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

Comparison of the performance of cardiovascular risk prediction tools in rural India: the Rishi Valley Prospective Cohort Study

AIMS

We compared the performance of cardiovascular risk prediction tools in rural India.

METHODS AND RESULTS

We applied the World Health Organization Risk Score (WHO-RS) tools, Australian Risk Score (ARS), and Global risk (Globorisk) prediction tools to participants aged 40-74 years, without prior cardiovascular disease, in the Rishi Valley Prospective Cohort Study, Andhra Pradesh, India. Cardiovascular events during the 5-year follow-up period were identified by verbal autopsy (fatal events) or self-report (non-fatal events). The predictive performance of each tool was assessed by discrimination and calibration. Sensitivity and specificity of each tool for identifying high-risk individuals were assessed using a risk score cut-off of 10% alone or this 10% cut-off plus clinical risk criteria of diabetes in those aged >60 years, high blood pressure, or high cholesterol. Among 2333 participants (10 731 person-years of follow-up), 102 participants developed a cardiovascular event. The 5-year observed risk was 4.4% (95% confidence interval: 3.6-5.3). The WHO-RS tools underestimated cardiovascular risk but the ARS overestimated risk, particularly in men. Both the laboratory-based (C-statistic: 0.68 and χ2: 26.5, P = 0.003) and non-laboratory-based (C-statistic: 0.69 and χ2: 20.29, P = 0.003) Globorisk tools showed relatively good discrimination and agreement. Addition of clinical criteria to a 10% risk score cut-off improved the diagnostic accuracy of all tools.

CONCLUSION

Cardiovascular risk prediction tools performed disparately in a setting of disadvantage in rural India, with the Globorisk performing best. Addition of clinical criteria to a 10% risk score cut-off aids assessment of risk of a cardiovascular event in rural India.

LAY SUMMARY

In a cohort of people without prior cardiovascular disease, tools used to predict the risk of cardiovascular events varied widely in their ability to accurately predict who would develop a cardiovascular event.The Globorisk, and to a lesser extent the ARS, tools could be appropriate for this setting in rural India.Adding clinical criteria, such as sustained high blood pressure, to a cut-off of 10% risk of a cardiovascular event within 5 years could improve identification of individuals who should be monitored closely and provided with appropriate preventive medications.

Evaluation of Statin Indication and Dose Intensification Among Type 2 Diabetic Patients at a Tertiary Hospital

Background

Diabetes mellitus (DM) increases cardiovascular disease (CVD) incidence and mortality. While guidelines endorse statin use in type 2 DM (T2DM) to mitigate cardiovascular risks and mortality, challenges like statin initiation and prompt treatment adjustments affect patient outcomes. This study aimed to assess the appropriateness of indications for and dose intensification of statin therapy among T2DM patients at Tikur Anbessa Specialized Hospital (TASH).

Methodology

A hospital-based cross-sectional study was conducted from April 1 to June 30 2020. In total, 405 T2DM patients were selected using a systematic random sampling technique. The data were analyzed using SPSS version 26.0. An adjusted odds ratio (OR) was used and a 95% confidence interval (CI) and p-values of <0.05 were utilized to determine statistical significance.

Results

Of the total 405 participants, 346 (85.4%) started taking statins for primary or secondary prevention purposes. Indication for statin use was appropriate in 96.2% patients, while for 216 (62.4%) patients their doses were appropriately intensified. Predictors of the inappropriateness of statin use were an atherosclerotic cardiovascular disease (ASCVD) score of ≥7.5% (AOR=0.28; 95% CI: 0.102-0.738, p=0.01), the presence of dyslipidemia (AOR=4.48; 95% CI: 1.85-10.84; p=0.001), initiation of aspirin therapy (AOR=3.7; 95% CI: 1.522-9.144; p=0.004), and an LDL-cholesterol level of 70-189 mg/dL (AOR=0.124; 95% CI: 0.042-0.365; p=0.001). DM duration of ≥10 years (AOR=2.51; 95% CI: 1.35-4.66, p=0.004), male gender (AOR=2.04; 95% CI: 1.16-3.58, p=0.013), age ≥65 years (AOR=2.15; 95% CI: 1.23-3.75, p=0.007) and uncontrolled blood pressure (AOR=2.09; 95% CI: 1.07-4.08, p=0.031) were associated with inappropriate statin intensification.

