Predicting the risk of coronary heart disease I. The use of conventional risk markers

Comparison of Genetic Susceptibility to Coronary Heart Disease in the Hungarian Populations: Risk Prediction Models for Coronary Heart Disease

Background and Aim: It was evaluated whether the integration of genetic risk scores (GRS-unweighted, wGRS-weighted) into conventional risk factor (CRF) models for coronary heart disease or acute myocardial infarction (CHD/AMI) could improve the predictive ability of the models. Methods: Subjects and data collected in a previous survey were used to perform regression and ROC curve analyses as well as to examine the role of genetic components. Thirty SNPs were selected, and genotype and phenotype data were available for 558 participants (general: N = 279 and Roma: N = 279). Results: The mean GRS (27.27 ± 3.43 vs. 26.68 ± 3.51, p = 0.046) and wGRS (3.52 ± 0.68 vs. 3.33 ± 0.62, p = 0.001) were significantly higher in the general population. The addition of the wGRS to the CRF model yielded the strongest improvement in discrimination among Roma (from 0.8616 to 0.8674), while the addition of GRS to the CRF model yielded the strongest improvement in discrimination in the general population (from 0.8149 to 0.8160). In addition to that, the Roma individuals were likely to develop CHD/AMI at a younger age than subjects in the general population. Conclusions: The combination of the CRFs and genetic components improved the model's performance and predicted AMI/CHD better than CRFs alone.

Prognostic Modelling Studies of Coronary Heart Disease—A Systematic Review of Conventional and Genetic Risk Factor Studies

This study aims to provide an overview of multivariable prognostic modelling studies developed for coronary heart disease (CHD) in the general population and to explore the optimal prognostic model by comparing the models’ performance. A systematic review was performed using Embase, PubMed, Cochrane, Web of Science, and Scopus databases until 30 November 2019. In this work, only prognostic studies describing conventional risk factors alone or a combination of conventional and genomic risk factors, being developmental and/or validation prognostic studies of a multivariable model, were included. A total of 4021 records were screened by titles and abstracts, and 72 articles were eligible. All the relevant studies were checked by comparing the discrimination, reclassification, and calibration measures. Most of the models were developed in the United States and Canada and targeted the general population. The models included a set of similar predictors, such as age, sex, smoking, cholesterol level, blood pressure, BMI, and diabetes mellitus. In this study, many articles were identified and screened for consistency and reliability using CHARM and GRIPS statements. However, the usefulness of most prognostic models was not demonstrated; only a limited number of these models supported clinical evidence. Unfortunately, substantial heterogeneity was recognized in the definition and outcome of CHD events. The inclusion of genetic risk scores in addition to conventional risk factors might help in predicting the incidence of CHDs; however, the generalizability of the existing prognostic models remains open. Validation studies for the existing developmental models are needed to ensure generalizability, improve the research quality, and increase the transparency of the study.

Social Stress-Induced Oxidative DNA Damage Is Related to Prospective Cardiovascular Risk

Psychosocial stress increases cardiovascular risk, which coincides with enhanced oxidative DNA damage. Increased sympathetic tone-related catecholamine release causes oxidative stress, which contributes to catecholamine-related cardiotoxicity. Therefore, we tested the hypothesis whether acute psychosocial stress induces oxidative DNA damage, its degree being related to the cardiovascular risk profile and depending on the sympathetic stress response. After assessment of the prospective cardiovascular Münster score (PROCAM) to determine the risk of acute myocardial infarction, 83 male and 12 female healthy volunteers underwent the Trier social stress test for groups (TSST-G). Heart rate variability was quantified by measuring the standard deviation (SDNN) and root mean square of successive differences (RMSSD) between normal-to-normal inter-beat intervals. Salivary α-amylase (sAA) activity was assessed as a surrogate for noradrenaline plasma concentrations. Oxidative DNA damage was determined using whole-blood single-cell gel electrophoresis ("tail moment" in the "comet assay"). A total of 33 subjects presented with a prospective risk of myocardial infarction (risk+) vs. 59 subjects without risk (risk-). The TSST-G stress significantly increased blood pressure, heart rate, and sAA in both groups, while oxidative DNA damage was only increased in the risk+ group. Immediately after the TSST-G, the "tail moment" showed significant inverse linear relations with both SDNN and RMSSD. Acute psychosocial stress may cause oxidative DNA damage, the degree of which is directly related to the individual cardiovascular risk profile and depends on the stress-induced increase in the sympathetic tone.

