Lifetime Perspectives on Primary Prevention of Atherosclerotic Cardiovascular Disease

Sex Associations Between Air Pollution and Estimated Atherosclerotic Cardiovascular Disease Risk Determination

Objective: The purpose of this study was to investigate the sex correlations of particulate matters (PM2.5, PM10, PM2.5-10), NO2 and NOx with ASCVD risk in the UK Biobank population. Methods: Among 285,045 participants, pollutants were assessed and correlations between ASCVD risk were stratified by sex and estimated using multiple linear and logistic regressions adjusted for length of time at residence, education, income, physical activity, Townsend deprivation, alcohol, smocking pack years, BMI and rural/urban zone. Results: Males presented higher ASCVD risk than females (8.63% vs. 2.65%, p < 0.001). In males PM2.5, PM10, NO2, and NOx each were associated with an increased ASCVD risk >7.5% in the adjusted logistic models, with ORs [95% CI] for a 10 μg/m3 increase were 2.17 [1.87-2.52], 1.15 [1.06-1.24], 1.06 [1.04-1.08] and 1.05 [1.04-1.06], respectively. In females, the ORs for a 10 μg/m3 increase were 1.55 [1.19-2.05], 1.22 [1.06-1.42], 1.07 [1.03-1.10], and 1.04 [1.02-1.05], respectively. No association was observed in both sexes between ASCVD risk and PM2.5-10. Conclusion: Our findings may suggest the possible actions of air pollutants on ASCVD risk.

Temporal Trends in the Remaining Lifetime Risk of Cardiovascular Disease Among Middle-Aged Adults Across 6 Decades: The Framingham Study

BACKGROUND

The remaining lifetime risk (RLR) is the probability of developing an outcome over the remainder of one's lifespan at any given age. The RLR for atherosclerotic cardiovascular disease (ASCVD) in three 20-year periods were assessed using data from a single community-based cohort study of predominantly White participants.

METHODS

Longitudinal data from the Framingham study in 3 epochs (epoch 1, 1960-1979; epoch 2, 1980-1999; epoch 3, 2000-2018) were evaluated. The RLR of a first ASCVD event (myocardial infarction, coronary heart disease death, or stroke) from 45 years of age (adjusting for competing risk of death) in the 3 epochs were compared overall, and according to the following strata: sex, body mass index, blood pressure and cholesterol categories, diabetes, smoking, and Framingham risk score groups.

RESULTS

There were 317 849 person-years of observations during the 3 epochs (56% women; 94% White) and 4855 deaths occurred. Life expectancy rose by 10.1 years (men) to 11.9 years (women) across the 3 epochs. There were 1085 ASCVD events over the course of 91 330 person-years in epoch 1, 1330 ASCVD events over the course of 107 450 person-years in epoch 2, and 775 ASCVD events over the course of 119 069 person-years in epoch 3. The mean age at onset of first ASCVD event was greater in the third epoch by 8.1 years (men) to 10.3 years (women) compared with the first epoch. The RLR of ASCVD from 45 years of age declined from 43.7% in epoch 1 to 28.1% in epoch 3 (P<0.0001), a finding that was consistent in both sexes (RLR [epoch 1 versus epoch 3], 36.3% versus 26.5% [women]; 52.5% versus 30.1% [men]; P<0.001 for both). The lower RLR of ASCVD in the last 2 epochs was observed consistently across body mass index, blood pressure, cholesterol, diabetes, smoking, and Framingham risk score strata (P<0.001 for all). The RLR of coronary heart disease events and stroke declined in both sexes (P<0.001).

CONCLUSIONS

Over the past 6 decades, mean life expectancy increased and the RLR of ASCVD decreased in the community-based, predominantly White Framingham study. The residual burden of ASCVD underscores the importance of continued and effective primary prevention efforts with better screening for risk factors and their effective treatment.

Associations of solid fuel use and ambient air pollution with estimated 10-year atherosclerotic cardiovascular disease risk

BACKGROUND

Although exposure to ambient air pollution (AAP) increases the risk for arteriosclerotic cardiovascular disease (ASCVD), evidence on the association of solid fuel use with ASCVD and its association modified by ambient air pollution remains limited.

