Discordance between 10-year cardiovascular risk estimates using the ACC/AHA 2013 estimator and coronary artery calcium in individuals from 5 racial/ethnic groups: Comparing MASALA and MESA

Role of coronary artery calcification detection in tailoring patient care, personalized risk assessment, and prevention of future cardiac events

PURPOSE OF REVIEW

We review the utility of coronary artery calcium (CAC) scoring in personalized risk assessment and initiation of cardiovascular disease risk modifying therapy.

RECENT FINDINGS

Many populations - including South Asians, patients with cancer, patients with human immunodeficiency virus (HIV), younger patients, and elderly patients - were not included during the conception of the current risk stratification tools. CAC scoring may allow clinicians to risk-stratify these individuals and help initiate preventive therapy in higher risk populations. Furthermore, CAC scoring may be able to be integrated into current imaging practices to allow for more ubiquitous and equitable screening practices.

SUMMARY

CAC scoring is an additional, objective metric that may allow for nuanced and personalized risk assessment of future atherosclerotic cardiovascular disease (ASCVD) events.

Cardiovascular Disease Risk in South Asians in the Baylor Scott and White Health DILWALE Registry

Background

Despite implementation of preventive interventions targeting cardiovascular disease (CVD), atherosclerotic CVD (ASCVD) remains a major public health concern in the South Asian (SA) population.

Objectives

The purpose of this study was to assess the risk factor prevalence and ASCVD outcomes in SA population in the United States.

Methods

The DIL Wellness and Arterial health Longitudinal Evaluation registry collected data retrospectively on SA adult patients receiving care in the Baylor Scott & White Healthcare system. Overall and sex stratified analyses were performed to assess the prevalence of traditional CVD risk factors and adverse ASCVD events.

Results

A total of 31,781 individuals were included (16,644 men, 15,137 women). ASVCD risk factor profile included hyperlipidemia (43.0%), hypertension (22.2%), diabetes mellitus (15.5%), and current smoking (3.6%). ASCVD risk factors were more prevalent among men compared to women; hyperlipidemia (55.0% vs 29.9%), hypertension (26.9% vs 17.1%), diabetes mellitus (18.5% vs 12.3%), and current smoking (6.18% vs 0.71%), all P < 0.001, respectively. The prevalence of ASCVD and premature ASCVD was 7.1% and 2.5%, respectively. The median age of ASCVD diagnosis was 65 (Q1, Q3: 53, 74) years in the overall cohort, 64 (Q1, Q3: 52, 73) years for men, and 70 (Q1, Q3: 60, 77) years for women. Risk factors were more prevalent in those with premature ASCVD as compared to those without ASCVD: hyperlipidemia (89.3% vs 39.4%), hypertension (68.3% vs 17.8%), and diabetes mellitus (39.2% vs 12.7%), all P < 0.001, respectively. Hypertension and hyperlipidemia were most strongly associated with ASCVD in both men and women (OR: 3.48 [95% CI: 3.06-3.96] and 3.53 [95% CI: 3.01-4.17]), respectively. Women with premature ASCVD were less likely to be prescribed lipid-lowering therapy (statins 80.5% vs 92.1%, P < 0.001; ezetimibe 8.6% vs 16.2%, P = 0.009).

Conclusions

ASCVD and premature ASCVD are prevalent among SA adults residing in the United States. Efforts toward risk factor treatment optimization are needed to slow the risk of ASCVD in this higher risk population.

Structural and social determinants of health: The multi-ethnic study of atherosclerosis

BACKGROUND

Researchers have increasingly recognized the importance of structural and social determinants of health (SSDOH) as key drivers of a multitude of diseases and health outcomes. The Multi-Ethnic Study of Atherosclerosis (MESA) is an ongoing, longitudinal cohort study of subclinical cardiovascular disease (CVD) that has followed geographically and racially/ethnically diverse participants starting in 2000. Since its inception, MESA has incorporated numerous SSDOH assessments and instruments to study in relation to CVD and aging outcomes. In this paper, we describe the SSDOH data available in MESA, systematically review published papers using MESA that were focused on SSDOH and provide a roadmap for future SSDOH-related studies.

METHODS AND FINDINGS

The study team reviewed all published papers using MESA data (n = 2,125) through January 23, 2023. Two individuals systematically reviewed titles, abstracts, and full text to determine the final number of papers (n = 431) that focused on at least one SSDOH variable as an exposure, outcome, or stratifying/effect modifier variable of main interest (discrepancies resolved by a third individual). Fifty-seven percent of the papers focused on racialized/ethnic groups or other macrosocial/structural factors (e.g., segregation), 16% focused on individual-level inequalities (e.g. income), 14% focused on the built environment (e.g., walking destinations), 10% focused on social context (e.g., neighborhood socioeconomic status), 34% focused on stressors (e.g., discrimination, air pollution), and 4% focused on social support/integration (e.g., social participation). Forty-seven (11%) of the papers combined MESA with other cohorts for cross-cohort comparisons and replication/validation (e.g., validating algorithms).