Conclusion

The study found that indication of statins was optimal and about two-thirds of patients had their doses appropriately intensified. Monitoring is needed to avoid inappropriate intensification of statin therapy, particularly in patients with longer diabetes duration, those of male gender and advanced age, and those with uncontrolled blood pressure.

Cardiovascular risk screening: a 10-year prediction cross-sectional study in a Nigerian agrarian community

Introduction

cardiovascular disease (CVD) is a major public health issue with a high global death rate and a significant death contribution from low-and middle-income countries. Modifiable and non-modifiable risk factors assessment and screening are important in their effective prevention and control. This study was designed to screen and assess cardiovascular risk factors in an agrarian community in Nigeria and to predict their 10-year CVD risk.

Methods

this was a cross-sectional study carried out in the Umueri community in Anambra State, Nigeria. Each participant responded to an epidemiologic survey using the World Health Organization (WHO) cardiovascular risk factors assessment tool with point-of-care screening procedures. The risk assessment for 10-year CV risk was conducted using region-specific WHO/ISH charts. Patients´ characteristics were analyzed and presented in frequencies and percentages.

Results

the mean age, systolic blood pressure, fasting plasma glucose, and total cholesterol of the study population were 54 years ± 1.27, 132 mmHg ± 2.088, 130 mg/dl ± 4.608, and 215 mg/dl ± 10.355 respectively. However, 98 (48.8%) have never had their blood pressure checked. About a quarter of the population had a high predicted risk of developing CVD within 10 years.

Conclusion

most of the assessed cardiovascular risk factors in the community are on average above the normal ranges and their probability risk of developing CVD within the next 10 years is high.

Agreement between ten-years cardiovascular disease risk assessment tools: An application to Iranian population in Shahedieh Cohort Study

Background and aim

Cardiovascular risk-prediction models are efficient primary prevention tools to detect high-risk individuals. The study aims to use three tools to estimate the 10-year risk of developing cardiovascular disease (CVD) and investigate their agreement in an Iranian adult population.

Methods

The current cross-sectional study was carried out on 8569 adults between 35 and 70 who participated in the first phase of the Shahedieh cohort study in Yazd, Iran, and were free of CVDs (cardiac ischemia or myocardial infarction or stroke). World Health Organization/International Society of Hypertension (WHO/ISH) chart, Laboratory-Based (LB) and Non-Laboratory-Based (NLB) Framingham Risk Score (FRS) were used to predict the 10-year risk of developing CVD. The agreement across tools was determined by Kappa.

Results

WHO/ISH chart indicated the highest prevalence of low CVD risk for males (96.10%) and females (96.50%), while NLB Framingham had the highest prevalence of high CVD risk for males (19.40%) and females (5.30%). In total, there was substantial agreement between both FRS models (Kappa = o.70), while there was a slight agreement between WHO/ISH and both FRS tools. For under 60 years males and females, substantial agreements were observed between FRS methods (kappa = 0.73 and kappa = 0.68). For males and females over 60 years, this agreement was moderate and substantial, respectively (kappa = 0.54 and kappa = 0.64). WHO/ISH and LB Framingham model had substantial agreement for over 60 years females (kappa = 0.61).

Conclusions

Framingham models classified more participants in the high-risk category than WHO/ISH. Due to the lethality of CVDs, categorizing individuals based on FRS can ensure that most of the real high-risk people are detected. Remarkable agreement between FRS methods in all sex-age groups suggested using the NLB Framingham model as a primary screening tool, especially in a shortage of resources condition.

Quality Appraisal of Screening Guidelines for Cardiovascular disease Prevention:a scoping review.. [DOI: 10.1101/2023.08.05.23293686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective

Each nation develops a guideline for managing and preventing cardiovascular disease (CVD) based on the available literature and the evidence-based consensus in their guideline’s recommendations. The goal of this review is to appraise the quality of many guidelines recommended by several international organizations for the early detection and prevention of CVD.

