Value of primordial and primary prevention for cardiovascular disease: a policy statement from the American Heart Association

Change in calculated cardiovascular risk due to guideline revision: A cross-sectional study in the Netherlands

BACKGROUND

Guidelines and accompanying risk charts concerning cardiovascular risk management (CVRM) are regularly revised worldwide.

OBJECTIVE

To evaluate whether revision of the Dutch CVRM guideline has led to the reclassification of patients and, accordingly, to changes in drug recommendations.

METHODS

All medical records (year 2011) of patients aged 40-65 years with no history of cardiovascular disease (CVD) but using antihypertensive and/or lipid-lowering drugs, were selected from the Registration Network of General Practices associated with Leiden University Medical Center. Multiple imputation techniques for missing determinants were used. The individual cardiovascular risk was calculated and the resulting drug recommendation was assessed according to both the 2006 and 2012 versions of the guideline.

RESULTS

In total, 2075 patients were selected, of whom 1248 fulfilled the guideline criteria (systolic blood pressure 115-180 mmHg and total cholesterol/high-density-lipoprotein-cholesterol ratio 3.5-8). According to the 2012 guideline, 58.2% of the patients had low risk and 249 patients (20.0%) shifted to a different risk category. For 150 of these patients (12.0%), this category shift implied a shift in drug recommendation. The probability of shifting in drug recommendation increased with increasing age, cholesterol level, and blood pressure, and by being male.

CONCLUSION

Guideline revision may have important implications: based on identical values for risk factors, according to the latest revision of the Dutch CVRM guideline 20% of patients shifted in risk category and 12% of the patients shifted in drug recommendation.

A Global Perspective on Cardiovascular Disease in Vulnerable Populations

Cardiovascular disease (CVD) is a major contributor to the growing public health epidemic in chronic diseases. Much of the disease and disability burden from CVDs are in people younger than the age of 70 years in low- and middle-income countries, formerly "the developing world." The risk of CVD is heavily influenced by environmental conditions and lifestyle variables. In this article we review the scope of the CVD problem in low- and middle-income countries, including economic factors, risk factors, at-risk groups, and explanatory frameworks that hypothesize the multifactorial drivers. Finally, we discuss current and potential interventions to reduce the burden of CVD in vulnerable populations including research needed to evaluate and implement promising solutions for those most at risk.

Prevalence of behavioural risk factors for cardiovascular disease in adolescents in low-income and middle-income countries: an individual participant data meta-analysis

BACKGROUND

Although overt manifestations of cardiovascular disease (CVD) rarely emerge before adulthood, CVD risk factors are often present in adolescents. However, the prevalence and magnitude of behavioural CVD risk factors in adolescents in low-income and middle-income countries remains unclear. We estimated the magnitude and co-occurrence of behavioural CVD risk factors in adolescents aged 12-15 years for 65 low-income and middle-income countries between 2003 and 2011.

METHODS

We extracted Global School-Based Student Health Surveys (GSHS) datasets from the Centers for Disease Control and Prevention (CDC) website. Pooled prevalence estimates of current tobacco use, alcohol use, low fruit and vegetable intake, low physical activity, obesity and co-occurrence of CVD risk factors for WHO regions and overall, was calculated with random-effects meta-analysis. We explored potential sources of heterogeneity for each CVD risk factor through random-effects meta-regression analysis.

FINDINGS

Between 2003 and 2011, of 169 369 adolescents, 12·1% (95% CI 10·2-14·1) used tobacco, 15·7% (12·3-19·5) used alcohol, 74·3% (71·9 -76·5) had low fruit and vegetable intake, 71·4% (69·5-73·3) reported low physical activity and 7·1% (5·6-8·7) were obese. The pooled regional prevalence of exposure to three or more CVD risk factors was lowest in the southeast Asian region (3·8%, 95% CI 1·2-7·5) and highest in the western Pacific region (18·6%, 12·8-25·3). Substantial heterogeneities within and across regions were not fully explained by major study characteristics.

INTERPRETATION

In low-income and middle-income countries, adolescents carry a substantial burden of behavioural CVD risk factors, which tend to co-occur. Surveillance, prevention, detection, and control initiatives are a global health priority.

FUNDING

None.

Disparities in long-term cardiovascular disease risk by sexual identity: The National Longitudinal Study of Adolescent to Adult Health

OBJECTIVE

To examine long-term cardiovascular disease (CVD) risk disparities by sexual identity using a nationally representative sample of young adults in the United States.

METHODS

Data include participants in wave 4 (2008/09; ages 24-34years) of the National Longitudinal Study of Adolescent to Adult Health (7087 females; 6340 males). Sexual identity was self-reported (heterosexual, mostly heterosexual, bisexual, mostly homosexual, homosexual) and a Framingham-based prediction model was used to estimate participants' risk of a CVD event over 30years. Differences in CVD risk by sexual identity, relative to heterosexuals, were calculated with linear regression models adjusted for age, race/ethnicity, education, and financial distress.

RESULTS

Average 30-year CVD risk was 17.2% (95% CI: 16.7, 17.7) in males and 9.0% (95% CI: 8.6, 9.3) in females. Compared to heterosexual females, mostly heterosexual (0.8%; 95% CI: 0.2, 1.4) and mostly homosexual females (2.8%; 95% CI: 0.8, 4.9) had higher CVD risk. Bisexual and homosexual females had higher but not statistically significant CVD risk compared to heterosexuals. Among males, differences in CVD risk by sexual identity were not statistically significant.

CONCLUSION

Sexual identity was associated with CVD risk in sexual minority subgroups. Population- and clinic-based prevention strategies are needed to minimize disparities in subsequent disease.