CONCLUSIONS

Overall, MESA has made significant contributions to the field and the published literature, with 20% of its published papers focused on SSDOH. Future SSDOH studies using MESA would benefit by using recently added instruments/data (e.g., early life educational quality), linking SSDOH to biomarkers to determine underlying causal mechanisms linking SSDOH to CVD and aging outcomes, and by focusing on intersectionality, understudied SSDOH (i.e., social support, social context), and understudied outcomes in relation to SSDOH (i.e., sleep, respiratory health, cognition/dementia).

Metabolite Profiles of Plant-Based Diets and Cardiometabolic Risk in the Mediators of Atherosclerosis in South Asians Living in America Study

BACKGROUND

Healthy plant-based diets have been associated with lower risk of type 2 diabetes (T2D). Metabolomics can be leveraged to identify potential pathways through which diet influences disease risk.

OBJECTIVES

This study aimed to identify profiles of serum metabolites reflective of plant-based diets of varying quality and examine associations with cardiometabolic risk and T2D.

METHODS

We included data from 687 participants of the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort. An overall plant-based diet index (PDI), healthy PDI (hPDI), and unhealthy PDI (uPDI) were estimated from food frequency questionnaires. Serum metabolites were assayed using ultraperformance liquid chromatography mass spectrometry. Elastic net regression was used to identify sets of metabolites predictive of each diet index, and metabolite profile scores were calculated as the weighted sum of the selected metabolites. Cross-sectional associations between metabolite profile scores and cardiometabolic measures and prospective associations with incident T2D were evaluated with multivariable-adjusted linear and logistic regressions.

RESULTS

Metabolite profiles for PDI, hPDI, and uPDI consisted of n = 51, 55, and 45 metabolites, respectively. Metabolites strongly positively correlated with diet indices included phosphatidylcholine (16:0/18:3) for PDI, phosphatidylethanolamine (20:1/20:4) and pantothenate for hPDI, and lysophosphatidylglycerol (18:2/0:0), proline, and lauric acid for uPDI. Higher metabolite profile scores for PDI and hPDI were associated with lower glycemia and lipids measures, whereas a higher uPDI metabolite score was associated with higher triglycerides and lower low density lipoprotein cholesterol and high density lipoprotein cholesterol. A higher metabolite score for hPDI was additionally associated with lower adiposity measures, higher liver fat attenuation, higher adiponectin, lower odds of overweight (odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.51, 0.81) and obesity (OR: 0.59; 95% CI: 0.48, 0.74), and lower odds of incident T2D (OR: 0.66; 95% CI: 0.45, 0.97).

CONCLUSIONS

Metabolite profiles of different plant-based diets were identified. Metabolite profiles of overall and healthy plant-based diets were associated with favorable cardiometabolic risk profiles.

The utility of coronary artery calcium scoring to enhance cardiovascular risk assessment for South Asian adults

South Asian individuals represent a highly diverse population and are one of the fastest growing ethnic groups in the United States. This population has a high prevalence of traditional and non-traditional cardiovascular disease (CVD) risk factors and a disproportionately high prevalence of coronary heart disease. To reflect this, current national society guidelines have designated South Asian ancestry as a "risk enhancing factor" which may be used to guide initiation or intensification of statin therapy. However, current methods of assessing cardiovascular risk in South Asian adults may not adequately capture the true risk in this diverse population. Coronary artery calcium (CAC) scoring provides a reliable, reproducible, and highly personalized method to provide CVD risk assessment and inform subsequent pharmacotherapy recommendations, if indicated. This review describes the utility of CAC scoring for South Asian individuals.

Association of cardiovascular health with subclinical coronary atherosclerosis progression among five racial and ethnic groups: The MASALA and MESA studies

BACKGROUND AND AIMS

South Asian adults (SA) are at higher risk for atherosclerotic cardiovascular disease (ASCVD) compared with other racial/ethnic groups. Life's Simple 7 (LS7) is a guideline-recommended, cardiovascular health (CVH) construct to guide optimization of cardiovascular risk factors. We sought to assess if the LS7 metrics predict coronary artery calcium (CAC) incidence and progression in asymptomatic SA compared with four other racial/ethnic groups.

METHODS

We assessed the distribution of CVH metrics (inadequate: score 0-8, average: 9-10, optimal: 11-14, and per 1-unit higher score) and its association with incidence and progression of CAC among South Asians in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study compared with other race/ethnic groups from the Multiethnic Study of Atherosclerosis (MESA).

RESULTS

We included 810 SA, 2622 Non-Hispanic White (NHW), and 4192 Other adults (collectively 1893 Black, 1496 Hispanic and 803 Chinese American participants, respectively). SA and White participants compared to Other race/ethnicity groups were more likely to have optimal CVH metrics (26% SA vs 28% White participants vs 21% Other, respectively, p < 0.001). Similar to NHW and the Other race/ethnic group, SA participants with optimal baseline CVH were less likely to develop incident CAC on follow-up evaluation compared to participants with inadequate CVH metrics, optimal CVH/CAC = 0: 24% SA, 28% NHW, and 15% Other (p < 0.01). In multivariable linear and logistic regression models, there was no difference in annualized CAC incidence or progression between each race/ethnic group (pinteraction = 0.85 and pinteraction = 0.17, respectively). Optimal blood pressure control was associated with lower CAC incidence among SA participants [OR (95% CI): 0.30 (0.14-0.63), p < 0.01] and Other race and ethnicity participants [0.32 (0.19-0.53), p < 0.01].

