Systematic Coronary Risk Evaluation System Research Articles

Association of epicardial adipose tissue and coronary artery calcium score in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Both coronary artery calcium (CAC) and epicardial adipose tissue (EAT) had been implicated in coronary artery disease (CAD) and risk of future adverse cardiovascular events. There are scarce data regarding the assessment and association of EAT volume and CAC score (CACS) in atrial fibrillation (AF) patients. Purpose To assess the association between EAT volume and the presence and severity of CAC in patients with AF. Methods Retrospective and single-centre study including consecutive patients with AF undergoing contrast-enhanced cardiac computed tomography for catheter ablation planning, from 2017 to 2019. Patients with known history of CAD and moderate to severe valvular heart disease were excluded. Baseline clinical and demographical data were collected, as well as their cardiovascular risk, based on the SCORE (Systematic Coronary Risk Evaluation) system and cardiovascular risk categories. We assessed CACS (Agatston method) and EAT volume and analysed their association. EAT was defined as the adipose tissue accumulated between the visceral pericardium and the myocardium and was semi-automatically reconstructed by manually tracing the pericardium. Patients were split into three groups according to CACS: 0, 1-99 and ≥100. A logistic regression (LR) analysis was performed to explore the relationship between EAT volume and the presence of CAC (CACS>0), adjusted for age, gender, obesity, diabetes mellitus and hypertension. Results A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. A CHA2DS2-VASc score ≥2 was present in 130 (37%) patients and most patients had low to moderate cardiovascular risk (n=213, 82%). More than half of the patients had a CACS>0 (n=185, 52%), of which 63 patients (18%) had a CACS≥100. The mean EAT volume was 79 ± 39 ml. There was a significant association between EAT volume and the presence of CAC: CACS=0 69 ± 34 ml vs CACS 1-99 84 ± 38 ml vs CACS ≥100 95 ± 45 ml (p<0.001) (Fig. 1). After covariate adjustment (LR model R2 = 0.373, p <0.0001), the presence of CAC was not associated with EAT volume (OR 1.00, 95%CI 1.00 - 1.01, p=0.2) or obesity, and only with higher age, male gender, hypertension and diabetes mellitus (Fig. 2). Conclusion In our cohort of patients with AF undergoing catheter ablation we observed an association between EAT and CACS. Nevertheless, EAT volume was not an independent predictor of CACS and only the classical cardiovascular risk factors remained significant.

Comparative assessment of cardiovascular risk in European and Korean ethnic groups in the Russian population using the SCORE and SCORE2

Aim. To carry out a comparative assessment of cardiovascular risk (CVR) in people aged 40-49 years of European and Korean ethnicity with a single residence area using the Systematic Coronary Risk Evaluation (SCORE) and SCORE2 scales.Material and methods. We examined 397 and 50 apparently healthy individuals of the European (EEG) and Korean (KEG) ethnic groups, respectively, who were evaluated for CVR according to the SCORE and SCORE2 charts.Results. According to the SCORE system, the median CVR in the EEG was 0 [0-0] vs 0 [0-1]% in the KEG (p<0,001), while from a clinical point of view, the groups did not differ from each other. The SCORE2 system demonstrated more significant clinical results as follows: the median risk in EEG individuals was 5 [3-8]%, which corresponds to a high CVR for this age group, and 8 [4-11]% in KEG individuals, which corresponds to a very high CVR (p=0,011). CVR assessment in apparently healthy individuals is decisive in considering the preventive measures. According to the SCORE system, 97,5% and 96% of apparently healthy EEG and KEG individuals, respectively, are classified as low and moderate risk. High and very high risk when using this system was determined in 2,5 and 4% among Europeans and Koreans, respectively. However, using the SCORE2 system, only 10,3% of Europeans were classified as low/ moderate risk, and among ethnic Koreans — 8%. At the same time, the category of high and very high risk was designated, respectively, for 63,7 and 25,9% in the EEG and 40 and 52% in the KEG, respectively. It has been established that according to the SCORE2 system, more than half of Koreans aged 40-49 already have a very high CVR, which significantly distinguishes this group from the European population.Conclusion. The SCORE2 system has a more differentiated approach in determining individual CVR. The SCORE2 assessment of non-high density lipoprotein cholesterol levels makes it more personalized for use in different ethnic populations.

