Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology

Prediction of individual lifetime cardiovascular risk and potential treatment benefit: development and recalibration of the LIFE-CVD2 model to four European risk regions

AIMS

The 2021 European Society of Cardiology prevention guidelines recommend the use of (lifetime) risk prediction models to aid decisions regarding initiation of prevention. We aimed to update and systematically recalibrate the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model to four European risk regions for the estimation of lifetime CVD risk for apparently healthy individuals.

METHODS AND RESULTS

The updated LIFE-CVD (i.e. LIFE-CVD2) models were derived using individual participant data from 44 cohorts in 13 countries (687 135 individuals without established CVD, 30 939 CVD events in median 10.7 years of follow-up). LIFE-CVD2 uses sex-specific functions to estimate the lifetime risk of fatal and non-fatal CVD events with adjustment for the competing risk of non-CVD death and is systematically recalibrated to four distinct European risk regions. The updated models showed good discrimination in external validation among 1 657 707 individuals (61 311 CVD events) from eight additional European cohorts in seven countries, with a pooled C-index of 0.795 (95% confidence interval 0.767-0.822). Predicted and observed CVD event risks were well calibrated in population-wide electronic health records data in the UK (Clinical Practice Research Datalink) and the Netherlands (Extramural LUMC Academic Network). When using LIFE-CVD2 to estimate potential gain in CVD-free life expectancy from preventive therapy, projections varied by risk region reflecting important regional differences in absolute lifetime risk. For example, a 50-year-old smoking woman with a systolic blood pressure (SBP) of 140 mmHg was estimated to gain 0.9 years in the low-risk region vs. 1.6 years in the very high-risk region from lifelong 10 mmHg SBP reduction. The benefit of smoking cessation for this individual ranged from 3.6 years in the low-risk region to 4.8 years in the very high-risk region.

CONCLUSION

By taking into account geographical differences in CVD incidence using contemporary representative data sources, the recalibrated LIFE-CVD2 model provides a more accurate tool for the prediction of lifetime risk and CVD-free life expectancy for individuals without previous CVD, facilitating shared decision-making for cardiovascular prevention as recommended by 2021 European guidelines.

Intensive postpartum antihypertensive treatment (IPAT) and healthy lifestyle education: Study protocol for a pilot randomized controlled trial for patients with hypertensive disorders of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy (HDP) complicate about 10 % of pregnancies and lead to postpartum hospital readmissions and cardiovascular complications. Following HDP, vascular dysfunction could persist and accelerate the trajectory of cardiovascular disease risk. The benefits of intensive blood pressure (BP) control following HDP have not been adequately investigated. Therefore, no standard guidelines exist to guide the management of mild-to-moderate hypertension in the postpartum period, leading to a wide variation in clinical practice. The present study will investigate the effect of intensive BP control and healthy lifestyle education on maternal cardiovascular health (CVH) and vascular function following HDP.

METHODS

The Intensive Postpartum Antihypertensive Treatment (IPAT) study is a randomized controlled, two-arm, single-site, pilot trial where 60 postpartum HDP patients will be randomized 1:1 to one of two groups: 1) Intensive postpartum BP control - nifedipine initiation at BP ≥140/90 mmHg to maintain BP <140/90 mmHg; or 2) Less intensive postpartum BP control - nifedipine initiation at BP ≥150/100 mmHg to maintain BP <150/100 mmHg. All participants will also undergo vascular function assessments and receive healthy lifestyle education. The study will primarily test feasibility of all study procedures. It will secondarily examine changes in BP and CVH scores from baseline to 12 months postpartum.

CONCLUSION

This pilot trial will study whether the BP threshold of 140/90 is superior to 150/100 for initiation of pharmacotherapy and evaluate feasibility to ultimately conduct a trial capable of generating robust evidence to standardize clinical practice and guidelines in postpartum HDP management.

TRIAL REGISTRATION NUMBER

NCT05687344.

Clinical Likelihood Prediction of Hemodynamically Obstructive Coronary Artery Disease in Patients With Stable Chest Pain

BACKGROUND

Selection for invasive angiography is recommended to be based on pretest probabilities (PTPs), and physiological measures of hemodynamical impairment by, for example, fractional flow reserve (FFR) should guide revascularization. The risk factor-weighted clinical likelihood (RF-CL) and coronary artery calcium score-weighted clinical likelihood (CACS-CL) models show superior discrimination of patients with suspected obstructive coronary artery disease (CAD), but validation against hemodynamic impairment is warranted.

OBJECTIVES

The aim of this study was to validate the RF-CL and CACS-CL models against hemodynamically obstructive CAD.

METHODS

Stable de novo chest pain patients (N = 4,371) underwent coronary computed tomography angiography and subsequently invasive coronary angiography with FFR measurements. Hemodynamically obstructive CAD was defined as invasive FFR ≤0.80 or high-grade stenosis by visual assessment (>90% diameter stenosis). For comparison, a guideline-endorsed basic PTP model was calculated based on age, sex, and symptom typicality. The RF-CL model additionally included the number of risk factors, and the CACS-CL model incorporated the coronary artery calcium score into the RF-CL.

RESULTS

In total, 447 of 4,371 (10.9%) patients had hemodynamically obstructive CAD. Both the RF-CL and CACS-CL models classified more patients with a very low clinical likelihood (≤5%) of obstructive CAD compared to the basic PTP model (33.0% and 53.7% vs 12.0%; P < 0.001) with a preserved low prevalence of hemodynamically obstructive CAD (<5% for all models). Against hemodynamically obstructive CAD, calibration and discrimination of the RF-CL and CACS-CL models were superior to the basic PTP model.

CONCLUSIONS

The RF-CL and CACS-CL models are well calibrated and superior to a currently recommended basic PTP model to predict hemodynamically obstructive CAD. (Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease [Dan-NICAD]; NCT02264717; Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 2 [Dan-NICAD 2]; NCT03481712, Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 3 [Dan-NICAD 3]; NCT04707859).

Low-dose aspirin, maternal cardiometabolic health, and offspring respiratory health 9 to 14 years after delivery: Findings from the EAGeR Follow-up Study

BACKGROUND

Accumulating evidence shows that peri-conceptional and in-utero exposures have lifetime health impacts for mothers and their offspring.