METHODS

A total of 16,779 adults were derived from the Henan Rural Cohort Study. Concentrations of ambient air pollutants (PM₁, PM_2.5, PM₁₀, and NO₂) were estimated by a spatiotemporal model based on satellites data. Solid fuel use was assessed by a self-reported questionnaire. The associations of solid fuel use with high 10-year ASCVD risk and the modified association by exposure to air pollutants were explored using logistic regression models.

RESULTS

There were positive associations of AAP exposure with high 10-year ASCVD risk among individuals with self-cooking. The joint associations between high AAP exposures and solid fuel use with high 10-year ASCVD risk were found. Compared to clean fuel user with low PM_2.5 exposure, the odds ratios (ORs) and 95% confidence intervals (CIs) of high 10-year ASCVD risk was 1.25 (1.09, 1.42) for solid fuel user with low PM_2.5 exposure, 1.93 (1.75, 2.12) for clean fuel user with high PM_2.5 exposure, and 3.08 (2.67, 3.54) for solid fuel user with high PM_2.5 exposure, respectively. Their additive effect on high 10-year ASCVD risk was observed (relative excess risk due to interaction (RERI): 0.90 (95 %CI: 0.50, 1.30), attributable proportion due to interaction (AP): 0.29 (95 %CI: 0.19, 0.40), and synergy index (SI): 1.77 (95 %CI: 1.38, 2.26)).

CONCLUSION

This study showed a synergistic effect of AAP and household air pollution reflected by solid fuel use on high 10-year ASCVD risk, suggesting that reducing solid cooking fuels and controlling air pollution may have a joint effect on public health improvement.

Cardiovascular Risk Awareness and Calculated 10-Year Risk Among Female Employees at Taibah University 2019

Cardiovascular diseases (CVD) are the most common cause of death and disability worldwide. Saudi Arabia, one of the middle-income countries has a proportional CVD mortality rate of 37%. Knowledge about CVD and its modifiable risk factors is a vital pre-requisite to change the health attitudes, behaviors, and lifestyle practices of individuals. Therefore, we intended to assess the employee knowledge about risk of CVD, symptoms of heart attacks, and stroke, and to calculate their future 10-years CVD risk. An epidemiological, cross-sectional, community-facility based study was conducted. The women aged ≥40 years who are employees of Taibah University, Al-Madinah Al-Munawarah were recruited. A screening self-administrative questionnaire was distributed to the women to exclude those who are not eligible. In total, 222 women met the inclusion criteria and were invited for the next step for the determination of CVD risk factors by using WHO STEPS questionnaire: It is used for the surveillance of non-communicable disease risk factor, such as CVD. In addition, the anthropometric measurements and biochemical measurements were done. Based on the identified atherosclerotic cardiovascular disease (ASCVD) risk factors and laboratory testing results, risk calculated used the Framingham Study Cardiovascular Disease (10-year) Risk Assessment. Data were analyzed using GraphPad Prism 7 software (GraphPad Software, CA, USA). The result showed the mean age of study sample was 55.6 ± 9.0 years. There was elevated percentage of obesity and rise in abdominal circumference among the women. Hypertension (HTN) was a considerable chronic disease among the participants where more than half of the sample had it, i.e., 53%. According to the ASCVD risk estimator, the study participants were distributed into four groups: 63.1% at low risk, 20.2% at borderline risk, 13.5% at intermediate risk, and 3.2% at high risk. A comparison between these categories based on the CVD 10-year risk estimator indicated that there were significant variations between the low-risk group and the intermediate and high-risk groups (P = 0.02 and P = 0.001, respectively). The multivariate analysis detected factors related to CVD risk for women who have an intermediate or high risk of CVD, such as age, smoking, body mass index (BMI), unhealthy diet, blood pressure (BP) measurements, and family history of CVD (P < 0.05). The present study reports limited knowledge and awareness of CVD was 8.6 that is considered as low knowledge. In conclusion, the present study among the university sample in Madinah reported limited knowledge and awareness of CVD risk. These findings support the need for an educational program to enhance the awareness of risk factors and prevention of CVD.