Coronary artery calcium in patients with atrial fibrillation undergoing catheter ablation – an opportunity to personalize cardiovascular and thromboembolic risk management

Abstract Introduction There is a well-established association between atrial fibrillation (AF) and coronary artery disease (CAD). Coronary artery calcium score (CACS) is a helpful tool to refine cardiovascular risk stratification and guide strategies of cardiovascular (CV) primary prevention. Purpose To evaluate the prevalence and clinical implications of CACS in terms of CV and thromboembolic risk stratification and preventive therapies, in patients with AF and atrial flutter (AFL) undergoing catheter ablation. Methods Cross-sectional study including patients with AF/AFL undergoing multidetector computed tomography (MDCT) for ablation procedure planning from 2017 to 2019. Baseline clinical and demographical data were collected. CV and thromboembolic risks were evaluated based on the SCORE (Systematic Coronary Risk Evaluation) system and CHA2DS2-VASc score. CACS was assessed in patients without history of coronary artery disease using the Agatston method. Results A total of 474 patients were included (441 with AF and 33 with AFL, mean age of 58±10 years, 62% male). Excluding those over 70 years of age (n=50, 11%), most patients had low (n=69, 22%) or moderate (n=188, 60%) CV risk and 277 (64%) patients had a CHA2DS2-VASc score ≥1 (male) or ≥2 (female). Overall, 265 patients (65%) were under chronic anticoagulation and 157 (39%) were under statin therapy. CAC was present in 254 (54%) patients and showed a multivessel distribution in 62% of the cases. The left main stem was affected in 81 (17%) patients and the left anterior descending artery in 211 (45%). Incorporating CACS>100 as a variable in CHA2DS2-VASc score (vascular disease parameter in patients without history of vascular disease) would have resulted in a significant score reclassification (n=87, 20%) and identification of new potential candidates for anticoagulation (n=12, 3%). Additional, anticoagulation would be indicated as a class IA recommendation in more 26 (6%) patients. Twenty three percent of patients with zero calcium were taking statins, and only 7% of patients with a CACS >300 were on high-intensity statin therapy. According to the recommendations and based on their CACS and current therapy, 103 (25%) patients would be candidates for statin therapy and 69 (17%) patients would be candidates for changes in the current statin therapy intensity (Table 1). Conclusion In our study, more than half of the patients undergoing MDCT before AF/AFL catheter ablation had coronary calcium above zero. Our findings suggest that an opportunistic evaluation of CACS can be clinically valuable in thromboembolic risk stratification and management of preventive pharmacological strategies such as anticoagulation and statins. Funding Acknowledgement Type of funding sources: None.

Relationship between plasma high-sensitivity C-reactive protein and traditional cardiovascular risk factors among active-duty military personnel in the Republic of Serbia

Background/Aim. Approximately one-third of individuals with only one cardiovascular (CV) risk factor or without any, as well as 40% of individuals with a concentration of cholesterol less than average, die from CV diseases (CVD). Recent studies underlined the significant role of inflammation in atherosclerosis and its complications. The aim of this study was to analyze the association of high-sensitivity C-reactive protein (hs-CRP) with traditional risk factors for coronary heart disease. This is the first such study in Serbia. Methods. This is an observational cross-sectional study, which included active-duty military personnel of similar socio-epidemiological and economic characteristics. Plasma hs-CRP and traditional CV risk factors were evaluated. The relative CV risk was staged as low (hs-CRP < 1 mg/L), intermediate (hs-CRP between 1 and 3 mg/L), and high (hs-CRP > 3 mg/L). The Systematic Coronary Risk Evaluation (SCORE) system was used for absolute CV risk assessment and total risk (fatal and non-fatal events). Results. The study included 205 participants, aver-age age of 39 (35?43) years, with median and interquartile range values of hs-CRP 0.80 mg/L (0.43?1.75 mg/L), with average hs-CRP values of 0.71 mg/L in participants younger than 40 years of age and 1.2 mg/L in the older than 40 years. The difference in hs-CRP values between these two groups was statistically significant (p = 0.006). There was a significant positive correlation between hs-CRP and age (r = 0.266, p < 0.001), weight (r = 0.223, p = 0.001), body mass index (BMI) (r = 0.344, p < 0.001), diastolic hypertension (r = 0.190, p = 0.007), LDL cholesterol (r = 0.152, p = 0.032), triglycerides (r = 0.144, p = 0.039), number of risk factors (r = 0.210, p < 0.003), as well as negative correlation with HDL cholesterol concentration (r = -0.148, p < 0.035). There was no significant correlation between hs- CRP concentration and total cholesterol (r = 0.131, p = 0.062). According to hs-CRP values, high CVD risk was found in 17.7% of participants older than 40 years of age, and based on SCORE system staging, 90% of participants have intermediate CVD risk. The results of stepwise multiple regression analyses showed that BMI was independently associated with an hs-CRP concentration in the group younger than 40 years of age. Among the older participants, age was found to be associated with concentration of fibrinogen. Conclusion. In the population of active military personnel in the Republic of Serbia, hs-CRP is correlated with some of the risk factors for CVD, and only BMI is in-dependently correlated with hs-CRP in those under 40 years of age. Levels of plasma hs-CRP are increased with aging, implying that hs-CRP measurement may provide a more ac-curate assessment of the individual overall risk profile for CVD in the Serbian military personnel population.