Methods

We conducted a scoping review using a few guideline-specific databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as the reporting guideline for this review. We used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to rate the methodological quality and rigorousness of the included guidelines for CVD prevention and early detection.

Results

Out of the 2,466 guidelines identified by our search, based on our eligibility criteria, we included a total of 20 distinct guidelines globally focused on screening for CVD prevention and early detection. (70%) of these guidelines were classified as "strongly recommended" while only (90%) were classified as just "recommended". The AGREE II appraisal domains with the highest median scores (percentile 25th, 75th) were “Clarity of Presentation”92% (81, 95.5), followed by Applicability88% (73, 93). The Rigour of Development and Editorial Independence were the lowest scores with a median of78% (66.5, 84) and75% (60.5, 92).

Conclusions

Using AGREE II quality appraisal tool, we provided a critical quality appraisal of several international CVD prevention guidelines and reveal opportunities to improve the CVD prevention guidelines’ quality.

What is already known in this review?

Each community develops a guideline for screening and managing CVD prevention based on the current evidence and evidence-based consensus.

AGREE II tool is an internationally standardized instrument to report the rigorousness of development, transparency, and methodological quality of the clinical practice guidelines.

What this review adds

This review provided a critical quality appraisal of several international CVD prevention guidelines.

The highest AGREE II domain median score was “Clarity of Presentation” while the least domains were “Editorial Independence” and “Rigour of Development”.

70%of these guidelines were classified as "strongly recommended".

How this review might affect research, practice, or policy

This review provided a critical quality appraisal of many CVD prevention guidelines and revealed opportunities to improve CVD prevention guidelines’ quality.

Comparison of Screening Guidelines for Cardiovascular disease Prevention and Early Detection:a scoping review.. [DOI: 10.1101/2023.08.05.23293697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective

Globally, cardiovascular disease (CVD) has a significant role in morbidity and early death. This review’s objective is to provide a summary of the strengths and weaknesses in the variety of screening guidelines made by several international organizations for the early identification and prevention of CVD.

Methods

As the reporting guideline for this review, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). We performed a scoping review using a few guideline-specific databases. We tabulated the main key differences between the included screening guidelines for CVD prevention and early detection from different perspectives.

Results

We included a total of 20 unique guidelines that were developed by various organizations throughout the world and focused on screening for CVD prevention and early detection out of the 2,466 guidelines discovered by our search based on our eligibility criteria. We concluded that the target populations, CVD risk assessment techniques, outcomes, and categories of the chosen CVD prevention guidelines widely varied. Additionally, some guidelines adopted no grading scheme for their evidence, while others did not advocate the use of any imaging screening tools in their evaluation of the CVD risk.

Conclusions

This scoping review highlights the areas of each guideline’s strengths and weaknesses and conducts a systematic comparison of a number of worldwide guidelines for CVD prevention and early diagnosis.

What is already known in this review?

Based on the most recent evidence and consensus among experts, each nation creates its own set of guidelines for the early detection and prevention of CVD.

What this review adds

This review conducted a systematic comparison and summarized the strengths and weaknesses of the various screening guidelines made by numerous international organizations for the early detection and prevention of CVD.

• How this review might affect research, practice or policy

This review provided opportunities to improve the future development of the clinical practice guidelines for CVD prevention and early detection.

Screening and Interventions for Cardiovascular Disease Prevention in the Limpopo Province, South Africa: Use of the Community Action Model