Effect of soluble-viscous dietary fibre on coronary heart disease risk score across 3 population health categories: data from randomized, double-blind, placebo-controlled trials

We applied the Framingham risk equation in healthy, metabolic syndrome, and diabetes populations, following treatment with viscous fibre from konjac-based blend (KBB). KBB yielded reduction in estimated risk score by 16% (1.04 ± 0.03 vs. 0.87 ± 0.04, p < 0.01) in type 2 diabetes, 24% (1.08 ± 0.01 vs. 0.82 ± 0.02, p < 0.01) in metabolic syndrome, and 25% (1.09 ± 0.05 vs. 0.82 ± 0.06, p < 0.01) in healthy individuals. Drivers for decreased risk were improvements in blood cholesterol and systolic blood pressure. The composite coronary heart disease risk across populations was reduced 22% (p < 0.01). Novelty Viscous fibre from konjac-xanthan reduced 10-year relative coronary heart disease using Framingham Risk Score across the glycemic status spectrum.

Comparing the Consistency and Performance of Various Coronary Heart Disease Prediction Models for Primary Prevention Using a National Representative Cohort in Taiwan

BACKGROUND

Predicting future coronary artery disease (CAD) risk by model-based approaches can facilitate identification of high-risk individuals for prevention and management. Therefore, we compared the consistency and performance of various CAD models for primary prevention using 1 external validation dataset from a national representative cohort in Taiwan.Methods and Results:The 10 CAD prediction models were assessed in a validation cohort of 3559 participants (≥35 years old, 53.5% women) from a Taiwanese national representative cohort that was followed up for a median 9.70 (interquartile range, 9.63-9.74) years; 63 cases were documented as developing CAD events. The overall κ value was 0.51 for all 10 models, with a higher value for women than for men (0.53 for women, 0.40 for men). In addition, the areas under the receiver operating characteristics curves ranged from 0.804 (95% confidence interval, 0.758-0.851) to 0.847 (95% confidence interval, 0.805-0.889). All non-significant chi-square values indicated good calibration ability.

CONCLUSIONS

Our study demonstrated these 10 CAD prediction models for primary prevention were feasible and validated for use in Taiwanese subjects. Further studies of screening and management are warranted.

Unfavourable cardiovascular disease risk profiles in a cohort of Dutch and British haemophilia patients

Cardiovascular disease (CVD) mortality is reported to be decreased in haemophilia patients, but reports on the prevalence of CVD risk factors are conflicting. A cross-sectional assessment of CVD risk profiles was performed in a large cohort of haemophilia patients. Baseline data on CVD risk factors of 709 Dutch and UK haemophilia patients aged ≥ 30 years were analysed and compared with the general age-matched male population. CVD risk profiles were assessed using the QRISK®2–2011 and SCORE algorithms. Although QRISK®2 was only validated in the UK, comparison with SCORE indicated similar properties of QRISK®2 in both Dutch and UK patients (correlation 0.86). Mean age was 49.8 years. Hypertension was more common in haemophilia patients than in the general population (49% vs. 40%), while the prevalences of obesity and hypercholesterolaemia were lower (15 vs. 20% and 44 vs. 68%, respectively), and those of diabetes and smoking were similar. The predicted 10-year QRISK®2 risk was significantly higher in haemophilia patients than in the general population (8.9 vs. 6.7%), indicating more unfavourable cardiovascular disease risk profiles. This increased risk became apparent after the age of 40 years. Our results indicate an increased prevalence of hypertension and overall more unfavourable CVD risk profiles in haemophilia patients compared with the general age-matched male population.

Cardiovascular risk assessment by FRS and SCORE in Iranian adult population

BACKGROUND

Handling the growing epidemic of coronary heart disease in developing nations hinges on primary prevention, which logistically requires directing preventive interventions to those at the highest risk. Therefore, implementing cardiovascular risk assessment profiles is crucial to distinguish high risk groups who truly need extensive preventive measures. We aimed to draw a picture of the cardiovascular risk profiles in the Iranian adult population for the first time.

METHODS

Demographic, anthropometric, and laboratory data as well as blood pressure and smoking status of 3944 subjects participating in the 2011 national surveillance of risk factors for non-communicable diseases were used to calculate the mean estimated risk of coronary artery disease and the relative frequency of low-, medium- and high-risk subjects based on FRS and SCORE indices in general population as well as different age, sex, and residence subgroups.

RESULTS

The average 10-year risk of coronary artery disease (FRS) and 10-year risk of fatal coronary and cerebrovascular accidents (SCORE) in the 25 to 64 year-old population was 13.82 and 0.72 respectively. The relative frequency of the intermediate- and high- risk subjects was 25.8 and 22.6% based on FRS and 9.2 and 1.8% based on SCORE respectively. Average FRS and SCORE were significantly higher among men than women, but were not significantly different among urban and rural residents.