Cardiovascular risk estimation in young patients with ankylosing spondylitis: A new model based on a prospective study in Constanta County, Romania.

Cardiovascular (CV) risk assessment charts are useful in establishing a patient therapeutic plan, but the most commonly used charts have essential limitations when applied to special populations. Our aim was to determine whether the Systematic Coronary Risk Evaluation (SCORE) chart underestimates the CV risk in young patients with ankylosing spondylitis (AS) and to promote the necessity of new risk assessment models. We conducted a prospective study in Constanta County, Romania including 70 consecutive patients ≤50 years of age, previously diagnosed with AS, without a history of established CV disease, diabetes mellitus and chronic kidney disease. We estimated the CV risk using SCORE based on total cholesterol, applied for a high-risk population, such as the Romanian population. Estimation of CV risk was also conducted with the relative risk (RR) chart, considering the following variables: Smoking, systolic blood pressure and total cholesterol. The majority of patients (n=46, 65.71%) had low risk according to the SCORE chart and only 24 (34.28%) were found to have moderate CV risk; none of them with high or very high CV risk. Ten patients (21.74%) of the 46 who were considered to have a low risk based on the SCORE system presented with carotid plaques. Twelve patients (50%) of the remaining 24 with moderate CV risk were found to have carotid plaques. According to 2016 'European Society of Cardiology' (ESC) guidelines, 22 of all 70 patients were at high/very high CV risk due to the presence of carotid plaques. Comparing the RR chart with carotid plaque detection, only 4 out of 30 (13.3%) patients with RR=1 had carotid plaques; the frequency was higher in those with RR>1. Our results attested that the SCORE system underestimates the risk in patients with carotid plaques. Carotid ultrasound provided a more heightened sensitivity of the RR chart. C-reactive protein (CRP) >3 mg/dl is associated with RR>1, making this chart a better CV risk predictive system in this particular category of patients.

Utility of Systematic Coronary Risk Evaluation (SCORE) system to predict coronary artery disease severity in low to moderate risk hypertensive patients undergoing elective coronary angiography

Background: Coronary artery disease (CAD) is the leading cause of mortality in hypertensive patients. Systematic Coronary Risk Evaluation (SCORE) is the preferred scoring system to predict future fatal cardiovascular events in hypertensive patients. However, the relationship between SCORE and coronary atherosclerosis is not well described. We aimed to investigate whether SCORE has a relationship with CAD severity in hypertensive patients, even in the absence of high risk features. Material and methods: Four hundred and fifty-two hypertensive patients who underwent elective coronary angiography and defined as low or moderate risk according to SCORE were included into the study. Patients were divided into two groups. Patients with a SCORE < 1% were defined as low risk group, and patients with a SCORE ≥ 1% and < 5% were defined as moderate risk group. The groups were compared regarding CAD severity. Results: The frequency of stenotic CAD and multivessel disease, and mean SYNTAX score, were significantly higher in SCORE ≥ 1%, and < 5% group compared to patients with SCORE < 1%. Correlation analysis revealed a significant positive moderate correlation between SCORE and SYNTAX score (Pearson’s r: 0.679, p < 0.001). ROC curve analysis demonstrated that a SCORE ≥ 3% predicted SYNTAX score > 22 with a sensitivity of 75% and a specificity of 86.5% (AUC: 0.879, p < 0.001). Furthermore, multivariate analysis demonstrated that SCORE was an independent predictor of stenotic CAD (OR: 1.616, p < 0.001), multivessel disease (OR: 1.913, p < 0.001), and SYNTAX score > 22. (OR: 1.817, p < 0.001). Conclusion: Our results suggest that SCORE is associated with CAD severity in hypertensive patients even in the absence of high risk features. The SCORE system may be useful in further risk stratification of hypertensive patients with moderate risk features and suspected CAD.