The rise in non-communicable diseases (NCDs) has been attributed to economic growth in developing countries, shifts in societal norms, and behaviors such as dietary habits and physical activity. Up to 80% of NCDs could be prevented by eliminating shared risk factors, mainly tobacco use, unhealthy diets, physical inactivity, and the harmful use of alcohol. The South African government’s national strategic plan to control NCDs, which includes cardiovascular disease (CVD) prevention, places a strong emphasis on the need to improve the prevention, detection, early intervention, and management of NCDs. In line with the above recommendations, this study aimed to screen rural communities using the non-laboratory INTERHEART Risk Score tool (NLIRS) and develop relevant and suitable intervention strategies for a patient at moderate risk of developing a heart attack. A quantitative research approach applying a household-based design was used to conduct this study and the community action model (CAM). The difference between pre-intervention and post-intervention results were analyzed using a t-test and Analysis of covariance (ANCOVA) with age, smoke, hypertension, and diabetes as the covariates. The study found a significant difference in proportions between pre and post-intervention for raised Systole (SBP), obesity by body mass index (BMI), and waist circumference (WC). In rural communities, using CAM to improve knowledge and behavioral practices of NCD risk factors is feasible and effective. This basket of interventions will assist community members in reducing their risk of developing metabolic syndromes as well as their risk of developing CVDs. Continued investment and research in CVD prevention interventions are required to improve health, reduce costs, and have long-term benefits for conflict-affected individuals and communities.

Evaluation of cardiovascular diseases risk calculators for CVDs prevention and management: scoping review

Background

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality globally. This review aimed to summarise evidence on the key features, usability and benefits of CVD risk calculators using digital platforms for CVDs prevention and management in populations.

Methods

We used search engines and thematic analyses to conduct a scoping review. As the reporting guideline for this review, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

Results

A total of 17 studies meeting eligibility criteria were included in the analysis, from which about 70% of the studies have prognostic level I (n = 8) and level II (n = 4) evidence. The review found that various guidelines are recommending different algorithms for CVD risk prediction. The QRISK® was the most accurate CVD risk calculator for several study populations, whereas World Health Organization/International Society of Hypertension (WHO/ISH) risk scores were the least accurate. The key features of CVD risk calculators are variables, predictive accuracy, discrimination index, applicability, understandability, and cost-effectiveness.

Conclusion

For the selected risk prediction tool, development and validation research must be done, which considers a mix of stroke-specific risk and CVD risk to establish its usability in the local community and advantages to the particular health-care environment. To get healthcare professionals more involved in preventing and treating CVDs, each healthcare setting should use an online CVD risk assessment tool that is more useful, accurate, and easy to use, based on the population and health system.

Mobile-Based and Self-Service Tool (iPed) to Collect, Manage, and Visualize Pedigree Data: Development Study

Background

Pedigree data (family history) are indispensable for genetics studies and the assessment of individuals' disease susceptibility. With the popularity of genetics testing, the collection of pedigree data is becoming more common. However, it can be time-consuming, laborious, and tedious for clinicians to investigate all pedigree data for each patient. A self-service robot could inquire about patients' family history in place of professional clinicians or genetic counselors.

Objective

The aim of this study was to develop a mobile-based and self-service tool to collect and visualize pedigree data, not only for professionals but also for those who know little about genetics.

Methods

There are 4 main aspects in the iPed construction, including interface building, data processing, data storage, and data visualization. The user interface was built using HTML, JavaScript libraries, and Cascading Style Sheets (version 3; Daniel Eden). Processing of the submitted data is carried out by PHP programming language. MySQL is used to document and manage the pedigree data. PHP calls the R script to accomplish the visualization.

Results

iPed is freely available to all users through the iPed website. No software is required to be installed, no pedigree files need to be prepared, and no knowledge of genetics or programs is required. The users can easily complete their pedigree data collection and visualization on their own and through a dialogue with iPed. Meanwhile, iPed provides a database that stores all users’ information. Therefore, when the users need to construct new pedigree trees for other genetic traits or modify the pedigree trees that have already been created, unnecessary duplication of operations can be avoided.

Conclusions

iPed is a mobile-based and self-service tool that could be used by both professionals and nonprofessionals at any time and from any place. It reduces the amount of time required to collect, manage, and visualize pedigree data.

Comparison of laboratory-based and non-laboratory-based WHO cardiovascular disease risk charts: a population-based study

Background

Determining the risk of Cardiovascular Disease (CVD) is a necessity for timely preventive interventions in high-risk groups. However, laboratory testing may be impractical in countries with limited resources. This study aimed at comparison and assessment of the agreement between laboratory-based and non-laboratory-based WHO risk charts models.