CONCLUSIONS

A significant proportion of the Iranian population, based on FRS model, will be at moderate to high risk of coronary events in the next 10 years. Urgent preventive plans are needed at the national level.

Association between human immunodeficiency virus infection and arterial stiffness in children

Background Human immunodeficiency virus infection (HIV) is associated with increased cardiovascular risk and adverse cardiovascular outcome in adults. Early recognition of changes in vascular properties might prove essential in cardiovascular prevention in HIV-infected patients. We investigated the relations between HIV infection and arterial stiffness in children. Methods This cross-sectional study included 51 HIV-infected and 52 healthy children (age 3.2-14.5 years, 49 males). All infected children had acquired HIV by vertical transmission and were receiving antiretroviral therapy at time of assessment. Arterial stiffness was measured by pulse wave velocity and aortic augmentation index, using the Arteriograph system (Tensiomed Kft, Budapest, Hungary). We applied multivariable general linear modeling to evaluate the relationship between HIV infection and arterial stiffness with further adjustment for confounders and possible intermediary variables. Findings represent mean group differences with 95% confidence intervals and p values. Results Aortic augmentation index was higher by 9.0% (5.6-12.5, p < 0.001) in HIV-infected than in healthy children. Adjustment for blood pressure, protease inhibitor use, biomarkers for level of inflammation, lipid- and glucose-metabolism, as possible intermediary variables, did not appreciably alter the results. There were no significant differences in pulse wave velocity between HIV-infected and healthy children (mean difference 0.28 m/s, -0.14-0.69, p = 0.19). Conclusion HIV-infected children have an increased aortic augmentation index, compared to healthy children. Early cardiovascular assessment may be important in targeted prevention for HIV-infected children.

Risk assessment in the prevention of cardiovascular disease in low-resource settings

INTRODUCTION

Cardiovascular disease (CVD) prevalence is increasing in low- and middle-income countries. Total risk assessment is key to prevention.

METHODS

Studies and guidelines published between 1990 and 2013 were sought using Medline database, PubMed, and World Health Organization report sheets. Search terms included 'risk assessment' and 'cardiovascular disease prevention'. Observational studies and randomized controlled trials were reviewed.

RESULTS

The ideal risk prediction tool is one that is derived from the population in which it is to be applied. Without national population-based cohort studies in sub-Saharan African countries like Nigeria, there is no tool that is used consistently. Regardless of which one is adopted by national guidelines, routine consistent use is advocated by various CVD prevention guidelines.

CONCLUSIONS

In low-resource settings, the consistent use of simple tools like the WHO charts is recommended, as the benefit of a standard approach to screening outweighs the risk of missing an opportunity to prevent CVD.

Effects of paediatric HIV infection on childhood vasculature

AIMS

Human immunodeficiency virus (HIV) infection may alter childhood vascular properties and influence future cardiovascular risk. Whether vascular changes are associated with HIV infection per se or antiretroviral therapy (ART) is unknown. We investigated the effects of ART-naive or ART-exposed HIV infection in children on childhood vascular characteristics.

METHODS AND RESULTS

We performed vascular ultrasound to measure carotid intima media thickness (cIMT), distensibility, and elastic modulus on 114 children with vertically acquired HIV infection (56 ART-naive, 58 ART treated) and 51 healthy children in Jakarta, Indonesia. Children also underwent clinical and blood examinations. We used general linear modelling to estimate associations between HIV infection/treatment status and vascular characteristics with adjustment for confounders or possible mediators. Vascular measurements were successful in 42 ART-naive HIV-infected [median age 4.0 years (min 0.4-max 11.5)]; 53 ART-treated HIV infected [5.7 years (0.6-12.2), median ART duration 2.4 years (0.1-9.9)]; and 48 healthy children, 6.5 years (2.4-14.0). The ART-naive HIV infected had thicker cIMT (difference 70.4 µm, 95% CI 32.1-108.7, P < 0.001), adjusted for age, sex, socioeconomic status, parental smoking, body mass index, systolic and diastolic blood pressure, LDL cholesterol, and HbA1c. Addition of high-sensitivity C-reactive protein (hs-CRP) level to the model did not affect the results (71.6 µm, 31.9-111.2, P = 0.001). The ART-exposed children had similar cIMT dimensions to healthy children. Distensibility was not significantly different between HIV infected, either ART-naive or -exposed, and healthy children, but adjusted analysis including only ART-exposed children with controlled HIV (CD4+ ≥200/mm³ or CD4+ ≥15%) showed that the ART-exposed had an increased elastic modulus (difference 37.9 kPa, 95% CI 6.5-69.3, P = 0.02), and following adjustment for hs-CRP (35.5 kPa, 95% CI 4.2-66.8, P = 0.03).