CML-105: A Validation of Vascular Adverse Events Risk Assessment Method for Japanese CML Patients with Tyrosine Kinase Inhibitors

Background and Aim Tyrosine kinase inhibitors (TKIs) have substantially improved the prognosis of chronic myeloid leukemia (CML). However, TKIs can cause serious vascular adverse events (VAEs) such as ischemic heart disease (IHD), peripheral artery occlusive disease (PAOD), cerebral infarction (CI), and pulmonary embolism (PE). The Framingham general cardiovascular risk scores (FRS), Suita score (SS), and SCORE (Systematic Coronary Risk Evaluation) system are commonly used to predict the incidence of cardiovascular events, but their usefulness as evaluation methods for patients with CML is unknown. We aimed to determine the appropriateness of these evaluation methods for a Japanese CML cohort. Methods We retrospectively surveyed patients with CML who visited our institute between January 2003 and March 2020. All patients were evaluated using the three risk assessment tools (FRS, SS, low-risk SCORE chart). To predict the 5-year event-free survival, we determined the cut-off values of each scoring system from the receiver operating characteristic analysis (ROC) curve. Results Sixty-nine patients with CML (38 males) were registered. Their median age was 66 years (range, 25–91years), and the median follow-up time was 48 months. Eight patients (2 males) had VAEs (3 IHD, 2 PAOD, 1 CI, 1 PE, and 1 sudden death). Four patients were treated with nilotinib, 2 with imatinib,1 with dasatinib, and 1 with bosutinib. The cut-off values obtained from the ROC curve for the SS and SCORE chart were 45 and 2, respectively. The sensitivity, specificity, and area under the curve (AUC) were 0.574, 0.875, and 0.713 for the SS and 0.689, 0.750, and 0.755 for the SCORE chart, respectively. We were unable to calculate the FRS because of the small number of men with thrombosis. However, the cut-off value was 11 points when limited to the female patients. The 5-year cumulative incidence rates of VTEs were 14.9% and 0% in patients with SS of ≥45 and Conclusion For this Japanese CML cohort, we propose that the SS and SCORE chart are valid evaluation methods for VAE assessment.

THE IMPACT OF OCCUPATIONAL AND LIFESTYLE FACTORS ON STATE OF ARTERIAL VESSELS IN COPPER INDUSTRY WORKERS

Introduction. Cardiovascular diseases (CVDs) are the leading cause of death in working-age population, including mortality occurring through occupational fatalities. The core principle in fighting CVDs is having special consideration for individuals with a high risk of its development. In order to identify those individuals, the SCORE (Systematic Coronary Risk Evaluation) system is advised. The realizations (i.e. the effects of exposure) with respect to the same risk factors may vary across individuals. Therefore, it is of urging importance to conduct an assessment of the integral cardiovascular risk estimates that are informative of coming-to-an-effect long-term exposures to adverse factors and helpful in identifying changes at early reversible stages of CVD. Material and methods. A cross-sectional study included 108 male workers aged 27-63 years, without apparent health disorders who been working in unsafe conditions over from 4 to 40 years, employed as occupational staff (converter furnace operators, charge workers, burners, smelters) in copper production enterprises of the Sverdlovsk region. Clinical examination and laboratory tests were conducted at the Yekaterinburg Medical Research Center in 2017-2018. The evaluated indices included: total cholesterol (TC), glucose, Pb and Cu level in blood. A 3D-sphygmography with CAVI assessment and aa. carotides ultrasound with intima-media thickness (IMT) assessment were performed. Cardiovascular risk (CVR) was evaluated according to the SCORE assessment. Results. The following CVR factors were identified: smoking (72.2%), obesity of various classes (33.3%), TC > 4.9 mmol/l (57.9%), high fasting glucose (73.9%) and arterial hypertension stages 1-2 (40.7%). An arterial vessel stiffness increase by CAVI (>8.0) was found in 28.7% of subjects. Associations were found between CAVI index and (i) total CVR level as evaluated by SCORE (p=0.00105), (ii) blood Cu level (r=0.33). Therefore, further research is needed.

P3402Validation of the SCORE O.P. for prediction of cardiovascular disease mortality in a large population of elderly individuals

Abstract Background Estimation of absolute cardiovascular risk in apparently healthy individuals, using SCORE (Systematic COronary Risk Evaluation) is recommended by the ESC guidelines on cardiovascular disease (CVD) prevention in clinical practice. Recently, the SCORE system has been extended by the SCORE O.P. aiming to improve estimates of cardiovascular risk specifically in older persons (65 years and older). Purpose The aim of this study was to validate the SCORE O.P. in an Austrian population of 34,909 healthy individuals aged between 65 and 80 years which were prospectively followed for a minimum of 10 years. Methods Predicted fatal CVD and coronary heart disease (CHD) event rates within 10 years were calculated using the “SCORE O.P. risk function for low risk regions” and compared to the actually observed rates, thereby assessing calibration. In addition, predicted probabilities were plotted against observed mortality by deciles of predicted risk. Regarding discrimination, receiver operating characteristics (ROC) analysis and corresponding c-statistics were used. Results In 14,586 males, 1,509 deaths from CVD (10.4%) and 847 deaths from CHD (5.8%) occurred within 10 years of follow-up. SCORE O.P. predicted 1,699 fatal CVD (11.7%) and 872 CHD (6.0%) events. In male high risk individuals (10th decile), SCORE O.P. overestimated mortality from CVD and CHD. C-statistics were 0.68 (95% CI 0.67–0.70) for CVD and 0.67 (0.65–0.69) for CHD. In 20,323 females, 1,340 deaths from CVD (6.6%) and 672 deaths from CHD (3.3%) were observed. SCORE O.P. predicted 1,232 fatal CVD (6.1%) and 539 CHD events (2.7%). In female high risk individuals (8–10th deciles), SCORE O.P. underestimated mortality from CVD and CHD. C-statistics were 0.77 (0.75–0.78) for CVD and 0.77 (0.75–0.79) for CHD. Conclusion With regard to overall accuracy, the SCORE O.P. performed considerably well in this elderly Austrian population. However, in high-risk individuals, cardiovascular risk was overestimated for males and underestimated for females. SCORE O.P. was able to discriminate high-risk from low-risk individuals, better in women than in men.