Examining the Potential for Coronary Artery Calcium (CAC) Scoring for Individuals at Low Cardiovascular Risk

Atherosclerosis is the commonest cause of death in Australia. Cardiovascular (CV) risk calculators have an important role in preventative cardiology, although they are are strongly age-dependent and designed to identify individuals at high risk of an imminent event. The imprecision around "intermediate" or "low" risk generates therapeutic uncertainty, and a significant proportion of patients presenting with myocardial infarction come from these groups, often with no warning. This highlights a conundrum: "Low" risk does not mean "no" risk. A fresh approach may be required to address the clinical conundrum around CV preventative approaches in non-high-risk individuals. While probabilistic calculators do not measure atherosclerosis, calculation of Coronary Artery Calcium (CAC) scores by low-dose computed tomography (CT) can provide a snapshot of atherosclerotic burden. In intermediate-risk individuals, CAC is well-established as an aid to CV risk prediction. Although CAC scoring in low-risk asymptomatic people may be considered controversial, CAC has emerged as the single best predictor of CV events in asymptomatic individuals, independent of traditional risk factor calculators. Therefore, apart from the contribution of age and sex, the somewhat arbitrary distinction between "intermediate" and "low" CV risk using probabilistic calculators may need to be reconsidered. A zero CAC score has a very low future event rate and non-zero CAC scores are associated with a progressive, graded increase in risk as the CAC score rises. In this review, we examine the evidence for CAC screening in low-risk individuals, and propose more widespread use of CAC using simple new model intended to enhance established CV risk prediction equations.

Prediction of individual life-years gained without cardiovascular events from lipid, blood pressure, glucose, and aspirin treatment based on data of more than 500 000 patients with Type 2 diabetes mellitus

AIMS

Although group-level effectiveness of lipid, blood pressure, glucose, and aspirin treatment for prevention of cardiovascular disease (CVD) has been proven by trials, important differences in absolute effectiveness exist between individuals. We aim to develop and validate a prediction tool for individualizing lifelong CVD prevention in people with Type 2 diabetes mellitus (T2DM) predicting life-years gained without myocardial infarction or stroke.

METHODS AND RESULTS

We developed and validated the Diabetes Lifetime-perspective prediction (DIAL) model, consisting of two complementary competing risk adjusted Cox proportional hazards functions using data from people with T2DM registered in the Swedish National Diabetes Registry (n = 389 366). Competing outcomes were (i) CVD events (vascular mortality, myocardial infarction, or stroke) and (ii) non-vascular mortality. Predictors were age, sex, smoking, systolic blood pressure, body mass index, haemoglobin A1c, estimated glomerular filtration rate, non- high-density lipoprotein cholesterol, albuminuria, T2DM duration, insulin treatment, and history of CVD. External validation was performed using data from the ADVANCE, ACCORD, ASCOT and ALLHAT-LLT-trials, the SMART and EPIC-NL cohorts, and the Scottish diabetes register (total n = 197 785). Predicted and observed CVD-free survival showed good agreement in all validation sets. C-statistics for prediction of CVD were 0.83 (95% confidence interval: 0.83-0.84) and 0.64-0.65 for internal and external validation, respectively. We provide an interactive calculator at www.U-Prevent.com that combines model predictions with relative treatment effects from trials to predict individual benefit from preventive treatment.

CONCLUSION

Cardiovascular disease-free life expectancy and effects of lifelong prevention in terms of CVD-free life-years gained can be estimated for people with T2DM using readily available clinical characteristics. Predictions of individual-level treatment effects facilitate translation of trial results to individual patients.

Would treatment decisions about secondary prevention of CVD based on estimated lifetime benefit rather than 10-year risk reduction be cost-effective?

OBJECTIVE

To test the hypothesis that treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.

METHODS

A microsimulation model was constructed for 10,000 patients with stable cardiovascular disease (CVD). Costs and quality-adjusted life years (QALYs) due to recurrent cardiovascular events and (non)vascular death were estimated for lifetime benefit-based compared to 10-year risk-based treatment, with PCSK9 inhibition as an illustration example. Lifetime benefit in months gained and 10-year absolute risk reduction were estimated using the SMART-REACH model, including an individualized treatment effect of PCSK9 inhibitors based on baseline low-density lipoprotein cholesterol. For the different numbers of patients treated (i.e. the 5%, 10%, and 20% of patients with the highest estimated benefit of both strategies), cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER), indicating additional costs per QALY gain.

