Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology

Assessment of Coronary Artery Calcium Scoring to Guide Statin Therapy Allocation According to Risk-Enhancing Factors: The Multi-Ethnic Study of Atherosclerosis

Importance

The 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol recommends the use of risk-enhancing factor assessment and the selective use of coronary artery calcium (CAC) scoring to guide the allocation of statin therapy among individuals with an intermediate risk of atherosclerotic cardiovascular disease (ASCVD).

Objective

To examine the association between risk-enhancing factors and incident ASCVD by CAC burden among those at intermediate risk of ASCVD.

Design, Setting, and Participants

The Multi-Ethnic Study of Atherosclerosis is a multicenter population-based prospective cross-sectional study conducted in the US. Baseline data for the present study were collected between July 15, 2000, and July 14, 2002, and follow-up for incident ASCVD events was ascertained through August 20, 2015. Participants were aged 45 to 75 years with no clinical ASCVD or diabetes at baseline, were at intermediate risk of ASCVD (≥7.5% to <20.0%), and had a low-density lipoprotein cholesterol level of 70 to 189 mg/dL.

Exposures

Family history of premature ASCVD, premature menopause, metabolic syndrome, chronic kidney disease, lipid and inflammatory biomarkers, and low ankle-brachial index.

Main Outcomes and Measures

Incident ASCVD over a median follow-up of 12.0 years.

Results

A total of 1688 participants (mean [SD] age, 65 [6] years; 976 men [57.8%]). Of those, 648 individuals (38.4%) were White, 562 (33.3%) were Black, 305 (18.1%) were Hispanic, and 173 (10.2%) were Chinese American. A total of 722 participants (42.8%) had a CAC score of 0. Among those with 1 to 2 risk-enhancing factors vs those with 3 or more risk-enhancing factors, the prevalence of a CAC score of 0 was 45.7% vs 40.3%, respectively. Over a median follow-up of 12.0 years (interquartile range [IQR], 11.5-12.6 years), the unadjusted incidence rate of ASCVD among those with a CAC score of 0 was less than 7.5 events per 1000 person-years for all individual risk-enhancing factors (with the exception of ankle-brachial index, for which the incidence rate was 10.4 events per 1000 person-years [95% CI, 1.5-73.5]) and combinations of risk-enhancing factors, including participants with 3 or more risk-enhancing factors. Although the individual and composite addition of risk-enhancing factors to the traditional risk factors was associated with improvement in the area under the receiver operating curve, the use of CAC scoring was associated with the greatest improvement in the C statistic (0.633 vs 0.678) for ASCVD events. For incident ASCVD, the net reclassification improvement for CAC was 0.067.

Conclusions and Relevance

In this cross-sectional study, among participants with CAC scores of 0, the presence of risk-enhancing factors was generally not associated with an overall ASCVD risk that was higher than the recommended treatment threshold for the initiation of statin therapy. The use of CAC scoring was associated with significant improvements in the reclassification and discrimination of incident ASCVD. The results of this study support the utility of CAC scoring as an adjunct to risk-enhancing factor assessment to more accurately classify individuals with an intermediate risk of ASCVD who might benefit from statin therapy.

Geographic and Sociodemographic Disparities in Cardiovascular Risk in Burkina Faso: Findings from a Nationwide Cross-Sectional Survey

Background

Cardiovascular disease (CVD) risk assessment is a critical step in the current approach to the primary prevention of CVD, particularly in low-income countries such as Burkina Faso. In this study, we aimed to assess the geographic and sociodemographic disparities of the ten-year cardiovascular risk in Burkina Faso.

Methods

We conducted a secondary analysis of the data from the first nationwide survey using the World Health Organization (WHO) STEPwise approach. Ten-year cardiovascular risk was determined using the WHO 2019 updated risk chart (WHO risk) as main outcome, and the Framingham risk score (FRS) and the Globorisk chart for secondary outcomes. We performed a modified Poisson regression model using a generalized estimating equation to examine the association between CVD risk and sociodemographic characteristics.

Results

A total of 3081 participants aged 30 to 64 years were included in this analysis. The overall age and sex-standardized mean of absolute ten-year cardiovascular risk assessed using the WHO risk chart was 2.5% (95% CI: 2.4–2.6), ranging from 2.3% (95% CI: 2.2–2.4) in Centre Est to 3.0% (95% CI: 2.8–3.2) in the Centre region. It was 4.6% (95% CI: 4.4–4.8) for FRS and 4.0% (95% CI: 3.8–4.1) for Globorisk. Regarding categorized CVD risk (absolute risk ≥10%), we found out that the age and sex-standardized prevalence of elevated risk was 1.7% (95% CI: 1.3–2.1) for WHO risk, 10.4% (95% CI: 9.6–11.2) for FRS, and 5.9% (95% CI: 5.1–6.6) for Globorisk. For all of the three risk scores, elevated CVD risk was associated with increasing age, men, higher education, urban residence, and health region (Centre).

Conclusion

We found sociodemographic and geographic inequalities in the ten-year CVD risk in Burkina Faso regardless of risk score used. Therefore, population-wide interventions are needed to improve detection and management of adult in the higher CVD risk groups in Burkina Faso.

Fewer patients receive recommendations for pharmacotherapy in primary prevention using the 2018 atherosclerotic cardiovascular disease risk estimator

Shortly after the introduction of the 2013 original Pooled Cohort Equation (PCE), an overestimation of risk was suggested. As such, the updated 2018 PCE was developed to more accurately assess atherosclerotic cardiovascular disease (ASCVD) risk in the population. Hence, this study aims to compare drug prescribing recommendations in a large, real-world patient population, depending on which PCE is used to estimate 10-year ASCVD risk. This retrospective cohort study identified 20,843 patients aged between 40 and 75 years with no previous ASCVD. The 10-year ASCVD risk score was assessed by using both PCE. Patients were assigned to the four risk categories according to the 2018 ACC/AHA guideline. The percentage of patients qualifying for guideline-recommended primary prevention with statins and/or anti-hypertensives were compared between both PCE. Risk reclassification occurred in 26.7% of patients overall (n = 5571), of which 98.1% (n = 5466) were assigned to lower risk categories with the updated PCE. Non-diabetic (14.0%) patients no longer met the threshold for recommending statins as primary prevention with the updated PCE. Likewise, 13.8% of patients with stage I hypertension no longer met the threshold for recommending antihypertensive drugs with the updated PCE. In conclusion, risk reclassification occurred among 26.7% of patients overall, mostly due to lower risk categories assigned by the updated PCE. Up to 14.0% of patients no longer met the threshold for recommending statin therapy and/or antihypertensive drugs by using the updated PCE. These findings suggest that using the updated PCE could translate into fewer patients receiving pharmacotherapy for ASCVD primary prevention.