Association of Depression and Anxiety With the 10-Year Risk of Cardiovascular Mortality in a Primary Care Population of Latvia Using the SCORE System.

Background: Depression and anxiety have been recognized as independent risk factors for both the development and prognosis of cardiovascular (CV) diseases (CVD). The Systematic Coronary Risk Evaluation (SCORE) function measures the 10-year risk of a fatal CVD and is a crucial tool for guiding CV patient management. This study is the first in Latvia to investigate the association of depression and anxiety with the 10-year CV mortality risk in a primary care population.Methods: This cross-sectional study was conducted at 24 primary care facilities. During a 1-week period in 2015, all consecutive adult patients were invited to complete a nine-item Patient Health Questionnaire (PHQ-9) and a seven-item Generalized Anxiety Disorder scale (GAD-7) followed by sociodemographic questionnaire and physical measurements. The diagnostic Mini International Neuropsychiatric Interview (M.I.N.I.) was administered by telephone in the period of 2 weeks after the first contact at the primary care facility. A hierarchical multivariate analysis was performed.Results: The study population consisted of 1,569 subjects. Depressive symptoms (PHQ-9 ≥10) were associated with a 1.57 (95% confidence interval (CI): 1.06–2.33) times higher odds of a very high CV mortality risk (SCORE ≥10%), but current anxiety disorder (M.I.N.I.) reduced the CV mortality risk with an odds ratio of 0.58 (95% CI: 0.38–0.90).Conclusions: Our findings suggest that individuals with SCORE ≥10% should be screened and treated for depression to potentially delay the development and improve the prognosis of CVD. Anxiety could possibly have a protective influence on CV prognosis.

Abstract P185: Prognostic Value of Endothelial Markers in Hypertensive Nondiabetic Patients

Aim: to study the prognostic value of the serum levels of stable nitric oxide metabolites (NOx), endothelin-1 (E1), homocystein (HC), von Willebrand factor (Wf), tissue plasminogen activator (tPA), in hypertensive nondiabetic patients without cardiovascular disease. Methods: 124 patients with hypertension (HTN), without diabetes were enrolled, the mean age was 51.4±6.5y, the mean duration of HTN was 8.5±7.6 y, 36 % were males, 35% were smokers, 54% were obese. The cardiovascular risk was estimated according to the SCORE (Systematic Coronary Risk Evaluation) system. Plasma NOx levels were determined by spectrophotometry, E1, HC, Wf, tPA levels by enzyme immunoassay. The follow-up period was 8±1.1y. Statistical analysis was done using the SPSS 11.1 software. Results: On initial investigation all patients were stratified according to the SCORE risk levels. The increase of SCORE risk levels were associated with the elevation of serum NOx, E1, HC, and Wf concentrations. The mean plasma NOx concentration increased along with the SCORE risk level: it was 36.4±12.7 in low risk, 41.1±15.7 in moderate risk, 44.9±19.8 in high risk, and 50.4±19.1 umol/L in very high risk categories (<0.05 between the low and high risk groups). The tPA levels did not differed in relation to the SCORE risk estimates. The SCORE risk level correlated with serum concentrations of NOx (r=0.74, p=0.0001), HC (r=0.54, p=0.0001), and Wf (r=0.43, p=0.001). Conclusions: The stable nitric oxide metabolites, homocystein, and von Willebrand factor are the markers of oxidative/nitrosative stress severity. Our results are indicative that this substances may be of prognostic value in hypertensive nondiabetic patients.

Factors influencing cardiometabolic risk profile in patients with psoriasis.

