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Hecht H, Blaha MJ, Berman DS, Nasir K, Budoff M, Leipsic J, Blankstein R, Narula J, Rumberger J, Shaw LJ. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:157-168. [PMID: 28283309 DOI: 10.1016/j.jcct.2017.02.010] [Citation(s) in RCA: 217] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 12/21/2022]
Abstract
This expert consensus statement summarizes the available data regarding the prognostic value of CAC in the asymptomatic population and its ability to refine individual risk prediction, addresses the limitations identified in the current traditional risk factor-based treatment strategies recommended by the 2013 ACC/AHA Prevention guidelines including use of the Pooled Cohort Equations (PCE), and the US Preventive Services Task Force (USPSTF) Recommendation Statement for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. It provides CAC based treatment recommendations both within the context of the shared decision making model espoused by the 2013 ACC/AHA Prevention guidelines and independent of these guidelines.
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Affiliation(s)
- Harvey Hecht
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Medical Center, New York, NY, USA.
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Daniel S Berman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Khurram Nasir
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
| | - Matthew Budoff
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Medical Center, New York, NY, USA
| | | | - Leslee J Shaw
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
While mortality rates related to cardiovascular disease (CVD) have decreased over time among adults with HIV, excess risk of CVD in the HIV-infected population may persist despite highly active antiretroviral therapy (HAART) treatment and aggressive CVD risk factor control. Beyond atherosclerotic CVD, recent studies suggest that HIV infection may be associated with left ventricular systolic and diastolic function, interstitial myocardial fibrosis, and increased cardiac fat infiltration. Thus, with the increasing average age of the HIV-infected population, heart failure and arrhythmic disorders may soon rival coronary artery disease as the most prevalent forms of CVD. Finally, the question of whether HIV infection should be considered in clinical risk stratification has never been resolved, and this question has assumed new importance with recent changes to lipid treatment guidelines for prevention of CVD.
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Lu WC, Tzeng NS, Kao YC, Yeh CB, Kuo TBJ, Chang CC, Chang HA. Correlation between health-related quality of life in the physical domain and heart rate variability in asymptomatic adults. Health Qual Life Outcomes 2016; 14:149. [PMID: 27765048 PMCID: PMC5073888 DOI: 10.1186/s12955-016-0555-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/14/2016] [Indexed: 01/02/2023] Open
Abstract
Background Reduced health-related quality of life in the physical domain (HRQOLphysical) has been reported to increase risks for cardiovascular disease (CVD); however, the mechanism underlying this phenomenon is still unclear. The autonomic nervous system (ANS) that connects the body and mind is a biologically plausible candidate to investigate this mechanism. The aim of our study is to examine whether the HRQOLphysical independently contributes to heart rate variability (HRV), which reflects ANS activity. Methods We recruited 329 physically and mentally healthy adults. All participants completed Beck Anxiety Inventory, Beck Depression Inventory and World Health Organization Questionnaire on Quality of Life: Short Form-Taiwanese version (WHOQOL-BREF). They were divided into groups of individuals having high or low scores of HRQOLphysical as discriminated by the quartile value of WHOQOL-BREF. We obtained the time and frequency-domain indices of HRV, namely variance (total HRV), the low-frequency power (LF; 0.05–0.15 Hz), which may reflect baroreflex function, the high-frequency power (HF; 0.15–0.40 Hz), which reflects cardiac parasympathetic activity, and the LF/HF ratio. Results There was an independent contribution of HRQOLphysical to explaining the variance in HRV after excluding potential confounding factors (gender, age, physical activity, alcohol use, depression and anxiety). Compared with the participants with high levels of HRQOLphysical, those with low levels of HRQOLphysical displayed significant reductions in variance and LF. Conclusions This study highlights the independent role of low HRQOLphysical in contributing to the reduced HRV in healthy adults and points to a potential underlying mechanism for HRQOLphysical to confer increased risks for CVD.