Preulcerous Risk Situation in Diabetic Foot Syndrome: Proposal for a Simple Ulcer Prevention Score

BACKGROUND

Preulcerous risk situations in patients with diabetes are often undiagnosed and care administered too late. Even with regular medical check-ups and status documentation, foot examinations have not been given enough attention. Diagnosing an individual patients' risk of developing diabetic foot ulcers may increase vigilance for diabetic foot syndrome (DFS), and the appropriate prevention measures matching the risk involved may prevent the emergence of diabetic ulcers. The classical DFS risk factors are well established and have been extensively covered in the literature; however, there is a lack of efficient screening tools that could be used for a rapid assessment of diabetic foot ulcer risk.

METHODS

A methodical literature search was conducted to assess relevant publications for the preparation of a simple risk score for amputation related to diabetic foot ulcer. We then analyzed the risk factors for predictive value as odds ratios in foot ulcers and/or amputation. We used the available data to deduce a mean value to reflect the authors' consensus.

RESULTS

In view of the current literature on the matter, we have developed a semi-quantitative scoring system using just a few items to allow rapid and visual risk assessment for diabetic foot ulcers alongside recommendations for prevention and a sensible follow-up strategy to match the risk.

CONCLUSION

This relatively simple score enables rapid risk classification for patients that can ease the way for both physicians and patients in gaining an insight into individual risk situations. The score provides more effective preventative measures for high-risk patients against future complications.

Cardiovascular Risk Assessment in Hypertensive Patients

Hypertension is a highly prevalent and causal risk factor for cardiovascular disease (CVD). Quantitative cardiovascular (CV) risk assessment is a new paradigm for stratifying hypertensive patients into actionable groups for clinical management and prevention of CVD. The large heterogeneity in hypertensive patients makes this evaluation complex, but recent advances have made CV risk assessment more feasible. In this review, we first describe the prognostic significance of various levels and temporal patterns of blood pressure (BP). We then discuss CV risk prediction equations and the rationale of taking global risk into account in hypertensive patients. Finally, we review several adjunctive biomarkers that may refine risk assessment in certain patients. We observe that, beyond individual cross-sectional measurements, both short-term and long-term BP patterns are associated with incident CVD; that current CV risk prediction performs well, and its incorporation into hypertension management is associated with potential population benefit; and that adjunctive biomarkers of target organ damage show the most promise in sequential screening strategies that target biomarker measurement to patients in whom the results are most likely to change clinical management. Implementation of quantitative risk assessment for CVD has been facilitated by tools and direct electronic health record integrations that make risk estimates accessible for counseling and shared decision making for CVD prevention. However, it should be noted that treatment does not return an individual to the risk of someone who never develops hypertension, underscoring the need for primordial prevention in addition to continued innovation in risk assessment.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Isolated diastolic vs. systolic hypertension phenotypes and outcomes: prospective cohort of newly diagnosed individuals with hypertension

AIMS

To evaluate whether different hypertension phenotypes, namely, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH) and systolic/diastolic hypertension (SDH) have a differential outcome effect by clinic and ambulatory blood pressure (BP) measurements.

METHODS

We prospectively evaluated in 569 never-treated patients with sustained hypertension (age 52.6 ± 11.6 years; men 55%; clinic BP 150 ± 15/95.5 ± 10 mmHg, systolic/diastolic; 24-h ambulatory BP 128.9 ± 12.6/80.6 ± 9.7) the incidence of major cardiovascular (CV) events within 5 years, after adjustment for confounders, including the rate of BP control and the weighted follow-up BP.

RESULTS

All participants received antihypertensive drug treatment (mean number of drugs 1.9 ± 1.1; follow-up visits 4.6/patient). Average clinic BP achieved during follow-up was 136 ± 12.6/83.9 ± 9.4 mmHg, with 39% of participants having clinic BP less than 140/90 mmHg in at least 75% of their visits, and 24% in 25-75% of visits. Prevalence of hypertension phenotypes defined using BP differed from that using ambulatory BP, whereas integration of both BP measurements reclassified the initial phenotype to another in 18% of participants. Although, no differential outcome effect was observed between clinic IDH and SDH assessed using clinic or ambulatory BP measurements, clinic BP-based ISH was associated with a higher outcome incidence than the IDH and SDH phenotypes (hazard ratio 4.8, 95% confidence interval 1.4-17.0, P = 0.015). ISH diagnosed by integration of clinic and ambulatory BP, also increased the outcome (hazard ratio 4.0, 95% confidence interval 1.0-15.6, P = 0.046).

CONCLUSION

In hypertensive patients at low/moderate CV risk, IDH and SDH phenotypes defined by clinic BP measurements, equally determined CV events but to a lower extent compared with ISH.

Performance of the American Heart Association/American College of Cardiology Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Self-reported Physical Activity Levels

Importance

The American Heart Association/American College of Cardiology pooled cohort equations (PCEs) are used for predicting 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Pooled cohort equation risk prediction capabilities across self-reported leisure-time physical activity (LTPA) levels and the change in model performance with addition of LTPA to the PCE are unclear.

Objective

To evaluate PCE risk prediction performance across self-reported LTPA levels and the change in model performance by adding LTPA to the existing PCE model.

Design, Setting, and Participants

Individual-level pooling of data from 3 longitudinal cohort studies-Atherosclerosis Risk in Communities, Multi-Ethnic Study of Atherosclerosis, and Cardiovascular Health Study-was performed. A total of 18 824 participants were stratified into 4 groups based on self-reported LTPA levels: inactive (0 metabolic equivalent of task [MET]-min/wk), less than guideline-recommended (<500 MET-min/wk), guideline-recommended (500-1000 MET-min/week), and greater than guideline-recommended (>1000 MET-min/wk). Pooled cohort equation risk discrimination was studied using the C statistic and reclassification capabilities were studied using the Greenwood Nam-D'Agostino χ2 goodness-of-fit test. Change in risk discrimination and reclassification on adding LTPA to PCEs was evaluated using change in C statistic, integrated discrimination index, and categorical net reclassification index.

Main Outcomes and Measures

Adjudicated ASCVD events during 10-year follow-up.

Results

Among 18 824 participants studied, 10 302 were women (54.7%); mean (SD) age was 57.6 (8.2) years. A total of 5868 participants (31.2%) were inactive, 3849 (20.4%) had less than guideline-recommended LTPA, 3372 (17.9%) had guideline-recommended LTPA, and 5735 (30.5%) had greater than guideline-recommended LTPA level. Higher LTPA levels were associated with a lower risk of ASCVD after adjustment for risk factors (hazard ratio [HR] per 1-SD higher LTPA, 0.91; 95% CI, 0.86-0.96). Across LTPA groups, PCE risk discrimination (C statistic, 0.76-0.78) and risk calibration (all χ2 P > .10) was similar. Addition of LTPA to the PCE model resulted in no significant change in the C statistic (0.0005; 95% CI, -0.0004 to 0.0015; P = .28) and categorical net reclassification index (-0.003; 95% CI, -0.010 to 0.010; P = .95), but a minimal improvement in the integrated discrimination index (0.0008; 95% CI, 0.0002-0.0013; P = .005) was observed. Similar results were noted when cohort-specific coefficients were used for creating the baseline model.