Psoriasis has been associated with metabolic syndrome and with an increased cardiovascular risk especially in patients with severe disease. The goal of this study was to estimate the prevalence of metabolic syndrome and other cardiovascular risk factors and its association with the psoriasis severity, sex and age. Consecutive patients with psoriasis were enrolled in a prospective study over a 1-year period. Blood samples were collected. Psoriasis area and severity index (PASI) and body surface area scores and two dermatology quality of life (DQOL) questionnaires were used to evaluate psoriasis severity and the impact of the disease. Altogether 178 patients were included, of whom 44% had moderate-severe psoriasis. The overall prevalence of metabolic syndrome was 30% (men 34%, women 26%) without significant differences between patients with severe and mild disease. Age and menopause appeared to increase the risk for metabolic syndrome. Patients with severe psoriasis smoked more heavily, were more likely to have diabetes or insulin resistance and had higher homocysteine and lower high density lipoprotein cholesterol (HDL-C) levels than patients with mild psoriasis (P < 0.05). In women, a higher waist circumference was observed. Women had higher HDL-C levels and lower smoking and alcohol consumption rates. In accordance with the systematic coronary risk evaluation system, 18% of the patients had a high 10-year risk of fatal cardiovascular disease. Psoriasis severity was associated with diabetes, insulin-resistance, smoking habit and higher cardiovascular risk. Metabolic syndrome was related to age and menopause but not to psoriasis severity.

ACC/AHA guidelines superior to ESC/EAS guidelines for primary prevention with statins in non-diabetic Europeans: the Copenhagen General Population Study

AimWe compared the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and the 2016 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines on prevention of atherosclerotic cardiovascular disease (ASCVD) using different risk prediction models [US Pooled Cohort Equations (US-PCE for any ASCVD) and European Systematic COronary Risk Evaluation system (European-SCORE for fatal ASCVD)] and different statin eligibility criteria.Methods and resultsWe examined 44 889 individuals aged 40–75 recruited in 2003–09 in the Copenhagen General Population Study, all free of ASCVD, diabetes, and statin use at baseline. We detected 2217 any ASCVD events and 199 fatal ASCVD events through 2014. The predicted-to-observed event ratio was 1.2 using US-PCE for any ASCVD and 5.0 using European-SCORE for fatal ASCVD. The US-PCE, but not the European-SCORE, was well-calibrated around decision thresholds for statin therapy. For a Class I recommendation, 42% of individuals qualified for statins using the ACC/AHA guidelines vs. 6% with the ESC/EAS guidelines. Using ACC/AHA- vs. ESC/EAS-defined statin eligibility led to a substantial gain in sensitivity (+62% for any ASCVD and +76% for fatal ASCVD) with a smaller loss in specificity (−35% for any ASCVD and −36% for fatal ASCVD). Similar differences between the ACC/AHA and ESC/EAS guidelines were found for men and women separately, and for Class IIa recommendations. The sensitivity and specificity of a US-PCE risk of 5% were similar to those of a European-SCORE risk of 1.4%, whereas a US-PCE risk of 7.5% was similar to a European-SCORE risk of 2.4%.ConclusionsThe ACC/AHA guidelines were superior to the ESC/EAS guidelines for primary prevention of ASCVD, that is, for accurately assigning statin therapy to those who would benefit.

Is representativeness the right question?

We agree completely that representative studies are immensely valuable for describing disease patterns, quantifying the burden of disease1 and generating risk stratification models.2 Given representativeness is time- and place-specific,3 these all need regular updates and more representative studies. For example, the SCORE (Systematic COronary Risk Evaluation) system for predicting fatal cardiovascular disease (CVD) uses the same risk factors in different models for high- and low-CVD-risk European countries,4 but over time countries may, also, be promoted from high to low risk.5 Clearly, such risk prediction models are not scientific models that describe nature consistently across space and time,6 but they are immensely useful for service planning, targeting treatment and saving lives. Conversely, experimental studies, such as animal models and randomized controlled trials (RCTs), do not require representativeness to test scientific models.6 On the other hand, whether observational epidemiological studies, representative or not, are useful for generating hypotheses or testing causal factors in scientific models is less clear. First, these represent the triumph of hope over experience.7 Second, as was pointed out over 20 years ago, nearly all possible hypotheses have already been generated.8 Third, some potentially relevant hypotheses may not be readily observed for conceptual or practical reasons. The current paradigm may exclude some hypotheses as impossible, making them imperceptible. Apart from well-known biases inherent in observational studies, causal factors may be invariant in commonly studied populations, expensive or difficult to measure, affected by preclinical disease or hidden within the (mis)classification of diseases by symptom rather than cause. Fourth, as a discipline we have not generally thought through the hierarchy of studies to refute a hypothesis. Our current methods, using the Bradford-Hill viewpoints as a touchstone, are much more focused on corroborating hypotheses, with an RCT as the pinnacle of corroboration. However, even something as simple as ‘field’ epidemiology may refute hypotheses. For example, the existence of populations with low birthweight and low rates of heart disease casts doubt on a major role of birthweight in heart disease.9 Given these issues if we want to make progress in identifying causal processes in population health, assuming it is possible,10 rather than focusing on representativeness in studies used to generate or test (corroborate) hypotheses, it might be more useful to look for better ways to generate and screen plausible hypotheses, before we test them in suitable studies.11 Other methods of generating hypotheses about the drivers of population health are not obvious, but include using general mechanistic principles, starting with effective treatments and taking advantage of mechanistic insights from genetics or RCTs which include potential mediators. Not only do we need to move on from the debate about representativeness, we need to move onto some different questions.