OBJECTIVES

We conducted a Follow-Up Study of the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial with two objectives. First, we determined if women who enrolled at the Utah site (N = 1001) of the EAGeR trial (2007-2011, N = 1228) could successfully be contacted and agree to complete an online questionnaire on their reproductive, cardio-metabolic, and offspring respiratory health 9-14 years after original enrollment. Second, we evaluated if maternal exposure to low-dose aspirin (LDA) during pregnancy was associated with maternal cardio-metabolic health and offspring respiratory health.

METHODS

The original EAGeR study population included women, 18-40 years of age, who had 1-2 prior pregnancy losses, and who were trying to become pregnant. At follow-up (2020-2021), participants from the Utah cohort completed a 13-item online questionnaire on reproductive and cardio-metabolic health, and those who had a live birth during EAGeR additionally completed a 7-item questionnaire on the index child's respiratory health. Primary maternal outcomes included hypertension and hypercholesterolemia; primary offspring outcomes included wheezing and asthma.

RESULTS

Sixty-eight percent (n = 678) of participants enrolled in the follow-up study, with 10% and 15% reporting maternal hypertension and hypercholesterolemia, respectively; and 18% and 10% reporting offspring wheezing and asthma. We found no association between maternal LDA exposure and hypertension (risk difference [RD] -0.001, 95% confidence interval [CI] -0.05, 0.04) or hypercholesterolemia (RD -0.01, 95% CI -0.06, 0.05) at 9-14 years follow-up. Maternal LDA exposure was not associated with offspring wheezing (RD -0.002, 95% CI -0.08, 0.08) or asthma (RD 0.13, 95% CI 0.11, 0.37) at follow-up. Findings remained robust after considering potential confounding and selection bias.

CONCLUSIONS

We observed no association between LDA exposure during pregnancy and maternal cardiometabolic or offspring respiratory health.

Estimating uncertainty when providing individual cardiovascular risk predictions: a Bayesian survival analysis

BACKGROUND

Cardiovascular disease (CVD) risk scores provide point estimates of individual risk without uncertainty quantification. The objective of the current study was to demonstrate the feasibility and clinical utility of calculating uncertainty surrounding individual CVD-risk predictions using Bayesian methods.

STUDY DESIGN AND SETTING

Individuals with established atherosclerotic CVD were included from the Utrecht Cardiovascular Cohort-Secondary Manifestations of ARTerial disease (UCC-SMART). In 8,355 individuals, followed for median of 8.2 years (IQR 4.2-12.5), a Bayesian Weibull model was derived to predict the 10-year risk of recurrent CVD events.

RESULTS

Model coefficients and individual predictions from the Bayesian model were very similar to that of a traditional ('frequentist') model but the Bayesian model also predicted 95% credible intervals (CIs) surrounding individual risk estimates. The median width of the individual 95%CrI was 5.3% (IQR 3.6-6.5) and 17% of the population had a 95%CrI width of 10% or greater. The uncertainty decreased with increasing sample size used for derivation of the model. Combining the Bayesian Weibull model with sampled hazard ratios based on trial reports may be used to estimate individual estimates of absolute risk reduction with uncertainty measures and the probability that a treatment option will result in a clinically relevant risk reduction.

CONCLUSION

Estimating uncertainty surrounding individual CVD risk predictions using Bayesian methods is feasible. The uncertainty regarding individual risk predictions could have several applications in clinical practice, like the comparison of different treatment options or by calculating the probability of the individual risk being below a certain treatment threshold. However, as the individual uncertainty measures only reflect sampling error and no biases in risk prediction, physicians should be familiar with the interpretation before widespread clinical adaption.

Evaluating a New Digital App-Based Program for Heart Health: Feasibility and Acceptability Pilot Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States, affecting a significant proportion of adults. Digital health lifestyle change programs have emerged as a promising method of CVD prevention, offering benefits such as on-demand support, lower cost, and increased scalability. Prior research has shown the effectiveness of digital health interventions in reducing negative CVD outcomes. This pilot study focuses on the Lark Heart Health program, a fully digital artificial intelligence (AI)-powered smartphone app, providing synchronous CVD risk counseling, educational content, and personalized coaching.

OBJECTIVE

This pilot study evaluated the feasibility and acceptability of a fully digital AI-powered lifestyle change program called Lark Heart Health. Primary analyses assessed (1) participant satisfaction, (2) engagement with the program, and (3) the submission of health screeners. Secondary analyses were conducted to evaluate weight loss outcomes, given that a major focus of the Heart Health program is weight management.

METHODS

This study enrolled 509 participants in the 90-day real-world single-arm pilot study of the Heart Health app. Participants engaged with the app by participating in coaching conversations, logging meals, tracking weight, and completing educational lessons. The study outcomes included participant satisfaction, app engagement, the completion of screeners, and weight loss.

RESULTS

On average, Heart Health study participants were aged 60.9 (SD 10.3; range 40-75) years, with average BMI indicating class I obesity. Of the 509 participants, 489 (96.1%) stayed enrolled until the end of the study (dropout rate: 3.9%). Study retention, based on providing a weight measurement during month 3, was 80% (407/509; 95% CI 76.2%-83.4%). Participant satisfaction scores indicated high satisfaction with the overall app experience, with an average score of ≥4 out of 5 for all satisfaction indicators. Participants also showed high engagement with the app, with 83.4% (408/489; 95% CI 80.1%-86.7%) of the sample engaging in ≥5 coaching conversations in month 3. The results indicated that participants were successfully able to submit health screeners within the app, with 90% (440/489; 95% CI 87%-92.5%) submitting all 3 screeners measured in the study. Finally, secondary analyses showed that participants lost weight during the program, with analyses showing an average weight nadir of 3.8% (SD 2.9%; 95% CI 3.5%-4.1%).

CONCLUSIONS

The study results indicate that participants in this study were satisfied with their experience using the Heart Health app, highly engaged with the app features, and willing and able to complete health screening surveys in the app. These acceptability and feasibility results provide a key first step in the process of evidence generation for a new AI-powered digital program for heart health. Future work can expand these results to test outcomes with a commercial version of the Heart Health app in a diverse real-world sample.