Conclusions and Relevance

Higher self-reported LTPA levels appear to be associated with lower ASCVD risk and increasing LTPA promotes cardiovascular wellness. These findings suggest the American Heart Association/American College of Cardiology PCEs are accurate at estimating the probability of 10-year ASCVD risk regardless of LTPA level. The addition of self-reported LTPA to PCEs does not appear to be associated with improvement in risk prediction model performance.

Association of Carotid Artery Plaque With Cardiovascular Events and Incident Coronary Artery Calcium in Individuals With Absent Coronary Calcification: The MESA

BACKGROUND

Absence of coronary artery calcium (CAC) identifies asymptomatic individuals at low cardiovascular disease risk. Carotid artery plaque is a marker of increased risk, but its association with cardiovascular risk and incident CAC in people without CAC is unclear.

METHODS

Multi-Ethnic Study of Atherosclerosis participants with CAC score of 0 at enrollment who also underwent carotid plaque measurement using B-mode ultrasonography were prospectively followed for incident coronary heart disease, stroke, and cardiovascular disease events, and CAC (score >0 on up to 3 serial computed tomography scans). The association of carotid plaque presence and plaque score (Ln[score+1]) at baseline with cardiovascular events and incident CAC was evaluated with Cox proportional hazards regression models adjusted for demographics, risk factors, and statin use.

RESULTS

Among these 2673 participants (58 years, 64% women, 34% White, 30% Black, 24% Hispanic, and 12% Chinese), carotid plaque at baseline was observed in 973 (36%) and the median plaque score (range, 1-12) among those with plaque was 1. A total of 79 coronary heart disease, 80 stroke, and 151 cardiovascular disease events were observed during 16.1 years of follow-up. Carotid plaque presence and plaque score were independently associated with coronary heart disease risk (HRs, 1.66 [95% CI, 1.04-2.66]; and 1.48 [95% CI, 1.01-2.17], respectively) but not with stroke and cardiovascular disease risk. A total of 973 (36.4%) participants developed CAC over the evaluation period (median 9.3 years). Carotid plaque presence and plaque score were independently associated with incident CAC (HRs, 1.34 [95% CI, 1.18-1.54]; and 1.37 [95% CI, 1.21-1.54]), respectively.

CONCLUSIONS

The presence and extent of carotid plaque are associated with long-term coronary heart disease risk and incident CAC among middle-aged asymptomatic individuals with an initial CAC score of 0.

A Systematic Review on the Correlations between Left Atrial Strain and Cardiovascular Outcomes in Chronic Kidney Disease Patients

Left atrial strain (LASr) represents a relatively new but promising technique for left atrial and left ventricle function evaluation. LASr was strongly linked to myocardial fibrosis and endocardial thickness, suggesting the utility of LASr in subclinical cardiac dysfunction detection. As CKD negatively impacts cardiovascular risk and mortality, underlying structural and functional abnormalities of cardiac remodeling are widely investigated. LASr could be used in LV diastolic dysfunction grading with an excellent discriminatory power. Our objectives were to assess the impact and existing correlations between LASr and cardiovascular outcomes, as reported in clinical trials, including patients with CKD. We searched PubMed, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials for full-text papers. As reported in clinical studies, LASr was associated with adverse cardiovascular outcomes, including cardiovascular death and major adverse cardiovascular events (HR 0.89, 95% CI, 0.84–0.93, p < 0.01), paroxysmal atrial fibrillation (OR 0.847, 95% CI, 0.760–0.944, p = 0.003), reduced exercise capacity (AUC 0.83, 95% CI, 0.78–0.88, p < 0.01), diastolic dysfunction (p < 0.05), and estimated pulmonary capillary wedge pressure (p < 0.001). Despite limitations attributed to LA deformation imaging (image quality, inter-observer variability, software necessity, learning curve), LASr constitutes a promising marker for cardiovascular events prediction and risk evaluation in patients with CKD.

Hypertensive Urgency: An Emergency Department Pipeline to Primary Care Pilot Study

BACKGROUND

Optimal triage of patients with hypertensive urgency (HU) in the emergency department (ED) is not well established. 2017 ACC/AHA hypertension (HTN) guidelines recommend treatment initiation and follow-up within 1 week. Objectives of our pilot study were to evaluate feasibility and impact of directly connecting ED patients with HU to outpatient HTN management on blood pressure (BP) control and ED utilization.

METHODS

ED patients with HU and no primary care physician were scheduled by a referral coordinator for an initial appointment in a HTN clinic embedded within a primary care practice. BP control and ED utilization over the subsequent 90 days were tracked and compared with BP at time of the referral ED visit, and ED utilization in the 90 days preceding referral.

RESULTS

Data are reported for the first 40 referred patients. Average time to first visit was 7.8 days. Mean age was 51 years (range 28-76), 75% were African-American, and mean pooled 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 20.8%. Mean BP declined from 198/116 mm Hg at ED visit to 167/98 mm Hg at HTN clinic visit 1 to 136/83 by 6 weeks and was sustained at 90 days. Total ED visits for the group decreased from 61 in the 90 days prior to referral, to 18 in the 90 days after the first HTN clinic visit.

CONCLUSIONS

In this pilot study, coordinated referral between the ED and primary care provides safe, timely care for this high ASCVD risk population and leads to sustained reductions in BP and ED utilization.

Cardiovascular Risk Assessment in the Older Athlete

CONTEXT

Limited data are available to guide cardiovascular screening in adult or masters athletes (≥35 years old). This review provides recommendations and the rationale for the cardiovascular risk assessment of older athletes.

EVIDENCE ACQUISITION

Review of available clinical guidelines, original investigations, and additional searches across PubMed for articles relevant to cardiovascular screening, risk assessment, and prevention in adult athletes (1990-2020).

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Atherosclerotic coronary artery disease (CAD) is the leading cause of exercise-induced acute coronary syndromes, myocardial infarction, and sudden cardiac death in older athletes. Approximately 50% of adult patients who experience acute coronary syndromes and sudden cardiac arrest do not have prodromal symptoms of myocardial ischemia. The risk of atherosclerotic cardiovascular disease (ASCVD) can be estimated by using existing risk calculators. ASCVD 10-year risk is stratified into 3 categories: low-risk (≤10%), intermediate-risk (between 10% and 20%), and high-risk (≥20%). Coronary artery calcium (CAC) scoring with noncontrast computed tomography provides a noninvasive measure of subclinical CAD. Evidence supports a significant association between elevated CAC and the risk of future cardiovascular events, independent of traditional risk factors or symptoms. Statin therapy is recommended for primary prevention if 10-year ASCVD risk is ≥10% (intermediate- or high-risk patients) or if the Agatston score is >100 or >75th percentile for age and sex. Routine stress testing in asymptomatic, low-risk patients is not recommended.