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Affiliation(s)
- Wan-Chun Lu
- Department of Psychiatry, Tri-Service General Hospital National Defense Medical Center, No. 325, Cheng-Kung Road, Sec. 2, Nei-Hu District, 114, Taipei, Taiwan
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital National Defense Medical Center, No. 325, Cheng-Kung Road, Sec. 2, Nei-Hu District, 114, Taipei, Taiwan.,Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Chen Kao
- Department of Psychiatry, Tri-Service General Hospital Songshan Branch, Taipei, Taiwan
| | - Chin-Bin Yeh
- Department of Psychiatry, Tri-Service General Hospital National Defense Medical Center, No. 325, Cheng-Kung Road, Sec. 2, Nei-Hu District, 114, Taipei, Taiwan
| | - Terry B J Kuo
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan
| | - Chuan-Chia Chang
- Department of Psychiatry, Tri-Service General Hospital National Defense Medical Center, No. 325, Cheng-Kung Road, Sec. 2, Nei-Hu District, 114, Taipei, Taiwan.
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital National Defense Medical Center, No. 325, Cheng-Kung Road, Sec. 2, Nei-Hu District, 114, Taipei, Taiwan.
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Abstract
Current American College of Cardiology/American Heart Association guidelines for the management of patients with elevated blood cholesterol increasingly emphasize assessment of atherosclerotic cardiovascular disease (ASCVD) risk in deciding when to initiate pharmacotherapy. The decision to treat is based primarily on mathematical integration of traditional risk factors, including age, sex, race, lipid values, systolic blood pressure, hypertension therapy, diabetes mellitus, and smoking. Advanced risk testing is selectively endorsed for patients when the decision to treat is otherwise uncertain, or more broadly interpreted as those patients who are at so-called "intermediate risk" of ASCVD events using traditional risk factors alone. These new guidelines also place new emphasis on a clinician-patient risk discussion, a process of shared decision making in which patient and physician consider the potential benefits of treatment, risk of adverse events, and patient preferences before making a final decision to initiate treatment. Advanced risk testing is likely to play an increasingly important role in this process as weaknesses in exclusive reliance on traditional risk factors are recognized, new non-statin therapies become available, and guidelines are iteratively updated. Comparative efficacy studies of the various advanced risk testing options suggest that coronary artery calcium scoring is most strongly predictive of ASCVD events. Most importantly, coronary artery calcium scoring appears to identify an important subgroup of patients with advanced subclinical atherosclerosis-who are "between" primary and secondary prevention-that might benefit from the most aggressive lipid-lowering pharmacotherapy.
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Affiliation(s)
- Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease and Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Qureshi WT, Rana JS, Yeboah J, Bin Nasir U, Al-Mallah MH. Risk Stratification for Primary Prevention of Coronary Artery Disease: Roles of C-Reactive Protein and Coronary Artery Calcium. Curr Cardiol Rep 2016; 17:110. [PMID: 26482753 DOI: 10.1007/s11886-015-0666-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Risk stratification of individuals at risk for atherosclerotic cardiovascular disease (ASCVD) plays an important role in primary prevention of cardiovascular disease. In addition to risk scores derived from conventional cardiovascular risk factors, high sensitivity C-reactive protein (hs-CRP) and coronary artery calcium (CAC) have emerged as two of the widely accepted non traditional risk factors for atherosclerotic disease that have shown incremental prognostic value in predicting cardiovascular events. This review systematically assesses the role of hs-CRP and CAC in various studies and demonstrates meta-analyses of the incremental prognostic value of hs-CRP and CAC in identifying patients at risk of future CVD events. Compared with this, CAC showed better incremental prognostic value and might be a better indicator of ASCVD risk in asymptomatic adults.