Cardiovascular disease screening

Cardiovascular disease is the leading cause of death amongst women worldwide. Cardiovascular risk assessment and primary prevention are important strategies to improve morbidity and mortality. In additional to the traditional risk factors, pregnancy complications such as pre-eclampsia and gestational diabetes increment future risk of developing cardiovascular complications. Additionally, several serum biomarkers are valuable measures for both risk assessment and predictors of clinical outcomes in women. The purpose of this review is to describe current risk stratification schemes as well as outline the role of obstetric history and serum biomarkers in adjusting risk stratification in women.

Other adverse pregnancy outcomes and future chronic disease

Cardiovascular disease is the leading cause of morbidity and mortality in females worldwide. Pregnancy is associated with significant physiologic changes that may function as a natural stress test to detect women at future risk. It is established that women who have had a pregnancy complicated by gestational diabetes or a hypertensive disorder of pregnancy are at increased risk of cardiovascular disease later in life, and there is growing evidence that women who deliver infants preterm or growth-restricted infants have an elevated risk as well. Consideration should be given to including these outcomes as indicators of cardiovascular risk. Pregnancy represents a teachable moment when it would be ideal to identify women at risk. Improved integration of women's primary health care and an enhanced knowledge base on the part of clinicians will be necessary to fully incorporate these findings into the clinical care of women.

Type 2 diabetes among Asian Americans: Prevalence and prevention

Type 2 diabetes mellitus (T2DM) is a growing problem among Asian Americans. Based on the Centers for Disease Control, the age-adjusted prevalence of T2DM for Asian Americans is 9%, placing them at “moderate risk”. However differential patterns of disease burden emerge when examining disaggregated data across Asian American ethnic groups; with Filipino, Pacific Islander, Japanese, and South Asian groups consistently described as having the highest prevalence of T2DM. Disentangling and strengthening prevalence data is vital for on-going prevention efforts. The strongest evidence currently available to guide the prevention of T2DM in the United States comes from a large multicenter randomized clinical control trial called the Diabetes Prevention Program, which targets individual lifestyle behavior changes. It has been translated and adopted for some Asian American groups, and shows promise. However stronger study designs and attention to several key methodological considerations will improve the science. Increased attention has also been directed toward population level downstream prevention efforts. Building an infrastructure that includes both individual and population approaches is needed to prevent T2DM among Asian American populations, and is essential for reducing health disparities.

Is blood pressure control for stroke prevention the correct goal? The lost opportunity of preventing hypertension

BACKGROUND AND PURPOSE

Although pharmacological treatment of hypertension has important health benefits, it does not capture the benefit of maintenance of ideal health through the prevention or delay of hypertension.

METHODS

A total of 26 875 black and white participants aged 45+ years were assessed and followed for incident stroke events. The association was assessed between incident stroke and: (1) systolic blood pressure (SBP)categorized as normal (<120 mm Hg), prehypertension (120-139 mm Hg), stage 1 hypertension (140-159 mm Hg), and stage 2 hypertension (160 mm Hg+), and (2) number of classes of antihypertensive medications, classified as none, 1, 2, or 3 or more.

RESULTS

During 6.3 years of follow-up, 823 stroke events occurred. Nearly half (46%) of the population were successfully treated (SBP<140 mm Hg) hypertensives. Within blood pressure strata, the risk of stroke increased with each additional class of required antihypertensive medication, with hazard ratio [HR], 1.33; 95% confidence interval, 1.16 to 1.52 for normotensive, HR, 1.15; 95% confidence interval, 1.05 to 1.26 for prehypertension, and HR, 1.22; 95% confidence interval, 1.06 to 1.39 for stage 1 hypertension. A successfully treated (SBP<120 mm Hg) hypertensive person on 3+ antihypertensive medication classes was at marginally higher stroke risk than a person with untreated stage 1 hypertension (HR, 2.48 versus HR=2.19; relative to those with SBP <120 on no antihypertensive medications).

CONCLUSIONS

Maintaining the normotensive status solely through pharmacological treatment has a profound impact, as nearly half of this general population cohort were treated to guideline (SBP<140 mm Hg) but failed to return to risk levels similar to normotensive individuals. Even with successful treatment, there is a substantial potential gain by prevention or delay of hypertension.

Prevalence of dyslipidemia in Iranian children and adolescents: A systematic review

BACKGROUND

Dyslipidemia is considered as an important modifiable risk factor for cardiovascular disease (CVD). The link between childhood dyslipidemia and occurrence of atherosclerosis and its sequels in adulthood are well-documented. This study aimed to systematically review the prevalence of dyslipidemia among Iranian children and adolescents.

MATERIALS AND METHODS

An electronic search was conducted on studies published from January 1990 to January 2014. The main international electronic data sources were PubMed and the NLM Gateway (for MEDLINE), Institute of Scientific Information (ISI), and SCOPUS. For Persian databases, we used domestic databases with systematic search capability including IranMedex, Irandoc, and Scientific Information Database (SID). We included all available population-based studies and national surveys conducted in the pediatric age group (aged <21 years).

RESULTS

In this review, 1772 articles were identified (PubMed: 1464; Scopus: 11; ISI: 58; SID: 90; IranMedex: 149; Irandoc: 57). During three refine steps and after removing of duplicates, 182 articles related to the study domain were selected. After quality assessment, 46 studies were selected for text appraisal, of which 26 qualified articles were evaluated at the final step. The prevalence range of hypercholesterolemia, hypertriglyceridemia, elevated low-density lipoprotein cholesterol, and low high-density lipoprotein cholesterol (HDL-C) were 3-48%, 3-50%, 5-20% and 5-88%, respectively. Low HDL-C and hypertriglyceridemia were the most prevalent lipid disorders in this group of population.