CONCLUSION

We propose a comprehensive risk assessment for older athletes that combines conventional and novel risk factors for ASCVD, a 12-lead resting electrocardiogram, and a CAC score. Available risk calculators provide a 10-year estimate of ASCVD risk allowing for risk stratification and targeted management strategies. CAC scoring can refine risk estimates to improve the selection of patients for initiation or avoidance of pharmacological therapy.

Does the risk of cardiovascular events differ between biopsy-proven NAFLD and MAFLD?

BACKGROUND/PURPOSE

Cardiovascular disease (CVD) is the leading cause of death among individuals with non-alcoholic fatty liver disease (NAFLD). Recently, NAFLD was renamed metabolic-associated fatty liver disease (MAFLD). This study aimed to compare cardiovascular risk (CVR) and CVD between patients with NAFLD and MAFLD.

METHODS

Retrospective cross-sectional study of biopsy-proven liver steatosis performed between 2013 and 2018 at a university hospital. Cases were divided into NAFLD or MAFLD and demographic, clinical, and laboratory data were collected to assess CVR (through the atherosclerotic cardiovascular disease risk estimator and atherogenic indices) and CVD.

RESULTS

Out of 1233 liver biopsies, 171 (13.9%) presented steatosis. Of these, 109 patients met diagnostic criteria for NAFLD (63.7%) and 154 (90.1%), for MAFLD. In the NAFLD group, 78% of the cases had steatohepatitis, 24.8% had cirrhosis, and 3.7%, hepatocellular carcinoma (HCC). In the MAFLD group, 72.7% of the cases had liver inflammatory activity, 28.6% had cirrhosis, and 13.6% had HCC. In patients with MAFLD and NAFLD, CVR was intermediate/high (36.4 and 25.7%, p = 0.209) and CVD occurred in 20.1 and 12.8% (p = 0.137) of the cases, respectively, with no influence of liver injury severity. We observed a significant increase in high 10-year CVR (p = 0.020) and CVD (p = 0.007) in patients with MAFLD and concomitant viral infection (HCV and/or HBV) compared to cases with MAFLD only.

CONCLUSION

Patients with both NAFLD and MAFLD had intermediate/high CVR, with a high rate of CVD. Patients with MAFLD and concomitant viral infection showed significantly increased CVR and CVD compared to those without viral infection.

Coronary artery calcium scoring: an evidence-based guide for primary care physicians

Primary care physicians often must decide whether statin therapy would be appropriate (in addition to lifestyle modification) for managing asymptomatic individuals with borderline or intermediate risk for developing atherosclerotic cardiovascular disease (ASCVD), as assessed on the basis of traditional risk factors. In appropriate subjects, a simple, noninvasive measurement of coronary artery calcium can help clarify risk. Coronary atherosclerosis is a chronic inflammatory disease, with atherosclerotic plaque formation involving intimal inflammation and repeated cycles of erosion and fibrosis, healing and calcification. Atherosclerotic plaque formation represents the prognostic link between risk factors and future clinical events. The presence of coronary artery calcification is almost exclusively an indication of coronary artery disease, except in certain metabolic conditions. Coronary artery calcification can be detected and quantified in a matter of seconds by noncontrast electrocardiogram-gated low-dose X-ray computed tomography (coronary artery calcium scoring [CACS]). Since the publication of the seminal work by Dr. Arthur Agatston in 1990, a wealth of CACS-based prognostic data has been reported. In addition, recent guidelines from various professional societies conclude that CACS may be considered as a tool for reclassifying risk for atherosclerotic cardiovascular disease in patients otherwise assessed to have intermediate risk, so as to more accurately inform decisions about possible statin therapy in addition to lifestyle modification as primary preventive therapy. In this review, we provide an overview of CACS, from acquisition to interpretation, and summarize the scientific evidence for and the appropriate use of CACS as put forth in current clinical guidelines.

Predicting Cardiovascular Risk Using Social Media Data: Performance Evaluation of Machine-Learning Models

Background

Current atherosclerotic cardiovascular disease (ASCVD) predictive models have limitations; thus, efforts are underway to improve the discriminatory power of ASCVD models.

Objective

We sought to evaluate the discriminatory power of social media posts to predict the 10-year risk for ASCVD as compared to that of pooled cohort risk equations (PCEs).

Methods

We consented patients receiving care in an urban academic emergency department to share access to their Facebook posts and electronic medical records (EMRs). We retrieved Facebook status updates up to 5 years prior to study enrollment for all consenting patients. We identified patients (N=181) without a prior history of coronary heart disease, an ASCVD score in their EMR, and more than 200 words in their Facebook posts. Using Facebook posts from these patients, we applied a machine-learning model to predict 10-year ASCVD risk scores. Using a machine-learning model and a psycholinguistic dictionary, Linguistic Inquiry and Word Count, we evaluated if language from posts alone could predict differences in risk scores and the association of certain words with risk categories, respectively.

Results

The machine-learning model predicted the 10-year ASCVD risk scores for the categories <5%, 5%-7.4%, 7.5%-9.9%, and ≥10% with area under the curve (AUC) values of 0.78, 0.57, 0.72, and 0.61, respectively. The machine-learning model distinguished between low risk (<10%) and high risk (>10%) with an AUC of 0.69. Additionally, the machine-learning model predicted the ASCVD risk score with Pearson r=0.26. Using Linguistic Inquiry and Word Count, patients with higher ASCVD scores were more likely to use words associated with sadness (r=0.32).

Conclusions

Language used on social media can provide insights about an individual’s ASCVD risk and inform approaches to risk modification.

A disease state approach to the pharmacological management of Type 2 diabetes in primary care: A position statement by Primary Care Diabetes Europe

Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to therapeutic inertia. This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients. It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.

The potential impact of mammographic breast arterial calcification on physician practices in a primary care setting

Aim: This study sought to determine breast arterial calcification (BAC) prevalence in a primary care setting and its potential use in guiding further cardiovascular workup. Materials & methods: A radiologist reviewed 282 consecutive mammograms. Characteristics of BAC-positive and negative women were compared. Results: BAC prevalence was 34%. BAC-positive women were older (mean age: 60 vs 52, p < 0.001), had higher mean 10-year cardiac risk (11 vs 6%, p < 0.001), more hypertension (65 vs 40%, p < 0.001) and coronary artery disease (10 vs 2%, p = 0.0041), statin (50 vs 32%, p = 0.006) and aspirin use (28 vs 16%, p = 0.012). Thirty-seven percent (33/96) of BAC-positive women could potentially benefit from further cardiac testing. Conclusion: Mammography identifies BAC-positive women with low traditionally assessed cardiovascular risk who might benefit from further cardiovascular workup.