Evolving mechanisms and presentations of cardiovascular disease in people with HIV: implications for management

People with HIV (PWH) are at elevated risk for cardiovascular diseases (CVDs), including myocardial infarction, heart failure, and sudden cardiac death, among other CVD manifestations. Chronic immune dysregulation resulting in persistent inflammation is common among PWH, particularly those with sustained viremia and impaired CD4+ T cell recovery. This inflammatory milieu is a major contributor to CVDs among PWH, in concert with common comorbidities (such as dyslipidemia and smoking) and, to a lesser extent, off-target effects of antiretroviral therapy. In this review, we discuss the clinical and mechanistic evidence surrounding heightened CVD risks among PWH, implications for specific CVD manifestations, and practical guidance for management in the setting of evolving data.

The Causal-Benefit Model to Prevent Cardiovascular Events

Selecting individuals for preventive lipid-lowering therapy is presently governed by the 10-year risk model. Once a prespecified level of cardiovascular disease risk is equaled or exceeded, individuals become eligible for preventive lipid-lowering therapy. A key limitation of this model is that only a small minority of individuals below the age of 65 years are eligible for therapy. However, just under one-half of all cardiovascular disease events occur below this age. Additionally, in many, the disease that caused their events after 65 years of age developed and progressed before 65 years of age. The causal-benefit model of prevention identifies individuals based both on their risk and the estimated benefit from lowering atherogenic apoB lipoprotein levels. Adopting the causal-benefit model would increase the number of younger subjects eligible for preventive treatment, would increase the total number of cardiovascular disease events prevented at virtually the same number to treat, and would be cost-effective.

Assessment of osteoprotegerin and RANKL levels and several cardiovascular risk scoring systems in acromegaly

PURPOSE

The OPG/RANKL (osteoprotegerin/receptor activator of nuclear factor kappa-B) system, which plays a crucial role in bone metabolism, is also associated with vascular calcification. Acromegaly is characterized by excessive secretion of growth hormone and insulin-like growth factor, and studies have demonstrated an elevated risk of cardiovascular disease in individuals with acromegaly. In this study, our objective was to investigate the relationship between OPG/RANKL and various cardiovascular risk scoring systems.

METHODS

We recruited 44 consecutive acromegaly patients and 41 healthy controls with a similar age and gender distribution for this study.

RESULTS

While RANKL levels were significantly higher in the acromegaly group compared to the controls, OPG levels were not found to be significantly different between the two groups. Furthermore, within the acromegaly group, RANKL levels were significantly higher in patients with active acromegaly compared to those with controlled acromegaly. Osteoprotegerin levels showed a positive correlation with the Framingham risk score (FRS) in the acromegaly group. Linear regression analysis revealed an association of OPG with FRS (adjusted R2 value of 21.7%).

CONCLUSION

OPG and RANKL may serve as potential markers for assessment of cardiovascular calcification and prediction of the cardiovascular risk status in acromegalic patients.

Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial

Importance

The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown.

Objective

To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years.

Design, Setting, and Participants

This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018.

Intervention

Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%).

Main Outcomes and Measures

Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021.

Results

High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85).

Conclusions and Relevance

The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04047147.

Predictors of program interest in a digital health pilot study for heart health

Digital health programs can play a key role in supporting lifestyle changes to prevent and reduce cardiovascular disease (CVD) risk. A key concern for new programs is understanding who is interested in participating. Thus, the primary objective of this study was to utilize electronic health records (EHR) to predict interest in a digital health app called Lark Heart Health. Because prior studies indicate that males are less likely to utilize prevention-focused digital health programs, secondary analyses assessed sex differences in recruitment and enrollment. Data were drawn from an ongoing pilot study of the Heart Health program, which provides digital health behavior coaching and surveys for CVD prevention. EHR data were used to predict whether potential program participants who received a study recruitment email showed interest in the program by "clicking through" on the email to learn more. Primary objective analyses used backward elimination regression and eXtreme Gradient Boost modeling. Recruitment emails were sent to 8,649 patients with available EHR data; 1,092 showed interest (i.e., clicked through) and 345 chose to participate in the study. EHR variables that predicted higher odds of showing interest were higher body mass index (BMI), fewer elevated lab values, lower HbA1c, non-smoking status, and identifying as White. Secondary objective analyses showed that, males and females showed similar program interest and were equally represented throughout recruitment and enrollment. In summary, BMI, elevated lab values, HbA1c, smoking status, and race emerged as key predictors of program interest; conversely, sex, age, CVD history, history of chronic health issues, and medication use did not predict program interest. We also found no sex differences in the recruitment and enrollment process for this program. These insights can aid in refining digital health tools to best serve those interested, as well as highlight groups who may benefit from behavioral intervention tools promoted by additional recruitment efforts tailored to their interest.

Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW

BACKGROUND

This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation.

DESIGN

We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey (n = 1,295); and (3) 10-year ASCVD risk prediction equations.

MEASURES

The primary outcome measure was 10-year ASCVD risk.

RESULTS

EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs.

CONCLUSION

Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level.

A tool to help patients visualize ASCVD risk and the potential impact of risk-lowering interventions

Risk assessment is a fundamental step in the current approach to primary prevention of atherosclerotic cardiovascular disease (ASCVD). When considering pharmacotherapy for primary prevention of ASCVD, current prevention guidelines in the United States recommend the use of the pooled cohort equations (PCE) to assess 10-year ASCVD risk and begin the important process of shared decision-making between patients and clinicians. Clinicians should support patients in the decisionmaking process by turning raw data into information that is easily understood and more effectively utilized for decisions around the treatment plan. In this work, we present a tool to help patients visualize ASCVD risk and the projected impact of risk-lowering interventions. We believe this visual tool can facilitate communication of ASCVD risk to patients, and improve patient understanding of risk and the potential impact of risklowering interventions, which we believe may help patients make more informed, empowered decisions that achieve greater risk reduction.