CONCLUSION

ART-naive HIV infection in children is associated with increased cIMT. Children with ART-controlled HIV may have increased arterial stiffness, although further confirmation is required.

Hierarchical modelling of blood lipids' profile and 10-year (2002-2012) all cause mortality and incidence of cardiovascular disease: the ATTICA study

Background

The traditional view on the relationship between lipid biomarkers and CVD risk has changed during the last decade. However, it is not clear whether novel lipid biomarkers are able to confer a better predictability of CVD risk, compared to traditional ones.Under this perspective, the aim of the present work was to evaluate the predictive ability of blood lipids’ profile on all cause mortality as well as 10-year incidence of CVD, in a sample of apparently healthy adults of the ATTICA epidemiological study. 

Methods

From May 2001 to December 2002, 1514 men and 1528 women (>18 y) without any clinical evidence of any other chronic disease, at baseline, were enrolled. In 2011–12, the 10-year follow-up was performed in 2583 participants (85 % follow-up participation rate). Incidence of fatal or non-fatal CVD was defined according to WHO-ICD-10 criteria. Baseline serum blood lipids’ profile (Total-C, HDL-, non HDL-, LDL-cholesterol, triglycerides (TG), apolipoprotein (Apo)A1 and B, and lipoprotein–(a) levels were also measured.

Results

The 10-year all-cause mortality rate was 5.7 % for men and 2.0 % for women (p = 0.55). The, 10-year CVD incidence was 19.7 % in men and 11.7 % in women (p < 0.001). Multi-adjusted analysis revealed that TC, non-HDL-C, TG and TG/HDL-C ratio, were independent predictors of all cause mortality (RR per 1 mg/dL or unit (95 % CI): 1.006 (1.000–1.013), 1.006 (1.000–1.013), 1.002 (1.000–1.004), 1.038 (1.001–1.077), respectively). Moreover, TC, HDL-, LDL-, non-HDL-cholesterol, TG, apoA1, TC/HDL-C and TG/HDL-C were independently associated with CVD risk. Among all lipid indices the ratio of apoB/apoA1 demonstrated the best correct reclassification ability, followed by non-HDL-C and TC/HDL-C ratio (continuous Net Reclassification Index 26.1 and 21.2 %, respectively).

Conclusion

Elevated levels of lipid biomarkers are independently associated with all-cause mortality, as well as CVD risk. The ratio of apoB/apoA1, followed by non-HDL-C, demonstrated the best correct classification ability of the developed CVD risk models.

A detailed family history of myocardial infarction and risk of myocardial infarction--a nationwide cohort study

BACKGROUND

Family history of myocardial infarction (MI) is an independent risk factor for MI. Several genetic variants are associated with increased risk of MI and family history of MI in a first-degree relative doubles MI risk. However, although family history of MI is not a simple dichotomous risk factor, the impact of specific, detailed family histories has not received much attention, despite its high clinical relevance. We examined risk of MI by MIs in first- and second-degree relatives and by number and age of affected relatives.

METHODS AND FINDINGS

Using Danish national registers, we established a nationwide cohort of persons born between 1930 and 1992 with identifiable first- or second-degree relatives. Incident MIs in both cohort members and relatives aged ≥20 years were identified. We calculated incidence rate ratios (IRRs) for MI by family history of MI, by Poisson regression. In 4.4 million persons followed for 104 million person-years, we identified 128,384 incident MIs. IRRs with 95% confidence intervals [CIs] for MI by history of MI in 1, 2 or ≥3 first-degree relatives were 1.46 (1.42-1.49), 2.38 (2.22-2.56) and 3.58 (2.66-4.81), respectively. Corresponding estimates for second-degree relatives were 1.17 (1.05-1.30), 1.87 (1.46-2.38) and 2.18 (1.09-4.36). A history of MI in combinations of first- and second-degree relatives increased risks 1.8- to 7-fold in middle-aged persons (36 to 55 years). Estimates were robust to adjustment for diabetes, hypertension, dyslipidemia and use of cardiovascular medications.

CONCLUSION

A detailed family history, particularly number of affected first- and second-degree relatives, contributes meaningfully to risk assessment, especially in middle-aged persons. Future studies should test for potential improvement of risk algorithm prediction using detailed family histories.