Cardiovascular Risk Calculators and their Applicability to South Asians

BACKGROUND

Estimation of absolute cardiovascular disease (CVD) risk and tailoring therapies according to the estimated risk is a fundamental concept in the primary prevention of CVD is assessed in this study. Numerous CVD risk scores are currently available for use in various populations but unfortunately, none exist for South Asians who have much higher CVD risk as compared to their western counterparts.

METHODS

A literature search was done using PubMed and Google search engines to prepare a narrative review on this topic.

RESULTS

Various currently available CVD risk scores and their pros and cons are summarized. The studies performed in native as well as migrant South Asians evaluating the accuracy of these risk scores for estimation of CVD risk are also summarized. The findings of these studies have generally been inconsistent, but it appears that the British risk scores (e.g. QRISK versions) may be more accurate because of inclusion of migrant South Asians in the derivation of these risk scores. However, the lack of any prospective study precludes our ability to draw any firm conclusions. Finally, the potential solution to these challenges, including the role of recalibration and subclinical atherosclerosis imaging, is also discussed.

CONCLUSION

This review highlights the need to develop large, representative, prospectively followed databases of South Asians providing information on various CVD risk factors and their contribution to incident CVD. Such databases will not only allow the development of validated CVD risk scores for South Asians but will also enable application of machine-learning approaches to provide personalized solutions to CVD risk assessment and management in these populations.

The National Lipid Association scientific statement on coronary artery calcium scoring to guide preventive strategies for ASCVD risk reduction

An Expert Panel of the National Lipid Association reviewed the evidence related to the use of coronary artery calcium (CAC) scoring in clinical practice for adults seen for primary prevention of atherosclerotic cardiovascular disease. Recommendations for optimal use of this test in adults of various races/ethnicities, ages and multiple domains of primary prevention, including those with a 10-year ASCVD risk <20%, those with diabetes or the metabolic syndrome, and those with severe hypercholesterolemia were provided. Recommendations were also made on optimal timing for repeat calcium scoring after an initial test, use of CAC scoring in those taking statins, and its role in informing the clinician patient discussion on the benefit of aspirin and anti-hypertensive drug therapy. Finally, a vision is provided for the future of coronary calcium scoring.

Left Atrial Strain Is the Best Predictor of Adverse Cardiovascular Outcomes in Patients with Chronic Kidney Disease

BACKGROUND

Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events, which is underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients.

METHODS

Two hundred forty-three prospectively recruited stage 3/4 CKD patients (male, 63%; mean age, 59.2 ± 14.4 years) without previous cardiac disease made up the study cohort. All participants underwent a transthoracic echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for 3.9 ± 2.7 years for the primary end point of cardiovascular death and major adverse cardiovascular event (MACE). The secondary end point was the composite of all-cause death and MACE.

RESULTS

Fifty-four patients met the primary end point, and 65 the secondary end point. On log-rank tests, older age, diabetes mellitus, anemia, greater LV mass, reduced LV global longitudinal strain, larger indexed LA volume, higher E/e' ratio, and reduced LA reservoir strain (LASr; P < .01 for all) were independent predictors of cardiovascular death and MACE. On multivariable regression analysis of univariate predictors, LASr (P < .01) was the only independent predictor for the primary end point as well as for the secondary end point. Receiver operating characteristic curve analysis showed LASr was a stronger predictor of adverse events (area under the curve [AUC] = 0.84) compared to the Framingham (AUC = 0.58) and Atherosclerotic Cardiovascular Disease (AUC = 0.59) risk scores.

CONCLUSIONS

LASr is an independent predictor of cardiovascular death and MACE in CKD patients, superior to clinical risk scores, LV parameters, and LA volume.

Management of Dyslipidemia for Cardiovascular Disease Risk Reduction: Synopsis of the 2020 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

DESCRIPTION

In June 2020, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) released a joint update of their clinical practice guideline for managing dyslipidemia to reduce cardiovascular disease risk in adults. This synopsis describes the major recommendations.

METHODS

On 6 August to 9 August 2019, the VA/DoD Evidence-Based Practice Work Group (EBPWG) convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature (English-language publications from 1 December 2013 to 16 May 2019), and developed 27 recommendations and a simple 1-page algorithm. The recommendations were graded by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis summarizes key features of the guideline in 7 crucial areas: targeting of statin dose (not low-density lipoprotein cholesterol goals), additional tests for risk prediction, primary and secondary prevention, laboratory testing, physical activity, and nutrition.

Macrophage maturation from blood monocytes is altered in people with HIV, and is linked to serum lipid profiles and activation indices: A model for studying atherogenic mechanisms

People with HIV (PWH) are at increased risk for atherosclerotic cardiovascular disease (ASCVD). Proportions of vascular homing monocytes are enriched in PWH; however, little is known regarding monocyte-derived macrophages (MDMs) that may drive atherosclerosis in this population. We isolated PBMCs from people with and without HIV, and cultured these cells for 5 days in medium containing autologous serum to generate MDMs. Differential gene expression (DGE) analysis of MDMs from PWH identified broad alterations in innate immune signaling (IL-1β, TLR expression, PPAR βδ) and lipid processing (LXR/RXR, ACPP, SREBP1). Transcriptional changes aligned with the functional capabilities of these cells. Expression of activation markers and innate immune receptors (CD163, TLR4, and CD300e) was altered on MDMs from PWH, and these cells produced more TNFα, reactive oxygen species (ROS), and matrix metalloproteinases (MMPs) than did cells from people without HIV. MDMs from PWH also had greater lipid accumulation and uptake of oxidized LDL. PWH had increased serum levels of free fatty acids (FFAs) and ceramides, with enrichment of saturated FAs and a reduction in polyunsaturated FAs. Levels of lipid classes and species that are associated with CVD correlated with unique DGE signatures and altered metabolic pathway activation in MDMs from PWH. Here, we show that MDMs from PWH display a pro-atherogenic phenotype; they readily form foam cells, have altered transcriptional profiles, and produce mediators that likely contribute to accelerated ASCVD.

People with HIV (PWH) are at greater risk for developing cardiovascular disease (CVD) than the general public, but the mechanisms underlying this increased risk are poorly understood. Macrophages play key roles in the pathogenesis of atherosclerosis, and are potential targets for therapeutic intervention. Here, we investigate phenotypic and functional abnormalities in monocyte-derived macrophages (MDMs) isolated from PWH that may drive CVD risk in this population. MDMs were differentiated in the presence of autologous serum, enabling us to explore the contributions of serum components (lipids, inflammatory cytokines, microbial products) as drivers of altered MDM function. We link serum levels of inflammatory biomarkers and CVD-associated lipid species to MDM activation. Our study provides new insight into drivers of pro-atherogenic MDM phenotype in PWH, and identifies directions for future study and potential intervention strategies to mitigate CVD risk.