CONCLUSIONS

Optimal CVH metrics are associated with lower incident CAC and CAC progression among South Asians, similar to other racial groups/ethnicities. These findings underscore the importance of optimizing and maintaining CVH to mitigate the future risk of subclinical atherosclerosis in this higher risk population.

Lipid Association of India 2023 update on cardiovascular risk assessment and lipid management in Indian patients: Consensus statement IV

OBJECTIVE

In 2016, the Lipid Association of India (LAI) developed a cardiovascular risk assessment algorithm and defined low-density lipoprotein cholesterol (LDL-C) goals for prevention of atherosclerotic cardiovascular disease (ASCVD) in Indians. The recent refinements in the role of various risk factors and subclinical atherosclerosis in prediction of ASCVD risk necessitated updating the risk algorithm and treatment goals.

METHODS

The LAI core committee held twenty-one meetings and webinars from June 2022 to July 2023 with experts across India and critically reviewed the latest evidence regarding the strategies for ASCVD risk prediction and the benefits and modalities for intensive lipid lowering. Based on the expert consensus and extensive review of published data, consensus statement IV was commissioned.

RESULTS

The young age of onset and a more aggressive nature of ASCVD in Indians necessitates emphasis on lifetime ASCVD risk instead of the conventional 10-year risk. It also demands early institution of aggressive preventive measures to protect the young population prior to development of ASCVD events. Wide availability and low cost of statins in India enable implementation of effective LDL-C-lowering therapy in individuals at high risk of ASCVD. Subjects with any evidence of subclinical atherosclerosis are likely to benefit the most from early aggressive interventions.

CONCLUSIONS

This document presents the updated risk stratification and treatment algorithm and describes the rationale for each modification. The intent of these updated recommendations is to modernize management of dyslipidemia in Indian patients with the goal of reducing the epidemic of ASCVD among Indians in Asia and worldwide.

Performance of Cardiovascular Risk Prediction Models in Korean Patients With New-Onset Rheumatoid Arthritis: National Cohort Study

BACKGROUND

This study aimed to compare the performance of established cardiovascular risk algorithms in Korean patients with new-onset rheumatoid arthritis.

METHODS AND RESULTS

This retrospective cohort study identified patients newly diagnosed with rheumatoid arthritis without a history of cardiovascular diseases between 2013 and 2019 using the National Health Insurance Service database. The cohort was followed up until 2020 for the development of the first major adverse cardiovascular event. General cardiovascular risk prediction algorithms, such as the systematic coronary risk evaluation model, the Korean risk prediction model for atherosclerotic cardiovascular diseases, the American College of Cardiology/American Heart Association pooled equations, and the Framingham Risk Score, were used. The discrimination and calibration of cardiovascular risk prediction models were evaluated. Hazard ratios were estimated using Cox proportional hazards regression. A total of 611 patients among 24 889 patients experienced a major adverse cardiovascular event during follow-up. The median 10-year atherosclerotic cardiovascular diseases risk score was significantly higher in patients with major adverse cardiovascular events than those without. The C-statistics of risk algorithms ranged between 0.72 and 0.74. Compared with the low-risk group, the actual risk of developing major adverse cardiovascular events increased significantly in the intermediate- and high-risk groups for all algorithms. However, the risk predictions calculated from all algorithms overestimated the observed cardiovascular risk in the middle to high deciles, and only the systematic coronary risk evaluation algorithm showed comparable observed and predicted event rates in the low-intermediate deciles with the highest sensitivity.

CONCLUSIONS

The systematic coronary risk evaluation model algorithm and the general risk prediction models discriminated patients with rheumatoid arthritis appropriately. However, overestimation should be considered when applying the cardiovascular risk prediction model in Korean patients.

Ten-year risk assessment for cardiovascular diseases using ASCVD risk estimator plus: outcomes from hypertension and diabetes patients

BACKGROUND

Cardiovascular risk prediction models encompass numerous CVD risk factors. Available prediction models were developed from non-Asian cohorts hence we decided to evaluate the performance of the ASCVD risk estimator model and the associated 10-year CVD predisposing factors in Punjab.

METHODS

We carried out a cross-sectional study among patients having hypertension and diabetes mellitus in a tertiary hospital in Punjab, India. 201 participants without ASCVD who were ≥ 40 years old and had been admitted to the medical ward were assessed. a pre-validated questionnaire was used to collect data on the socio-demographics and behavioral patterns. Lipid profile and blood pressure measurements were collected as per standard protocols. The respondents' CVD risk was assessed using ASCVD Risk Estimator Plus. Data were analyzed using IBM SPSS version 26; bivariate analysis was done using Chi-square and binary logistic regression was used to identify the predictors of 10-year risk for CVD at a 5% level of significance.