RESULTS

Lifetime benefit-based treatment of 5%, 10%, and 20% of patients with the highest estimated benefit resulted in an ICER of €36,440/QALY, €39,650/QALY, or €41,426/QALY. Ten-year risk-based treatment decisions of 5%, 10%, and 20% of patients with the highest estimated risk reduction resulted in an ICER of €48,187/QALY, €53,368/QALY, or €52,390/QALY.

CONCLUSION

Treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.

The low-density lipoprotein cholesterol lowering is an ineffective surrogate marker of statin responsiveness to predict cardiovascular outcomes: The 10-year experience of matched population (a STROBE-compliant article)

Statins therapy decrease both low-density lipoprotein cholesterol (LDL-C) levels and the risk of atherosclerotic cardiovascular disease (ASCVD) with considerable individual variability. Whether the amount of LDL-C lowering is a surrogate maker of statin responsiveness to ASCVD prevention has not been fully investigated. Among 2352 eligible patients with statin prescriptions in a cardiovascular center between January 2005 and February 2014, one-third of patients (33%) on statin therapy failed to achieve effective reductions in LDL-C (LDL-C level reduction of less than 15%). By using, propensity-score matched population (480 pairs, n = 960), the 5-year cumulative incidences of total major adverse cardiac events (MACE) were evaluated. The 5-year total MACE did not differ between normal cholesterol responders and non-responders (15.4% vs 16.1%, respectively; P = .860). In the subgroup analysis, male sex, older age, percutaneous coronary intervention, and heart failure were positive predictors, and dyslipidemia at the beginning of statin therapy was the only negative predictor of MACE in the 5-year follow-up (all P value < .05). However, cholesterol responsiveness after statin therapy did not influence the incidence of MACE (P = .860). The amount of LDL-C lowering did not predict beneficial effect on clinical outcomes of ASCVD after statin therapy. This result supports that given statin therapy, total ASCVD risk reduction should be tailored, which may not dependent to adherence to degree of LDL-C lowering or LDL-C goal based treatment.

Looking back and thinking forwards - 15 years of cardiology and cardiovascular research

The first issue of Nature Reviews Cardiology was published in November 2004 under the name Nature Clinical Practice Cardiovascular Medicine. To celebrate our 15th anniversary in 2019, we invited six of our Advisory Board members to discuss what they considered the most important advances in their field of cardiovascular research or clinical practice in the past 15 years and what changes they envision for cardiovascular medicine in the next 15 years. Several practice-changing breakthroughs are described, including advances in procedural techniques to treat arrhythmias and hypertension and the development of novel therapeutic strategies to treat heart failure and pulmonary arterial hypertension, as well as those that target risk factors such as inflammation and elevated LDL-cholesterol levels. Furthermore, these key opinion leaders predict that machine learning technology and data derived from wearable devices will pave the way towards the coveted goal of personalized medicine.

Long-Term All-Cause and Cause-Specific Mortality in Asymptomatic Patients With CAC ≥1,000: Results From the CAC Consortium

OBJECTIVES

This study thoroughly explored the demographic and imaging characteristics, as well as the all-cause and cause-specific mortality risks of patients with a coronary artery calcium (CAC) score ≥1,000 in the largest dataset of this population to date.

BACKGROUND

CAC is commonly used to quantify cardiovascular risk. Current guidelines classify a CAC score of >300 or 400 as the highest risk group, yet little is known about the potentially unique imaging characteristics and mortality risk in individuals with a CAC score ≥1,000.

METHODS

A total of 66,636 asymptomatic adults were included from the CAC consortium, a large retrospective multicenter clinical cohort. Mean patient follow-up was 12.3 ± 3.9 years for patients with cardiovascular disease (CVD), coronary heart disease (CHD), cancer, and all-cause mortality. Multivariate Cox proportional hazards regression models adjusted for age, sex, and conventional risk factors were used to assess the relative mortality hazard of individuals with CAC ≥1,000 compared with, first, a CAC reference of 0, and second, with patients with a CAC score of 400 to 999.