Predictors of coronary artery calcium incidence and progression: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

BACKGROUND AND AIMS

There are limited data on serial coronary artery calcium (CAC) assessments outside North American and European populations. We sought to investigate risk factors for CAC incidence and progression in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

METHODS

We included individuals with no prior cardiovascular disease and two CAC measurements in ELSA-Brasil. Incident CAC was defined as a baseline CAC of 0 followed by CAC >0 on the second study. CAC progression was defined according to multiple published criteria. We performed logistic and linear regression to identify risk factors for CAC incidence and progression. We also examined risk factor effect modification by baseline CAC (0 vs. >0).

RESULTS

A total of 2707 individuals were included (57% women, age 48.6 ± 7.7 years). Participants self-identified as white (55%), brown (24%), black (16%), Asian (4%) and Indigenous (1%). The mean period between CAC assessments was 5.1 ± 0.9 years. CAC incidence occurred in 282 (13.3%) of 2127 individuals with baseline CAC of 0. CAC progression occurred in 319 (55%) of 580 participants with baseline CAC >0. Risk factors for CAC incidence included older age, male sex, white race, hypertension, diabetes, higher BMI, smoking, lower HDL-C, higher LDL-C and triglycerides, and metabolic syndrome. Older age and elevated LDL-C were associated with CAC incidence, but not progression. Risk factors consistently associated with CAC progression were hypertension, diabetes, hypertriglyceridemia, and metabolic syndrome. On interaction testing, these four risk factors were more strongly associated with CAC progression as compared to CAC incidence.

CONCLUSIONS

CAC incidence was associated with multiple traditional risk factors, whereas the only risk factors associated with progression of CAC were hypertension, diabetes, hypertriglyceridemia, and metabolic syndrome.

HOPE for Rational Statin Allocation for Primary Prevention: A Coronary Artery Calcium Picture Is Worth 1000 Words

Allocation of statin therapy for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) in borderline- and intermediate-risk patients has traditionally been based on population-based global risk assessment and other clinical and laboratory characteristics. Patient-specific treatment decisions are needed to provide maximal benefit and avoid unnecessary treatment. Guideline-based lipid management proposes that coronary artery calcium scoring is reasonable to implement in patients with a 10-year risk of 5.0% to 19.9% (borderline to intermediate risk) by using the pooled cohort equations when the decision about whether to initiate statin therapy is uncertain. We report data from both observational studies and a large primary prevention randomized controlled trial that support the position that this decision is, in fact, uncertain in about half of such patients because of risk misclassification. Such misclassification can be largely avoided by more widespread implementation of coronary calcium scoring, which helps to identify those with coronary artery calcium scores of 0, a finding associated with a less than 5.0% 10-year probability of an ASCVD event. Deferral of statin therapy in such patients, in the absence of smoking, diabetes, or a family history of premature ASCVD, provides more individualized and appropriate care and avoids the expense and potential adverse effects of statin therapy in those with low potential for absolute risk reduction. A rationale is also provided for the importance of coronary artery calcium scoring in women 50 years and older, possibly in place of 1 screening mammogram in women at least 55 years of age to avoid incremental radiation exposure, on the basis of the substantially higher lifetime risk of morbidity and mortality from ASCVD than from breast cancer. In patients with borderline or intermediate ASCVD risk, coronary artery calcium scoring should be used, whenever possible, as an aid to rational statin allocation for the primary prevention of ASCVD.

The Role of Sex-Specific Risk Factors in the Risk Assessment of Atherosclerotic Cardiovascular Disease for Primary Prevention in Women

PURPOSE OF REVIEW

Robust evidence is emerging regarding the contribution of sex-specific risk factors to a woman's unique risk of atherosclerotic cardiovascular disease (ASCVD). This review summarizes the available literature regarding the association of sex-specific risk factors and ASCVD in women.

RECENT FINDINGS

The American College of Cardiology and American Heart Association Guidelines recommend estimation of 10-year risk of a first ASCVD event using the 2013 Pooled Cohort Equations. This can be further personalized by identifying sex-specific risk factors present in a woman's history. There are multiple vulnerable periods across a woman's life course that are associated with increased risk of ASCVD. Risk factors across the reproductive life course that have been shown to correlate with higher risk for future ASCVD include early menarche, adverse pregnancy outcomes (such as pre-eclampsia or preterm birth), and early natural or surgical menopause. In addition, certain conditions that are more common among women, including autoimmune diseases, history of chest irradiation, and certain chemotherapies, also need to be considered. Finally, risk assessment can be refined with subclinical disease imaging (coronary calcium score) if there remains uncertainty about clinical management with lipid-lowering therapies for primary prevention after inclusion of these risk enhancers. Risk assessment for ASCVD in women requires a personalized approach that incorporates sex-specific risk factors to guide primary prevention measures, such as lipid-lowering therapies. Coronary calcium score imaging may also help further refine risk assessment, but no clinical trials conducted to date have addressed this question.

Cardiovascular Risk Estimation in Patients with Hypertension: A Cross- Sectional Study

Introduction: Cardiovascular disease is a disease caused by the misfunctioning of the heart and blood vessels. Atherosclerosis is the main cause of cardiovascular disease. Prevention and control of cardiovascular disease can be done with early detection through screening activities. Framingham Risk Score using Body Mass Index (FRS BMI) risk assessment is very useful and easy, which is used without using lipid indicator. This study aims to estimate the risk of cardiovascular disease on patients with hypertension with Framingham Risk Score BMI.Methods: The study used a descriptive method with cross-sectional design. The samples in this study were 130 respondents who were selected using consecutive sampling and retrieval technique by using FRS BMI application questionnaire.Results: There were 11.5% respondents in low risk of CVD, 22.7% respondents at moderate risk and 60.8% respondents in higher category of cardiovascular disease 10 years later.Conclusion: Majority of patients with hypertension showed a high risk of CVD for the next 10 years. Patients’ sex and age also play an important role to increase the risk, whereby men show a higher risk of CVD for the next ten years. The hospital management and health worker should pay more attention and educate the patient about the prevention of heart disease for the next 10 years, especially for those with high risk of CVD based on FRS BMI measurement.

Coronary artery calcium scoring in patients with hypertension

Coronary artery calcium (CAC) is increased by high blood pressure (BP), predicts new-onset hypertension, and is a powerful predictor of atherosclerotic cardiovascular disease events in patients with and without hypertension. Unlike other diseases (e.g., hypercholesterolemia), the clinical use of CAC scoring to personalize the treatment of high BP has not received much attention and therefore remains less well defined. Herein, we provide an updated review of studies investigating the relationship between CAC and BP. Finally, we propose a clinical algorithm to incorporate CAC into hypertension management, with a focus on its potential value in tailoring the timing of medication therapy and in helping to personalize BP goals.

