Uncontrolled Cardiovascular Risk Factors Research Articles

Abstract PO4-12-07: INSTITUTIONAL EXPERIENCE IN PATIENTS WITH EARLY BREAST CANCER WHO RECEIVED CARDIOTOXIC THERAPY IN CARDIONCOLOGY UNIT

Abstract Introduction: Early breast cancer (eBC) is the most frequent malignancy diagnosed in women worldwide; fortunately, survival is increasing related to early diagnosis and the incorporation of new drugs. In this scenario, preventing long-term toxicities become essential. Cardiac adverse events related to anthracyclines or trastuzumab such as reduction in left ventricular (LV) systolic function and clinical heart failure (HF), are well known and are the leading cause of morbidity in breast cancer survivors. Cardioprotective strategies and early diagnoses of asymptomatic cardiac dysfunction are essential to optimized management and prevention of overt cardiovascular (CV) disease. We made a specific cardiac assessment within an Oncocardiology multidisciplinary Unit in patients receiving anticancer therapies. We present the experience in patients with eBC treated with anthracyclines, trastuzumab or both in the past five years. Materials and Methods: We conducted an institutional, interventional, prospective study in patients who received anthracyclines, trastuzumab or both according to the standard of care (SoC) in eBC. Basal CV risk stratification included lipid profile, glycated haemoglobin, high-sensitive troponin T (hs-TnT) and N-terminal ProB-type natriuretic peptide (NT-ProBNP) was done. Image assessment was done by echocardiogram (echo), including myocardial deformation assessed by speckle tracking (STRAIN). Follow-up was done according to anthracycline or trastuzumab therapy with echo and cardiac biomarkers during the systemic therapy and at the end of anticancer treatment, 1, 2 and 5 years after. Patients with uncontrolled CV risks factors according to local protocol, asymptomatic cardiac dysfunction defined as decreased strain (>15% compared with baseline) or increased cardiac biomarkers (Hs-TnT >14 at baseline or x3 basal value during the follow-up; NT-ProBNP > 300 in patients with < 50y; > 600 in patients between 50-75-y or >900 in patients > 75 years or older) or patients who develop heart failure during the treatment or follow-up were referred to cardiologist. Results: between 2018 and 2022, 1125 patients were diagnosed with eBC in our institution, and 435 patients received systemic treatment with anthracyclines, trastuzumab or both. During the study period, 165 of these patients were referred to the cardio-oncologist. 60% received treatment with anthracyclines, 36% with trastuzumab and 4.1% with both. The median age was 58(±23.2), 60% had previous CV risk factors. The main reason to refer patients to the cardio-oncologist was asymptomatic cardiac dysfunction and uncontrolled CV risk factors. (Table 1). 60% of patients initiated angiotensin-converting-enzyme inhibitors or Beta-blockers, and only two patients stopped anticancer therapy due to severe cardiac dysfunction. The period of high risk of developing cardiotoxicity was the first year after the end of treatment. Conclusion: multidisciplinary evaluation within a cardio-oncology unit is useful to optimize CV risk factors and to detect asymptomatic cardiac dysfunction in patients receiving cardiotoxic drugs. Table 1. Main reasons to refer patients to cardiologist. Citation Format: Tamara Martos, Laia Carla Belarte-Tornero, Mireia Ble, Eva Gimeno, Laura Sanhauja, Felicidad Martines-Medina, Maria Martinez-García, Maria Castro-Henriques, Joan Albanell, Sonia Servitja. INSTITUTIONAL EXPERIENCE IN PATIENTS WITH EARLY BREAST CANCER WHO RECEIVED CARDIOTOXIC THERAPY IN CARDIONCOLOGY UNIT [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-12-07.

Pulmonary edema in a young male with severe uncontrolled cardiovascular risk factors and pan-vascular atherosclerosis: a case report.

Cardiovascular risk factors are the cause of atherosclerotic disease, which can involve all the elastic and muscolo-elastic arteries. The etiopathogenesis of atherosclerosis is multifactorial since genetics, lifestyle, and comorbidities can be simultaneously involved. Clinical manifestations can be heterogeneous and include myocardial infarction, stroke, aortic aneurysms, renal artery stenosis, renal insufficiency, peripheral artery disease, etc. Currently, 70% of clinical events cannot be prevented with available drug therapy, statins included, and at least 10% of coronary events occur in apparently healthy individuals in the absence of major traditional risk factors. The case of a young male with a history of coronary artery disease and multiple atherosclerotic risk factors not properly treated who was admitted to the emergency department for pulmonary edema and high blood pressure is presented. During the diagnostic workup, a dramatic atherosclerotic involvement of all arterial trees emerged. Moreover, the patient presented with thrombosis of the right subclavian artery, which was treated with a heparin infusion and later complicated by cerebral hemorrhage with residual hemiplegia.