RESULTS

There were 2,869 patients with CAC ≥1,000 (86.3% male, mean 66.3 ± 9.7 years of age). Most patients with CAC ≥1,000 had 4-vessel CAC (mean: 3.5 ± 0.6 vessels) and had greater total CAC area, higher mean CAC density, and more extracoronary calcium (79% with thoracic artery calcium, 46% with aortic valve calcium, and 21% with mitral valve calcium) than those with CAC scores of 400 to 999. After full adjustment, those with CAC ≥1,000 had a 5.04- (95% confidence interval [CI]: 3.92 to 6.48), 6.79- (95% CI: 4.74 to 9.73), 1.55- (95% CI:1.23 to 1.95), and 2.89-fold (95% CI: 2.53 to 3.31) risk of CVD, CHD, cancer, and all-cause mortality, respectively, compared to those with CAC score of 0. The CAC ≥1,000 group had a 1.71- (95% CI: 1.41 to 2.08), 1.84- (95% CI: 1.43 to 2.36), 1.36- (95% CI:1.07 to 1.73), and 1.51-fold (95% CI: 1.33 to 1.70) increased risk of CVD, CHD, cancer, and all-cause mortality compared to those with CAC scores 400 to 999. Graphic analysis of CAC ≥1,000 patients revealed continued logarithmic increase in risk, with no clear evidence of a risk plateau.

CONCLUSIONS

Patients with extensive CAC (CAC ≥1,000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients. Future guidelines should consider CAC ≥1,000 patients to be a distinct risk group who may benefit from the most aggressive preventive therapy.

Cerebrovascular Disease: Primary and Secondary Stroke Prevention

Despite advances in earlier diagnosis and available aggressive treatments for vascular risk factors, stroke remains a leading cause of death and long-term disability worldwide. Disparities exist in stroke risk, rates of stroke, and treatment. Stroke is a heterogeneous disease with multiple additive risk factors and causes. Primary prevention of stroke focusing on risk factor modification plays an important role in reducing the burden of stroke in an aging population. Secondary prevention of recurrent strokes relies on the workup and a tailored treatment targeted at the mechanisms responsible for the incident stroke or transient ischemic attack.

Estimated Life Expectancy Without Recurrent Cardiovascular Events in Patients With Vascular Disease: The SMART-REACH Model

Background In patients with vascular disease, risk models may support decision making on novel risk reducing interventions, such as proprotein convertase subtilisin/kexin type 9 inhibitors or anti-inflammatory agents. We developed and validated an innovative model to estimate life expectancy without recurrent cardiovascular events for individuals with coronary, cerebrovascular, and/or peripheral artery disease that enables estimation of preventive treatment effect in lifetime gained. Methods and Results Study participants originated from prospective cohort studies: the SMART (Secondary Manifestations of Arterial Disease) cohort and REACH (Reduction of Atherothrombosis for Continued Health) cohorts of 14 259 ( REACH Western Europe), 19 170 ( REACH North America) and 6959 ( SMART , The Netherlands) patients with cardiovascular disease. The SMART-REACH model to estimate life expectancy without recurrent events was developed in REACH Western Europe as a Fine and Gray competing risk model incorporating cardiovascular risk factors. Validation was performed in REACH North America and SMART . Outcomes were (1) cardiovascular events (myocardial infarction, stroke, cardiovascular death) and (2) noncardiovascular death. Predictors were sex, smoking, diabetes mellitus, systolic blood pressure, total cholesterol, creatinine, number of cardiovascular disease locations, atrial fibrillation, and heart failure. Calibration plots showed high agreement between estimated and observed prognosis in SMART and REACH North America. C-statistics were 0.68 (95% confidence interval, 0.67-0.70) in SMART and 0.67 (95% confidence interval, 0.66-0.68) in REACH North America. Performance of the SMART-REACH model was better compared with existing risk scores and adds the possibility of estimating lifetime gained by novel therapies. Conclusions The externally validated SMART-REACH model could be used for estimation of anticipated improvements in life expectancy without recurrent cardiovascular events in individual patients with cardiovascular disease in Western Europe and North America.

Primary prevention of cardiovascular disease: The past, present, and future of blood pressure- and cholesterol-lowering treatments

In a Perspective, M. Afran Ikram and Maarten Leening discuss the evolving approaches to determining cardiovascular risk.