Association between Blood Heavy Metal Levels and Predicted 10-Year Risk for A First Atherosclerosis Cardiovascular Disease in the General Korean Population

Background: Atherosclerotic cardiovascular disease (ASCVD) is a preventable type of disease, thus, specifying factors that increase the occurrence of this type of disease is needed. Heavy metals such as cadmium (Cd), lead (Pb), and mercury (Hg) have been suggested as possible factors influencing the development of cardiovascular disease. We aimed to link blood heavy metal levels (Cd, Pb, Hg) with 10-year ASCVD risk scores. Methods: A population of 993 men and 1431 women who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) were included. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) pooled cohort equations risk prediction model and Korean Risk Prediction Model (KRPM) were used as means for risk prediction. Following multivariate adjustment; blood Cd; Pb; and Hg levels were divided into quartiles for analysis using linear trends estimation and multiple regression models. Results: There was an overall positive trend between blood Cd, Pb, and Hg levels and 10-year ASCVD risk scores; KRPM risk score increasing by quartile for blood Cd (men p < 0.0001, women p = 0.0024), Pb (men p = 0.0097, women p = 0.0330), Hg (men p = 0.0096, women p = 0.0030) rates and pooled cohort equations risk score increasing by quartile for Cd (men p < 0.0001, women p = 0.0034) and Hg (men p = 0.0099, women p = 0.0010) with linear trends. Urban population showed a stronger relationship between blood Cd, Pb, and Hg levels and 10-year ASCVD risk score especially among men with multiple regression analysis. Conclusion: Blood Cd, Pb, and Hg levels are associated with ASCVD risk. Thus, they should be considered while developing preventive measures for ASCVD.

How Clinicians Discuss Medications During Primary Care Encounters Among Older Adults with Cognitive Impairment

BACKGROUND

People with cognitive impairment experience high rates of polypharmacy and potentially inappropriate medication use. How clinicians communicate about medications may affect to what extent patients and family companions understand and participate in decisions about medication use.

OBJECTIVE

To characterize how primary care clinicians discuss medications during encounters with older adults with cognitive impairment and their companions.

DESIGN

Qualitative content analysis of audio-recorded clinical encounters from SAME Page, a randomized controlled trial to examine the effects of a patient-family agenda setting checklist on primary care visit communication among patients with cognitive impairment. Visits occurred between August 2016 and August 2017.

PARTICIPANTS

Patients were 65 or older, had > 1 incorrect answer on a cognitive screener, and attended visits with a relative or unpaid companion. Clinicians were physicians, nurse practitioners, or physician assistants at participating practices.

APPROACH

The encounters were transcribed verbatim. We used qualitative content analysis to identify major themes.

KEY RESULTS

Patients were on average 79.9 years of age. The average MMSE score was 21.6. About half of clinicians reported practicing for 15 or more years (n = 8). We identified three major themes. First, we found numerous instances in which primary care clinicians introduced patients and companions to key principles of optimal prescribing and deprescribing. Second, clinicians used a variety of approaches to foster shared decision-making about medication use. Third, several challenges prevented clinicians from working together with patients and companions to optimize prescribing and deprescribing.

CONCLUSIONS

This study offers insight into key language clinicians can use to initiate discussions about optimizing prescribing, as well as barriers they face in doing so. Examples identified in these transcripts should be tested with patients and caregivers to examine how such communications are received and interpreted. Future research should develop and test interventions that seek to overcome obstacles to optimizing prescribing for older adults with cognitive impairment.

Usefulness of Aspirin for Primary Prevention of Atherosclerotic Cardiovascular Disease

Aspirin use in the prevention of cardiovascular events has been a mainstay of treatment for decades. However, the use of aspirin in primary prevention of atherosclerotic cardiovascular disease has recently come under scrutiny. Several recent studies have evaluated the use of aspirin in primary prevention and the results suggest that in many patients the risks may outweigh the benefits. Closer examination of these trials suggests that the use of aspirin therapy for primary prevention may have a role but likely needs a more tailored approach and that caution is needed in prescribing aspirin for primary prevention. In conclusion, in this article we review the evolving evidence for aspirin in the primary prevention of atherosclerotic cardiovascular disease.

Detection and Management of Heart Disease in Athletes

Primary care clinicians fulfill critical roles of screening for, diagnosing, and managing cardiovascular disease. In young athletes, primary structural and electrical diseases are the focus. Coronary artery disease is the chief concern in older athletes. Sudden cardiac arrest may be the initial presentation of disease and is more common in young athletes than historically appreciated. The traditional preparticipation evaluation, or sports physical, is limited in its ability to accurately raise suspicion of underlying disease. The 12-lead electrocardiogram is a more accurate screening tool. Contemporary risk stratification and treatment protocols may allow for safe return to sport on a case-by-case basis.

Targeting the peptidase PCSK9 to reduce cardiovascular risk: Implications for basic science and upcoming challenges

LDL cholesterol (LDL-C) plays a central role in the progression of atherosclerosis. Statin therapy for lowering LDL-C reduces the risk of atherosclerotic cardiovascular disease and is the recommended first-line treatment for patients with high LDL-C levels. However, some patients are unable to achieve an adequate reduction in LDL-C with statins or are statin-intolerant; thus, PCSK9 inhibitors were developed to reduce LDL-C levels, instead of statin therapy. PCSK9 monoclonal antibodies dramatically reduce LDL-C levels and cardiovascular risk, and promising new PCSK9 inhibitors using different mechanisms are currently being developed. The absolute benefit of LDL-C reduction depends on the individual absolute risk and the achieved absolute reduction in LDL-C. Therefore, PCSK9 inhibitors may provide the greatest benefits from further LDL-C reduction for the highest risk patients. Here, we focus on PCSK9-targeted therapies and discuss the challenges of LDL-C reduction for prevention of atherosclerotic cardiovascular disease.

Carotid Artery Imaging Is More Strongly Associated With the 10-Year Atherosclerotic Cardiovascular Disease Score Than Coronary Artery Imaging

PURPOSE

The aim of this study was to compare coronary and carotid artery imaging and determine which one shows the strongest association with atherosclerotic cardiovascular disease (ASCVD) score.

PATIENTS AND METHODS

Two separate series patients who underwent either coronary computed tomography angiography (CTA) or carotid CTA were included. We recorded the ASCVD scores and assessed the CTA imaging. Two thirds were used to build predictive models, and the remaining one third generated predicted ASCVD scores. The Bland-Altman analysis analyzed the concordance.

RESULTS

A total of 110 patients were included in each group. There was no significant difference between clinical characteristics. Three imaging variables were included in the carotid model. Two coronary models (presence of calcium or Agatston score) were created. The bias between true and predicted ASCVD scores was 0.37 ± 5.72% on the carotid model, and 2.07 ± 7.18% and 2.47 ± 7.82% on coronary artery models, respectively.