HIGH RISK STRATEGY EFFICACY IN PROGNOSIS OF PRIMARY ONSET OF ISCHEMIC HEART

High morbidity and mortality from ischemic heart disease (CHD) in RF presupposes the significance of individual prognosis of cardiovascular risk and of primary prevention.

Aim.To analyze the level of risk that could be calculated in patients with CHD debut just before the manifest of the disease and therefore to evaluate the opportunities for the CHD debut by standard scores; to evaluate the relation of a real volume of primary prevention events to current Guidelines.

Material and methods.In 122 patients hospitalized with CHD debut as an acute coronary syndrome, a retrospective cardiovascular risk evaluation, which could be found just before the onset of the disease.

Results.The prevalence of traditional risk factors among persons with CHD onset was high: 88% patients had ≥3 risk factors. However, before the onset of acute coronary syndrome 68% patients at Framingham scale and 47% by SCORE could have been under the low and moderate calculated risk that shows low sensitivity for the real CHD risk. Calculated risk by the scores has not correlated with the severity of coronary vessels lesion. In analysis of primary prevention events in was found that in the studied group drug therapy of dyslipidemia was not being performed as primary prevention, though it is indicated by the standards for at least 82% patients.

Conclusion.The data shows that the use of the main risk scores underestimates real chance of CHD development in the exact patient. Also even for the patients, who require statin prescription for the aim of primary prevention, this therapy is not prescribed. 

Comprehensive analysis of clinico-pathological data reveals heterogeneous relations between atherosclerosis and cancer

AIMS

Atherosclerosis and cancer share common risk factors and involve similar molecular pathomechanisms. Most clinical and epidemiological studies show a positive correlation between atherosclerosis and smoking-related cancers and heterogeneous results for non-smoking-related cancers. However, up-to-date large-scale autopsy studies including a detailed analysis of cancer types are lacking. Therefore, we sought to investigate the relation between major cancer types and the grade of atherosclerosis in a recent well-powered autopsy cohort.

METHODS

In 2101 patients, both autopsy data and clinical data including demographics, disease groups, tumour type, cause of death and grade of atherosclerosis were reviewed and statistically analysed.

RESULTS

We found cancer in general is associated with less atherosclerosis (OR 0.60, p<0.0001). In particular, haematological neoplasm and sarcomas were associated with much less atherosclerosis (OR=0.45, p<0.0001 and OR=0.43, p=0.087), while carcinomas were associated with moderately less atherosclerosis (OR=0.72, p=0.002). Furthermore, non-smoking-related cancers were associated with much less atherosclerosis (OR=0.41, p<0.0001), while possibly smoking-related cancer and smoking-related cancer showed no significant association. In a comprehensive analysis of 21 cancer types, biliary tract cancer, lymphomas/lymphoid leukaemias and kidney cancer were associated with much less atherosclerosis (OR=0.19, p<0.0001; OR=0.41, p<0.0001; and OR=0.48, p=0.029). In an exploratory analysis of treatment strategies, we found that tumours with a recommendation of oxazaphosphorines and pyrimidine antagonist treatment were significantly associated with less atherosclerosis (OR=0.33, p=0.0068 and OR=0.58, p=0.012).

CONCLUSIONS

In conclusion, the study showed an inverse association between cancer and atherosclerosis postmortem that depends on the cancer type and suggests a possible impact of chemotherapy regimens.

Pathogenesis and prevention of rheumatic disease: focus on preclinical RA and SLE

Established and emerging data demonstrate that a 'preclinical' period of disease precedes the onset of clinical rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), as well as other autoimmune rheumatic diseases (ARDs).This preclinical stage of development of disease is characterized by abnormalities in disease-related biomarkers before the onset of the clinically apparent signs and symptoms. Numerous genetic and environmental risk factors for ARDs have also been identified, and many of these factors are likely to act before the clinical appearance of tissue injury to initiate and/or propagate autoimmunity and autoimmune disease. Thus, biomarkers representative of these autoimmune processes could potentially be used in conjunction with other clinical parameters during the preclinical period of ARDs to predict the future development of clinically apparent disease. This Review focuses on the preclinical stages of RA and SLE, as our current understanding of these diseases can be used to present an overall model of the development of ARDs that might ultimately be used to develop screening programmes and preventive strategies. Important considerations for the future development of such approaches, in particular, the issues that require additional research and how they might be addressed, are also discussed.

Should your family history of coronary heart disease scare you?