Association of left ventricular abnormalities with incident cerebrovascular events and sources of thromboembolism in patients with chronic Chagas cardiomyopathy

BACKGROUND

Although Chagas cardiomyopathy is related to thromboembolic stroke, data on risk factors for cerebrovascular events in Chagas disease is limited. Thus, we assessed the relationship between left ventricular (LV) impairment and cerebrovascular events and sources of thromboembolism in patients with Chagas cardiomyopathy.

METHODS

This retrospective cohort included patients with chronic Chagas cardiomyopathy who underwent cardiovascular magnetic resonance (CMR). CMR was performed with a 1.5 T scanner to provide LV volumes, mass, ejection fraction (LVEF), and myocardial fibrosis. The primary outcome was a composite of incident ischemic cerebrovascular events (stroke or transient ischemic attack-TIA) and potential thromboembolic sources (atrial fibrillation (AF), atrial flutter, or intracavitary thrombus) during the follow-up.

RESULTS

A total of 113 patients were included. Median age was 56 years (IQR: 45-67), and 58 (51%) were women. The median LVEF was 53% (IQR: 41-62). LV aneurysms and LV fibrosis were present in 38 (34%) and 76 (67%) individuals, respectively. The median follow-up time was 6.9 years, with 29 events: 11 cerebrovascular events, 16 had AF or atrial flutter, and two had LV apical thrombosis. In the multivariable model, only lower LVEF remained significantly associated with the outcomes (HR: 0.96, 95% CI: 0.93-0.99). Patients with reduced LVEF lower than 40% had a much higher risk of cerebrovascular events and thromboembolic sources (HR: 3.16 95% CI: 1.38-7.25) than those with normal LVEF. The combined incidence rate of the combined events in chronic Chagas cardiomyopathy patients with reduced LVEF was 13.9 new cases per 100 persons-year.

CONCLUSIONS

LV systolic dysfunction is an independent predictor of adverse cerebrovascular events and potential sources of thromboembolism in patients with chronic Chagas cardiomyopathy.

Atherosclerotic risk is associated with cerebral perfusion - A cross-sectional study using arterial spin labeling MRI

BACKGROUND

Arterial spin labeling (ASL) magnetic resonance imaging (MRI) may be a promising technique to evaluate the presence of cerebral atherosclerosis. We tested whether the new and easily calculated ASL MRI parameter for vascular and tissue signal distribution - 'spatial coefficient of variation' (ASL-sCoV) - is a better radiological marker for atherosclerotic risk than the more conventional markers of white matter hyperintensity (WMH) volume and cerebral blood flow (ASL-CBF).

METHODS

Participants of the preDIVA trial (n = 195), aged 72-80 years with systolic hypertension (>140 mmHg) underwent two MRI scans two to three years apart. WMH volume was derived from 3D FLAIR-MRI; gray matter ASL-CBF and ASL-sCoV from ASL-MRI. Atherosclerotic risk was operationalized as 10-year cardiovascular risk by the Systematic COronary Risk Evaluation Older Persons (SCORE O.P) and calculated at baseline and follow-up. Data were analyzed using linear regression.

RESULTS

ASL-CBF was associated with atherosclerotic risk scores at baseline (standardized-beta = -0.26, 95 %CI = -0.40 to -0.13, p < 0.001) but not at follow-up (standardized-beta = -0.14, 95 %CI = -0.33 to 0.04, p = 0.12). ASL-sCoV was associated with atherosclerotic risk scores at both time points (baseline standardized-beta = 0.23, 95 %CI = 0.10 to 0.36, p < 0.0001, follow-up standardized beta = 0.20, 95 %CI = 0.03 to 0.36, p = 0.02). WMH volume was not associated with atherosclerotic risk scores at either time-point. There were no longitudinal associations between changes in MRI parameters and baseline atherosclerotic risk scores.

CONCLUSIONS

Our findings suggest that ASL-sCoV correlates better with atherosclerotic risk than the more conventional markers ASL-CBF and WMH volume. Our data reaffirm that non-invasive imaging with MRI is highly informative and could provide additional information about cerebrovascular damage.

The Profile of Circulating Blood microRNAs in Outpatients with Vulnerable and Stable Atherosclerotic Plaques: Associations with Cardiovascular Risks

Non-coding RNAs reflect many biological processes in the human body, including athero-sclerosis. In a cardiology outpatient department cohort (N = 83), we aimed to compare the levels of circulating microRNAs in groups with vulnerable plaques (N = 22), stable plaques (N = 23) and plaque-free (N = 17) depending on coronary computed tomography angiography and to evaluate associations of microRNA levels with calculated cardiovascular risks (CVR), based on the SCORE2 (+OP), ACC/AHA, ATP-III and MESA scales. Coronary computed tomography was performed on a 640-slice computed tomography scanner. Relative plasma levels of microRNA were assessed via a real-time polymerase chain reaction. We found significant differences in miR-143-3p levels (p = 0.0046 in plaque-free vs. vulnerable plaque groups) and miR-181b-5p (p = 0.0179 in stable vs. vulnerable plaques groups). Analysis of microRNA associations with CVR did not show significant differences for SCORE2 (+OP) and ATPIII scales. MiR-126-5p and miR-150-5p levels were significantly higher (p < 0.05) in patients with ACC/AHA risk >10% and miR-145-5p had linear relationships with ACC/AHA score (adjusted p = 0.0164). The relative plasma level of miR-195 was higher (p < 0.05) in patients with MESA risk > 7.5% and higher (p < 0.05) in patients with zero coronary calcium index (p = 0.036). A linear relationship with coronary calcium was observed for miR-126-3p (adjusted p = 0.0484). A positive correlation with high coronary calcium levels (> 100 Agatson units) was found for miR-181-5p (p = 0.036). Analyzing the biological pathways of these microRNAs, we suggest that miR-143-3p and miR-181-5p can be potential markers of the atherosclerosis process. Other miRNAs (miR-126-3p, 126-5p, 145-5p, 150-5p, 195-5p) can be considered as potential cardiovascular risk modifiers, but it is necessary to validate our results in a large prospective trial.