Abstract WP258: Younger Patients Have a Higher Likelihood of Recurrent Vessel Small Subcortical Infarct: A Post-Hoc Analysis of the SPS3 Trial

Introduction: Recurrent ischemic stroke due to intracranial large artery disease occurs in up to 20% of patients and is associated with uncontrolled cardiovascular risk factors. However less is known of recurrent vessel small subcortical infarcts (rvSSI), which may be related to branch atherosclerotic disease. The aim of this study was to describe the clinical risk factors associated with rvSSI. Methods: We performed a post-hoc analysis of the Secondary Prevention of Small Subcortical Strokes (SPS3) dataset which enrolled participants between 2003 and 2007. All participants were ≥ 30 years old and had a SSI index event within the preceding 6 months of randomization, confirmed by MRI with a maximal diameter on diffusion weighted imaging (DWI) of ≤ 20 mm, and were without competing stroke mechanism (e.g. ipsilateral carotid stenosis ≥ 50%). Participants were followed over a mean duration of 4 years post-enrollment during which stroke recurrence was noted and characterized. rvSSI was defined as recurrent SSI within the same vascular distribution as an index enrolling infarct confirmed by brain MRI. Chi-squared and student’s T test were used for categorical and continuous variables, respectively. Adjusted logistic regression models were formed to calculate odds ratio. Statistical significance was ≤ 0.05. Results: Of the 3020 participants enrolled in SPS3, 1245 participants met inclusion criteria with 15 having a rvSSI (mean time post-enrollment: 427 days). Participants with rvSSI were younger (54.5 ± 10.2 years vs 61.2 ± 10.6 years, p = 0.008) and had enrollment diagnoses of obesity [BMI ≥ 30 kg/m2; 80% (12/15) vs 49% (598/1230), p = 0.016] and hyperlipidemia [87% (13/15) vs 58% (713/1230), p = 0.025]. Sex, former/current tobacco use, and known diagnoses of hypertension and diabetes mellitus did not differ. For every advancing decade of life, the likelihood of developing a rvSSI was 0.46 (95%CI 0.26 - 0.82, p = 0.008). Conclusions: Participants of the SPS3 trial who were younger in age had rvSSI more frequently with the likelihood decreasing by roughly half with advancing decade of life.

Effect of a standalone rehabilitation programme for patients with peripheral arterial disease on claudication, cardiovascular risk factors and quality of life

Background/Aims There have been calls to make rehabilitation programmes more accessible to patients with peripheral arterial disease. This study aimed to evaluate the effectiveness of a standalone peripheral arterial disease rehabilitation programme on walking outcomes, quality of life and cardiovascular risk factors as primary outcomes. Secondary outcomes relating to the characteristics that may have influenced change in walking outcomes and reasons for non-attendance or non-completion were also explored. Methods In this prospective, observational, one-site study, new patients were offered a 10-week programme, consisting of exercise, education and intervention for uncontrolled cardiovascular risk factors, in line with international peripheral arterial disease guidelines. Claudication times were measured using the Gardner-Skinner protocol and quality of life was measured using VascuQol. Pre- and post-intervention data were analysed using the SPSS version 23, with Pearson's Rho, Spearman's Rho and t tests being performed as appropriate. Statistical significance was set at P<0.05. Results Of the 160 referrals received, 114 patients were enrolled in the programme and 89 (78%) completed it. Reasons for non-completion were mainly either logistical (domestic commitments or return to work) or perceptions of insuitability relating to age, infirmity or severity of peripheral arterial disease. Of those who completed the programme, the median age was 66 years, 81% were men, 71% had a history of hypertension, 25% had diabetes and 37% smoked. There were significant pre–post improvements (P<0.05) in initial and maximum claudication time and distance, systolic and diastolic blood pressure, total cholesterol, low-density lipoprotein and quality of life scores. Improvements in maximum claudication times were associated with lower baseline initial claudication times, lower body mass index, some quality of life scores and male gender. Conclusions The peripheral arterial disease rehabilitation programme was effective in improving functional capacity, quality of life and some cardiovascular risk factors. Factors found to influence improvements in claudication times could be discussed with patients before and during the programme to address misperceptions, provide encouragement and improve compliance and recruitment. The safe environment of supervised exercise may have contributed to these results, prompting efforts to make exercise accessible to all patients with peripheral arterial disease.

ELN Criteria for Cytoreduction Start Identify Patients with Polycythemia Vera at Higher Thrombotic Risk