Traditional risk factors explain most of the risk associated with coronary heart disease, and after adjustment for risk factors family history was believed to contribute very little to population-attributable risk of coronary heart disease. However, the INTERHEART study demonstrated an independent association of family history of coronary heart disease with acute myocardial infarction. To assess this relationship more comprehensively in multiple datasets in different populations, we carried out a detailed review of the available evidence. Case-control studies involving 17,202 cases and 30,088 controls yielded a pooled unadjusted odds ratio (random-effects model, overall I(2) = 64.6%, P = 0.000) of 2.03 (95% confidence interval: 1.79-2.30), whereas cohort studies that included 313,837 individuals yielded an unadjusted relative risk for future coronary heart disease (random-effects model, overall I(2) = 88.7%, P = 0.000) of 1.60 (95% confidence interval: 1.44-1.77). Although the presence of family history of coronary heart disease indicates a cumulative exposure of shared genes and environment, the risk estimates for family history did not attenuate significantly after adjustment for conventional coronary heart disease risk factors in several studies. It is probably an oversimplification to dichotomize the family history variable into a simple "yes" or "no" risk factor, as the significance of family history is influenced by several variables, such as age, sex, number of relatives, and age at onset of disease in the relatives. Moreover, a quantitative risk-assessment model for the family history variable, such as the "family risk score," has a positive linear relationship with coronary heart disease. More studies are warranted to assess the benefits and risks of intensive interventions, both targeted individually and at the family level, among individuals with a valid family history and borderline elevated risk factors.

Can rheumatoid arthritis be prevented?

The discovery of elevations of rheumatoid arthritis (RA)-related biomarkers prior to the onset of clinically apparent RA raises hopes that individuals who are at risk of future RA can be identified in a preclinical phase of disease that is defined as abnormalities of RA-related immune activity prior to the clinically apparent onset of joint disease. Additionally, there is a growing understanding of the immunologic processes that are occurring in preclinical RA, as well as a growing understanding of risk factors that may be mechanistically related to RA development. Furthermore, there are data supporting that treatment of early RA can lead to drug-free remission. Taken as a whole, these findings suggest that it may be possible to use biomarkers and other factors to accurately identify the likelihood and timing of onset of future RA, and then intervene with immunomodulatory therapies and/or risk factor modification to prevent the future onset of RA in at-risk individuals. Importantly, several clinical prevention trials for RA have already been tried, and one is underway. However, while our growing understanding of the mechanisms and natural history of RA development may be leading us to the implementation of prevention strategies for RA, there are still several challenges to be met. These include developing sufficiently accurate methods of predicting those at high risk of future RA so that clinical trials can be developed based on accurate rates of development of arthritis and subjects can be adequately informed of their risk of disease, identifying the appropriate interventions and biologic targets for optimal prevention, and addressing the psychosocial and economic aspects that are crucial to developing broadly applicable prevention measures for RA. These issues notwithstanding, prevention of RA may be within reach in the near future.

Periodontal disease is associated with increased coronary heart disease risk: A meta-analysis based on 38 case-control studies

AIM: To investigate whether periodontal disease (PD) is associated with increasing coronary heart disease (CHD) risk by performing a meta-analysis.

METHODS: Two authors independently searched PubMed and China National Knowledge Infrastructure up to January 10^th, 2013 for relevant case-control studies that investigated the association between PD and CHD. After quality assessment using Newcastle-Ottawa Scale and data extraction by two independent authors, the overall and subgroup meta-analyses were performed and publication bias were examined using the Comprehensive Meta-Analysis V2 software. Potential publication bias was assessed using visual inspection of the funnel plots, Egger linear regression test, and trims and fill method.

RESULTS: Finally 38 relevant case-control studies were identified, involving 4950 CHD patients and 5490 controls. Eleven studies were rated low quality and 27 were high quality. Based on random-effects, a significant association was identified between PD and CHD (OR 3.79, 95%CI: 2.23-6.43, P < 0.001, I² = 98.59%), and sensitivity analysis showed that this result was robust. Subgroup analyses according to adjusted/unadjusted ORs, source of control, methodological quality, end point, assessment of PD/CHD, and ethnicity also indicated a significant association. Publication bias was detected, and the estimated OR including the “missing” studies did not substantially differ from our estimate with adjustment for missing studies (OR 4.15, 95%CI: 2.62-6.54, P < 0.001).

CONCLUSION: Based on the meta-analysis, PD is probably associated with CHD risk independently and significantly.