CONCLUSION

Dyslipidemia is a common health problem among Iranian children and adolescents. Few data were available in preschool children. This finding provides useful information for health policy makers to implement action-oriented interventions for prevention and early control of this important CVD risk factor.

Leading Causes of Death among Asian American Subgroups (2003-2011)

BACKGROUND

Our current understanding of Asian American mortality patterns has been distorted by the historical aggregation of diverse Asian subgroups on death certificates, masking important differences in the leading causes of death across subgroups. In this analysis, we aim to fill an important knowledge gap in Asian American health by reporting leading causes of mortality by disaggregated Asian American subgroups.

METHODS AND FINDINGS

We examined national mortality records for the six largest Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) and non-Hispanic Whites (NHWs) from 2003-2011, and ranked the leading causes of death. We calculated all-cause and cause-specific age-adjusted rates, temporal trends with annual percent changes, and rate ratios by race/ethnicity and sex. Rankings revealed that as an aggregated group, cancer was the leading cause of death for Asian Americans. When disaggregated, there was notable heterogeneity. Among women, cancer was the leading cause of death for every group except Asian Indians. In men, cancer was the leading cause of death among Chinese, Korean, and Vietnamese men, while heart disease was the leading cause of death among Asian Indians, Filipino and Japanese men. The proportion of death due to heart disease for Asian Indian males was nearly double that of cancer (31% vs. 18%). Temporal trends showed increased mortality of cancer and diabetes in Asian Indians and Vietnamese; increased stroke mortality in Asian Indians; increased suicide mortality in Koreans; and increased mortality from Alzheimer's disease for all racial/ethnic groups from 2003-2011. All-cause rate ratios revealed that overall mortality is lower in Asian Americans compared to NHWs.

CONCLUSIONS

Our findings show heterogeneity in the leading causes of death among Asian American subgroups. Additional research should focus on culturally competent and cost-effective approaches to prevent and treat specific diseases among these growing diverse populations.

New metrics needed to visualize the long-term impact of early LDL-C lowering on the cardiovascular disease trajectory

Short-term absolute cardiovascular event rates in young/middle-aged people are low even if they have risk factors, and parameters such as number-needed-to-treat over 5years are inadequate to visualize and to communicate the lifelong benefit of interventions such as statin therapy to individuals and to healthcare providers. To understand more fully the impact of risk factors, and lifestyle and pharmacological interventions, there is a need to focus on disease trajectory over a lifetime and to develop new metrics of success. A shift to primordial ('true') prevention of the formation of atherosclerotic lesions will require new tools and approaches in the interaction between physicians and patients as individuals or populations.

Physiological geroscience: targeting function to increase healthspan and achieve optimal longevity

Most nations of the world are undergoing rapid and dramatic population ageing, which presents great socio-economic challenges, as well as opportunities, for individuals, families, governments and societies. The prevailing biomedical strategy for reducing the healthcare impact of population ageing has been 'compression of morbidity' and, more recently, to increase healthspan, both of which seek to extend the healthy period of life and delay the development of chronic diseases and disability until a brief period at the end of life. Indeed, a recently established field within biological ageing research, 'geroscience', is focused on healthspan extension. Superimposed on this background are new attitudes and demand for 'optimal longevity' - living long, but with good health and quality of life. A key obstacle to achieving optimal longevity is the progressive decline in physiological function that occurs with ageing, which causes functional limitations (e.g. reduced mobility) and increases the risk of chronic diseases, disability and mortality. Current efforts to increase healthspan centre on slowing the fundamental biological processes of ageing such as inflammation/oxidative stress, increased senescence, mitochondrial dysfunction, impaired proteostasis and reduced stress resistance. We propose that optimization of physiological function throughout the lifespan should be a major emphasis of any contemporary biomedical policy addressing global ageing. Effective strategies should delay, reduce in magnitude or abolish reductions in function with ageing (primary prevention) and/or improve function or slow further declines in older adults with already impaired function (secondary prevention). Healthy lifestyle practices featuring regular physical activity and ideal energy intake/diet composition represent first-line function-preserving strategies, with pharmacological agents, including existing and new pharmaceuticals and novel 'nutraceutical' compounds, serving as potential complementary approaches. Future research efforts should focus on defining the temporal patterns of functional declines with ageing, identifying the underlying mechanisms and modulatory factors involved, and establishing the most effective lifestyle practices and pharmacological options for maintaining function. Continuing development of effective behavioural approaches for enhancing adherence to healthy ageing practices in diverse populations, and ongoing analysis of the socio-economic costs and benefits of healthspan extension will be important supporting goals. To meet the demands created by rapid population ageing, a new emphasis in physiological geroscience is needed, which will require the collaborative, interdisciplinary efforts of investigators working throughout the translational research continuum from basic science to public health.

Health promotion for primordial prevention of tobacco use

Prevention of tobacco use is critical for primordial prevention of cardiovascular diseases. Low- and middle-income countries such as India face a burgeoning burden of tobacco-related cardiovascular diseases. A focus on adolescents and young people is consistent with a primordial approach to cardiovascular disease prevention and appropriate given the natural history of tobacco use, in regards to its onset and progression. The primordial prevention approach is feasible, because it attempts to bring about behavior change (sustained abstinence for nonusers) at the population level. This paper reviews effective strategies for population-based tobacco control among adolescents including settings-based interventions at school, at home, and in the community, as well as policy and media interventions. It goes on to briefly touch on the pivotal role that medical professionals, particularly cardiologists, play in fortifying such interventions and summarizes some key recommendations based on review of evidence on the effectiveness of these interventions.