Introduction Recently, the European Leukemia Net (ELN) recommended cytoreduction in patients (pts) with Polycythemia Vera (PV) at low risk (LR) (age <60 yrs & no previous thromboses) but carrying additional criteria for therapy start (CTS) ( Marchetti M et al, Lancet Haematol 2022). Little is known about: 1] efficacy of hydroxyurea (HU) in LR pts, high risk due to age >60 yrs (HR-AGE) or high risk due to previous thrombosis regardless of age (HR-THRO); 2] impact of CTS on thrombotic risk. Aims In a large cohort of HU-treated PV pts, we investigated if thrombotic risk was influenced by: 1] conventional risk factors for thrombosis; 2] ELN-defined complete response (CR) at 12 mos; 3] presence of CTS. Methods After IRB approval, data of 961 WHO2016-defined PV pts were retrospectively collected by 21 Hematology Centers. In April 2023, an update was performed in 10 participating Centers with specific focus on CTS at diagnosis and HU start; 504 HU-treated pts resulted eligible for this analysis. Therapy was at discretion of the treating hematologist. Pts were followed until death or data cut-off date. CTS evaluated for association with thrombosis included: persistent/progressive leukocytosis (100% increase if white blood cells (WBC) <10 x10 9/L or 50% increase if WBC>10 or WBC>15 at diagnosis and HU start); extreme persistent thrombocytosis (>1000 x10 9/L platelets (PLT) at diagnosis and HU start); progressive splenomegaly (increase of >5 cm from diagnosis); inadequate hematocrit (Hct) control (>6 PHL/yr; HCT >53% at diagnosis and HU start; PHL intolerance); uncontrolled cardiovascular risk factors (CVRF). Symptoms were present as the only ELN criterion in 40 patients, of whom none had thrombosis; therefore, they were not included in the analysis. Results 504 pts received HU: 81 pts were at LR and 423 (83.9%) were at HR (HR-AGE, no. 290, 57.5%; HR-THRO, no. 133, 26.4%). Median time on HU was 11.6 yrs (0.1-23.1). During HU, 53 pts had 69 thromboses (35 arterial) for an incidence rate of thrombosis (IR-thro) of 1.5 %p-y, comparably in LR and HR ( Table 1). Notably, IR-thro was equal in LR and HR-AGE (p=0.94), but significantly higher in HR-THRO pts (p=0.005 vs LR and p=0.009 vs HR-AGE). At 12 months, CR was achieved by 8.2%, 23% and 25% of LR, HR-AGE and HR-THRO pts, respectively (LR vs HR-AGE and HR-THRO, p<0.001 and p=0.003). Thrombosis-free survival (TFS) by landmark analysis at 12 months was significantly better in CR pts (p=0.01). Specifically, best TFS was observed in LR and HR-AGE pts with CR, while HR-THRO pts without CR had the worst TFR (p=0.009). CTS were observed in 255 (50.6%) pts: 48 LR (59.3%), 139 HR-AGE (47.9%) and 68 HR-THRO (51.1%). In the remaining LR pts, HU was triggered by mild thrombocytosis (<1000 x10 9/L) and/or mild leukocytosis (<15 x10 9/L) and/or mild splenomegaly (<5 cm from costal margin) and/or persistent systemic symptoms. CTS were associated to significantly increased of IR-thro in the overall cohort (p<0.001), in LR pts (p=0.04), in HR-AGE pts (p=0.02) and in HR-THRO pts (p=0.03) ( Table 1) . The impact of CTS was confirmed in the overall cohort both for arterial (1.30 vs 0.44 %p-y, p=0.01) and venous thrombosis (1.37 vs 0.44 %p-y, p=0.007). TFS at 5 yrs was 87% and 95% in pts with or without CTS (p<0.001) ( Fig.1a). In presence of CTS, TFS of LR and HR-AGE pts were comparable to HR-THRO pts without CTS ( Fig. 1b). In multivariate Cox analysis considering age>60 yrs, previous thrombosis, CTS, and CR to HU at 12 months, CTS and previous thrombosis remained associated with thrombotic risk (HR: 2.7, 95% CI: 1.4-5, p =0.002; HR: 2.4, 95% CI: 1.4-4.2, p =0.001). Finally, in 59 additional LR pts untreated with HU, IR-thro was 0.78 in absence of CTS, and 1.57 %p-y in presence of such criteria. Conclusions Albeit retrospective, this study shows for the first time that ELN criteria for therapy start including splenomegaly, leukocytosis, thrombocytosis, uncontrolled Hct and CVRF, identified an increased risk phenotype either in LR and HR pts treated with HU. This was confirmed also in HU-untreated pts. Also, lack of CR at 12 months was detrimental on TFS particularly in HR-THRO pts, and less significantly than CTS. These findings, that complement data from the Majic-PV trial ( Harrison CN et al, J Clin Oncol 2023), dictate better management of HU therapy, and call for greater attention to CTS and their integration into prognostic models that go beyond the two categories related only to age and thrombotic history.

Primary Prevention of Cardiovascular Disease at Community Clinics in the State of Sao Paulo, Brazil: Results from the Epidemiological Information Study of Communities.

Primary prevention of cardiovascular disease (CVD) remains a major challenge, especially in communities of low- and middle-income countries with poor medical assistance influenced by distinct local, financial, infrastructural, and resource-related factors. This a community-based study aimed to determine the proportion and prevalence of uncontrolled cardiovascular risk factors (CRF) in Brazilian communities. The EPICO study was an observational, cross-sectional, and community clinic-based study. Subjects were living in Brazilian communities and were of both sexes and ≥18 years old, without a history of a stroke or myocardial infarction but presenting at least one of the following cardiovascular risk factors: hypertension, diabetes mellitus and hypercholesterolemia. The study was carried out in Brazil, including 322 basic health units (BHU) in 32 cities. A total of 7,724 subjects with at least one CRF were evaluated, and one clinical visit was performed. Mean age was 59.2 years-old (53.7% were >60 years old). A total of 66.7% were women. Of the total, 96.2% had hypertension, 78.8% had diabetes mellitus type II, 71.1% had dyslipidemia, and 76.6% of patients were overweight/obese. Controlled hypertension (defined by <130/80 mmHg or <140/90 mmHg) was observed in 34.9% and 55.5% patients among respective criteria, the rates of controlled blood glucose in patients taking antidiabetic medications was 29.5%, and among those with documented dyslipidemia who received any lipid-lowering medication, only 13.9% had LDL-c on target. For patients presenting three CRF less than 1.9% had LDL-c < 100 mg/dL once their BP and blood glucose were on target. High education level as associated with blood pressure (BP) target of less than 130 / 80mm Hg. The glucose and LDL-c levels on target were associated with the presence of hypertension and diabetes mellitus. In Brazilian community clinics, regarding most patients in primary prevention, the CRF such as BP, blood glucose, and lipid levels are poorly controlled, with a majority of patients not achieving guidelines/recommendations.