Methods

This study was performed using the baseline data of 8138 participants in the pars cohort study who had no history of CVD and stroke. The updated 2019 WHO model was used to determine the 10-year fatal and non-fatal CVD risks. In general, there are two types of new WHO risk prediction models for CVD. The scores were determined based on age, sex, smoking status, diabetes, Systolic Blood Pressure (SBP), and total cholesterol for the laboratory-based model and age, sex, smoking status, SBP, and Body Mass Index (BMI) for the non-laboratory-based model. The agreement of these two models was determined via kappa statistics for the classified risk (low: < 10%, moderate: 10–< 20%, high: ≥ 20%). Correlation coefficients (r) and scatter plots was used for correlation between scores.

Results

The results revealed very strong correlation coefficients for all sex and age groups (r = 0.84 for males < 60 years old, 0.93 for males ≥ 60 years old, 0.85 for females < 60 years old, and 0.88 for females ≥ 60 years old). In the laboratory-based model, low, moderate, and high risks were 76.10%, 18.17%, and 5.73%, respectively. These measures were respectively obtained as 77.00%, 18.08%, and 4.92% in the non-laboratory-based model. Based on risk classification, the agreement was substantial for males < 60 years old and for both males and females aged ≥ 60 years (kappa values: 0.79 for males < 60 years old, 0.65 for males ≥ 60 years old, and 0.66 for females ≥ 60 years old) and moderate for females < 60 years old (kappa = 0.46).

Conclusions

The non-laboratory-based risk prediction model, which is simple, inexpensive, and non-invasive, classifies individuals almost identically to the laboratory-based model. Therefore, in countries with limited resources, these two models can be used interchangeably.

Does Adding Adverse Pregnancy Outcomes Improve the Framingham Cardiovascular Risk Score in Women? Data from the Tehran Lipid and Glucose Study

Background

Limited and conflicting evidence is available regarding the predictive value of adding adverse pregnancy outcomes (APOs) to established cardiovascular disease (CVD) risk factors. Hence, the objective of this study was to determine whether adding APOs to the Framingham risk score improves the prediction of CVD events in women.

Methods and Results

Out of 5413 women who participated in the Tehran Lipid and Glucose Study, 4013 women met the eligibility criteria included for the present study. The exposure and the outcome variables were collected based on the standard protocol. Cox proportional hazard model was used to evaluate the association of APOs and CVDs. The variant of C‐statistic for survivals and reclassification of subjects into Framingham risk score categories after adding APOs was reported. Out of the 4013 eligible subjects, a total of 1484 (36.98%) women reported 1 APO, while 395 (9.84%) of the cases reported multiple APOs. Univariate proportional hazard Cox models showed the significant relations between CVD events and APOs. The enhanced model had a higher C‐statistic indicating more acceptable discrimination as well as a slight improvement in discrimination (C‐statistic differences: 0.0053). Moreover, we observed a greater risk of experiencing a CVD event in women with a history of multiple APOs compared with cases with only 1 APO (1 APO: hazard ratio [HR] = 1.22; 2 APOs: HR; 1.94; ≥3 APOs: HR = 2.48).

Conclusions

Beyond the established risk factors, re‐estimated CVDs risk by adding APOs to the Framingham risk score may improve the accurate risk estimation of CVD. Further observational studies are needed to confirm our findings.

Cardiovascular risk assessment tools in Asia

Cardiovascular disease (CVD) is becoming the most important burden to health care systems in most part of the world, especially in Asia. Aiming at identifying high risk individuals and tailoring preventive treatment, many cardiovascular risk assessment tools have been established and most of them were developed in Western countries. However, these cardiovascular risk assessment tools cannot be used interchangeably without recalibration because of the different risk factor profiles (ie, greater absolute burden of hypertension and lower level of total‐cholesterol in Asians and higher prevalence of metabolic disorders in South Asians) and different CVD profiles (higher ratio of stroke/coronary heart disease in Asians) between Western and Asian populations. Original risk models such as Prediction for ASCVD Risk in China (China‐PAR) and Japan Arteriosclerosis Longitudinal Study (JALS) score have been developed and well validated for specific countries, while most of countries/regions in Asia are using established models. Due to higher incidence of stroke in Asians, risk factors like hypertension should weigh more in cardiovascular risk assessment comparing with Western populations, but their actual proportions should be based on CVD profiles in specific countries/regions. The authors encourage the development of new cardiovascular risk assessment tools for Asians, if possible. Still, modifying established models with native epidemiological data of risk factor as well as CVD is acceptable in regions where health care resources are insufficient.