A simple healthy lifestyle index as a proxy of wellness: a proof of concept

The evidence supporting the importance of a healthy lifestyle (active life, healthy diet, not smoking, and low stress) as a part of programs for primary and secondary prevention of cardiometabolic diseases is strong, compelling, and continuously growing. In this study, we test whether a simple web-based healthy lifestyle index, using self-reports, is related to indices of cardiovascular health and metabolic syndrome and could be employed in large wellness programs intended to promote healthy lifestyle. We studied 411 workers in an Italian multinational factory who were enrolled in a voluntary program consisting of a health checkup and an online questionnaire on lifestyle. These domains were combined into a single simple index. Participants were subdivided into three healthy lifestyle index (HI) groups (red, yellow, and green) ranging from poor to good HI quality (HI from red to green: 41.8 ± 14.6; 75.7 ± 8.5; 93.8 ± 2.2; p < 0.05). The groups differed in indicators of cardiovascular and metabolic health (waist circumference females: 82.1 ± 9.56, 78.9 ± 9.3, 72.7 ± 6.6; males: 95.2 ± 11.7, 90.0 ± 9.5, 85.7 ± 6.1 cm; group difference p < 0.05). Moreover, they differed significantly in the likelihood of having more components of the metabolic syndrome and, conversely, fewer components of the ideal cardiovascular health profile (with red having the worst profile). The red group was also characterized by the highest absenteeism. We report for the first time that a web-based self-reported poor health behavior was significantly associated with clinical and laboratory (partial correlation between HI and high-density cholesterol 0.192; body mass index -0.288; systolic blood pressure -0.130; all p < 0.05) results indicating a negative cardiometabolic profile.

Healthy lifestyle in the primordial prevention of cardiovascular disease among young women

BACKGROUND

Overall mortality rates from coronary heart disease (CHD) in the United States have declined in recent decades, but the rate has plateaued among younger women. The potential for further reductions in mortality rates among young women through changes in lifestyle is unknown.

OBJECTIVES

The aim of this study was to estimate the proportion of CHD cases and clinical cardiovascular disease (CVD) risk factors among young women that might be attributable to poor adherence to a healthy lifestyle.

METHODS

A prospective analysis was conducted among 88,940 women ages 27 to 44 years at baseline in the Nurses' Health Study II who were followed from 1991 to 2011. Lifestyle factors were updated repeatedly by questionnaire. A healthy lifestyle was defined as not smoking, a normal body mass index, physical activity ≥ 2.5 h/week, television viewing ≤ 7 h/week, diet in the top 40% of the Alternative Healthy Eating Index-2010, and 0.1 to 14.9 g/day of alcohol. To estimate the proportion of CHD and clinical CVD risk factors (diabetes, hypertension, and hypercholesterolemia) that could be attributed to poor adherence to a healthy lifestyle, we calculated the population-attributable risk percent.

RESULTS

During 20 years of follow-up, we documented 456 incident CHD cases. In multivariable-adjusted models, nonsmoking, a healthy body mass index, exercise, and a healthy diet were independently and significantly associated with lower CHD risk. Compared with women with no healthy lifestyle factors, the hazard ratio for CHD for women with 6 lifestyle factors was 0.08 (95% confidence interval: 0.03 to 0.22). Approximately 73% (95% confidence interval: 39% to 89%) of CHD cases were attributable to poor adherence to a healthy lifestyle. Similarly, 46% (95% confidence interval: 43% to 49%) of clinical CVD risk factor cases were attributable to a poor lifestyle.

CONCLUSIONS

Primordial prevention through maintenance of a healthy lifestyle among young women may substantially lower the burden of CVD.

Macrophage Heterogeneity and Plasticity: Impact of Macrophage Biomarkers on Atherosclerosis

Cardiovascular disease (CVD) is a global epidemic, currently representing the worldwide leading cause of morbidity and mortality. Atherosclerosis is the fundamental pathophysiologic component of CVD, where the immune system plays an essential role. Monocytes and macrophages are key mediators in this aspect: due to their heterogeneity and plasticity, these cells may act as either pro- or anti-inflammatory mediators. Indeed, monocytes may develop heterogeneous functional phenotypes depending on the predominating pro- or anti-inflammatory microenvironment within the lesion, resulting in classic, intermediate, and non-classic monocytes, each with strikingly differing features. Similarly, macrophages may also adopt heterogeneous profiles being mainly M1 and M2, the former showing a proinflammatory profile while the latter demonstrates anti-inflammatory traits; they are further subdivided in several subtypes with more specialized functions. Furthermore, macrophages may display plasticity by dynamically shifting between phenotypes in response to specific signals. Each of these distinct cell profiles is associated with diverse biomarkers which may be exploited for therapeutic intervention, including IL-10, IL-13, PPAR-γ, LXR, NLRP3 inflammasomes, and microRNAs. Direct modulation of the molecular pathways concerning these potential macrophage-related targets represents a promising field for new therapeutic alternatives in atherosclerosis and CVD.

microRNAs Distinctively Regulate Vascular Smooth Muscle and Endothelial Cells: Functional Implications in Angiogenesis, Atherosclerosis, and In-Stent Restenosis

Endothelial cells (EC) and vascular smooth muscle cells (VSMC) are the main cell types within the vasculature. We describe here how microRNAs (miRs)--noncoding RNAs that can regulate gene expression via translational repression and/or post-transcriptional degradation--distinctively modulate EC and VSMC function in physiology and disease. In particular, the specific roles of miR-126 and miR-143/145, master regulators of EC and VSMC function, respectively, are deeply explored. We also describe the mechanistic role of miRs in the regulation of the pathophysiology of key cardiovascular processes including angiogenesis, atherosclerosis, and in-stent restenosis post-angioplasty. Drawbacks of currently available therapeutic options are discussed, pointing at the challenges and potential clinical opportunities provided by miR-based treatments.

Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies

BACKGROUND

Several systematic reviews and meta-analyses demonstrated the association between depression and the risk of coronary heart disease (CHD), but the previous reviews had some limitations. Moreover, a number of additional studies have been published since the publication of these reviews. We conducted an updated meta-analysis of prospective studies to assess the association between depression and the risk of CHD.

METHODS

Relevant prospective studies investigating the association between depression and CHD were retrieved from the PubMed, Embase, Web of Science search (up to April 2014) and from reviewing reference lists of obtained articles. Either a random-effects model or fixed-effects model was used to compute the pooled risk estimates when appropriate.

RESULTS

Thirty prospective cohort studies with 40 independent reports met the inclusion criteria. These groups included 893,850 participants (59,062 CHD cases) during a follow-up duration ranging from 2 to 37 years. The pooled relative risks (RRs) were 1.30 (95% CI, 1.22-1.40) for CHD and 1.30 (95% CI, 1.18-1.44) for myocardial infarction (MI). In the subgroup analysis by follow-up duration, the RR of CHD was 1.36 (95% CI, 1.24-1.49) for less than 15 years follow-up, and 1.09 (95% CI, 0.96-1.23) for equal to or more than 15 years follow-up. Potential publication bias may exist, but correction for this bias using trim-and-fill method did not alter the combined risk estimate substantially.

CONCLUSIONS

The results of our meta-analysis suggest that depression is independently associated with a significantly increased risk of CHD and MI, which may have implications for CHD etiological research and psychological medicine.

Effects of lifestyle modification programs on cardiac risk factors

Medicare conducted a payment demonstration to evaluate the effectiveness of two intensive lifestyle modification programs in patients with symptomatic coronary artery disease: the Dr. Dean Ornish Program for Reversing Heart Disease (Ornish) and Cardiac Wellness Program of the Benson-Henry Mind Body Institute. This report describes the changes in cardiac risk factors achieved by each program during the active intervention year and subsequent year of follow-up. The demonstration enrolled 580 participants who had had an acute myocardial infarction, had undergone coronary artery bypass graft surgery or percutaneous coronary intervention within 12 months, or had documented stable angina pectoris. Of these, 98% completed the intense 3-month intervention, 71% the 12-month intervention, and 56% an additional follow-up year. Most cardiac risk factors improved significantly during the intense intervention period in both programs. Favorable changes in cardiac risk factors and functional cardiac capacity were maintained or improved further at 12 and 24 months in participants with active follow-up. Multivariable regressions found that risk-factor improvements were positively associated with abnormal baseline values, Ornish program participation for body mass index and systolic blood pressure, and with coronary artery bypass graft surgery. Expressed levels of motivation to lose weight and maintain weight loss were significant independent predictors of sustained weight loss (p = 0.006). Both lifestyle modification programs achieved well-sustained reductions in cardiac risk factors.

Predicted long-term cardiovascular risk among young adults in the national longitudinal study of adolescent health

OBJECTIVES

We estimated the distribution of predicted long-term cardiovascular disease (CVD) risk among young adults in the United States.

METHODS

Our data were derived from National Longitudinal Study of Adolescent Health participants (n = 14 333; average age: 28.9 years). We used a Framingham-derived risk prediction function to calculate 30-year risks of "hard" and "general" CVD by gender and race/ethnicity.

RESULTS

Average 30-year risks for hard and general CVD were 10.4% (95% confidence interval [CI] = 10.1%, 10.7%) and 17.3% (95% CI = 17.0%, 17.7%) among men and 4.4% (95% CI = 4.3%, 4.6%) and 9.2% (95% CI = 8.9%, 9.5%) among women. Average age-adjusted risks of hard and general CVD were higher among Blacks and American Indians than among Whites and lower among Asian/Pacific Islander women than White women. American Indian men continued to have a higher risk of general CVD after adjustment for socioeconomic status. Four percent of women (95% CI = 3.6%, 5.0%) and 26.2% of men (95% CI = 24.7%, 27.8%) had a 20% or higher risk of general CVD. Racial differences were detected but were not significant after adjustment for socioeconomic status.

CONCLUSIONS

Average CVD risk among young adults is high. Population-based prevention strategies and improved detection and treatment of high-risk individuals are needed to reduce the future burden of CVD.

Pediatric lipid management: an earlier approach

The National Heart, Lung and Blood Institute Expert Panel Integrated Guidelines promote the prevention of cardiovascular disease (CVD) events by encouraging healthy behaviors in all children, screening and treatment of children with genetic dyslipidemias, usage of specific lifestyle modifications, and limited administration of lipid pharmacotherapy in children with the highest CVD risk. These recommendations place children in the center of the fight against future CVD. Pediatric providers may be in a position to shift the focus of CVD prevention from trimming multiple risk factors to cutting out the causes CVD.

Lifestyle-based prediction model for the prevention of CVD: the Healthy Heart Score

Background

Clinical practice focuses on the primary prevention of cardiovascular (CV) disease (CVD) through the modification and pharmacological treatment of elevated risk factors. Prediction models based on established risk factors are available for use in the primary prevention setting. However, the prevention of risk factor development through healthy lifestyle behaviors, or primordial prevention, is of paramount importance to achieve optimal population‐wide CV health and minimize long‐term CVD risk.

Methods and Results

We developed a lifestyle‐based CVD prediction model among 61 025 women in the Nurses’ Health Study and 34 478 men in the Health Professionals Follow‐up Study, who were free of chronic disease in 1986 and followed for ≤24 years. Lifestyle factors were assessed by questionnaires in 1986. In the derivation step, we used the Bayes Information Criterion to create parsimonious 20‐year risk prediction models among a random two thirds of participants in each cohort separately. The scores were validated in the remaining one third of participants in each cohort. Over 24 years, there were 3775 cases of CVD in women and 3506 cases in men. The Healthy Heart Score included age, smoking, body mass index, exercise, alcohol, and a composite diet score. In the validation cohort, the risk score demonstrated good discrimination (Harrell's C‐index, 0.72; 95% confidence interval [CI], 0.71, 0.74 [women]; 0.77; 95% CI, 0.76, 0.79 [men]), fit, and calibration, particularly among individuals without baseline hypertension or hypercholesterolemia.