The Burden of Uncontrolled Cardiovascular Risk Factors in MenWithProstate Cancer: A RADICAL-PC Analysis.

Cardiovascular disease (CVD) incidence is higher in men with prostate cancer (PC) than without. We describe the rate and correlates of poor cardiovascular risk factor control among men with PC. We prospectively characterized 2,811 consecutive men (mean age 68 ± 8 years) with PC from 24 sites in Canada, Israel, Brazil, and Australia. We defined poor overall risk factor control as≥3 of the following: suboptimal low-density lipoprotein cholesterol (>2mmol/L if Framingham Risk Score [FRS]≥15 and≥3.5mmol/L if FRS<15), current smoker, physical inactivity (<600 MET min/wk), suboptimal blood pressure (BP) (≥140/90mmHg if no other risk factors, systolic BP ≥120mmHg if known CVD or FRS≥15, and≥130/80mmHg if diabetic), and waist:hip ratio>0.9. Among participants (9% with metastatic PC and 23% with pre-existing CVD), 99% had≥1 uncontrolled cardiovascular risk factor, and 51% had poor overall risk factor control. Not taking a statin (odds ratio [OR]: 2.55; 95% CI: 2.00-3.26), physical frailty (OR: 2.37; 95% CI: 1.51-3.71), need for BP drugs (OR: 2.36; 95% CI: 1.84-3.03), and age (ORper 10-year increase: 1.34; 95% CI: 1.14-1.59) were associated with poor overall risk factor control after adjustment for education, PC characteristics, androgen deprivation therapy, depression, and Eastern Cooperative Oncology Group functional status. Poor control of modifiable cardiovascular risk factors is common in men with PC, highlighting thelargegap in care and the need for improved interventions to optimize cardiovascular risk management inthispopulation.

Clinician perceptions of a clinical decision support system to reduce cardiovascular risk among prediabetes patients in a predominantly rural healthcare system

BackgroundThe early detection and management of uncontrolled cardiovascular risk factors among prediabetes patients can prevent cardiovascular disease (CVD). Prediabetes increases the risk of CVD, which is a leading cause of death in the United States. CVD clinical decision support (CDS) in primary care settings has the potential to reduce cardiovascular risk in patients with prediabetes while potentially saving clinicians time. The objective of this study is to understand primary care clinician (PCC) perceptions of a CDS system designed to reduce CVD risk in adults with prediabetes.MethodsWe administered pre-CDS implementation (6/30/2016 to 8/25/2016) (n = 183, 61% response rate) and post-CDS implementation (6/12/2019 to 8/7/2019) (n = 131, 44.5% response rate) independent cross-sectional electronic surveys to PCCs at 36 randomized primary care clinics participating in a federally funded study of a CVD risk reduction CDS tool. Surveys assessed PCC demographics, experiences in delivering prediabetes care, perceptions of CDS impact on shared decision making, perception of CDS impact on control of major CVD risk factors, and overall perceptions of the CDS tool when managing cardiovascular risk.ResultsWe found few significant differences when comparing pre- and post-implementation responses across CDS intervention and usual care (UC) clinics. A majority of PCCs felt well-prepared to discuss CVD risk factor control with patients both pre- and post-implementation. About 73% of PCCs at CDS intervention clinics agreed that the CDS helped improve risk control, 68% reported the CDS added value to patient clinic visits, and 72% reported they would recommend use of this CDS system to colleagues. However, most PCCs disagreed that the CDS saves time talking about preventing diabetes or CVD, and most PCCs also did not find the clinical domains useful, nor did PCCs believe that the clinical domains were useful in getting patients to take action. Finally, only about 38% reported they were satisfied with the CDS.ConclusionsThese results improve our understanding of CDS user experience and can be used to guide iterative improvement of the CDS. While most PCCs agreed the CDS improves CVD and diabetes risk factor control, they were generally not satisfied with the CDS. Moreover, only 40–50% agreed that specific suggestions on clinical domains helped patients to take action. In spite of this, an overwhelming majority reported they would recommend the CDS to colleagues, pointing for the need to improve upon the current CDS.Trial registration: NCT02759055 03/05/2016.