Tools for Assessing Cardiovascular Disease Risk Factors in Underserved Young Adult Populations: A Systematic Review

Cardiovascular disease (CVD, i.e., disease of the heart and blood vessels) is a major cause of death globally. Current assessment tools use either clinical or non-clinical factors alone or in combination to assess CVD risk. The aim of this review was to critically appraise, compare, and summarize existing non-clinically based tools for assessing CVD risk factors in underserved young adult (18–34-year-old) populations. Two online electronic databases—PubMed and Scopus—were searched to identify existing risk assessment tools, using a combination of CVD-related keywords. The search was limited to articles available in English only and published between January 2008 and January 2019. Of the 10,383 studies initially identified, 67 were eligible. In total, 5 out of the 67 articles assessed CVD risk in underserved young adult populations. A total of 21 distinct CVD risk assessment tools were identified; six of these did not require clinical or laboratory data in their estimation (i.e., non-clinical). The main non-clinically based tools identified were the Heart Disease Fact Questionnaire, the Health Beliefs Related to CVD-Perception measure, the Healthy Eating Opinion Survey, the Perception of Risk of Heart Disease Scale, and the WHO STEPwise approach to chronic disease factor surveillance (i.e., the STEPS instrument).

Cardiovascular Risk and Factors Associated to the Health in Hypertensive African Descent People Resident in Quilombola Community

Introduction: Hypertension is a cardiovascular risk factor of wide magnitude among people of African descent, especially those living in Quilombos. However, little is known about the factors associated with cardiovascular risk in residents of the urban Quilombola community. Objetive: To analyze the cardiovascular risk and health-related factors in the family context of hypertensive Afro-descendants living in an urban Quilombola. Materials and methods: It is a cross-sectional and community-based study carried out from November 2017 to March 2018. The study’s population consisted of 303 hypertensive patients enrolled in the family health unit, with ages ranging from 35 to 79 years old, of both genders; and using antihypertensive drugs. The instruments used for data production were: The Primary Arterial Hypertension Questionnaire and the Framingham Risk Score. Results: There was a significant association between cardiovascular risk and cardiovascular disease (CVD) family history (p<0.011), type II diabetes (p<0.001) and overweight and obesity (p<0.010). Conclusion. Research has shown that hypertensive Quilombola people have consistent cardiovascular risk outcomes, especially with CVD family history, type II diabetes, overweight and obesity, schooling and gender with significant associations.

The Promise of Clinical Decision Support Systems Targetting Low-Resource Settings

Low-resource clinical settings are plagued by low physician-to-patient ratios and a shortage of high-quality medical expertise and infrastructure. Together, these phenomena lead to over-burdened healthcare systems that under-serve the needs of the community. Alleviating this burden can be undertaken by the introduction of clinical decision support systems (CDSSs); systems that support stakeholders (ranging from physicians to patients) within the clinical setting in their day-to-day activities. Such systems, which have proven to be effective in the developed world, remain to be under-explored in low-resource settings. This review attempts to summarize the research focused on clinical decision support systems that either target stakeholders within low-resource clinical settings or diseases commonly found in such environments. When categorizing our findings according to disease applications, we find that CDSSs are predominantly focused on dealing with bacterial infections and maternal care, do not leverage deep learning, and have not been evaluated prospectively. Together, these highlight the need for increased research in this domain in order to impact a diverse set of medical conditions and ultimately improve patient outcomes.

Factors influencing the implementation of cardiovascular risk scoring in primary care: a mixed-method systematic review

BACKGROUND

Cardiovascular disease (CVD) such as ischemic heart disease and stroke is the leading causes of death and disability globally with a growing burden in low and middle-income countries. A credible way of managing the incidence and prevalence of cardiovascular diseases is by reducing risk factors. This understanding has led to the development and recommendation for the clinical use of cardiovascular risk stratification tools. These tools enhance clinical decision-making. However, there is a lag in the implementation of these tools in most countries. This systematic review seeks to synthesise the current knowledge of the factors influencing the implementation of cardiovascular risk scoring in primary care settings.