MEASUREMENTS

We examined the stratification of the predicted outcomes and evaluated the associations between individual risk factors and the predicted cardiovascular events. Our study categorized the results of these outcomes into 4 categories: low category (1-5%), borderline category (6-9%) intermediate category (10-20%), and high category (21-95%).

RESULTS

Out of the 201 participants that enrolled in our study, the majority 76 (37.8%) were in the intermediate category, 56 (27.9%) were in the high category, 41 (20.4%) were in the borderline category, 28 (13.9%) were in the low category. The median ASCVD percentage was 14.20%. Respondents who were alcoholics, smokers, and drug abusers (OR = 5.8, 95% CI 0.397-83.584) were associated with the highest likelihood of developing CVDs. Furthermore, males had a significantly higher mean predicted CVD outcome % (M = 23.18%) compared to females (M = 14.91%).

CONCLUSION

According to our prediction study, it was discovered that 145 (72.1%) participants were not likely to have had an ASCVD in the next 10 years. However, middle-aged males should be more cautious with their lifestyle habits, particularly in dealing with risk factors that can expose them to CVDs.

A South Asian Mediterranean-style diet is associated with favorable adiposity measures and lower diabetes risk: The MASALA cohort

OBJECTIVE

The Mediterranean diet is associated with lower risks for type 2 diabetes (T2D) and cardiovascular disease in certain populations, although data among diverse groups are limited. This study evaluated cross-sectional and prospective associations between a novel South Asian Mediterranean-style (SAM) diet and cardiometabolic risk among US South Asian individuals.

METHODS

The study included 891 participants at baseline in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Culturally relevant foods were grouped into nine categories to construct the SAM score. The study examined associations of this score with cardiometabolic risk factors and incident T2D.

RESULTS

At baseline, higher adherence to the SAM diet was associated with lower glycated hemoglobin (-0.43% ± 0.15% per 1-unit increase in SAM score; p = 0.004) and lower pericardial fat volume (-1.22 ± 0.55 cm3 ; p = 0.03), as well as a lower likelihood of obesity (odds ratio [OR]: 0.88, 95% CI: 0.79-0.98) and fatty liver (OR: 0.82, 95% CI: 0.68-0.98). Over the follow-up (~5 years), 45 participants developed T2D; each 1-unit increase in SAM score was associated with a 25% lower odds of incident T2D (OR: 0.75, 95% CI: 0.59-0.95).

CONCLUSIONS

A greater intake of a SAM diet is associated with favorable adiposity measures and a lower likelihood of incident T2D.

PIK3R3 is a candidate regulator of platelet count in people of Bangladeshi ancestry

Background

Blood platelets are mediators of atherothrombotic disease and are regulated by complex sets of genes. Association studies in European ancestry populations have already detected informative platelet regulatory loci. Studies in other ancestries can potentially reveal new associations because of different allele frequencies, linkage structures, and variant effects.

Objectives

To reveal new regulatory genes for platelet count (PLT).

Methods

Genome-wide association studies (GWAS) were performed in 20,218 Bangladeshi and 9198 Pakistani individuals from the Genes & Health study. Loci significantly associated with PLT underwent fine-mapping to identify candidate genes.

Results

Of 1588 significantly associated variants (P < 5 × 10-8) at 20 loci in the Bangladeshi analysis, most replicated findings in prior transancestry GWAS and in the Pakistani analysis. However, the Bangladeshi locus defined by rs946528 (chr1:46019890) did not associate with PLT in the Pakistani analysis but was in the same linkage disequilibrium block (r2 ≥ 0.5) as PLT-associated variants in prior East Asian GWAS. The single independent association signal was refined to a 95% credible set of 343 variants spanning 8 coding genes. Functional annotation, mapping to megakaryocyte regulatory regions, and colocalization with blood expression quantitative trait loci identified the likely mediator of the PLT phenotype to be PIK3R3 encoding a regulator of phosphoinositol 3-kinase (PI3K).

Conclusion

Abnormal PI3K activity in the vessel wall is already implicated in the pathogenesis of atherothrombosis. Our identification of a new association between PIK3R3 and PLT provides further mechanistic insights into the contribution of the PI3K pathway to platelet biology.

Association of Coronary Artery Calcium Density and Volume With Predicted Atherosclerotic Cardiovascular Disease Risk and Cardiometabolic Risk Factors in South Asians: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study

Individuals of South Asian (SA) ancestry are predisposed to a higher risk of atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium (CAC) volume and density can identify coronary plaque characteristics unique to SA that may provide important prognostic information to identify high risk individuals beyond traditional CAC scores. We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA). CAC density and volume were assessed according to established protocols. ASCVD risk was estimated using the pooled cohort equations (PCE). Multivariable-adjusted linear regression models were used to study the association between the PCE and advanced CAC measures, and between cardiovascular risk factors and CAC density and volume. Our analyses included 1,155 participants (mean age 57 (SD 9) years, 52% men) with information on advanced CAC measures. After multivariable-adjustment, the PCE was associated with both CAC density (β 0.24, 95% CI 0.12,0.35) and CAC volume (β 0.43, 95% CI 0.38,0.48). High-density lipoprotein cholesterol was directly associated with CAC density while waist circumference was inversely associated with it. Body mass index, hypertension status, statin use, diabetes, and HOMA-IR were all directly associated with CAC volume. Estimated ASCVD risk was associated with both CAC volume and density. Different cardiometabolic risk factors are associated with CAC density and volume. Future longitudinal studies are required to demonstrate the interrelationship of advanced CAC measures and cardiovascular risk factors with incident ASCVD outcomes.