CONCLUSIONS

Both carotid and coronary artery imaging features can predict ASCVD score. The carotid artery was more associated to the ASCVD score than the coronary artery.

Is type 2 diabetes mellitus a coronary heart disease equivalent or not? Do not just enjoy the debate and forget the patient!

In the last several years there has been a large debate whether patients with type 2 diabetes (T2DM) should be treated as those with high or very high cardiovascular risk, and whether T2DM should be considered as equivalent to coronary heart disease (CHD). It all started in the 2001 in National Cholesterol Education Program - Adult Treatment Panel III recommendations, and the knowledge has changed on this issue at least several times. But the main problem is that due to these inconsistencies and different approaches to the cardiovascular risk of T2DM patients, we have more and more patients with T2DM not effectively treated, and diabetologists mostly focus on glucose (glucocentric approach), often forgetting about the overall cardiovascular risk of those patients. In this review we discuss the above-mentioned topic, try to give some practical suggestions, and raise the issue of whether we should start a discussion on treating all patients with T2DM as those at very high cardiovascular risk, or to at least to try to unify the definition and find such variables/risk factors which are easy to measure to help physicians to treat those patients optimally. We have obviously discussed these issues in the context of new European Society of Cardiology (ESC)/European Association for the Study of Diabetes (EASD) Guidelines 2019.

Direct Versus Calculated LDL Cholesterol and C-Reactive Protein in Cardiovascular Disease Risk Assessment in the Framingham Offspring Study

BACKGROUND

Increases in circulating LDL cholesterol (LDL-C) and high-sensitivity C-reactive protein (hsCRP) concentrations are significant risk factors for cardiovascular disease (CVD). We assessed direct LDL-C and hsCRP concentrations compared to standard risk factors in the Framingham Offspring Study.

METHODS

We used stored frozen plasma samples (-80 °C) obtained after an overnight fast from 3147 male and female participants (mean age, 58 years) free of CVD at cycle 6 of the Framingham Offspring Study. Overall, 677 participants (21.5%) had a CVD end point over a median of 16.0 years of follow-up. Total cholesterol (TC), triglyceride (TG), HDL cholesterol (HDL-C), direct LDL-C (Denka Seiken and Kyowa Medex methods), and hsCRP (Dade Behring method) concentrations were measured by automated analysis. LDL-C was also calculated by both the Friedewald and Martin methods.

RESULTS

Considering all CVD outcomes on univariate analysis, significant factors included standard risk factors (age, hypertension, HDL-C, hypertension treatment, sex, diabetes, smoking, and TC concentration) and nonstandard risk factors (non-HDL-C, direct LDL-C and calculated LDL-C, TG, and hsCRP concentrations). On multivariate analysis, only the Denka Seiken direct LDL-C and the Dade Behring hsCRP were still significant on Cox regression analysis and improved the net risk reclassification index, but with modest effects. Discordance analysis confirmed the benefit of the Denka Seiken direct LDL-C method for prospective hard CVD endpoints (new-onset myocardial infarction, stroke, and/or CVD death).

CONCLUSIONS

Our data indicate that the Denka Seiken direct LDL-C and Dade Behring hsCRP measurements add significant, but modest, information about CVD risk, compared to standard risk factors and/or calculated LDL-C.

The Evolving View of Coronary Artery Calcium: A Personalized Shared Decision-Making Tool in Primary Prevention

The 2018 American Heart Association and American College of Cardiology (AHA/ACC) cholesterol management guideline considers current evidence on coronary artery calcium (CAC) testing while incorporating learnings from previous guidelines. More than any previous guideline update, this set encourages CAC testing to facilitate shared decision making and to individualize treatment plans. An important novelty is further separation of risk groups. Specifically, the current prevention guideline recommends CAC testing for primary atherosclerotic cardiovascular disease (ASCVD) prevention among asymptomatic patients in borderline and intermediate risk groups (5–7.5% and 7.5–20% 10-year ASCVD risk). This additional sub-classification reflects the uncertainty of treatment strategies for patients broadly considered to be “intermediate risk,” as treatment recommendations for high and low risk groups are well established. The 2018 guidelines, for the first time, clearly recognize the significance of a CAC score of zero, where intensive statin therapy is likely not beneficial and not routinely recommended in selected patients. Lifestyle modification should be the focus in patients with CAC = 0. In this article, we review the recent AHA/ACC cholesterol management guideline and contextualize the transition of CAC testing to a guideline-endorsed decision aid for borderline-to-intermediate risk patients who seek more definitive risk assessment as part of a clinician-patient discussion. CAC testing can reduce low-value treatment and focus primary prevention therapy on those most likely to benefit.

10-Year Risk Equations for Incident Heart Failure in the General Population

BACKGROUND

Primary prevention strategies to mitigate the burden of heart failure (HF) are urgently needed. However, no validated risk prediction tools are currently in use.

OBJECTIVES

This study sought to derive 10-year risk equations of developing incident HF.

METHODS

Race- and sex-specific 10-year risk equations for HF were derived and validated from individual-level data from 7 community-based cohorts with at least 12 years of follow-up. Participants who were recruited between 1985 and 2000, between 30 to 79 years, and were free of cardiovascular disease at baseline were included to create a pooled cohort (PC) and were randomly split for derivation and internal validation. Model performance was also assessed in 2 additional cohorts.

RESULTS

In the derivation sample of the PC (n = 11,771), 58% were women, 22% were black with a mean age of 52 ± 12 years, and HF occurred in 1,339 participants. Predictors of HF included in the race-sex-specific models were age, blood pressure (treated or untreated), fasting glucose (treated or untreated), body mass index, cholesterol, smoking status, and QRS duration. The PC equations to Prevent HF model had good discrimination and strong calibration in internal and external validation cohorts. A web-based tool was developed to facilitate clinical application of this tool.

CONCLUSIONS

The authors present a contemporary analysis from 33,010 men and women demonstrating the utility of the sex- and race-specific 10-year PC equations to Prevent HF risk score, which integrates clinical parameters readily available in primary care settings. This tool can be useful in risk-based decision making to determine who may merit intensive screening and/or targeted prevention strategies.

Metformin in patients with and without diabetes: a paradigm shift in cardiovascular disease management

With an increasing global burden of coronary artery disease (CAD), early detection and timely management of risk factors are crucial to reduce morbidity and mortality in such patients. Diabetes mellitus (DM) is considered an independent risk factor for the development of CAD. Metformin, an anti-diabetic drug, has been shown in pre-clinical and clinical studies, to lower the cardiovascular events in the DM patients. Growing evidence suggests that metformin has a protective effect on coronary artery beyond its hypoglycemic effects. Given its global availability, route of administration and cost, metformin provides an alternate/additional therapeutic option for primary and secondary prevention of CAD in DM and non-diabetics alike. Future prospective cohort-based studies and randomized clinical trials are needed to identify ‘at-risk’ population who may potentially benefit from metformin.