Depression and cardiovascular risk in primary care patients

ObjectiveThis study assessed the relationship of both depression diagnosis and clinically significant depressive symptoms with individual cardiovascular risk factors and estimated total cardiovascular risk in primary care patients. MethodsThis study used a cross-sectional and retrospective design. Patients who had a primary care encounter between January 2016 and September 2018 and completed depression screening (PHQ-9) during the year prior to their appointment (N = 70,980) were included in this study. Data examining estimated total cardiovascular risk, specific cardiovascular risk factors, and relevant clinical diagnoses (including depression diagnosis) were extracted from the electronic health record. Patients were categorized into three groups: no depression (PHQ-9 < 10 and no depression diagnosis), controlled depression (PHQ-9 < 10 with previous depression diagnosis), and current depression (PHQ-9 ≥ 10). Groups were compared on estimated total risk and specific cardiovascular risk factors (e.g., body mass index [BMI], smoking status, lipids, blood pressure, and glucose). ResultsIn adjusted analyses, patients with current depression (n = 18,267) demonstrated significantly higher 10-year and 30-year cardiovascular risk compared to patients with controlled depression (n = 33,383; 10-year: b = 0.59 [95% CI = 0.44,0.74]; 30-year: OR = 1.32 [95% CI = 1.26,1.39]) and patients without depression (n = 19,330; 10-year: b = 0.55 [95% CI = 0.37,0.73]; 30-year: OR = 1.56 [95% CI = 1.48,1.65]). Except for low-density lipoprotein (LDL), patients with current depression had the greatest cardiovascular risk across specific risk factors. ConclusionsIndividuals who had a depression diagnosis and clinically significant depressive symptoms had the greatest cardiovascular risk. Pathways to prevent cardiovascular disease in those with depression might focus on treating depressive symptoms as well as specific uncontrolled cardiovascular risk factors.

Impact of a cardio-oncology unit on prevention of cardiovascular events in cancer patients.

AimsAs the world population grows older, the co‐existence of cancer and cardiovascular comorbidities becomes more common, complicating management of these patients. Here, we describe the impact of a large Cardio‐Oncology unit in Southern Italy, characterizing different types of patients and discussing challenges in therapeutic management of cardiovascular complications.Methods and resultsWe enrolled 231 consecutive patients referred to our Cardio‐Oncology unit from January 2015 to February 2020. Three different types were identified, according to their chemotherapeutic statuses at first visit. Type 1 included patients naïve for oncological treatments, Type 2 patients already being treated with oncological treatments, and Type 3 patients who had already completed cancer treatments. Type 2 patients presented the highest incidence of cardiovascular events (46.2% vs. 12.3% in Type 1 and 17.9% in Type 3) and withdrawals from oncological treatments (5.1% vs. none in Type 1) during the observation period. Type 2 patients presented significantly worse 48 month‐survival (32.1% vs. 16.7% in Type 1 and 17.9% in Type 3), and this was more evident when in the three groups we focused on patients with uncontrolled cardiovascular risk factors or overt cardiovascular disease at the first cardiologic assessment. Nevertheless, these patients showed the greatest benefit from our cardiovascular assessments, as witnessed by a small, but significant improvement in ejection fraction during follow‐up (Type 2b: from 50 [20; 67] to 55 [35; 65]; P = 0.04).ConclusionsPatients who start oncological protocols without an accurate baseline cardiovascular evaluation are at major risk of developing cardiac complications due to antineoplastic treatments.

Impact of diet on the management of cardiovascular risk factors

Summary Background and aims A healthy diet is recommended for the management of hypertension, dyslipidaemia and diabetes. Whether a healthy diet contributes to risk factor control has seldom been assessed. We aimed at assessing the dietary intake of subjects treated for cardiovascular risk factors according to their control levels. Methods Cross-sectional data from two periods (2009-2012 and 2014-2017) of a population-based study conducted in Lausanne, Switzerland. Participants medically treated for hypertension, dyslipidaemia or diabetes were included. Dietary intake was assessed using a self-administered, semi-quantitative food frequency questionnaire, and compared between participants controlled and not controlled for their risk factor. Results After multivariable adjustment, controlled hypertension was associated with a higher compliance with fish consumption in the second period: odds ratio and (95% CI): 1.41 (1.08-1.85). Controlled dyslipidaemia was associated with a higher compliance with fish consumption in both periods: 1.68 (1.13-2.49) and 2.13 (1.24-3.66) for the first and the second period, respectively, and with at least three dietary guidelines in the second period: 2.32 (1.04-5.19). Controlled diabetes was associated with a lower consumption of total fat (32.7±0.7 vs. 35.6±0.6% of total energy intake), SFA and MUFA in the first period, and with a lower vegetable consumption and compliance with vegetables intake in the second period: 0.23 (0.06-0.82). No difference was found for most dietary markers for the three risk factors in both periods. Conclusion Dietary intake differed little between participants with controlled and uncontrolled cardiovascular risk factors. Increased fish consumption might be beneficial to help control hypertension and dyslipidaemia.

Impact of chronic coronary syndromes on cardiovascular hospitalization and mortality: the ESC-EORP CICD-LT registry

