risk factor management, clearly underlining that residual risk is an unmet clinical challenge.

Association of lipoprotein(a) levels with recurrent events in patients with coronary artery disease

ObjectiveWhether lipoprotein(a) (Lp(a)) is a predictor for recurrent cardiovascular events (RCVEs) in patients with coronary artery disease (CAD) has not been established. This study, hence, aimed to examine the potential...

Lifetime cardiovascular risk is associated with a multimarker score of systemic oxidative status in young adults independently of traditional risk factors

Cardiovascular risk (CVR) tends to be estimated in the short-term, which underestimates lifetime (LT)-CVR of young subjects. We determined whether LT-CVR is associated with a multimarker score of oxidative status in young adults and whether this association is independent of traditional CVR factors. Seventy-two young adults were stratified into: (1) low or (2) high LT-CVR, and (3) stable coronary artery disease (SCAD). CVR was estimated with QRisk and atherosclerotic CV disease (ASCVD) risk estimators, or second manifestations of arterial disease (SMART). Risk score. oxidative damage was determined by measuring carbonyls, oxidized LDL (oxLDL), 8-hydroxy-2'-deoxyguanosine (8-OHdG), and xanthine oxidase activity. Antioxidant defence was determined by total antioxidant capacity (TAC), catalase (CAT) activity and superoxide dismutase (SOD) activity. Multimarker scores of systemic oxidative damage (OxyScore) and antioxidant defence (AntioxyScore) were computed as standardized variables. Subjects with high LT-CVR had significantly higher levels of oxLDL, 8-OHdG, TAC, and CAT activity than subjects with low LT-CVR or with SCAD. QRisk and ASCVD estimators correlated positively with oxLDL, TAC, and CAT activity, while SMART Risk Score correlated with carbonyls and SOD activity. OxyScore and AntioxyScore were significantly higher in subjects with high LT-CVR than with low LT-CVR or with SCAD. OxyScore, but not AntioxyScore, was associated with LT-CVR independently of each traditional CVR factor. This study for the first time demonstrates a positive association between oxidative stress and the risk of first and recurrent CV events in young adults.

Routinely measured hematological parameters and prediction of recurrent vascular events in patients with clinically manifest vascular disease.

Background and aimsThe predictive value of traditional risk factors for vascular events in patients with manifest vascular disease is limited, underscoring the need for novel biomarkers to improve risk stratification. Since hematological parameters are routinely assessed in clinical practice, they are readily available candidates.MethodsWe used data from 3,922 vascular patients, who participated in the Second Manifestations of ARTerial Disease (SMART) study. We first investigated associations between recurrent vascular events and 22 hematological parameters, obtained from the Utrecht Patient Oriented Database (UPOD), and then assessed whether parameters associated with outcome improved risk prediction.ResultsAfter adjustment for all SMART risk score (SRS) variables, lymphocyte %, neutrophil count, neutrophil % and red cell distribution width (RDW) were significantly associated with vascular events. When individually added to the SRS, lymphocyte % improved prediction of recurrent vascular events with a continuous net reclassification improvement (cNRI) of 17.4% [95% CI: 2.1, 32.1%] and an increase in c-statistic of 0.011 [0.000, 0.022]. The combination of lymphocyte % and neutrophil count resulted in a cNRI of 22.2% [3.2, 33.4%] and improved c-statistic by 0.011 [95% CI: 0.000, 0.022]. Lymphocyte % and RDW yielded a cNRI of 18.7% [3.3, 31.9%] and improved c-statistic by 0.016 [0.004, 0.028]. However, the addition of hematological parameters only modestly increased risk estimates for patients with an event during follow-up.ConclusionsSeveral hematological parameters were independently associated with recurrent vascular events. Lymphocyte % alone and in combination with other parameters enhanced discrimination and reclassification. However, the incremental value for patients with a recurrent event was limited.