Correlation between total cardiovascular risk and bone density in postmenopausal women

AbstractThe aim of the paper was to examine the correlation between the total risk of cardiovascular events, determined by the SCORE (Systematic Coronary Risk Evaluation) system, and bone density in postmenopausal women. Examinees and method: The research involved 300 postmenopausal women. On the basis of bone density measurements, the participants were divided into three groups: group I — 84 examinees had osteoporosis, group II — 115 examinees had osteopenia, and group III — 101 examinees had normal bone mineral density (BMD). Results: Participants with high SCORE risk were statistically significantly older compared to low-risk women (60±3 vs. 55±5; p&lt;0.001). They had significantly lower BMD and T scores (−1.09±0.94 vs. −2.86±0.63; p&lt;0.001). Elevation of the SCORE risk by 1% caused a BMD decrease of 0.033 g/cm2(0.029 to 0.036 gr/cm2). Multivariate logistic regression analysis showed that the following factors caused a significant increase in the risk of decreasing BMD: every year of life by 20%, menopause duration by 26%, increase in systolic blood pressure (BP) by 1 mm Hg by 7%, increase in SCORE risk by 1% by 5.31 times, physical inactivity by 5.96 times, and osteoporosis in the family history by 3.91 times. Conclusion: Postmenopausal women who are at high risk for cardiovascular diseases have a lower BMD than those who are not at high risk for cardiovascular diseases.

Using clinical cardiovascular risk scores to predict coronary artery plaque severity and stenosis detected by CT coronary angiography in asymptomatic Chinese subjects

We aimed to determine whether the Framingham risk score (FRS), systematic coronary risk evaluation (SCORE), and Chinese multi-provincial cohort study (CMCS) could predict anatomic severity of coronary plaques. From January 2007 to October 2010, we performed a contrast-enhanced 64-slice or 256-slice multidetector computed tomography coronary angiography as part of a health check-up protocol in 806 asymptomatic subjects (70.5% male, 56 ± 9 year-old). Risk scores significantly correlated with calcium volume score, plaque stenosis score and plaque distribution score (P < 0.001). Of the 3 risk scores, the SCORE system showed the best correlation. Overall, 180 (22%) and 37 (5%) subjects were found to have stenosis of 50-69% and more than 70% in at-least one coronary artery segment, respectively. In the prediction of the presence of obstructive CAD (≥ 50% diameter stenosis), all risk scores had similar discrimination. In the prediction of severe CAD (≥ 70% diameter stenosis), FRS and CMCS had similar area under curves but SCORE discriminated better than FRS (P < 0.05). The optimal cutoff point to predict obstructive CAD was 9.54% for FRS, 1.05% for CMCS, and 0.95% for SCORE, whereas to predict severe CAD was 9.63, 1.05, 1.15% for FRS, CMCS, SCORE, respectively, with a sensitivity of 0.61-0.70 and a specificity of 0.55-0.66. Cardiovascular risk scores are associated with the severity and extent of coronary artery plaque. The stronger association might translate into a better discrimination using SCORE. These findings will aid in the appropriate selection or recalibration of the risk assessment system for cardiovascular disease screening.

Endothelial function in a cardiovascular risk population with borderline ankle&amp;ndash;brachial index