Conclusions

The Healthy Heart Score accurately identifies individuals at elevated risk for CVD and may serve as an important clinical and public health screening tool for the primordial prevention of CVD.

Developing a statewide childhood body mass index surveillance program

BACKGROUND

Several states have implemented childhood obesity surveillance programs supported by legislation. Representatives from Idaho wished to develop a model for childhood obesity surveillance without the support of state legislation, and subsequently report predictors of overweight and obesity in the state.

METHODS

A coalition comprised of the Idaho State Department of Education and 4 universities identified a randomized cluster sample of schools. After obtaining school administrator consent, measurement teams traveled to each school to measure height and weight of students. Sex and race/ethnicity data were also collected.

RESULTS

The collaboration between the universities resulted in a sample of 6735 students from 48 schools and 36 communities. Overall, 29.2% of the youth in the sample were classified as overweight or obese, ranging from 24.0% for grade 1 to 33.8% for grade 5. The prevalence of overweight and obesity across schools was highly variable (31.2 ± 7.58%). Hierarchical logistic regression indicated that sex, age, race/ethnicity, socioeconomic status, and region were all significant predictors of overweight and obesity, whereas school was not.

CONCLUSIONS

This coalition enabled the state of Idaho to successfully estimate the prevalence of overweight and obesity on a representative sample of children from all regions of the state, and subsequently identify populations at greatest risk.

Geographical variation in health-related physical fitness and body composition among Chilean 8th graders: a nationally representative cross-sectional study

PURPOSE

In addition to excess adiposity, low cardiorespiratory fitness (CRF) and low musculoskeletal fitness (MSF) are important independent risk factors for future cardio-metabolic disease in adolescents, yet global fitness surveillance in adolescents is poor. The objective of this study was to describe and investigate geographical variation in levels of health-related physical fitness, including CRF, MSF, body mass index (BMI), and waist circumference (WC) in Chilean 8th graders.

METHODS

This cross-sectional study was based on a population-based, representative sample of 19,929 8th graders (median age = 14 years) in the 2011 National Physical Education Survey from Chile. CRF was assessed with the 20-meter shuttle run test, MSF with standing broad jump, and body composition with BMI and WC. Data were classified according to health-related standards. Prevalence of levels of health-related physical fitness was mapped for each of the four variables, and geographical variation was explored at the country level by region and in the Santiago Metropolitan Area by municipality.

RESULTS

Girls had significantly higher prevalence of unhealthy CRF, MSF, and BMI than boys (p<0.05). Overall, 26% of boys and 55% of girls had unhealthy CRF, 29% of boys and 35% of girls had unhealthy MSF, 29% of boys and 44% of girls had unhealthy BMI, and 31% of adolescents had unhealthy WC. High prevalence of unhealthy fitness levels concentrates in the northern and middle regions of the country and in the North and Southwest sectors for the Santiago Metropolitan Area.

CONCLUSION

Prevalence of unhealthy CRF, MSF, and BMI is relatively high among Chilean 8th graders, especially in girls, when compared with global estimates. Identification of geographical regions and municipalities with high prevalence of unhealthy physical fitness presents opportunity for targeted intervention.

Cardiovascular risk factors one year after a hypertensive disorder of pregnancy

OBJECTIVE

To identify differences in women's cardiovascular risk, independent of obesity, one year after delivery of a pregnancy complicated by a hypertensive disorder of pregnancy (HDP).

METHODS

We compared traditional and novel cardiovascular risk factors of women recruited at delivery following the diagnosis of an HDP with those of women with uncomplicated pregnancies, at 3 months and 12-18 months postpartum. Measures included blood pressure, fasting lipids, inflammatory biomarkers, and measures of insulin resistance. Multiple linear regressions were used to adjust for body mass index (BMI) and other characteristics.

RESULTS

We studied 71 subjects: 31 women with HDP and 40 with an uncomplicated pregnancy. There were no significant differences between groups for total cholesterol, HDL-c, LDL-c, triglycerides, HgbA1c, or homeostasis model assessment-estimated insulin resistance. Values for tumor necrosis factor-α were significantly higher in the HDP group (p<0.01), while those for interleukin-6 and c-reactive protein were not. A diagnosis of HDP was associated with a 9 mm Hg difference in systolic blood pressure at both 3 months and 1 year, after adjustment for age, BMI, race, family history of cardiovascular disease, tobacco use, and insurance.

CONCLUSIONS

Women with HDP had significantly higher blood pressure 3 months and 1 year after delivery, independent of obesity. There were no significant differences in lipids or measures of insulin resistance after adjusting for BMI. Elevated blood pressure may account for the observed associations between HDP and future cardiovascular disease.

Psychiatrists’ approach to vascular risk assessment in Latin America

AIM: To explore the way in which Latin American psychiatrists approach the screening of vascular risk factors in patients receiving antipsychotic medication.

METHODS: This was a descriptive, cross sectional study that surveyed Latin-American physicians to evaluate differences between groups divided in three main sections. The first section included demographic and professional data. The second section asked about the available medical resources: weighing scales, sphygmomanometer and measuring tape. Finally, the third section aimed at looking into the attitudes towards cardiovascular prevention. The latter was also divided into two subsections. In the first one, the questions were about weight, blood pressure and waist perimeter. In the second subsection the questions asked about the proportion of patients: (1) that suffered from overweight and/or obesity; (2) whose lipids and glycemia were controlled by the physician; (3) that were questioned by, and received information from the physician about smoking; and (4) that received recommendations from the physician to engage in regular physical activity. The participants were physicians, users of the medical website Intramed. The visitors were recruited by a banner that invited them to voluntarily access an online self-reported structured questionnaire with multiple options.