Cost-effectiveness of optimized adherence to prevention guidelines in European patients with coronary heart disease: Results from the EUROASPIRE IV survey

BackgroundThis study aims to assess the cost-effectiveness of optimized guideline adherence in patients with a history of coronary heart disease. MethodsAn individual-based decision tree model was developed using the SMART risk score tool which estimates the 10-year risk for recurrent vascular events in patients with manifest cardiovascular disease (CVD). Analyses were based on the EUROASPIRE IV survey. Outcomes were expressed as an incremental cost-effectiveness ratio (ICER). ResultsData from 4663 patients from 13 European countries were included in the analyses. The mean estimated 10-year risk for a recurrent vascular event decreased from 20.13% to 18.61% after optimized guideline adherence. Overall, an ICER of 52,968€/QALY was calculated. The ICER lowered to 29,093€/QALY when only considering high-risk patients (≥20%) with decreasing ICERs in higher risk patients. Also, a dose-response relationship was seen with lower ICERs in older patients and in those patients with higher risk reductions. A less stringent LDL target (<2.5 mmol/L vs. <1.8 mmol/L) lowered the ICER to 32,591€/QALY and intensifying cholesterol treatment in high-risk patients (≥20%) instead of high-cholesterol patients lowered the ICER to 28,064€/QALY. An alternative method, applying risk reductions to the CVD events instead of applying risk reductions to the risk factors lowered the ICER to 31,509€/QALY. ConclusionDepending on the method used better or worse ICERs were found. In addition, optimized guidelines adherence is more cost-effective in higher risk patients, in patients with higher risk reductions and when using a less strict LDL-C target. Current analyses advice to maximize guidelines adherence in particular patient subgroups.

Distribution of Estimated 10-Year Risk of Recurrent Vascular Events and Residual Risk in a Secondary Prevention Population.

Among patients with clinically manifest vascular disease, the risk of recurrent vascular events is likely to vary. We assessed the distribution of estimated 10-year risk of recurrent vascular events in a secondary prevention population. We also estimated the potential risk reduction and residual risk that can be achieved if patients reach guideline-recommended risk factor targets. The SMART score (Second Manifestations of Arterial Disease) for 10-year risk of myocardial infarction, stroke, or vascular death was applied to 6904 patients with vascular disease. The risk score was externally validated in 18 436 patients with various manifestations of vascular disease from the TNT (Treating to New Targets), IDEAL (Incremental Decrease in End Points Through Aggressive Lipid Lowering), SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels), and CAPRIE (Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events) trials. The residual risk at guideline-recommended targets was estimated by applying relative risk reductions from meta-analyses to the estimated risk for targets for systolic blood pressure, low-density lipoprotein cholesterol, smoking, physical activity, and use of antithrombotic agents. The external performance of the SMART risk score was reasonable, apart from overestimation of risk in patients with 10-year risk >40%. In patients with various manifestations of vascular disease, median 10-year risk of a recurrent major vascular event was 17% (interquartile range, 11%-28%), varying from <10% in 18% to >30% in 22% of the patients. If risk factors were at guideline-recommended targets, the residual 10-year risk would be <10% in 47% and >30% in 9% of the patients (median, 11%; interquartile range, 7%-17%). Among patients with vascular disease, there is very substantial variation in estimated 10-year risk of recurrent vascular events. If all modifiable risk factors were at guideline-recommended targets, half of the patients would have a 10-year risk <10%. These data suggest that even with optimal treatment, many patients with vascular disease will remain at >20% and even >30% 10-year risk, clearly delineating an area of substantial unmet medical need.

The influence of baseline risk on the relation between HbA1c and risk for new cardiovascular events and mortality in patients with type 2 diabetes and symptomatic cardiovascular disease.