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Affiliation(s)
- Waqas T Qureshi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27157, USA.
| | - Jamal S Rana
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, CA, 94609, USA.,Department of Medicine, University of California, San Francisco, San Francisco, CA, 94143, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, 94609, USA
| | - Joseph Yeboah
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27157, USA
| | - Usama Bin Nasir
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27157, USA
| | - Mouaz H Al-Mallah
- Cardiac Imaging King Abdul-Aziz Cardiac Center, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical research center, Riyadh, Kingdom of Saudi Arabia
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Giner-Galvañ V, Esteban-Giner MJ, Pallarés-Carratalá V. Overview of guidelines for the management of dyslipidemia: EU perspectives. Vasc Health Risk Manag 2016; 12:357-369. [PMID: 27660458 PMCID: PMC5019442 DOI: 10.2147/vhrm.s89038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Modern medicine is characterized by a continuous genesis of evidence making it very difficult to translate the latest findings into a better clinical practice. Clinical practice guidelines (CPG) emerge to provide clinicians evidence-based recommendations for their daily clinical practice. However, the high number of existing CPG as well as the usual differences in the given recommendations usually increases the clinician’s confusion and doubts. It has apparently been the case for the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of Blood Cholesterol. These CPG proposed new and controversial concepts that have usually been considered an antagonist shift respective to European CPG. The most controversial published proposals are: 1) to consider evidence just from randomized clinical trials, 2) creation of a new cardiovascular (CV) risk calculator, 3) to consider reducing CV risk instead of reducing low-density lipoprotein cholesterol (LDLc) as the target of the treatment, and 4) consideration of statins as the only drugs for treatment. A deep analysis of the 2013 American College of Cardiology/American Heart Association CPG and comparison with the European ones show that from a practical and clinical point of view, there are more similarities than differences. To further help clinicians in their daily work, in the present globalized world, it is time to discuss and adopt a mutually agreed upon document created by both sides of the Atlantic. Probably it is not a short-term solution. Meanwhile, taking advantage of the similarities, the recommended practical attitude for the daily clinical practice should be based on 1) early detection of people with increased CV risk promoting the use of validated local scales, 2) reinforce the mainstream importance of nonpharmacological treatment, and 3) need for periodically monitoring response with analytical parameters (LDL or non-high-density lipoprotein cholesterol) and global CV risk estimation. Technological solutions such as the big data technology could help to obtain high-quality evidence in an intermediate term.
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Affiliation(s)
- Vicente Giner-Galvañ
- Department of General Internal Medicine, Unit of Hypertension and Cardiometabolic Risk, Hospital Mare de Déu dels Lliris, Alcoy, Alicante
| | - María José Esteban-Giner
- Department of General Internal Medicine, Unit of Hypertension and Cardiometabolic Risk, Hospital Mare de Déu dels Lliris, Alcoy, Alicante
| | - Vicente Pallarés-Carratalá
- Department of Health Surveillance, Unión de Mutuas, Castellón de la Plana; Department of Medicine, Universitat Jaume I, Castellón, Spain
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Kianoush S, Al Rifai M, Whelton SP, Shaya GE, Bush AL, Graham G, Wong ND, Blaha MJ. Stratifying cardiovascular risk in diabetes: The role of diabetes-related clinical characteristics and imaging. J Diabetes Complications 2016; 30:1408-15. [PMID: 27179751 DOI: 10.1016/j.jdiacomp.2016.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 02/07/2023]
Abstract
Diabetes is a major coronary heart disease (CHD) and cardiovascular disease (CVD) risk factor and has traditionally been classified as a CHD risk equivalent. CVD risk, however, is heterogeneous among diabetic patients and thus further evaluation is warranted before initiating or titrating preventive pharmacotherapy. Prognostic clinical characteristics of diabetes such as age of onset, duration, and severity of diabetes, as well as concomitant cardiometabolic factors account for much of the variability in CHD and CVD risk. This heterogeneity can also be evaluated directly using non-invasive imaging, which allows for a more individualized risk assessment in order to minimize both under and overtreatment. In this paper, we review guideline recommendations for atherosclerotic CVD risk assessment driving the use of statins or aspirin for certain subgroups of patients with diabetes. We further discuss imaging techniques, such as stress myocardial perfusion imaging, coronary computed tomography angiography, and coronary artery calcium (CAC) scoring that can guide the decision to treat high-risk patients. Among imaging tests, current guidelines consider CAC scoring the most appropriate risk stratification tool for asymptomatic individuals with diabetes that can guide initiating/intensifying or withholding the most aggressive pharmacological therapies among high-risk (CAC>100) or low-risk (CAC=0) individuals, respectively.