Introduction:The diagnosis of peripheral arterial disease (PAD) can be made by measuring the ankle–brachial index (ABI). Traditionally ABI values > 1.00–1.40 have been considered normal and ABI ≤ 0.90 defines PAD. Recent studies, however, have shown that individuals with ABI values between 0.90–1.00 are also at risk of cardiovascular events. We studied this cardiovascular risk population subgroup in order to determine their endothelial function using peripheral arterial tonometry (PAT).Methods:We selected 66 individuals with cardiovascular risk and borderline ABI. They all had hypertension, newly diagnosed glucose disorder, metabolic syndrome, obesity, or a ten year risk of cardiovascular disease death of 5% or more according to the Systematic Coronary Risk Evaluation System (SCORE). Subjects with previously diagnosed diabetes or cardiovascular disease were excluded. Endothelial function was assessed by measuring the reactive hyperemia index (RHI) from fingertips using an Endo-PAT device.Results:The mean ABI was 0.95 and mean RHI 2.11. Endothelial dysfunction, defined as RHI < 1.67, was detected in 15/66 (23%) of the subjects. There were no statistically significant differences in RHI values between subjects with different cardiovascular risk factors. The only exception was that subjects with impaired fasting glucose (IFG) had slightly lower RHI values (mean RHI 1.91) than subjects without IFG (mean RHI 2.24) (P = 0.02).Conclusions:In a cardiovascular risk population with borderline ABI nearly every fourth subject had endothelial dysfunction, indicating an elevated risk of cardiovascular events. This might point out a subgroup of individuals in need of more aggressive treatment for their risk factors.

Cardiovascular disease risk profiles among ‘healthy’ siblings of patients with early-onset cardiovascular disease: application of the new SCORE system

Cardiovascular disease (CVD) occurs more frequently in individuals with a family history of premature CVD. Within families the demographics of CVD are poorly described. We examined the risk estimation based on the Systematic Coronary Risk Evaluation (SCORE) system and the Joint British Guidelines (JBG) for older unaffected siblings of patients with premature CVD (onset </=55 years for men and </=60 years for women). Between August 1999 and November 2003 laboratory and demographic details were collected on probands with early-onset CVD and their older unaffected siblings. Siblings were screened for clinically overt CVD by a standard questionnaire and 12-lead electrocardiogram (ECG). A total of 790 siblings was identified and full demographic details were available for 645. The following siblings were excluded: 41 with known diabetes mellitus; seven with random plasma glucose of 11.1 mmol/l or greater; and eight with ischaemic ECG. Data were analysed for 589 siblings from 405 families. The mean age was 55.0 years, 43.1% were men and 28.7% were smokers. The mean total serum cholesterol was 5.8 mmol/l and hypertension was present in 49.4%. Using the SCORE system, when projected to age 60 years, 181 men (71.3%) and 67 women (20.0%) would be eligible for risk factor modification. Using JBG with a 10-year risk of 20% or greater, 42 men (16.5%) and four women (1.2%) would be targeted. Large numbers of these asymptomatic individuals meet both European and British guidelines for the primary prevention of CVD and should be targeted for risk factor modification. The prevalence of individuals defined as eligible for treatment is much higher when using the SCORE system.

Guidelines on cardiovascular risk assessment and management

Cardiovascular disease is the major cause of premature death in most European populations. The underlying pathology is usually atherosclerosis. Cardiovascular disease is closely related to lifestyle and modifiable physiological factors, and risk factor modification has been shown to reduce cardiovascular morbidity and mortality. The current joint European Guidelines differ from previous ones in that the emphasis has moved from coronary heart disease prevention to cardiovascular disease prevention. The Systematic Coronary Risk Evaluation system is recommended to assess an individual's total cardiovascular risk. The guidelines define priorities for intervention and address lifestyle change and management of major cardiovascular risk factors to reduce cardiovascular events. Reduction of overweight and obesity is an important component in reducing cardiovascular risk.

Consequences of using different methods to assess cardiovascular risk in primary care

There are two promising methods to assess cardiovascular risk: the Adult Treatment Panel III (ATPIII) and the Systematic Coronary Risk Evaluation (SCORE). The ATPIII calculates the 10-year risk of coronary events based on an adaptation of the original Framingham function. The SCORE chart is based on European studies and measures the absolute risk of cardiovascular mortality in the next 10 years. To evaluate the clinical consequences of using different methods to calculate cardiovascular risk and different primary prevention guidelines. A cross sectional study of 914 dyslipidemic patients from three primary health centres from Catalonia, Spain, was conducted. Outcome variables were the risk level according to the different equations (classical Framingham table by Anderson, ATPIII adapted Framingham table, and SCORE system), and candidates for lipid lowering treatment according to European and ATPIII guidelines. The proportion of high-risk patients according to the three equations and excluding diabetic patients was 13.5%, 11.4% and 7.1%, respectively, and 20.2%, 25.7% and 29.2%, respectively when including diabetic patients. The prevalence of candidates for lipid lowering treatment according to European guidelines and ATPIII guidelines were 28.8% and 39.3%, respectively. A 49% disagreement with a Kappa of -0.1, and a 37% disagreement with a Kappa of 0.08 were observed when comparing candidates identified for lipid lowering treatment and patients actually receiving that treatment, according to ATPIII and SCORE guidelines, respectively. Our results suggest important clinical and economic consequences when comparing European guidelines or ATPIII guidelines for the treatment of dyslipidemic patients in general practice.