Abstract Background In Europe, global data on guideline adherence, potential geographic variations and determinants of major clinical events in chronic coronary syndromes (CCS) remain suboptimal. The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Chronic Ischemic Cardiovascular Disease Long-Term (CICD-LT) registry, a prospective European registry, was designed and conducted to describe the profile, care and outcomes of patients with CCS across the ESC countries Purpose We aimed to investigate clinical events at one-year follow-up from the ESC EORP CICD-LT Registry and identify the variables associated with an increased risk of clinical events. Methods Consecutive adults presenting with a diagnosis of CCS during a routine ambulatory visit or an elective coronary revascularisation procedure at participating centres were recruited across 154 centers from 20 countries between 1 May 2015 and 31 July 2018. Information on clinical and survival status was collected after 1 year from study inclusion. Composite events were cardio-vascular (CV) mortality and/or CV rehospitalisations, all-cause mortality and/or all cause rehospitalisation. A multivariable Cox regression analysis was performed to identify the independent predictors of each composite. Cox models were also performed with age, sex and region forced in the model. Significance levels of 0.05 were required to allow a variable to stay within the model. Co-linearity between all candidate variables (variables with p&amp;lt;0.05 in univariable) within the model and variables considered of relevant clinical interest were tested before proceeding to the multivariable model. Missing data were not imputed. Results One-year outcomes of 6655 patients from the 9174 recruited in this European registry were analyzed. Overall, 168 patients (2.5%) died, mostly from CV causes (n=97, 1.5%). Northern Europe had the lowest CV mortality rate, while southern Europe had the highest (0.5% vs 2.0%, p=0.04). Women had a higher rate of CV mortality compared with men (2.0% vs 1.3%, p=0.02). During follow-up, 1606 patients (27.1%) were hospitalised at least once, predominantly for CV indications (n=1220, 20.6%). Among the population with measured LDL-cholesterol level at one year, 1434 patients (66.5%) were above the currently recommended target. Age, history of atrial fibrillation, previous stroke, liver disease, chronic obstructive pulmonary disease or asthma, increased serum creatinine and impaired left ventricular function were each independently associated with an increased risk of CV death or hospitalization. Conclusion In the CICD registry, the majority of patients with CCS have uncontrolled CV risk factors. The mortality rate at one year was low, but these patients are frequently hospitalised for CV causes. Early identification of comorbidities may represent an opportunity for enhanced care and better outcomes. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): The study was funded by the EORP program.

Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams.

Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care. The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes. This was a quasi-experimental study with a comparator group. The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices). Our outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated. In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program. Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.

Prevalence of untreated and uncontrolled cardiovascular risk factors in survivors of allogeneic cell transplantation.

Cardiovascular risk factors (CVRF) are frequent among long-term survivors after allogeneic hematopoietic cell transplantation (HCT) but prospective data on CVRF are sparse. We conducted a cross-sectional single center study including patients who underwent a first HCT mostly for hematologic malignancies at our center between 2000 and 2016, surviving at least 1 year. 260 patients (median age 54 years [range 19-78], 40% female) who were median 6 years (range 1-16) after transplantation were included. Most patients (232, 89%) had peripheral blood stem cell transplantation. cGVHD was present in 41% at the time of study inclusion. Prevalence of hypertension, dyslipidemia, and diabetes was 58%, 63% and 9%, respectively. Untreated hypertension, dyslipidemia and diabetes was found in 15%, 35% and 2%. Among patients with treated hypertension, 38% did not have blood pressure controlled to levels ≤140/90 mmHg. 36% patients under lipid-lowering therapy did not reach their LDL target. Multivariable logistic regression analyses showed that age and diabetes increased the likelihood for hypertension and dyslipidemia, whereas body mass index, cGVHD and male sex predicted hypertension only. In summary, CVRF in long-term survivors are frequent and persisting after cessation of immunosuppression. A large proportion of CVRF are either untreated or uncontrolled.

DEVELOPMENT OF EXPERT SYSTEM TO IMPROVE THE MANAGEMENT AND COMPLIANCE OF THERAPEUTIC RECOMMENDATIONS IN WORKING POPULATION WITH VERY HIGH CARDIOVASCULAR RISK

Objective: The aim of this study was to implement an expert system (ES) to help professionals in clinical decision-making by providing an assessment of the health of workers at very high cardiovascular risk (CVR), in a Mutual insurance company that collaborates with the National Social Security. Design and method: Prospective cohort study. An expert web operating system was developed to assess uncontrolled cardiovascular risk factors (CVRF) such as smoking, diabetes mellitus or hypertension. The system is applied to patients with very high CVR (SCORE >= 10) based on the criteria of the European Guidelines on Cardiovascular Disease Prevention. In the case of specifying an intervention or modification of pharmacological treatment, the expert system proposes a therapeutic scheme. Results: To date, 148 cases (all male, with a mean age of 64.5 ± 8.3 years) have been managed through the expert system. Although 73.6% were hypertensive and the prevalence of dyslipidemia was 55.2%, only 50.7% and 34.3% of them were receiving antihypertensive and/or lipid-lowering treatment respectively, at baseline. After a 1-year follow-up, significant differences were observed in the percentage of patients who met the goal of a controlled blood pressure and cholesterol. Conclusions: These results suggest that the use of an expert system is useful to improve the management and compliance of therapeutic recommendations in workers with very high CVR.