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Affiliation(s)
- Sina Kianoush
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | - Mahmoud Al Rifai
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | | | - Aaron L Bush
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
| | - Garth Graham
- Aetna Foundation, Hartford, CT, USA; University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Nathan D Wong
- Division of Cardiology, University of California, Irvine, Irvine, CA, USA.
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins, Baltimore, MD, USA.
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Khamis RY, Hughes AD, Caga-Anan M, Chang CL, Boyle JJ, Kojima C, Welsh P, Sattar N, Johns M, Sever P, Mayet J, Haskard DO. High Serum Immunoglobulin G and M Levels Predict Freedom From Adverse Cardiovascular Events in Hypertension: A Nested Case-Control Substudy of the Anglo-Scandinavian Cardiac Outcomes Trial. EBioMedicine 2016; 9:372-380. [PMID: 27333022 PMCID: PMC4972545 DOI: 10.1016/j.ebiom.2016.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/20/2016] [Accepted: 06/06/2016] [Indexed: 10/25/2022] Open
Abstract
AIMS We aimed to determine whether the levels of total serum IgM and IgG, together with specific antibodies against malondialdehyde-conjugated low-density lipoprotein (MDA-LDL), can improve cardiovascular risk discrimination. METHODS AND RESULTS The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) randomized 9098 patients in the UK and Ireland into the Blood Pressure-Lowering Arm. 485 patients that had cardiovascular (CV) events over 5.5years were age and sex matched with 1367 controls. Higher baseline total serum IgG, and to a lesser extent IgM, were associated with decreased risk of CV events (IgG odds ratio (OR) per one standard deviation (SD) 0.80 [95% confidence interval, CI 0.72,0.89], p<0.0001; IgM 0.83[0.75,0.93], p=0.001), and particularly events due to coronary heart disease (CHD) (IgG OR 0.66 (0.57,0.76); p<0.0001, IgM OR 0.81 (0.71,0.93); p=0.002). The association persisted after adjustment for a basic model with variables in the Framingham Risk Score (FRS) as well as following inclusion of C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (NtProBNP). IgG and IgM antibodies against MDA-LDL were also associated with CV events but their significance was lost following adjustment for total serum IgG and IgM respectively. The area under the receiver operator curve for CV events was improved from the basic risk model when adding in total serum IgG, and there was improvement in continuous and categorical net reclassification (17.6% and 7.5% respectively) as well as in the integrated discrimination index. CONCLUSION High total serum IgG levels are an independent predictor of freedom from adverse cardiovascular events, particularly those attributed to CHD, in patients with hypertension.
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Affiliation(s)
- Ramzi Y Khamis
- Vascular Sciences Section, NHLI, Imperial College London, United Kingdom
| | - Alun D Hughes
- International Centre for Circulatory Health, NHLI, Imperial College London, United Kingdom; Institute of Cardiovascular Science, University College London, United Kingdom
| | - Mikhail Caga-Anan
- Vascular Sciences Section, NHLI, Imperial College London, United Kingdom
| | - Choon L Chang
- International Centre for Circulatory Health, NHLI, Imperial College London, United Kingdom
| | - Joseph J Boyle
- Vascular Sciences Section, NHLI, Imperial College London, United Kingdom
| | - Chiari Kojima
- Vascular Sciences Section, NHLI, Imperial College London, United Kingdom
| | - Paul Welsh
- Division of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Naveed Sattar
- Division of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom
| | - Michael Johns
- Vascular Sciences Section, NHLI, Imperial College London, United Kingdom
| | - Peter Sever
- International Centre for Circulatory Health, NHLI, Imperial College London, United Kingdom
| | - Jamil Mayet
- International Centre for Circulatory Health, NHLI, Imperial College London, United Kingdom
| | - Dorian O Haskard
- Vascular Sciences Section, NHLI, Imperial College London, United Kingdom.