Cardiovascular Disease Risk Modeling for Astronauts: Making the Leap From Earth to Space

NASA has recently completed several long-duration missions to the International Space Station and is solidifying plans to return to the Moon, with an eye toward Mars and beyond. As NASA pushes the boundaries of human space exploration, the hazards of spaceflight, including space radiation, levy an increasing burden on astronaut health and performance. The cardiovascular system may be especially vulnerable due to the combined impacts of space radiation exposure, lack of gravity, and other spaceflight hazards. On Earth, the risk for cardiovascular disease (CVD) following moderate to high radiation doses is well-established from clinical, environmental, and occupational exposures (largely from gamma- and x-rays). Less is known about CVD risks associated with high-energy charged ions found in space and increasingly used in radiotherapy applications on Earth, making this a critical area of investigation for occupational radiation protection. Assessing CVD risk is complicated by its multifactorial nature, where an individual's risk is strongly influenced by factors such as family history, blood pressure, and lipid profiles. These known risk factors provide the basis for development of a variety of clinical risk prediction models (CPMs) that inform the likelihood of medical outcomes over a defined period. These tools improve clinical decision-making, personalize care, and support primary prevention of CVD. They may also be useful for individualizing risk estimates for CVD following radiation exposure both in the clinic and in space. In this review, we summarize unique aspects of radiation risk assessment for astronauts, and we evaluate the most widely used CVD CPMs for their use in NASA radiation risk assessment applications. We describe a comprehensive dual-use risk assessment framework that supports both clinical care and operational management of space radiation health risks using quantitative metrics. This approach is a first step in using personalized medicine for radiation risk assessment to support safe and productive spaceflight and long-term quality of life for NASA astronauts.

Cardiovascular Risk in Patients With Takayasu Arteritis Directly Correlates With Diastolic Dysfunction and Inflammatory Cell Infiltration in the Vessel Wall: A Clinical, ex vivo and in vitro Analysis

Background

Takayasu Arteritis (TAK) increases vascular stiffness and arterial resistance. Atherosclerosis leads to similar changes. We investigated possible differences in cardiovascular remodeling between these diseases and whether the differences are correlated with immune cell expression.

Methods

Patients with active TAK arteritis were compared with age- and sex-matched atherosclerotic patients (Controls). In a subpopulation of TAK patients, Treg/Th17 cells were measured before (T0) and after 18 months (T18) of infliximab treatment. Echocardiogram, supraaortic Doppler ultrasound, and lymphocytogram were performed in all patients. Histological and immunohistochemical changes of the vessel wall were evaluated as well.

Results

TAK patients have increased aortic valve dysfunction and diastolic dysfunction. The degree of dysfunction appears associated with uric acid levels. A significant increase in aortic stiffness was also observed and associated with levels of peripheral T lymphocytes. CD3+ CD4+ cell infiltrates were detected in the vessel wall samples of TAK patients, whose mean percentage of Tregs was lower than Controls at T0, but increased significantly at T18. Opposite behavior was observed for Th17 cells. Finally, TAK patients were found to have an increased risk of atherosclerotic cardiovascular disease (ASCVD).

Conclusion

Our data suggest that different pathogenic mechanisms underlie vessel damage, including atherosclerosis, in TAK patients compared with Controls. The increased risk of ASCVD in TAK patients correlates directly with the degree of inflammatory cell infiltration in the vessel wall. Infliximab restores the normal frequency of Tregs/Th17 in TAK patients and allows a possible reduction of steroids and immunosuppressants.

Influence of shift work on cardiovascular disease risk in Southern African long-distance truck drivers: a cross-sectional study

OBJECTIVES

Cardiovascular disease (CVD) is a major problem globally. Truck drivers have an increased risk of CVD due to a sedentary lifestyle, irregular working hours and behavioural choices. We aimed to get insight into the contribution of night shift work to CVD risk in long-distance truck drivers in South Africa.

DESIGN

A cross-sectional study.

SETTING

Enrolment took place at three South African truck stop locations in two provinces; Bloemfontein (Free State), Pomona Road (Gauteng) and Soweto (Gauteng).

PARTICIPANTS

607 males aged ≥18 years with full-time employment as a long-distance truck driver were included. The criteria for inclusion were willingness and being able to provide informed consent and to complete the study procedures.

PRIMARY AND SECONDARY OUTCOME MEASURES

Information was collected on sociodemographics, occupational and health characteristics. Physical measurements, an ECG and carotid intima-media thickness (CIMT) measurements were taken. A night shift was defined as working at least 3 hours between 22:00 and 6:00 hours once a week. CVD risk was defined with the Framingham Risk Score (FRS), the Atherosclerotic Cardiovascular Disease (ASCVD) risk algorithm, left ventricular hypertrophy (LVH) and CIMT.

RESULTS

In total, 607 truck drivers were included of which 305 (50.2%) worked in day shifts only and 302 (49.8%) worked day and night shifts. There was a high prevalence of CVD risk factors in both groups as 33% were hypertensive, 28% obese and 37% had abnormal lipid levels. Working day and night shifts compared with working only day shifts did not result in differences in FRS, ASCVD risk or LVH. No difference was found in CIMT measurements, except for the maximum bulb thickness which was higher in day shift workers.

CONCLUSIONS

CVD risk factors are considerably present in male truck drivers in South Africa. CVD risk does not differ between dayshift and day-night shift workers in this cross-sectional analysis.

Reducing Cardiovascular Risk in the Medicare Million Hearts Risk Reduction Model: Insights From the National Cardiovascular Data Registry PINNACLE Registry

BACKGROUND

The Million Hearts Cardiovascular Disease Risk Reduction Model provides financial incentives for practices to lower 10-year atherosclerotic cardiovascular disease (ASCVD) risk for high-risk (ASCVD ≥30%) Medicare patients. To estimate average practice-level ASCVD risk reduction, we applied optimal trial outcomes to a real-world population with high ASCVD risk.

METHODS

This study uses observational registry data from the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence Registry from January 2013 to June 2016. We modeled ASCVD risk reductions using historical clinical trial data (reducing cholesterol by 26.5%, reducing systolic blood pressure by 10.9%, reducing smoking rates by 21.8%) the average reduction in ASCVD risk associated with individual and combined risk factor modifications, and then percentage of practices achieving the various incentive thresholds for the Million Hearts Model.