BackgroundStrict glycaemic control in patients with type 2 diabetes has proven to have microvascular benefits while the effects on CVD and mortality are less clear, especially in high risk patients. Whether strict glycaemic control would reduce the risk of future CVD or mortality in patients with type 2 diabetes and pre-existing CVD, is unknown. This study aims to evaluate whether the relation between baseline HbA1c and new cardiovascular events or mortality in patients with type 2 diabetes and pre-existing cardiovascular disease (CVD) is modified by baseline vascular risk.MethodsA cohort of 1096 patients with type 2 diabetes and CVD from the Second Manifestations of ARTerial Disease (SMART) study was followed. The relation between HbA1c at baseline and future vascular events (composite of myocardial infarction, stroke and vascular mortality) and all-cause mortality was evaluated with Cox proportional hazard analyses in a population that was stratified for baseline risk for vascular events as calculated with the SMART risk score. The mean follow-up duration was 6.9 years for all-cause mortality and 6.4 years for vascular events, in which period 243 and 223 cases were reported, respectively.ResultsA 1 % increase in HbA1c was associated with a higher risk for all-cause mortality (HR 1.18, 95 % CI 1.06–1.31). This association was also found in the highest SMART risk quartile (HR 1.33, 95 % CI 1.11–1.60). There was no relation between HbA1c and the occurrence of cardiovascular events during follow-up (HR 1.03, 95 % CI 0.91–1.16). The interaction term between HbA1c and SMART risk score was not significantly related to any of the outcomes.ConclusionIn patients with type 2 diabetes and CVD, HbA1c is related to the risk of all-cause mortality, but not to the risk of cardiovascular events. The relation between HbA1c and all-cause mortality in patients with type 2 diabetes and vascular disease is not dependent on baseline vascular risk.

Risk stratification and treatment effect of statins in secondary cardiovascular prevention in old age: Additive value of N-terminal pro-B-type natriuretic peptide.

To date, no validated risk scores exist for prediction of recurrence risk or potential treatment effect for older people with a history of a cardiovascular event. Therefore, we assessed predictive values for recurrent cardiovascular disease of models with age and sex, traditional cardiovascular risk markers, and 'SMART risk score', all with and without addition of N-terminal pro-B-type natriuretic peptide (NT-proBNP). Treatment effect of pravastatin was assessed across low and high risk groups identified by the best performing models. Post-hoc analysis in 2348 participants (age 70-82 years) with a history of cardiovascular disease within the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) study. Composite endpoint was a recurrent cardiovascular event/cardiovascular mortality. The models with age and sex, traditional risk markers and SMART risk score had comparable predictive values (area under the curve (AUC) 0.58, 0.61 and 0.59, respectively). Addition of NT-proBNP to these models improved AUCs with 0.07 (p for difference ((pdiff)) = 0.003), 0.05 (pdiff = 0.009) and 0.06 (pdiff < 0.001), respectively. For the model with age, sex and NT-proBNP, the hazard ratio for the composite endpoint in pravastatin users compared with placebo was 0.67 (95% confidence interval 0.49-0.90) for those in the highest third of predicted risk and 0.91 (0.57-1.46) in the lowest third, number needed to treat 12 and 115 (pdiff = 0.038) respectively. In secondary cardiovascular prevention in old age addition of NT-proBNP improves prediction of recurrent cardiovascular disease, cardiovascular mortality and treatment effect of pravastatin. A minimal model including age, sex and NT-proBNP predicts as accurately as complex risk models including NT-proBNP.

Incremental value of a genetic risk score for the prediction of new vascular events in patients with clinically manifest vascular disease