RESULTS: We surveyed 1185 general physicians and 792 psychiatrists. Regarding basic medical resources, a significantly higher proportion of general physicians claimed to have weighing scales (χ² = 404.9; P < 0.001), sphygmomanometers (χ² = 419.3; P < 0.001), and measuring tapes (χ² = 336.5; P < 0.001). While general physicians measured overweight and metabolic indexes in the general population in a higher proportion than in patients treated with antipsychotics (Z = -11.91; P < 0.001), psychiatrists claimed to measure them in patients medicated with antipsychotics in a higher proportion than in the general population (Z = -3.26; P < 0.001). Also general physicians tended to evaluate smoking habits in the general population more than psychiatrists (Z = -7.02; P < 0.001), but psychiatrists evaluated smoking habits in patients medicated with antipsychotics more than general physicians did (Z = -2.25; P = 0.024). General physicians showed a significantly higher tendency to control blood pressure (χ² = 334.987; P < 0.001), weight (χ² = 435.636; P < 0.001) and waist perimeter (χ² = 96.52; P < 0.001) themselves and they did so in all patients. General physicians suggested physical activity to all patients more frequently (Z = -2.23; P = 0.026), but psychiatrists recommended physical activity to patients medicated with antipsychotics more frequently (Z = -7.53; P < 0.001).

CONCLUSION: Psychiatrists usually check vascular risk factors in their patients, especially in those taking antipsychotics. General practitioners check them routinely without paying special attention to this population.

The implications of fundamental cause theory for priority setting

Application of fundamental cause theory to Powers and Faden's model of social justice highlights the ethical superiority of upstream public health interventions. In this article, I assess the ramifications of fundamental cause theory specifically in context of public health priority setting. Ethically optimal public health policy simultaneously maximizes overall population health and compresses health inequalities. The fundamental cause theory is an important framework in helping to identify which categories of public health interventions are most likely to advance these twin goals.

Blood pressure response to a community-based program and long-term cardiovascular outcome

BACKGROUND

The significance in terms of the cardiovascular outcome of different patterns of blood pressure (BP) response to community-based activities has not been previously studied. The aim of our study was to evaluate the relationship between changes of BP observed during a community-based program and long-term rate of cardiovascular disease (CVD) events.

METHODS

A program focused on the prevention of CVDs was implemented in a small city in Argentina over a 6-year period (1997-2003). The program was evaluated using a cohort of 1,526 randomly selected individuals. The population's mean systolic BP (SBP) decreased approximately 5mm Hg, but BP changes were heterogeneous. Eight years after the intervention had stopped, 1,124 individuals of the cohort were surveyed to evaluate incident CVD events. The sample was divided into 3 SBP change categories during the intervention: decrease (< -5mm Hg), no change (-5 to 5mm Hg) and increase (> 5mm Hg). Cox models were used to estimate the hazard ratio (HR) of CVD events for each category adjusted for age, sex, and baseline BP.

RESULTS

At the end of the intervention, individuals who had increased their SBP showed an adjusted HR for CVD that was double those whose SBP levels decreased or did not change. An inverse relationship between baseline SBP and ΔSBP was observed: individuals with an increase in BP during the intervention had lower SBP at the beginning of the study.

CONCLUSIONS

BP increase during the community-based program was an independent predictor of CVD events.

Healthy lifestyle change and subclinical atherosclerosis in young adults: Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND

The benefits of healthy habits are well established, but it is unclear whether making health behavior changes as an adult can still alter coronary artery disease risk.

METHODS AND RESULTS

The Coronary Artery Risk Development in Young Adults (CARDIA) prospective cohort study (n=3538) assessed 5 healthy lifestyle factors (HLFs) among young adults aged 18 to 30 years (year 0 baseline) and 20 years later (year 20): not overweight/obese, low alcohol intake, healthy diet, physically active, nonsmoker. We tested whether change from year 0 to 20 in a continuous composite HLF score (HLF change; range, -5 to +5) is associated with subclinical atherosclerosis (coronary artery calcification and carotid intima-media thickness) at year 20, after adjustment for demographics, medications, and baseline HLFs. By year 20, 25.3% of the sample improved (HLF change ≥+1); 40.4% deteriorated (had fewer HLFs); 34.4% stayed the same; and 19.2% had coronary artery calcification (>0). Each increase in HLFs was associated with reduced odds of detectable coronary artery calcification (odds ratio=0.85; 95% confidence interval, 0.74-0.98) and lower intima-media thickness (carotid bulb β=-0.024, P=0.001), and each decrease in HLFs was predictive to a similar degree of greater odds of coronary artery calcification (odds ratio=1.17; 95% confidence interval, 1.02-1.33) and greater intima-media thickness (β=+0.020, P<0.01).

CONCLUSIONS

Healthy lifestyle changes during young adulthood are associated with decreased risk and unhealthy lifestyle changes are associated with increased risk for subclinical atherosclerosis in middle age.

Improving assessment of cardiovascular disease risk by using family history: an integrative literature review

BACKGROUND

Cardiovascular disease (CVD) is the number one killer in the United States. Although the causes of CVD are multifactorial, including genetic and environmental influences, it is largely a preventable disease. The cornerstone of CVD prevention is accuracy in risk prediction to identify patients who will benefit from interventions aimed at reducing risk. Nurse practitioners commonly perform CVD risk assessments and are well positioned to impact preventive therapy. Cardiovascular disease risk scoring systems currently in use substantially underestimate risk in large part because these do not include family history of premature CVD as a high-risk factor.