Leveling the playing field: The utility of coronary artery calcium scoring in cardiovascular risk stratification in South Asians

South Asian (SA) individuals, particularly those that reside in the United States and other Westernized countries, are at an elevated risk for ASCVD and mortality related to ASCVD. The 2018 ACC/AHA/Multi-society Cholesterol guideline listed SA as a high-risk ethnicity, underscoring the importance of treating modifiable risk factors to reduce ASCVD burden. Coronary artery calcium (CAC), a highly specific marker of subclinical atherosclerosis, may be a useful test to improve risk stratification among SA individuals. CAC testing is a cost-effective, highly reproducible, and specific marker of subclinical atherosclerosis, shown to improve ASCVD risk assessment across all racial/ethnic groups, thereby serving as a guide for initiating or deferring preventive therapies. In this White Paper we will discuss the use of CAC scoring to optimize risk stratification and delivery of preventive therapies to individuals of SA ethnicity.

Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.

Performance of the pooled cohort equation in South Asians: insights from a large integrated healthcare delivery system

South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a "risk enhancer" in the 2018 American College of Cardiology/American Heart Association Guidelines. Risk estimation and statin eligibility in South Asians is not well understood; we studied the accuracy of 10-years ASCVD risk prediction by the pooled cohort equation (PCE), based on statin use, in a South Asian cohort. This is a retrospective cohort study of Kaiser Permanente Northern California South Asian members without existing ASCVD, age range 30-70, and 10-years follow up. ASCVD events were defined as myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use during the study period: never; at baseline and during follow-up; and only during follow-up. Predicted probability of ASCVD, using the PCE was calculated and compared to observed ASCVD events for low < 5.0%, borderline 5.0 to < 7.5%, intermediate 7.5 to < 20.0%, and high ≥ 20.0% risk groups. A total of 1835 South Asian members were included: 773 never on statin, 374 on statins at baseline and follow-up, and 688 on statins during follow-up only. ASCVD risk was underestimated by the PCE in low-risk groups: entire cohort: 1.8 versus 4.9%, p < 0.0001; on statin at baseline and follow-up: 2.58 versus 8.43%, p < 0.0001; on statin during follow-up only: 2.18 versus 7.77%, p < 0.0001; and never on statin: 1.37 versus 2.09%, p = 0.12. In this South Asian cohort, the PCE underestimated risk in South Asians, regardless of statin use, in the low risk ASCVD risk category.

Machine learning derived ECG risk score improves cardiovascular risk assessment in conjunction with coronary artery calcium scoring

Background

Precision estimation of cardiovascular risk remains the cornerstone of atherosclerotic cardiovascular disease (ASCVD) prevention. While coronary artery calcium (CAC) scoring is the best available non-invasive quantitative modality to evaluate risk of ASCVD, it excludes risk related to prior myocardial infarction, cardiomyopathy, and arrhythmia which are implicated in ASCVD. The high-dimensional and inter-correlated nature of ECG data makes it a good candidate for analysis using machine learning techniques and may provide additional prognostic information not captured by CAC. In this study, we aimed to develop a quantitative ECG risk score (eRiS) to predict major adverse cardiovascular events (MACE) alone, or when added to CAC. Further, we aimed to construct and validate a novel nomogram incorporating ECG, CAC and clinical factors for ASCVD.

Methods

We analyzed 5,864 patients with at least 1 cardiovascular risk factor who underwent CAC scoring and a standard ECG as part of the CLARIFY study (ClinicalTrials.gov Identifier: NCT04075162). Events were defined as myocardial infarction, coronary revascularization, stroke or death. A total of 649 ECG features, consisting of measurements such as amplitude and interval measurements from all deflections in the ECG waveform (53 per lead and 13 overall) were automatically extracted using a clinical software (GE Muse™ Cardiology Information System, GE Healthcare). The data was split into 4 training (S_tr) and internal validation (S_v) sets [S_tr (1): S_v (1): 50:50; S_tr (2): S_v (2): 60:40; S_tr (3): S_v (3): 70:30; S_tr (4): S_v (4): 80:20], and the results were compared across all the subsets. We used the ECG features derived from S_tr to develop eRiS. A least absolute shrinkage and selection operator-Cox (LASSO-Cox) regularization model was used for data dimension reduction, feature selection, and eRiS construction. A Cox-proportional hazards model was used to assess the benefit of using an eRiS alone (M_ecg), CAC alone (M_cac) and a combination of eRiS and CAC (M_ecg+cac) for MACE prediction. A nomogram (M_nom) was further constructed by integrating eRiS with CAC and demographics (age and sex). The primary endpoint of the study was the assessment of the performance of M_ecg, M_cac, M_ecg+cac and M_nom in predicting CV disease-free survival in ASCVD.