RESULTS

The final study population included 135 166 patients, with 16 248 (12.0%) with 10-year ASCVD risk of ≥30%, but without existing ASCVD. The mean 10-year ASCVD risk was 41.9% (±1 SD of 11.6). Using risk factor reductions from clinical trials, lowering cholesterol, blood pressure, and smoking rates reduced 10-year ASCVD risk by 3.3% (±3.1), 6.3% (±1.1) and 0.5% (±1.3), respectively. Combining all 3 reductions resulted in a 9.7% (±3.6) reduction, with 67 (27.0%) of practices achieving a patient-level average 10-year ASCVD risk reduction of ≥10%, 181 (73.0%) achieving a 2 to 10% reduction, and no practice achieving <2% reduction.

CONCLUSIONS

In cardiology practices, about 1 out of 8 patients have a 10-year ASCVD risk ≥30% and qualify as high risk in the Million Hearts Model. If practices target the three main modifiable risk factors and achieve reductions similar to clinical trial results, ASCVD risk could be substantially lowered and all practices could receive incentive payments. These findings support the potential benefit of the Million Hearts Model and provide guidance to participating practices.

Validating risk models versus age alone for atrial fibrillation in a young Dutch population cohort: should atrial fibrillation risk prediction be expanded to younger community members?

BACKGROUND

Advancing age is the primary selection criterion for community screening for atrial fibrillation (AF), with selection often restricted to those aged ≥65 years. If multivariable models were shown to have considerable additional value over age alone in predicting AF risk among younger individuals, AF screening could be expanded to patients with lower age, but with high AF risk as per a validated risk model.

METHODS

We validated risk models CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology model for AF) and FHS-AF (Framingham Heart Study model for AF), and risk scores CHA₂DS₂-VASc and CHA₂DS₂-VA, and presented their predictive abilities for 5-year and 10-year AF risk versus that of age alone in a young Dutch population cohort (PREVEND) free from AF at baseline. We assessed discrimination by the C-statistic and calibration by the calibration plot and stratified Kaplan-Meier plot using survey-weighted Cox models.

RESULTS

During 5-year and 10-year follow-up there were n=98 (2.46/1000 person-years) and n=249 (3.29/1000 person-years) new AF cases, respectively, among 8265 participants with mean age 49±13 years. CHARGE-AF and FHS-AF both showed good discrimination for 5-year and 10-year AF (C-statistic range 0.83-0.86) with accurate calibration for 5-year AF, but overestimation of 10-year AF risk in highest-risk individuals. CHA₂DS₂-VASc and CHA₂DS₂-VA relatively underperformed. Age alone showed similar discrimination to that of CHARGE-AF and FHS-AF both in the overall, young PREVEND cohort and in subgroups for lower age and lower stroke risk.

CONCLUSION

Multivariable models accurately discriminate for 5-year and 10-year AF risk among young European community-dwelling individuals. However, their additional discriminatory value over age alone was limited. Selection strategies for primary AF screening using multivariable models should not be expanded to younger individuals.

Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk

Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.

Psychosocial stressors predict lower cardiovascular disease risk among Mexican-American adults living in a high-risk community: Findings from the Texas City Stress and Health Study

The objective of this study was to examine the link between systemic and general psychosocial stress and cardiovascular disease (CVD) risk in a group of U.S. Latinos as a function of acculturation and education within the blended guiding conceptual framework of the biopsychosocial model of the stress process plus the reserve capacity model. We analyzed data from self-identifying Mexican-origin adults (n = 396, 56.9% female, Mage = 58.2 years, 55.5% < 12 years of education, 79% U.S.-born) from the Texas City Stress and Health Study. We used established measures of perceived stress (general stress), neighborhood stress and discrimination (systemic stress) to capture psychosocial stress, our primary predictor. We used the atherosclerotic CVD calculator to assess 10-year CVD risk, our primary outcome. This calculator uses demographics, cholesterol, blood pressure, and history of hypertension, smoking, and diabetes to compute CVD risk in the next 10 years. We also created an acculturation index using English-language use, childhood interaction, and preservation of cultural values. Participants reported years of education. Contrary to expectations, findings showed that higher levels of all three forms of psychosocial stress, perceived stress, neighborhood stress, and perceived discrimination, predicted lower 10-year CVD risk. Acculturation and education did not moderate the effects of psychosocial stress on 10-year CVD risk. Contextualized within the biopsychosocial and reserve capacity framework, we interpret our findings such that participants who accurately reported their stressors may have turned to their social networks to handle the stress, thereby reducing their risk for CVD. We highlight the importance of examining strengths within the sociocultural environment when considering cardiovascular inequities among Latinos.

Communicating personalised statin therapy-effects as 10-year CVD-risk or CVD-free life-expectancy: does it improve decisional conflict? Three-armed, blinded, randomised controlled trial

OBJECTIVE

To determine whether communicating personalised statin therapy-effects obtained by prognostic algorithm leads to lower decisional conflict associated with statin use in patients with stable cardiovascular disease (CVD) compared with standard (non-personalised) therapy-effects.

DESIGN

Hypothesis-blinded, three-armed randomised controlled trial SETTING AND PARTICIPANTS: 303 statin users with stable CVD enrolled in a cohort INTERVENTION: Participants were randomised in a 1:1:1 ratio to standard practice (control-group) or one of two intervention arms. Intervention arms received standard practice plus (1) a personalised health profile, (2) educational videos and (3) a structured telephone consultation. Intervention arms received personalised estimates of prognostic changes associated with both discontinuation of current statin and intensification to the most potent statin type and dose (ie, atorvastatin 80 mg). Intervention arms differed in how these changes were expressed: either change in individual 10-year absolute CVD risk (iAR-group) or CVD-free life-expectancy (iLE-group) calculated with the SMART-REACH model (http://U-Prevent.com).

OUTCOME

Primary outcome was patient decisional conflict score (DCS) after 1 month. The score varies from 0 (no conflict) to 100 (high conflict). Secondary outcomes were collected at 1 or 6 months: DCS, quality of life, illness perception, patient activation, patient perception of statin efficacy and shared decision-making, self-reported statin adherence, understanding of statin-therapy, post-randomisation low-density lipoprotein cholesterol level and physician opinion of the intervention. Outcomes are reported as median (25th- 75th percentile).