METHODS

We searched bibliographic databases and grey literature for studies of any design relating to the topic. Titles, abstracts and full texts were independently assessed for eligibility by two reviewers. This was followed by quality assessment and data extraction. We analysed data using an integrated and best fit framework synthesis approach to identify these factors. Quantitative and qualitative forms of data were combined into a single mixed-methods synthesis. The Consolidated Framework for Implementation Research was used as the guiding tool and template for this analysis.

RESULTS

Twenty-five studies (cross-sectional n = 12, qualitative n = 9 and mixed-methods n = 4) were included in this review. Twenty (80%) of these were conducted in high-income countries. Only four studies (16%) included patients as participants. This review reports on a total of eleven cardiovascular risk stratification tools. The factors influencing the implementation of cardiovascular risk scoring are related to clinical setting and healthcare system (resources, priorities, practice culture and organisation), users (attributes and interactions between users) and the specific cardiovascular risk tool (characteristics, perceived role and effectiveness).

CONCLUSIONS

While these findings bolster the understanding of implementation complexity, there exists limited research in the context of low and middle-income countries. Notwithstanding the need to direct resources in bridging this gap, it is also crucial that these efforts are in concert with providing high-quality evidence on the clinical effectiveness of using cardiovascular risk scoring to improve cardiovascular disease outcomes of mortality and morbidity.

TRIAL REGISTRATION

PROSPERO registration number: CRD42018092679.

Agreement between Framingham, IraPEN and non-laboratory WHO-EMR risk score calculators for cardiovascular risk prediction in a large Iranian population

Introduction: Estimation of the risk of cardiovascular diseases (CVD), may lead to prophylactic therapies. This study aims to compare and evaluate the agreement between CVD prediction of Iran Package of Essential Non-communicable Disease (IraPEN) and Framingham risk score (FRS).

Methods: All 40-79 years old participants in the Yazd Health Study who did not have a history of CVD were included. The 10-years risk of CVD was estimated by the laboratory (IraPEN), non-laboratory WHO-EMR B and FRS. The risk was classified into low, moderate and high-risk groups. Cohen’s weighted kappa statistics were used to assess agreement between tools. To assess discrepancies McNemar’s χ2 test for paired data was used. P values < 0.05 were considered statistically significant.

Results: In total, 2103 participant was included and the risk scores were calculated. Of them, 26.5% were stratified as high risk by FRS, compared with 6.1% by IraPEN. A slight agreement (37.9%) was observed (kappa 0.17, P < 0.0001), in other words. This discrepancy between IraPEN vs. FRS was seen in both sexes (P < 0.0001), although in women the agreement ratio was higher (52.1% vs. 21.3%). The discrepancy between FRS and IraPEN in categorizing people at risk of CVD was 55.5%, (P < 0.0001) but this was not significant between IraPEN and non-laboratory WHO-EMR-B (World Health Organization - Eastern Mediterranean Regional-B group countries) score (P < 0.523; discrepancies, 5.8%).

Conclusion: Our study shows a slight agreement between various CVD risk scores. Thus, reviewing the IraPEN and using alternative tools for the low-risk group should be considered by decision-makers. It is important to use a more reliable score for nation-wide risk assessment.

A Hybrid Risk Assessment Model for Cardiovascular Disease Using Cox Regression Analysis and a 2-means clustering algorithm