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Lee SH, Choi SH, Kim EK, Yang JH, Song YB, Hahn JY, Choi JH, Gwon HC, Lee SH, Kim DK. Borderline ankle-brachial index is associated with poor short-term clinical outcome after coronary artery intervention. Atherosclerosis 2016; 249:186-90. [PMID: 27124651 DOI: 10.1016/j.atherosclerosis.2016.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the association between borderline ankle-brachial index (ABI) and clinical outcome in patients who underwent percutaneous coronary intervention (PCI). METHODS From August 2009 to August 2012, ABI was measured in 1291 patients who underwent PCI. Patients with borderline ABI were compared with those who had normal ABI. The primary outcome was major adverse cardiac and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction, stroke, and repeat revascularization. RESULTS Of the 1291 patients, 1154 (82%) had normal ABI and 89 (7%) had borderline ABI. The median overall follow-up duration was 19 (interquartile range 13-26) months. After adjustment with IPTW, the incidence of stroke (HR, 6.28; CI 95%, 1.95-20.19; P < 0.01) and MACCE (HR, 2.54; CI 95%, 1.40-4.62; P < 0.01) were higher in the borderline ABI group. In a propensity score-matched population, the incidence of stroke (HR, 4.68; CI 95%, 1.18-18.52; p = 0.03) and MACCE (HR, 2.12; CI 95%, 1.09-4.11; P = 0.03) were still significantly higher. CONCLUSION The presence of borderline ABI was associated with worse clinical outcome and increased stroke rate compared with normal ABI during the short-term follow-up period in patients who underwent coronary intervention.
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Affiliation(s)
- Seung Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Hoon Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Duk-Kyung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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A history of preeclampsia is associated with a risk for coronary artery calcification 3 decades later. Am J Obstet Gynecol 2016; 214:519.e1-519.e8. [PMID: 26874301 DOI: 10.1016/j.ajog.2016.02.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/22/2016] [Accepted: 02/04/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND A history of preeclampsia is an independent risk factor for cardiac events and stroke. Changes in vasculature structure that contribute to these associations are not well understood. OBJECTIVE The aim of this study was to quantify coronary artery calcification (CAC), a known risk factor for cardiac events, in a prospective cohort of women with and without histories of preeclampsia. STUDY DESIGN Women without prior cardiovascular events (40 with and 40 without histories of preeclampsia, matched for parity and age at index birth) were recruited from a large population-based cohort of women who were residents of Olmsted County, Minnesota, and who delivered from 1976 through 1982. Computed tomography was performed to measure CAC in Agatston units. All pregnancy histories and covariates were confirmed by review of the medical records. Current clinical variables were assessed at the time of imaging. Differences between women with and without histories of preeclampsia were examined using χ(2) tests and tests; CAC, in particular, was compared as a categorical and ordinal variable, with a χ(2) test and with Wilcoxon 2-sample tests and ordinal logistic regression, as appropriate. RESULTS Mean age (SD) at imaging was 59.5 (±4.6) years. Systolic and diastolic blood pressures, hyperlipidemia, and current diabetes status did not differ between women with and without histories of preeclampsia. However, the frequencies of having a current clinical diagnosis of hypertension (60% vs 20%, P < .001) and higher body mass index in kg/m(2) (expressed as median [25th-75th percentile], 29.8 [25.9-33.7] vs 25.3 [23.1-32.0], P = .023) were both greater in the women with histories of preeclampsia compared to those without. The frequency of a CAC score >50 Agatston units was also greater in the preeclampsia group (23% vs 0%, P = .001). Compared to women without preeclampsia, the odds of having a higher CAC score was 3.54 (confidence interval [CI], 1.39-9.02) times greater in women with prior preeclampsia without adjustment, and 2.61 (CI, 0.95-7.14) times greater after adjustment for current hypertension. After adjustment for body mass index alone, the odds of having a higher CAC based on a history of preeclampsia remained significant at 3.20 (CI, 1.21-8.49). CONCLUSION In this first prospective cohort study with confirmation of preeclampsia by medical record review, a history of preeclampsia is associated with an increased risk of CAC >30 years after affected pregnancies, even after controlling individually for traditional risk factors. A history of preeclampsia should be considered in risk assessment when initiating primary prevention strategies to reduce cardiovascular disease in women. Among women with histories of preeclampsia, the presence of CAC may be able to identify those at a particularly high cardiovascular risk, and should be the subject of future studies.