BackgroundSeveral genetic markers are related to incidence of cardiovascular events. We evaluated whether a genetic risk score (GRS) based on 30 single-nucleotide-polymorphisms associated with coronary artery disease (CAD) can improve prediction of 10-year risk of new cardiovascular events in patients with clinical manifest vascular disease. MethodsIn 5742 patients with symptomatic vascular disease enrolled in the SMART study, we developed Cox regression models based on the SMART Risk Score (SRS) and based on the SRS plus the GRS in all patients, in patients with a history of acute arterial thrombotic events and in patients with a history of more stable atherosclerosis and without CAD. The discriminatory ability was expressed by the c-statistic. Model calibration was evaluated by calibration plots. The incremental value of adding the GRS was assessed by net reclassification index (NRI) and decision curve analysis. ResultsDuring a median follow-up of 6.5 years (IQR4.0–9.5), the composite outcome of myocardial infarction, stroke, or vascular death occurred in 933 patients. Hazard ratios of GRS ranging from 0.86 to 1.35 were observed. The discriminatory capacity of the SRS for prediction of 10-year risk of cardiovascular events was fairly good (c-statistic 0.70, 95%CI 0.68–0.72), similar to the model based on the SRS plus the GRS. Calibration of the models based on SRS and SRS plus GRS was adequate. No increase in c-statistics, categorical NRIs and decision curves was observed when adding the GRS. The continuous NRI improved only in patients with stable atherosclerosis (0.14, 95%CI 0.03–0.25), increasing further excluding patients with a history of CAD (0.21, 95%CI 0.06–0.36). ConclusionsIn patients with symptomatic vascular disease, a GRS did not improve risk prediction of 10-year risk of cardiovascular events beyond clinical characteristics. The GRS might improve risk prediction of first vascular events in the subgroup of patients with a history of stable atherosclerosis.

Development and validation of a prediction rule for recurrent vascular events based on a cohort study of patients with arterial disease: the SMART risk score

ObjectivesTo enable risk stratification of patients with various types of arterial disease by the development and validation of models for prediction of recurrent vascular event risk based on vascular risk...

Microvascular dysfunction and pulse wave reflection characterize different vascular pathologies in patients at cardiovascular risk

Endothelial function and arterial pulse wave reflections play a crucial role in the pathogenesis of atherosclerosis. While the endothelium-dependent reactive hyperemia index (RHI) of the digital arteries is considered as a marker of microvascular function, an increased augmentation index (AI) may indicate beginning macrovascular damage. In this study we assessed the interrelationships among these noninvasive measures of vascular function. In 178 all-comer patients with documented cardiovascular risk factors (22 % female; 65 % coronary artery disease, CAD), we measured radial AI (rAI) by radial applanation tonometry and digital AI (dAI) as well as RHI by using fingertip peripheral arterial tonometry. A modified SMART risk score was calculated in all participants based on cardiovascular risk factors and preexisting vascular disease. dAI and rAI demonstrated a significant and robust overall correlation (Pearson rank coefficient r = 0.63, p < 0.01), which was not affected by age, sex, diabetes mellitus and CAD. In contrast, both parameters demonstrated at most a weak correlation (dAI: r = 0.26, p < 0.01 and rAI: r = 0.12, p = 0.10) with microvascular function (RHI). While dAI and rAI were significantly correlated to female sex, age, low body height, low heart rate and the presence of CAD, RHI was associated with the presence of diabetes mellitus and nicotine use. Finally, only microvascular function was associated with the modified SMART risk score, but not augmentation indices. RHI and increased pulse wave reflection appear to represent two distinct vascular pathologies in patients with cardiovascular risk. In contrast, RHI might be useful to identify patients at highest cardiovascular risk once atherosclerotic disease has been diagnosed.

Carotid and brachial intima-media thickness, arterial diameter and resistivity indices in aortic regurgitation

To evaluate signs of atherosclerosis in carotid and brachial arteries in patients with aortic regurgitation (AR). The sonograms of 33 patients (24 M and 9 F, 16-67 years old) with pure AR and 20 control subjects (15 M and 5 F, 19-49 years old) were evaluated. Patients with AR and control subjects completed a questionnaire with SMART risk score based on pre-existing vascular disease and risk factors. AR patients and control subjects were assessed for intima-media thickness (IMT) of common carotid artery (CCA), IMT of brachial artery (BA), CCA diameter, and resistivity index (RI) of CCA and RI of internal carotid artery (ICA). There was no significant difference in the cardiovascular risk score between the patients with AR and control subjects. All measured parameters were statistically significantly greater in AR patients than in control subjects with P values 0.0233 for CCA IMT, 0.0034 for BA IMT, 0.0429 for CCA diameter, <0.0001 for CCA RI, and 0.0002 for ICA RI. AR is associated with signs generally considered to represent atherosclerosis, such as increased CCA and BA IMT, CCA diameter, and CCA and ICA RI.