Usefulness of the addition of beta-2-microglobulin, cystatin C and C-reactive protein to an established risk factors model to improve mortality risk prediction in patients undergoing coronary angiography

Evidence-based therapies are available to reduce the risk for death from cardiovascular disease, yet many patients go untreated. Novel methods are needed to identify those at highest risk for cardiovascular death. In this study, the biomarkers β2-microglobulin, cystatin C, and C-reactive protein were measured at baseline in a cohort of participants who underwent coronary angiography. Adjusted Cox proportional-hazards models were used to determine whether the biomarkers predicted all-cause and cardiovascular mortality. Additionally, improvements in risk reclassification and discrimination were evaluated by calculating the net reclassification improvement, C-index, and integrated discrimination improvement with the addition of the biomarkers to a baseline model of risk factors for cardiovascular disease and death. During a median follow-up period of 5.6 years, there were 78 deaths among 470 participants. All biomarkers independently predicted future all-cause and cardiovascular mortality. A significant improvement in risk reclassification was observed for all-cause (net reclassification improvement 35.8%, p = 0.004) and cardiovascular (net reclassification improvement 61.9%, p = 0.008) mortality compared to the baseline risk factors model. Additionally, there was significantly increased risk discrimination with C-indexes of 0.777 (change in C-index 0.057, 95% confidence interval 0.016 to 0.097) and 0.826 (change in C-index 0.071, 95% confidence interval 0.010 to 0.133) for all-cause and cardiovascular mortality, respectively. Improvements in risk discrimination were further supported using the integrated discrimination improvement index. In conclusion, this study provides evidence that β2-microglobulin, cystatin C, and C-reactive protein predict mortality and improve risk reclassification and discrimination for a high-risk cohort of patients who undergo coronary angiography.

New computer model for prediction of individual 10-year mortality on the basis of conventional atherosclerotic risk factors

BACKGROUND

Large cohort studies have revealed that subjects with atherosclerotic risk factors have high mortality. However, there has been no method to predict individual mortality based on these risk factors. Accordingly, we developed a computer model predicting the 10-year mortality of an individual with atherosclerotic risk factors.

METHODS

We enrolled two different cohorts in Japan. One was from Tanushimaru-town and the other was from Uku-town. Residents over the age of 40 underwent baseline examinations and were followed-up for ten years. 1851 Subjects in Tanushimaru-town were randomly divided into 1486 training samples and 365 test samples. We applied supervised statistical pattern recognition (SSPR) techniques to develop, using the training samples, a computer model to predict the 10-year mortality of an individual based on 6 conventional risk factors. The test samples were then used to evaluate the predictive accuracy.

RESULTS

There were 49 deaths and 316 survivors in the test samples in Tanushimaru-town. The correctly simulated number of deaths and survival was 36 and 250, respectively. The predictive accuracy of death was 73.5% (36/49) and that of survival was 79.1% (250/316) with c-statistics of 0.827. In order to verify our model, we predicted death and survival for the other test samples (Uku-town, n = 170). The predictive accuracy of death was 72.9% (35/48) and that of survival was 76.2% (93/122) with c-statistics of 0.848.

CONCLUSIONS

This is the first computer model to use SSPR methods to estimate individual 10-year mortality based on conventional risk factors with high accuracy.

Cardiovascular risk

Cardiovascular disease is a major, growing, worldwide problem. It is important that individuals at risk of developing cardiovascular disease can be effectively identified and appropriately stratified according to risk. This review examines what we understand by the term risk, traditional and novel risk factors, clinical scoring systems, and the use of risk for informing prescribing decisions. Many different cardiovascular risk factors have been identified. Established, traditional factors such as ageing are powerful predictors of adverse outcome, and in the case of hypertension and dyslipidaemia are the major targets for therapeutic intervention. Numerous novel biomarkers have also been described, such as inflammatory and genetic markers. These have yet to be shown to be of value in improving risk prediction, but may represent potential therapeutic targets and facilitate more targeted use of existing therapies. Risk factors have been incorporated into several cardiovascular disease prediction algorithms, such as the Framingham equation, SCORE and QRISK. These have relatively poor predictive power, and uncertainties remain with regards to aspects such as choice of equation, different risk thresholds and the roles of relative risk, lifetime risk and reversible factors in identifying and treating at-risk individuals. Nonetheless, such scores provide objective and transparent means of quantifying risk and their integration into therapeutic guidelines enables equitable and cost-effective distribution of health service resources and improves the consistency and quality of clinical decision making.

Relation of red cell distribution width with the presence, severity, and complexity of coronary artery disease

OBJECTIVES

Red cell distribution width (RDW) is a measure of the heterogeneity of cell size in the peripheral blood and has been shown to be an independent correlate of adverse outcomes in healthy participants and in some cardiac conditions. We examined the association between RDW and the complexity of coronary artery disease (CAD).