Abstract WP518: Use of American Heart Association/American Stroke Association Secondary Stroke Prevention Recommendations in Hispanic/Latino Adults With Stroke/TIA: The Hispanic Community Health Study/Study of Latinos

Background: Population studies showed that Hispanic/Latino adults have elevated rates of uncontrolled cardiovascular risk factors (CVRFs) with noticeable sex-specific variations . We investigated prevalence of CVRFs and the use of American Heart Association (AHA) secondary stroke prevention strategies in Hispanics/Latinos in the United States. Methods: Data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) were used to examine sociodemographic characteristics, use of antithrombotic agents and statins, and treatment of CVRFs in persons with a history of stroke or transient ischemic attack (TIA). CVRFs were categorized as “controlled” if the CVRF met the goals defined by the AHA irrespective of whether the subject was on treatment for it or not; and “unaware” if the participant denied having a CVRF but met the diagnostic criteria for it. Differences between men and women were tested using ANOVA test and Pearson’s χ 2 . Factors associated with adherence to AHA recommendations were investigated using logistic regression. Results: These analyses included 404 individuals with history of stroke/TIA (men=159; women=245). Women were slightly older than men (55.1±1.5 vs. 54.1±1.6 years; p&lt;0.0001). The prevalence of hypertension (HTN), hypercholesterolemia (HC), and diabetes (DM) were 59%, 65% and 39%. The rates of awareness/controlled CVRFs were 90%/49%, 75%/32%, and 83%/54% for HTN, HC, and DM, respectively. Approximately 49% of the individuals were on antithrombotic agents, 39% on statins, and 26% on dual treatment with antithrombotics and statins. Rates were comparable between men and women except for HC control which was lower in women (41±6% vs. 23±5%; p=0.02). In logistic regression analysis, older age was associated with poorer adherence to AHA recommendations. Female sex and residence &gt;10 years in the US were associated with uncontrolled HC and DM, respectively. Conclusion: Hispanics/Latinos with stroke have elevated rates of awareness but suboptimal use of AHA secondary stroke prevention strategies. Older persons and women are vulnerable groups that may benefit from targeted interventions.

Premature atrial and ventricular complexes in outpatients referred from a primary care facility.

BackgroundPremature complexes are common electrocardiographic findings in daily clinical practice that require further evaluation. Investigation may sometimes be complex and expensive. The aim of our study was to analyze variables associated with premature beats identified in outpatients referred from a primary care facility.Materials and methodsWe performed a cross-sectional study of 407 outpatients (aged 55.8±11years; 56% women) who were followed by general practitioners and were referred for resting 12-lead electrocardiograms for a routine clinical follow-up. After signing informed consent, patients answered a questionnaire and underwent physical examinations, laboratory diagnostics, transthoracic echocardiograms and 24-hour Holter monitoring to evaluate for the presence of premature complexes. After the univariate analyses, logistic regression analyses were performed with adjustment for age, sex, and cardiovascular diseases.ResultsPremature complexes distribution revealed that they were frequent but with low density. Premature atrial complexes (≥ 4/hours) were associated with age (Odds Ratio (OD) = 1.030, Confidence Interval (CI) 95% = 1.002 ─ 1.059, p = 0.029), brain natriuretic peptide (BNP) levels > 20mg/dL (OR = 4.489, 95%CI = 1.918 ─ 10.507, p = 0.0005), intraventricular blocks (OR = 4.184, 95%CI = 1.816 ─ 9.406, p = 0.0005) and left atrial diameter (OR = 1.065, 95%CI = 1.001 ─ 1.134, p = 0.046). Premature ventricular complexes (≥ 5/hour) were related to age (OR = 1.032, 95%CI = 1.010 ─ 1.054, p = 0.004), the use of calcium channel blockers (OR = 2.248, 95%CI = 1.019 ─ 4.954, p = 0.045), HDL-cholesterol levels (OR = 0.971, 95%CI = 0.951 ─ 0.992, p = 0.007), BNP levels > 20mg/dL (OR = 2.079, 95%CI = 0.991 ─ 0.998, p = 0.033), heart rate (OR = 1.019, 95%CI = 1.001 ─ 1.038, p = 0.041), left ventricular hypertrophy (OR = 2.292, 95%CI = 1.402 ─ 3.746, p = 0.001) and left ventricular ejection fraction (OR = 0.938, 95%CI = 0.900 ─ 0.978, p = 0.002).ConclusionsPremature complexes had low density and were associated with BNP levels > 20mg/dL, lower levels of HDL-cholesterol, left atrial enlargement and ventricular hypertrophy. The identification of premature complexes on 24-hour Holter monitor recordings of outpatients in a primary public healthcare setting was associated with uncontrolled cardiovascular risk factors that may be addressed with medical advice and therapy in a primary care setting.

Coronaropathie de la femme : rôle des hormones sexuelles

During their lives, women go through three different phases during which sex hormones play a fundamental role in contributing to specific cardiovascular and coronary risks. To evaluate this risk, we must take into account these various phases with their associated cardiovascular risk factors, and this during three key steps: contraception, pregnancy and menopause. Arterial risk linked to estrogen combined with progestin contraception, depends on the dosage of estrogen. The main cardiovascular risk factor responsible for increasing the risk of myocardial infarction is tobacco, especially after 35 years of age, contraindicating estrogen combined with progestin contraception at the benefit of progestin. Spontaneous dissections and coronary emboli are the most common coronary lesions linked with oestroprogestative contraception. Acute myocardial infarction during pregnancy occurs mostly in the peripartum or postpartum period; and is often caused by spontaneous coronary dissection lesions. Fertility treatment is not associated with an increased risk of developing cardiovascular disease later in life. Hormone therapy during menopause does not increase coronary risk in the first 10 years after menopause and may even have a protective effect, by sustaining arterial integrity. The transdermal route is to be preferred for its metabolic effect. Hormonal treatment during menopause is nonetheless contraindicated in the case of proven coronary disease and uncontrolled cardiovascular risk factors.