Findings

Over a median follow-up of 14 months, 494 patients had MACE. The feature selection strategy preserved only about 18% of the features that were consistent across the various strata (S_tr). The M_ecg model, comprising of eRiS alone was found to be significantly associated with MACE and had good discrimination of MACE (C-Index: 0.7, p = <2e-16). eRiS could predict time-to MACE (C-Index: 0.6, p = <2e-16 across all S_v). The M_ecg+cac model was associated with MACE (C-index: 0.71). Model comparison showed that M_ecg+cac was superior to M_ecg (p = 1.8e-10) or M_cac (p < 2.2e-16) alone. The M_nom, comprising of eRiS, CAC, age and sex was associated with MACE (C-index 0.71). eRiS had the most significant contribution, followed by CAC score and other clinical variables. Further, M_nom was able to identify unique patient risk-groups based on eRiS, CAC and clinical variables.

Conclusion

The use of ECG features in conjunction with CAC may allow for improved prognostication and identification of populations at risk. Future directions will involve prospective validation of the risk score and the nomogram across diverse populations with a heterogeneity of treatment effects.

Cardiovascular Risk Management in the South Asian Patient: A Review

South Asians represent a growing percentage of the diverse population in the U.S. and are disproportionately impacted by a greater burden of aggressive and premature cardiovascular disease. There are multiple potential explanations for these findings including a high prevalence of traditional risk factors (particularly diabetes, dyslipidemia, and obesity), a genetic predisposition, and unique lifestyle factors. In this review, we discuss the cardiovascular risk stratification and disease management goals for South Asian adults. We review the pharmacologic and non-pharmacologic interventions studied in this population and discuss the role of specialized clinics and digital outreach to improve care for this vulnerable group of patients.

Coronary Artery Calcium for Risk Stratification of Sudden Cardiac Death: The Coronary Artery Calcium Consortium

BACKGROUND

Coronary artery calcium (CAC) is a marker of plaque burden. Whether CAC improves risk stratification for incident sudden cardiac death (SCD) beyond atherosclerotic cardiovascular disease (ASCVD) risk factors is unknown.

OBJECTIVES

SCD is a common initial manifestation of coronary heart disease (CHD); however, SCD risk prediction remains elusive.

METHODS

The authors studied 66,636 primary prevention patients from the CAC Consortium. Multivariable competing risks regression and C-statistics were used to assess the association between CAC and SCD, adjusting for demographics and traditional risk factors.

RESULTS

The mean age was 54.4 years, 33% were women, 11% were of non-White ethnicity, and 55% had CAC >0. A total of 211 SCD events (0.3%) were observed during a median follow-up of 10.6 years, 91% occurring among those with baseline CAC >0. Compared with CAC = 0, there was a stepwise higher risk (P trend < 0.001) in SCD for CAC 100 to 399 (subdistribution hazard ratio [SHR]: 2.8; 95% CI: 1.6-5.0), CAC 400 to 999 (SHR: 4.0; 95% CI: 2.2-7.3), and CAC >1,000 (SHR: 4.9; 95% CI: 2.6-9.9). CAC provided incremental improvements in the C-statistic for the prediction of SCD among individuals with a 10-year risk <7.5% (ΔC-statistic = +0.046; P = 0.02) and 7.5% to 20% (ΔC-statistic = +0.069; P = 0.003), which were larger when compared with persons with a 10-year risk >20% (ΔC-statistic = +0.01; P = 0.54).

CONCLUSIONS

Higher CAC burden strongly associates with incident SCD beyond traditional risk factors, particularly among primary prevention patients with low-intermediate risk. SCD risk stratification can be useful in the early stages of CHD through the measurement of CAC, identifying patients most likely to benefit from further downstream testing.

A healthy plant-based diet is favorably associated with cardiometabolic risk factors among participants of South Asian ancestry

BACKGROUND

Plant-based diets are recommended for chronic disease prevention, yet there has been little focus on plant-based diet quality among participants of South Asian ancestry who consume a predominantly plant-based diet.

OBJECTIVES

We evaluated cross-sectional and prospective associations between plant-based diet quality and cardiometabolic risks among participants of South Asian ancestry who are living in the United States.

METHODS

We included 891 participants of South Asian ancestry who completed the baseline visit in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. The prospective analysis included 735 participants who completed exam 2 (∼5 years after baseline). The plant-based diet quality was assessed using 3 indices: an overall plant-based diet index (PDI) that summarizes the consumption of plant foods, a healthy PDI (hPDI) that measures consumption of healthy plant foods, and an unhealthy PDI (uPDI) that reflects consumption of less healthy plant foods.