METHODS

The study population included 193 nonanemic patients who had undergone coronary angiography for stable angina pectoris. Baseline RDW was measured as part of the automated complete blood count. Patients were classified depending on whether the SYNTAX score was 0 (no angiographically apparent CAD) or at least 1 where CAD was present angiographically.

RESULTS

Patients with angiographic CAD had significantly elevated RDW levels compared with the patients without CAD (14.4±1.3 vs. 12.5±0.9, P<0.001). There was a good correlation between RDW and the SYNTAX score (r=0.55, P<0.001). In a receiver operating characteristic curve analysis, an RDW value of 13.25 was identified as an effective cut-point in the segregation of the presence or absence of CAD [area under curve=0.87, 95% confidence interval (CI) 0.81-0.92]. An RDW value of more than 13.25 yielded a sensitivity of 84%, a specificity of 79%, a positive predictive value of 89%, and a negative predictive value of 71%. In multivariate analysis, RDW was observed to be an independent predictor for both angiographic CAD (odds ratio=4.80, 95% CI 2.41-9.57, P<0.001) and for a high (>32) SYNTAX score (odds ratio=2.28, 95% CI 1.45-3.60, P=0.01).

CONCLUSION

RDW is a readily available clinical laboratory value that is associated with both the presence and the complexity of CAD.

Cardiovascular metabolic syndrome: mediators involved in the pathophysiology from obesity to coronary heart disease

Patients with obesity and diabetes mellitus are at increased risk for cardiovascular events and have a higher cardiovascular morbidity and mortality. This worse prognosis is partly explained by the late recognition of coronary heart disease in these patients, due to the absence of symptoms. Early identification of coronary heart disease is vital, to initiate preventive medical therapy and improve prognosis. At present, with the use of cardiovascular risk models, the identification of coronary heart disease in these patients remains inadequate. To this end, biomarkers should improve the early identification of patients at increased cardiovascular risk. The first part of this review describes the pathophysiologic pathway from obesity to coronary heart disease. The second part evaluates several mediators from this pathophysiologic pathway for their applicability as biomarkers for the identification of coronary heart disease.

Atherosclerosis drug development in jeopardy: the need for predictive biomarkers of treatment response

The limited predictability of phase II biomarkers for atherosclerosis outcomes in phase III studies stands in contrast to the number and varied types of biomarkers--soluble, imaging, and functional--that have been used in a diverse array of trials. Although collectively abundant, these biomarker data exist in a fragmented state. Most biomarkers are studied one at a time, only measure a specific aspect of atherosclerosis, are not integrated in a substantive way, and compete with one another for validation; in the end, progress is slow. The proposed solution from the Atherosclerosis Working Group, a committee of experts from academia, the pharmaceutical industry, government, and the nonprofit sector and managed by the Foundation for the National Institutes of Health Biomarkers Consortium, is to integrate these different measures into an in silico model of atherosclerosis. Through integration of diverse biomarker measurements and outcomes in silico, we may be able to improve trial design as well as the predictive power of short-term markers for longer-term outcomes.

Distribution of 10-year and lifetime predicted risk for cardiovascular disease in the Indian Sentinel Surveillance Study population (cross-sectional survey results)

INTRODUCTION

Cardiovascular disease (CVD) prevention guidelines recommend lifetime risk stratification for primary prevention of CVD, but no such risk stratification has been performed in India to date.

METHODS

The authors estimated short-term and lifetime predicted CVD risk among 10,054 disease-free, adult Indians in the 20-69-year age group who participated in a nationwide risk factor surveillance study. The study population was then stratified into high short-term (≥ 10% 10-year risk or diabetes), low short-term (<10%)/high lifetime and low short-term/low lifetime CVD risk groups.

RESULTS

The mean age (SD) of the study population (men=63%) was 40.8 ± 10.9 years. High short-term risk for coronary heart disease was prevalent in more than one-fifth of the population (23.5%, 95% CI 22.7 to 24.4). Nearly half of individuals with low short-term predicted risk (48.2%, 95% CI 47.1 to 49.3) had a high predicted lifetime risk for CVD. While the proportion of individuals with all optimal risk factors was 15.3% (95% CI 14.6% to 16.0%), it was 20.6% (95% CI 18.7% to 22.6%) and 8.8% (95% CI 7.7% to 10.5%) in the highest and lowest educational groups, respectively.

CONCLUSION

Approximately one in two men and three in four women in India had low short-term predicted risks for CVD in this national study, based on aggregate risk factor burden. However, two in three men and one in two women had high lifetime predicted risks for CVD, highlighting a key limitation of short-term risk stratification.