Impact of cardiovascular risk factor control on long-term cardiovascular and all-cause mortality in the general population

Purpose: In clinical trials, lowering cardiovascular risk factors (CVRFs) reduces cardiovascular (CV) morbidity and mortality. We assessed the impact of controlling CVRFs at baseline on long-term all-cause and CV mortality in the general population.Methods: Analysis was based on the Third French MONICA population-based survey (1994–1997). Vital status was obtained 18 years after inclusion. Statistical analysis was based on Cox-modelling.Results: About 3402 participants aged 35–64 were included and 569 (17%) presented with 2 or more uncontrolled CVRFs, 1194 (35%) had one uncontrolled CVRF, 770 (23%) had all CVRFs controlled under treatment (or were former smokers) and 869 (25%) exhibited no CVRF. During the follow-up, 389 deaths occurred (76 were due to CV causes). Considering all-cause mortality, the adjusted hazard ratios (aHR) for subjects with one uncontrolled CVRF and for those with two or more were 1.38 [1.03–1.83] (p = 0.029) and 1.80 [1.33–2.43](p < 0.001), respectively, as compared with subjects presenting with all their CVRFs controlled. For subjects exhibiting no CVRF, the aHR was 0.66 [0.44–0.98] (p = 0.042). Considering CV mortality, aHRs for subjects presenting with one and two or more uncontrolled CVRF were 1.70 [0.84–3.42] (p = 0.138) and 3.67 [1.85–7.29] (p < 0.001), respectively, as compared with subjects who had either all their CVRFs controlled or exhibited no CVRF.Conclusions: Failing to control CVRFs significantly increases long-term all-cause and CV mortality in the French general population.Key messagesOnly 30% of patients with cardiovascular risk factors were controlled.Failing to control cardiovascular risk factors significantly increased long-term cardiovascular and all-cause mortality.A residual risk for all-cause mortality remained even when patients were controlled.

Abstract 170: High Prevalence of Uncontrolled Cardiovascular Risk Factors in a Majority Hispanic Cohort of People Living with HIV

Objective: Chronic HIV infection itself confers cardiovascular (CV) risk, but CV risk reduction is often not a focus in the primary care of people living with HIV (HIV+). We examined the prevalence and predictors of poor control of CV risk factors (RF) in a predominantly Hispanic HIV+ cohort. Methods: From the South Texas HIV Cohort, a registry of HIV+ patients in a public primary care clinic and serving the entire region, we used electronic medical record (EMR) data to assess control of 5 CV RFs in a cross-sectional study. We selected HIV+ adults with ≥2 HIV clinic visits in 2013 and identified: active smokers, uncontrolled hypertension (HTN), elevated cholesterol, obesity, and uncontrolled diabetes mellitus (DM). Active smokers were documented as having ongoing use in 2013. Persons with uncontrolled HTN had ≥2 blood pressures &gt;140/90 mmHg. A total cholesterol &gt;200mg/dl was categorized as poorly controlled. Persons with obesity had median BMI ≥30kg/m 2 in 2013. Among persons with DM based on ≥2 ICD-9-CM diagnosis codes or a hemoglobin A1c ≥6.5%, uncontrolled DM was defined as any A1c ≥8%. Virologic suppression was defined as all HIV-1 plasma RNA measurements &lt;200 copies/ml in 2013. Logistic regressions were used to predict the odds of ≥1 RF and of each RF separately adjusting for years living with HIV, age, race, gender, insurance, HIV risk factor, HCV infection, substance abuse and virologic suppression. Results: Of 1696 patients meeting inclusion criteria, the median age was 44.8 yr (IQR: 34.5, 51.5), 76.3% were men, 61.6% Hispanic, and 17.7% African American. The most common HIV RF was men who have sex with men (MSM, 56.4%); 82.6% of the cohort was receiving antiretroviral therapy and 60.5% were virologically suppressed. DM was found in 14.4% of the cohort. At least 1 CV RF was present for 69.5% (1180 of 1698). The proportions with each RF were: 32.0% active smoking, 25.6% uncontrolled HTN, 15.4% uncontrolled cholesterol, and 27.7% obese; 28.3% DM were uncontrolled (69 of 244). Multiple CV RFs (≥2) were present for 27.8% of the cohort. Medicaid insurers were 80% more likely to have multiple CV RFs than Medicare insurers (AOR=1.80, 95% CI: 1.12, 2.91); and patients with heterosexual transmission were 47% more likely to have multiple CV RFs than those with MSM (AOR=1.47, 95% CI: 1.06, 2.05). Women were more than twice as likely to be obese than men (AOR=2.55; 95% CI: 1.80, 3.63). Conclusions: In this majority Hispanic HIV+ cohort, 70% of patients had at ≥1 uncontrolled CV risk factor and 28% had two. Persons with Medicaid insurance and heterosexual transmission were significantly more likely to have an uncontrolled CV risk factor, and women were more than twice as likely to be obese. Without population-appropriate CV risk reduction interventions, the life expectancy gains achieved with highly active antiretroviral therapy in this vulnerable population are jeopardized by the threat of CV morbidity and mortality.