Cardiovascular disease (CVD) refers to a state that indicates narrowed or blocked blood vessels, and it can lead to cardiac arrest, chest pain (angina) or stroke. CVD is a leading cause of silent massive heart attacks and is a major threat to life. The mere prediction of the presence or absence of CVD alone is inefficient in current scenarios. Rather, a major need has arisen for the prediction of CVD, the acquisition of knowledge about CVD and the assessment of the likelihood that an individual will experience cardiac arrest. The objective of establishing an individual CVD risk assessment has been attained in this paper using a hybrid model. The CVD of an individual is due to various controllable and uncontrollable factors. The computation and analysis of all these factors are difficult and time consuming. Only a few attributes are identified to be the most critical. This optimization of the critical features is performed using a modified Differential Evolution (DE) algorithm. The identified critical factors are sufficient to predict the presence/absence of CVD. In this paper, these identified critical features of individuals are considered using Cox regression analysis that evaluates the prevalence rates of the critical attributes. These individual prevalence rates together predict the cumulative prevalence ratios of the respective individuals. This cumulative prevalence ratio of an individual, along with the class attribute, is processed using the 2-means clustering technique to determine the risk of a particular individual developing CVD. The evaluation of the risk assessment model is carried out in this paper by calculating the prediction accuracy of the Cox regression analysis and the Davies-Bouldin (DB) index for 2-means clustering. The Cox regression analysis results in a 91% CVD prediction accuracy using the critical attributes and is comparatively higher than that of other models. The DB index of 2-means clustering with specific initial means for clusters of individuals with CVD is 0.282 and that for clusters of individuals without CVD is 0.2836, which are comparatively lower than those of the traditional k-means clustering algorithm.

Cardiovascular Programming During and After Diabetic Pregnancy: Role of Placental Dysfunction and IUGR

Intrauterine growth restriction (IUGR) is a condition whereby a fetus is unable to achieve its genetically determined potential size. IUGR is a global health challenge due to high mortality and morbidity amongst affected neonates. It is a multifactorial condition caused by maternal, fetal, placental, and genetic confounders. Babies born of diabetic pregnancies are usually large for gestational age but under certain conditions whereby prolonged uncontrolled hyperglycemia leads to placental dysfunction, the outcome of the pregnancy is an intrauterine growth restricted fetus with clinical features of malnutrition. Placental dysfunction leads to undernutrition and hypoxia, which triggers gene modification in the developing fetus due to fetal adaptation to adverse utero environmental conditions. Thus, in utero gene modification results in future cardiovascular programming in postnatal and adult life. Ongoing research aims to broaden our understanding of the molecular mechanisms and pathological pathways involved in fetal programming due to IUGR. There is a need for the development of effective preventive and therapeutic strategies for the management of growth-restricted infants. Information on the mechanisms involved with in utero epigenetic modification leading to development of cardiovascular disease in adult life will increase our understanding and allow the identification of susceptible individuals as well as the design of targeted prevention strategies. This article aims to systematically review the latest molecular mechanisms involved in the pathogenesis of IUGR in cardiovascular programming. Animal models of IUGR that used nutrient restriction and hypoxia to mimic the clinical conditions in humans of reduced flow of nutrients and oxygen to the fetus will be discussed in terms of cardiac remodeling and epigenetic programming of cardiovascular disease. Experimental evidence of long-term fetal programming due to IUGR will also be included.

Gender differences in cardiovascular risk assessment in elderly adults in Ecuador: evidence from a national survey

The present study aimed to predict the risk of developing cardiovascular disease (CVD) over a 5-year period and how it might vary by sex in an ethnically diverse population of older adults. We used a novel CVD risk model built and validated in older adults named the Systematic Coronary Risk Evaluation in Older Persons (SCORE OP). A population-based study analyzed a total of 1307 older adults. Analyses were done by various risk categories and sex. Of the study population, 54% were female with a mean age of 75±7.1 years. According to the SCORE OP model, individuals were classified as having low (9.8%), moderate (48.1%), and high or very high risk (42.1%) of CVD-related mortality. Individuals at higher risk of CVD were more likely to be male compared with females, 53.9% vs 31.8%, respectively (p<0.01). Males were more likely to be younger, living in rural areas, had higher levels of schooling, and with the exception of smoking status and serum triglycerides, had lower values of traditional risk factors than females. In addition, males were less likely to require blood pressure-lowering therapy and statin drugs than females. This gender inequality could be driven by sociocultural determinants and a risk factor paradox in which lower levels of the cardiovascular risk factors are associated with an increase rather than a reduction in mortality. These data can be used to tailor primary prevention strategies such as lifestyle counseling and therapeutic measures in order to improve male elderly health, especially in low-resource settings.