Assessing gaps in cholesterol treatment guidelines for primary prevention of cardiovascular disease based on available randomised clinical trial evidence: The Rotterdam Study

Background

The purpose of this study was to determine how American College of Cardiology/American Heart Association (ACC/AHA) 2013 and European Society of Cardiology 2016 guidelines for the primary prevention of atherosclerotic cardiovascular disease (CVD) compare in reflecting the totality of accrued randomised clinical trial evidence for statin treatment at population level.

Methods

From 1997–2008, 7279 participants aged 45–75 years, free of atherosclerotic cardiovascular disease, from the population-based Rotterdam Study were included. For each participant, we compared eligibility for each one of 11 randomised clinical trials on statin use in primary prevention of CVD, with recommendations on lipid-lowering therapy from the ACC/AHA and European Society of Cardiology (ESC) guidelines. Atherosclerotic cardiovascular disease incidence and cardiovascular disease mortality rates were calculated.

Results

The proportion of participants eligible for each trial ranged from 0.4% for ALLHAT-LLT to 30.8% for MEGA. The likelihood of being recommended for lipid-lowering treatment was lowest for those eligible for low-to-intermediate risk RCTs (HOPE-3, MEGA, and JUPITER), and highest for high-risk individuals with diabetes (MRC/BHF HPS, CARDS, and ASPEN) or elderly PROSPER. Eligibility for an increasing number of randomised clinical trials correlated with a greater likelihood of being recommended lipid-lowering treatment by either guideline (p < 0.001 for both guidelines).

Conclusion

Compared to RCTs done in high risk populations, randomised clinical trials targeting low-to-intermediate risk populations are less well-reflected in the ACC/AHA, and even less so in the ESC guideline recommendations. Importantly, the low-to-intermediate risk population targeted by HOPE-3, the most recent randomised clinical trial in this field, is not well-captured by the current European prevention guidelines and should be specifically considered in future iterations of the guidelines.

Management of Asymptomatic Patients With Positive Coronary Artery Calcium Scans

Background

The widespread availability of the coronary artery calcium scan to diagnose coronary artery atheroma semiquantitatively and its prognostic significance has frequently resulted in a difficult therapeutic decision for physicians caring for asymptomatic patients.

Patients and Risk Factors

Of particular concern are patients over 40 years of age and young adults characterized by multiple cardiovascular risk factors. The correct prognostic interpretation of coronary artery calcium scores and the potential benefits and risks of various therapeutic modalities need to be understood.

Conclusion

This review describes the therapeutic choices available to endocrinologists and provides recommendations for various treatment options.

Prediction of Cardiovascular Disease by the Framingham-REGICOR Equation in the High-Risk PREDIMED Cohort: Impact of the Mediterranean Diet Across Different Risk Strata

BACKGROUND

The usefulness of cardiovascular disease (CVD) predictive equations in different populations is debatable. We assessed the efficacy of the Framingham-REGICOR scale, validated for the Spanish population, to identify future CVD in participants, who were predefined as being at high-risk in the PREvención con DIeta MEDiterránea (PREDIMED) study-a nutrition-intervention primary prevention trial-and the impact of adherence to the Mediterranean diet on CVD across risk categories.

METHODS AND RESULTS

In a post hoc analysis, we assessed the CVD predictive value of baseline estimated risk in 5966 PREDIMED participants (aged 55-74 years, 57% women; 48% with type 2 diabetes mellitus). Major CVD events, the primary PREDIMED end point, were an aggregate of myocardial infarction, stroke, and cardiovascular death. Multivariate-adjusted Cox regression was used to calculate hazard ratios for major CVD events and effect modification from the Mediterranean diet intervention across risk strata (low, moderate, high, very high). The Framingham-REGICOR classification of PREDIMED participants was 25.1% low risk, 44.5% moderate risk, and 30.4% high or very high risk. During 6-year follow-up, 188 major CVD events occurred. Hazard ratios for major CVD events increased in parallel with estimated risk (2.68, 4.24, and 6.60 for moderate, high, and very high risk), particularly in men (7.60, 13.16, and 15.85, respectively, versus 2.16, 2.28, and 3.51, respectively, in women). Yet among those with low or moderate risk, 32.2% and 74.3% of major CVD events occurred in men and women, respectively. Mediterranean diet adherence was associated with CVD risk reduction regardless of risk strata (P>0.4 for interaction).