RESULTS

At baseline, the PDI score was inversely associated with fasting glucose. We observed inverse associations between PDI and hPDI scores and HOMA-IR, LDL cholesterol, weight, and BMI (all P values < 0.05). Higher scores on the hPDI, but not PDI, were associated with lower glycated hemoglobin, higher adiponectin, a smaller visceral fat area, and a smaller pericardial fat volume. Each 5-unit higher hPDI score was associated with lower likelihoods of fatty liver (OR: 0.76; 95% CI: 0.64, 0.90) and obesity (OR: 0.88; 95% CI: 0.80, 0.97). There were no associations between uPDI scores and cardiometabolic risks. Prospectively, after covariate adjustment for baseline values, each 5-unit higher hPDI score was associated with an 18% lower risk of incident type 2 diabetes (OR: 0.82; 95% CI: 0.67, 1.00).

CONCLUSIONS

A higher intake of healthful plant-based foods was associated with a favorable cardiometabolic risk profile. Dietary recommendations to lower chronic disease risks among participants of South Asian ancestry should focus on the quality of plant-based foods.

Primary and Secondary Prevention of CAD: A Review

Coronary artery disease is the leading cause of death in both men and women, yet adequate control of risk factors can largely reduce the incidence and recurrence of cardiac events. In this review, we discuss various life style and pharmacological measures for both the primary and secondary prevention of coronary artery disease. With a clear understanding of management options, health care providers have an excellent opportunity to educate patients and ameliorate a significant burden of morbidity and mortality.

Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke: JACC Focus Seminar 3/9

Notable racial and ethnic differences and disparities exist in coronary artery disease (CAD) and stroke epidemiology and outcomes despite substantial advances in these fields. Racial and ethnic minority subgroups remain underrepresented in population data and clinical trials contributing to incomplete understanding of these disparities. Differences in traditional cardiovascular risk factors such as hypertension and diabetes play a role; however, disparities in care provision and process, social determinants of health including socioeconomic position, neighborhood environment, sociocultural factors, and racial discrimination within and outside of the health care system also drive racial and ethnic CAD and stroke disparities. Improved culturally congruent and competent communication about risk factors and symptoms is also needed. Opportunities to achieve improved and equitable outcomes in CAD and stroke must be identified and pursued.

Polygenic Risk Scores for Atherosclerotic Cardiovascular Disease in the Asia-Pacific Region

Approximately one-half of the phenotypic susceptibility to atherosclerotic cardiovascular disease (ASCVD) has a genetic basis. Although individual allelic variants generally impart a small effect on risk for ASCVD, an emerging body of data has shown that the aggregation and weighting of many of these genetic variations into "scores" can further discriminate an individual's risk beyond traditional risk factors alone. Consistent with the theory of population genetics, such polygenic risk scores (PRS) appear to be ethnicity specific because their elements comprise single-nucleotide variants that are always ethnicity specific. The currently available PRS are derived predominantly from European ancestry and thus predictably perform less well among non-European participants, a fact that has implications for their use in the Asia-Pacific region. This paper describes the current state of knowledge of PRS, the available data that support their use in this region, and highlights the needs moving forward to safely and effectively implement them in clinical care in the Asia-Pacific region.

Association of Diabetes Subgroups With Race/Ethnicity, Risk Factor Burden and Complications: The MASALA and MESA Studies

INTRODUCTION

There are known disparities in diabetes complications by race and ethnicity. Although diabetes subgroups may contribute to differential risk, little is known about how subgroups vary by race/ethnicity.

METHODS

Data were pooled from 1293 (46% female) participants of the Mediators of Atherosclerosis in South Asians Living in America (MASALA) and the Multi-Ethnic Study of Atherosclerosis (MESA) who had diabetes (determined by diabetes medication use, fasting glucose, and glycated hemoglobin [HbA1c]), including 217 South Asian, 240 non-Hispanic white, 125 Chinese, 387 African American, and 324 Hispanic patients. We applied k-means clustering using data for age at diabetes diagnosis, body mass index, HbA1c, and homeostatic model assessment measures of insulin resistance and beta cell function. We assessed whether diabetes subgroups were associated with race/ethnicity, concurrent cardiovascular disease risk factors, and incident diabetes complications.

RESULTS

Five diabetes subgroups were characterized by older age at diabetes onset (43%), severe hyperglycemia (26%), severe obesity (20%), younger age at onset (1%), and requiring insulin medication use (9%). The most common subgroup assignment was older onset for all race/ethnicities with the exception of South Asians where the severe hyperglycemia subgroup was most likely. Risk for renal complications and subclinical coronary disease differed by diabetes subgroup and, separately, race/ethnicity.

CONCLUSIONS

Racial/ethnic differences were present across diabetes subgroups, and diabetes subgroups differed in risk for complications. Strategies to eliminate racial/ethnic disparities in complications may need to consider approaches targeted to diabetes subgroup.

New Recommendations and Revised Concepts in Recent Guidelines on the Management of Dyslipidemias to Prevent Cardiovascular Disease: the 2018 ACC/AHA and 2019 ESC/EAS Guidelines

PURPOSE OF REVIEW

The purpose of this review is to discuss the updated guideline recommendations on management of dyslipidemia for prevention and treatment of cardiovascular disease.