PURPOSE

We sought to examine the state of evidence for the use of family history as a predictor in CVD risk stratification.

CONCLUSIONS

A comprehensive literature search using the Medical Subject Headings terms of family history of CVD, family history of premature CVD, risk assessment, and risk estimation displayed 416 articles; a review of the titles and subsequent evaluation of the articles eliminated 392 references, leaving 24 for review. By incorporating family history in risk assessment, categorization of CVD risk improves substantially. The evidence demonstrates that family history is an independent contributor to risk appraisal and unequivocally supports its incorporation to improve accuracy in global CVD risk estimation.

CLINICAL IMPLICATIONS

Underestimation of CVD risk leaves patients and providers misinformed, promoting the ongoing epidemic of chronic disease. Translating this evidence into practice by establishing a clinical algorithm that incorporates family history into risk prediction will standardize CVD risk assessment, improve the identification of high-risk patients, and provide the indicated aggressive care to prevent CVD.

The Obesity Epidemic: The United States as a Cautionary Tale for the Rest of the World

Obesity is a global epidemic and its prevalence continues to increase in many developed and developing countries. This brief review provides an update on the prevalence of obesity in the United States (US) and globally, reviews the underlying mechanism of several comorbidities associated with obesity, and discusses the economic burden of obesity. Although the overall prevalence of obesity in the US is not increasing, racial and ethnic minorities continue to struggle with rising obesity rates. Globally, the largest increases are being observed in developing continues. Given the comorbidities associated with obesity and its immense economic burden, nearly every country will soon struggle with the financial and healthcare implications of the epidemic.

Importance of engaging obstetrician/gynecologists in cardiovascular disease prevention

PURPOSE OF REVIEW

To review recent evidence regarding traditional and sex-specific factors identified among women during their reproductive years and their importance in lifetime risk for cardiovascular disease (CVD).

RECENT FINDINGS

Longitudinal studies demonstrated a woman's burden of risk during her reproductive years is associated with future risk of CVD. Similarly, women with a healthy lifestyle are relatively protected and have the lowest lifetime risk. Some primary prevention strategies, when implemented during this age window, were cost-effective. The link between pregnancy outcome and future CVD risk is now better understood, and evidence now relates pregnancy-associated hypertension and diabetes, as well as a preterm delivery or a low birth weight delivery, to excess risk. Gaps in preventive healthcare for women in this age group included low rates of treatment initiation for hypertension and failure to follow guidelines for diabetes surveillance among women with a history of gestational diabetes. Knowledge gaps for standard CVD prevention, as well as the link between pregnancy complications and future CVD risk, were identified among both primary care providers and obstetrician/gynecologists.

SUMMARY

Traditional and sex-specific risk factors for CVD present during women's reproductive years. Engaging the obstetrician/gynecologist provides a strategy to enhance prevention.

Unique transcriptomic signature of omental adipose tissue in Ossabaw swine: a model of childhood obesity

To better understand the impact of childhood obesity on intra-abdominal adipose tissue phenotype, a complete transcriptomic analysis using deep RNA-sequencing (RNA-seq) was performed on omental adipose tissue (OMAT) obtained from lean and Western diet-induced obese juvenile Ossabaw swine. Obese animals had 88% greater body mass, 49% greater body fat content, and a 60% increase in OMAT adipocyte area (all P < 0.05) compared with lean pigs. RNA-seq revealed a 37% increase in the total transcript number in the OMAT of obese pigs. Ingenuity Pathway Analysis showed transcripts in obese OMAT were primarily enriched in the following categories: 1) development, 2) cellular function and maintenance, and 3) connective tissue development and function, while transcripts associated with RNA posttranslational modification, lipid metabolism, and small molecule biochemistry were reduced. DAVID and Gene Ontology analyses showed that many of the classically recognized gene pathways associated with adipose tissue dysfunction in obese adults including hypoxia, inflammation, angiogenesis were not altered in OMAT in our model. The current study indicates that obesity in juvenile Ossabaw swine is characterized by increases in overall OMAT transcript number and provides novel data describing early transcriptomic alterations that occur in response to excess caloric intake in visceral adipose tissue in a pig model of childhood obesity.

Translating personality psychology to help personalize preventive medicine for young adult patients

The rising number of newly insured young adults brought on by health care reform will soon increase demands on primary care physicians. Physicians will face more young adult patients, which presents an opportunity for more prevention-oriented care. In the present study, we evaluated whether brief observer reports of young adults' personality traits could predict which individuals would be at greater risk for poor health as they entered midlife. Following the cohort of 1,000 individuals from the Dunedin Multidisciplinary Health and Development Study (Moffitt, Caspi, Rutter, & Silva, 2001), we show that very brief measures of young adults' personalities predicted their midlife physical health across multiple domains (metabolic abnormalities, cardiorespiratory fitness, pulmonary function, periodontal disease, and systemic inflammation). Individuals scoring low on the traits of Conscientiousness and Openness to Experience went on to develop poorer health even after accounting for preexisting differences in education, socioeconomic status, smoking, obesity, self-reported health, medical conditions, and family medical history. Moreover, personality ratings from peer informants who knew participants well, and from a nurse and receptionist who had just met participants for the first time, predicted health decline from young adulthood to midlife despite striking differences in level of acquaintance. Personality effect sizes were on par with other well-established health risk factors such as socioeconomic status, smoking, and self-reported health. We discuss the potential utility of personality measurement to function as an inexpensive and accessible tool for health care professionals to personalize preventive medicine. Adding personality information to existing health care electronic infrastructures could also advance personality theory by generating opportunities to examine how personality processes influence doctor-patient communication, health service use, and patient outcomes.