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Thanassoulis G, Williams K, Altobelli KK, Pencina MJ, Cannon CP, Sniderman AD. Individualized Statin Benefit for Determining Statin Eligibility in the Primary Prevention of Cardiovascular Disease. Circulation 2016; 133:1574-81. [PMID: 26945047 DOI: 10.1161/circulationaha.115.018383] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 02/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines recommend statins in the primary prevention of cardiovascular disease on the basis of predicted cardiovascular risk without directly considering the expected benefits of statin therapy based on the available randomized, controlled trial evidence. METHODS AND RESULTS We included 2134 participants representing 71.8 million American residents potentially eligible for statins in primary prevention from the National Health and Nutrition Examination Survey for the years 2005 to 2010. We compared statin eligibilities using 2 separate approaches: a 10-year risk-based approach (≥7.5% 10-year risk) and an individualized benefit approach (ie, based on predicted absolute risk reduction over 10 years [ARR10] ≥2.3% from randomized, controlled trial data). A risk-based approach led to the eligibility of 15.0 million (95% confidence interval, 12.7-17.3 million) Americans, whereas a benefit-based approach identified 24.6 million (95% confidence interval, 21.0-28.1 million). The corresponding numbers needed to treat over 10 years were 21 (range, 9-44) and 25 (range, 9-44). The benefit-based approach identified 9.5 million lower-risk (<7.5% 10-year risk) Americans not currently eligible for statin treatment who had the same or greater expected benefit from statins (≥2.3% ARR10) compared with higher-risk individuals. This lower-risk/acceptable-benefit group includes younger individuals (mean age, 55.2 versus 62.5 years; P<0.001 for benefit based versus risk based) with higher low-density lipoprotein cholesterol (140 versus133 mg/dL; P=0.01). Statin treatment in this group would be expected to prevent an additional 266 508 cardiovascular events over 10 years. CONCLUSIONS An individualized statin benefit approach can identify lower-risk individuals who have equal or greater expected benefit from statins in primary prevention compared with higher-risk individuals. This approach may help develop guideline recommendations that better identify individuals who meaningfully benefit from statin therapy.
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Affiliation(s)
- George Thanassoulis
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.).
| | - Ken Williams
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Kathleen Kimler Altobelli
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Michael J Pencina
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Christopher P Cannon
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Allan D Sniderman
- From Preventive and Genomic Cardiology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, QC, Canada (G.T., A.D.S.); KenAnCo Biostatistics, San Antonio, TX (K.W., K.K.); Department of Medicine, University of Texas Health Science Center at San Antonio (K.W.); Duke Clinical Research Institute, Durham, NC (M.J.P.); and Harvard Clinical Research Institute and Brigham and Women's Hospital, Boston, MA (C.P.C.)
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An Update on the Utility of Coronary Artery Calcium Scoring for Coronary Heart Disease and Cardiovascular Disease Risk Prediction. Curr Atheroscler Rep 2016; 18:13. [DOI: 10.1007/s11883-016-0565-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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64
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Sanz J. Coronary Calcium Score and the New Guidelines. J Am Coll Cardiol 2015; 66:1669-71. [DOI: 10.1016/j.jacc.2015.08.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 11/28/2022]
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Superko HR. Nontraditional Markers of Cardiovascular Disease Risk Can Improve the 2013 American College of Cardiology/American Heart Association Prevention Guidelines: Insights From the Multi-Ethnic Study of Atherosclerosis Investigation. Circulation 2015. [PMID: 26224807 DOI: 10.1161/circulationaha.115.018141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- H Robert Superko
- From Cholesterol, Genetics, and Heart Disease Institute, Carmel, CA.
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