RECENT FINDINGS

The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) published revised cholesterol management guidelines in 2018 and 2019, respectively, to reflect new evidence in the field. Broadly speaking, both emphasize refining cardiovascular disease risk estimation and aggressively lowering low-density lipoprotein-cholesterol (LDL-C) with statin and non-statin agents to curb cardiovascular risk. While they share the same guiding principles, there are important differences in the recommendations from both societies including how they define risk categories and goals for LDL-C lowering. This review summarizes current methods of managing dyslipidemia with a focus on the common themes and notable differences between the 2018 ACC/AHA and 2019 ESC/EAS cholesterol management guidelines.

Advanced Lipid Thinking Prior to Incorporating Advanced Lipid Testing

Lipid profiles help estimate patient's short- and long-term atherosclerotic cardiovascular disease risk over the life course and inform treatment decisions. Advanced lipid testing can provide additional information in selected patients. New 2018 cholesterol guidelines suggest which patients may benefit from additional testing. In patients ages 40-75 years, calculation of a 10-year atherosclerotic cardiovascular disease risk score begins the clinician-patient risk discussion. In those at intermediate risk (10-year risk 7.5%-19.9%) for future events, inclusion of enhancing factors personalizes the risk decision. The guidelines identify enhancing factors that can support initiating statin therapy. Two advanced lipid tests may be used. Apolipoprotein B levels improve risk estimations and identify genetic disorders in hypertriglyceridemic patients. In patients with a family history of premature atherosclerotic cardiovascular disease, significantly elevated lipoprotein (a) levels may reclassify risk. The decision-making cascade of estimating 10-year risk, personalizing risk status with risk-enhancing factors, and, if appropriate, reclassifying risk with a coronary artery calcium score is advanced lipid thinking that can utilize advanced lipid testing to optimize atherosclerotic cardiovascular disease prevention.

Lipids in South Asians: Epidemiology and Management

Purpose of Review

This review focuses on lipoprotein abnormalities in South Asians (SA) and addresses risk stratification and management strategies to lower atherosclerotic cardiovascular disease (ASCVD) in this high-risk population.

Recent Findings

South Asians (SAs) are the fastest growing ethnic group in the United States (U.S) and have an increased risk of premature coronary artery disease (CAD). While the etiology may be multifactorial, lipoprotein abnormalities play a key role. SAs have lower low-density lipoprotein cholesterol (LDL-C) compared with Whites and at any given LDL-C level, SA ethnicity poses a higher risk of myocardial infarction (MI) and coronary artery disease (CAD) compared with other non-Asian groups. SAs have lower high-density lipoprotein cholesterol (HDL-C) with smaller particle sizes of HDL-C compared with Whites. SAs also have higher triglycerides than Whites which is strongly related to the high prevalence of metabolic syndrome in SAs. Lipoprotein a (Lp(a)) levels are also higher in SAs compared with many other ethnic groups. This unique lipoprotein profile plays a vital role in the elevated ASCVD risk in SAs. Studies evaluating dietary patterns of SAs in the U.S show high consumption of carbohydrates and saturated fats.

Summary

SAs have a high-risk lipoprotein profile compared with other ethnicities. Lipid abnormalities play a central role in the pathogenesis of CAD in SAs. More studies are needed to understand the true impact of the various lipoproteins and their contribution to increasing ASCVD in SAs. Aggressive lowering of LDL-C in high-risk groups using medications, such as statins, and lifestyle modification including dietary changes is essential in overall CAD risk reduction.

Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe

South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group - particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.

Size of Anterior Wall Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention in United States Versus Europe/Australia Versus India (from the CRISP-AMI Randomized Controlled Trial)

International variability in infarct size following acute anterior ST-elevation myocardial infarction without shock treated with primary percutaneous coronary intervention (PCI) has been little studied. Patients enrolled in the Counterpulsation to Reduce Infarct Size pre-PCI for Acute Myocardial Infarction international randomized trial were analyzed according to their region of enrollment: United States (US) (n = 60), Europe/Australia (EU/AU) (n = 104), or India (n = 123). Cardiac magnetic resonance imaging was performed 3-5 days after PCI to assess infarct size, expressed as percentage of left ventricular mass, and analyzed by an imaging core laboratory. The relation between infarct size and region was modelled using multivariable linear regression adjusting for time from symptom onset to first hospital contact, myocardial infarction severity, and baseline characteristics. Infarct size was 36.4% of left ventricular mass in US patients (95% confidence interval [CI] 31.5 to 41.4), 36.5% (95% CI 32.6 to 40.4) in EU/AU patients, and 44.7% (95% CI 41.1 to 48.2) in patients from India (p = 0.01). In multiplicity-adjusted regression analysis, mean infarct size in patients from India was higher than in US patients (mean difference of 8.3%; 95% CI 0.7 to 15.8; p = 0.03), and EU/AU patients (mean difference of 8.2%; 95% CI 1.6 to 14.8; p = 0.01). There was no significance difference in infarct size between patients from the EU/AU and the US (mean difference of 0.1%; 95% CI -7.5 to 7.4; p = 0.99). ln conclusion, in patients with anterior ST-elevation myocardial infarction without cardiogenic shock treated with primary PCI, infarct size was larger in India compared to the United States and EU/AU, even after adjustment for performance metrics, including time to treatment, and other potential confounders. Future studies are needed to better elucidate this discrepancy.