CONCLUSIONS

Incident CVD increased in parallel with estimated risk in the PREDIMED cohort, but most events occurred in non-high-risk categories, particularly in women. Until predictive tools are improved, promotion of the Mediterranean diet might be useful to reduce CVD independent of baseline risk.

CLINICAL TRIAL REGISTRATION

URL: http://www.Controlled-trials.com. Unique identifier: ISRCTN35739639.

Can cardiovascular disease guidelines that advise treatment decisions based on absolute risk be improved?

BACKGROUND

Cardiovascular disease (CVD) will remain the predominant cause of death and a major cause of morbidity for the foreseeable future. Consequently, CVD prevention offers the greatest potential for the prevention of premature mortality and the compression of morbidity.

DISCUSSION

The 2013 guidelines of the American College of Cardiology and the American Heart Association expand the eligibility for CVD preventive treatment based on the calculated 10-year CVD risk derived from the pooled cohort equation to all persons who have a 10-year risk of CVD of ≥7.5% as estimated by the pooled cohort equation. Previous analyses show that the use of a uniform 10-year risk threshold of 7.5% for all ages disadvantages younger individuals for whom preventive therapy has most to offer. Here I show that reducing the threshold to 3% in younger adults (women aged <66 years and men aged <56 years) will substantially increase the number of cardiovascular events prevented at a similar number needed to treat to prevent one event. Importantly, this increase in cardiovascular event prevention will occur in individuals with greater life expectancy.

CONCLUSION

Reducing the threshold 10-year risk of CVD derived from the pooled cohort equation for CVD preventive treatment to 3% in younger adults (women aged <66 years and men aged <56 years) will more effectively prevent premature mortality and compress morbidity to an older age.

Pharmacoeconomics of PCSK9 inhibitors in 103 hypercholesterolemic patients referred for diagnosis and treatment to a cholesterol treatment center

Background

PCSK9 inhibitor therapy has been approved by the FDA as an adjunct to diet-maximal tolerated cholesterol lowering drug therapy for adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (ASCVD) with suboptimal LDL cholesterol (LDLC) lowering despite maximal diet-drug therapy. With an estimated ~24million of US hypercholesterolemic patients potentially eligible for PCSK9 inhibitors, costing ~ $14,300/patient/year, it is important to assess health-care savings arising from PCSK9 inhibitors vs ASCVD cost.

Methods

In 103 patients with HeFH, and/or ASCVD and/or suboptimal LDLC lowering despite maximally tolerated diet-drug therapy, we assessed pharmacoeconomics of PCSK9 inhibitor therapy with lowering of LDLC. For HeFH diagnosis, we applied Simon Broome’s or WHO Dutch Lipid Criteria (score >8). Estimates of direct and indirect costs for ASCVD events were calculated using American Heart Association (AHA), U.S. DHHS, Healthcare Bluebook, and BMC Health Services Research databases. We used the ACC/AHA 10-year ASCVD risk calculator to estimate 10-year ASCVD risk and estimated corresponding direct and indirect costs. Assuming a 50 % reduction in ASCVD events on PCSK9 inhibitors, we calculated direct and indirect health-care savings.

Results

We started 103 patients (58 [56 %] women and 45 [44 %] men), on either alirocumab (62 %) or evolocumab (38 %), median age 63, BMI 29.0, and LDLC 149 mg/dl. Of the 103 patients, 28 had both HeFH and ASCVD, 33 with only ASCVD, 33 with only HeFH, and 9 had neither. Of the 103 patients, 61 had a first ASCVD event at median age 55 and on best tolerated cholesterol-lowering therapy median LDLC was 137 mg/dl. In these 61 patients, total direct costs attributable to ASCVD were $8,904,361 ($4,328,623 direct, $4,575,738 indirect), the median 10-year risk of a new CVD event was calculated to be 13.1 % with total cost $1,654,758. Assuming a 50 % reduction in ASCVD events on PCSK9 inhibitors in our 61 patients, $4,452,180 would have been saved in the past; and future 10-year savings would be $1,123,345.

Conclusion

In the 61 CVD patients, net costs/patient/year were estimated to be $7,000 in the past, with future 10-year intervention net costs/patient/year being $12,459, both below the $50,000/year quality adjusted life-year gained by PCSK9 inhibitor therapy.