RESULTS

Decisional conflict differed between the intervention arms: median control 27 (20-43), iAR-group 22 (11-30; p-value vs control 0.001) and iLE-group 25 (10-31; p-value vs control 0.021). No differences in secondary outcomes were observed.

CONCLUSION

In patients with clinically manifest CVD, providing personalised estimations of treatment-effects resulted in a small but significant decrease in decisional conflict after 1 month. The results support the use of personalised predictions for supporting decision-making.

TRIAL REGISTRATION

NTR6227/NL6080.

Evaluating the association of social needs assessment data with cardiometabolic health status in a federally qualified community health center patient population

BACKGROUND

Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients' Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients' clinical condition.

METHODS

In this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management.

RESULTS

Social needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950).

CONCLUSIONS

Associations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance.

SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions

AIMS

The aim of this study was to derive and validate the SCORE2-Older Persons (SCORE2-OP) risk model to estimate 5- and 10-year risk of cardiovascular disease (CVD) in individuals aged over 70 years in four geographical risk regions.

METHODS AND RESULTS

Sex-specific competing risk-adjusted models for estimating CVD risk (CVD mortality, myocardial infarction, or stroke) were derived in individuals aged over 65 without pre-existing atherosclerotic CVD from the Cohort of Norway (28 503 individuals, 10 089 CVD events). Models included age, smoking status, diabetes, systolic blood pressure, and total- and high-density lipoprotein cholesterol. Four geographical risk regions were defined based on country-specific CVD mortality rates. Models were recalibrated to each region using region-specific estimated CVD incidence rates and risk factor distributions. For external validation, we analysed data from 6 additional study populations {338 615 individuals, 33 219 CVD validation cohorts, C-indices ranged between 0.63 [95% confidence interval (CI) 0.61-0.65] and 0.67 (0.64-0.69)}. Regional calibration of expected-vs.-observed risks was satisfactory. For given risk factor profiles, there was substantial variation across the four risk regions in the estimated 10-year CVD event risk.

CONCLUSIONS

The competing risk-adjusted SCORE2-OP model was derived, recalibrated, and externally validated to estimate 5- and 10-year CVD risk in older adults (aged 70 years or older) in four geographical risk regions. These models can be used for communicating the risk of CVD and potential benefit from risk factor treatment and may facilitate shared decision-making between clinicians and patients in CVD risk management in older persons.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Ursodeoxycholic acid as a means of preventing atherosclerosis, steatosis and liver fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality in patients with nonalcoholic fatty liver disease (NAFLD). Weight loss is a key factor for successful NAFLD and CVD therapy. Ursodeoxycholic acid (UDCA), which is one of the first-line therapeutic agents for treatment of NAFLD, is reported to have a beneficial effect on dyslipidemia and ASCVD risk because of antioxidant properties.

AIM

To evaluate the effects of 6 mo of UDCA treatment on hepatic function tests, lipid profile, hepatic steatosis and fibrosis, atherogenesis, and ASCVD risk in men and women with NAFLD, as well as to assess the impact of > 5% weight reduction on these parameters.

METHODS

An open-label, multicenter, international noncomparative trial was carried out at primary health care settings and included 174 patients with ultrasound-diagnosed NAFLD who received 15 mg/kg/d UDCA for 6 mo and were prescribed lifestyle modification with diet and exercise. The efficacy criteria were liver enzymes, lipid profile, fatty liver index (FLI), noninvasive liver fibrosis tests (nonalcoholic fatty liver disease fibrosis score and liver fibrosis index), carotid intima-media thickness (CIMT), and ASCVD risk score. To test statistical hypotheses, the Wilcoxon test, paired t-test, Fisher's exact test, and Pearson's chi-squared test were used.

RESULTS

The alanine aminotransferase (ALT) level changed by -14.1 U/L (-31.0; -5.3) from baseline to 3 mo and by -6.5 U/L (-14.0; 0.1) from 3 to 6 mo. The magnitude of ALT, aspartate transaminase, and glutamyltransferase decrease was greater during the first 3 mo of treatment compared to the subsequent 3 mo (P < 0.001, P < 0.01, P < 0.001, respectively). At 6 mo, in the total sample, we observed a statistically significant decrease in body weight and levels of FLI: 84.9 ± 10.4 vs 72.3 ± 17.6, P < 0.001, total cholesterol: 6.03 ± 1.36 vs 5.76 ± 1.21, Р < 0.001, low-density lipoprotein: 3.86 ± 1.01 vs 3.66 ± 0.91, Р < 0.001, and triglyceride: 3.18 (2.00; 4.29) vs 2.04 (1.40; 3.16), Р < 0.001. No effect on nonalcoholic fatty liver disease fibrosis score or liver fibrosis index was found. The CIMT decreased significantly in the total sample (0.985 ± 0.243 vs 0.968 ± 0.237, P = 0.013), whereas the high-density lipoprotein (Р = 0.036) and 10-year ASCVD risk (Р = 0.003) improved significantly only in women. Fifty-four patients (31%) achieved > 5% weight loss. At the end of the study, the FLI decreased significantly in patients with (88.3 ± 10.2 vs 71.4 ± 19.6, P < 0.001) and without > 5% weight loss (83.5 ± 10.3 vs 72.8 ± 16.7, P < 0.001). The changes in ALT, aspartate transaminase, glutamyltransferase, total cholesterol, and low-density lipoprotein levels were similar between the subgroups.

CONCLUSION

UDCA normalizes liver enzymes greatly within the first 3 mo of treatment, improves lipid profile and hepatic steatosis independent of weight loss, and has a positive effect on CIMT in the total sample and 10-year ASCVD risk in women after 6 mo of treatment.

Association of Cumulative Systolic Blood Pressure With Long-Term Risk of Cardiovascular Disease and Healthy Longevity: Findings From the Lifetime Risk Pooling Project Cohorts

Hypertension is a major risk factor for cardiovascular disease (CVD), but previous studies have mostly been limited to a single exam, a single cohort, a short follow-up period, or a limited number of outcomes. This study aimed to assess the association of 10-year cumulative systolic blood pressure (BP) in middle age with long-term risk of any CVD, coronary heart disease, stroke, heart failure, all-cause mortality, and healthy longevity. Individuals (11 502) from 5 racially/ethnically diverse US community-based cohorts were included in this study once they met all the inclusion criteria: ≥10 year of observation in the included cohort, aged 45 to 60 years, free of CVD, and had ≥3 visits with BP exams over the preceding 10 years. For each participant, systolic BP level was predicted for each year of the 10-year prior inclusion, based on the available exams (median of 4.0; spread over, 9.1 [range, 7.2-10] years). Lower 10-year cumulative systolic BP was associated with 4.1 years longer survival and 5.4 years later onset of CVD, resulting in living longer life with a shorter period with morbidity. Models adjusted for sociodemographic characteristics, cardiovascular risk factors, and index systolic BP demonstrated associations of 10-year cumulative systolic BP (per 130 mm Hg×year change, the threshold for stage-1 hypertension) with CVD (hazard ratio [HR], 1.28 [95% CI, 1.20-1.36]), coronary heart disease (HR, 1.29 [95% CI, 1.19-1.40]), stroke (HR, 1.33 [95% CI, 1.20-1.47]), heart failure (HR, 1.12 [95% CI, 1.02-1.23]), and all-cause mortality (HR, 1.21 [95% CI, 1.14-1.29]). These findings emphasize the importance of 10-year cumulative systolic BP as a risk factor to CVD, above and beyond current systolic BP.

Mediterranean Personalized Diet Combined with Physical Activity Therapy for the Prevention of Cardiovascular Diseases in Italian Women

Cardiovascular diseases (CVDs) and inflammatory risk indexes are used to calculate the exposure to morbidity. Most of them are suggested by the American College of Cardiology/American Heart Association to predict the risk of CVDs diagnosis in primary prevention, instead of treating the ongoing pathology. Prevention starts from habit changes with the prescription of diet and physical activity (PA). The aim of the study is to investigate the effectiveness of a personalized Mediterranean Diet (MD) and a PA intervention, on the risk indexes Atherogenic Index of Plasma (AIP), Lipid Accumulation Product (LAP) and Fatty Liver Index (FLI) in a population of women at risk of CVDs with different pathological conditions. After treatment, patients achieved the best results in body composition (BC) and laboratory tests. The BC analysis showed a significant reduction of total body Fat Mass (FM). CVDs risk indexes significantly decreased, except for Neutrophil/Lymphocyte (NLR) and Platelet/Lymphocyte Ratios (PLR). The reduction of the CVDs indexes associated with lipid profile was linked to both weight and FM decrease. AIP and LAP were significantly reduced when losing fat mass and body weight, respectively. A personalized MD therapy plus a PA program led to body weight loss, BC remodelling and risk indexes reduction.

A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices

OBJECTIVE

To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices.

STUDY SETTING

A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018.

STUDY DESIGN

We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk-stratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention.

DATA COLLECTION/ EXTRACTION METHODS

Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry.

PRINCIPLE FINDINGS

ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions.

CONCLUSION

A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices. Registration: ClinicalTrials.Gov 15-0479.

Maternal cardiovascular disease risk factors as predictors of preterm birth in California: a case-control study

OBJECTIVE

To determine whether maternal cardiovascular disease (CVD) risk factors predict preterm birth.

DESIGN

Case control.

SETTING

California hospitals.

PARTICIPANTS

868 mothers with linked demographic information and biospecimens who delivered singleton births from July 2009 to December 2010.

METHODS

Logistic regression analysis was employed to calculate odds ratios for the associations between maternal CVD risk factors before and during pregnancy (including diabetes, hypertensive disorders and cholesterol levels) and preterm birth outcomes.

PRIMARY OUTCOME

Preterm delivery status.

RESULTS

Adjusting for the other maternal CVD risk factors of interest, all categories of hypertension led to increased odds of preterm birth, with the strongest magnitude observed in the pre-eclampsia group (adjusted OR (aOR), 13.49; 95% CI 6.01 to 30.27 for preterm birth; aOR, 10.62; 95% CI 4.58 to 24.60 for late preterm birth; aOR, 17.98; 95% CI 7.55 to 42.82 for early preterm birth) and chronic hypertension alone for early preterm birth (aOR, 4.58; 95% CI 1.40 to 15.05). Diabetes (types 1 and 2 and gestational) was also associated with threefold increased risk for preterm birth (aOR, 3.06; 95% CI 1.12 to 8.41). A significant and linear dose response was found between total and low-density lipoprotein (LDL) cholesterol and aORs for late and early preterm birth, with increasing cholesterol values associated with increased risk (likelihood χ2 differences of 8.422 and 8.019 for total cholesterol for late and early, and 9.169 and 10.896 for LDL for late and early, respectively). Receiver operating characteristic curves using these risk factors to predict late and early preterm birth produced C statistics of 0.601 and 0.686.

CONCLUSION

Traditional CVD risk factors are significantly associated with an increased risk of preterm birth; these findings reinforce the clinical importance of integrating obstetric and cardiovascular risk assessment across the healthcare continuum in women.

Statin use in patients with non-HMGCR idiopathic inflammatory myopathies: A retrospective study

Background

Statins are the most widely used lipid lowering therapies which reduce cardiovascular risk, but are associated with muscular adverse events (AEs). Idiopathic inflammatory myopathies (IIM) are autoimmune diseases of the muscle with higher risk of cardiovascular disease. More data is needed regarding statin safety in patients with intrinsic muscle disease such as IIM.

Hypothesis

Statins are tolerated in patients with IIM without leading to significant increase in muscular AEs.

Methods

Statin use was retrospectively examined in a longitudinal IIM cohort. Safety analysis included assessment of muscular and nonmuscular AEs by chart review. IIM patients receiving a statin during the cohort follow‐up period were matched to IIM patients not receiving a statin for comparative analysis of longitudinal outcomes.

Results

33/214 patients had a history of statin use. 63% started for primary prevention, while others were started for clinical ASCVD events, vascular surgery, IIM related heart failure, and cardiac transplantation. A high intensity statin was used in nine patients with non‐HMGCR myositis, and tolerated in 8/9 patients. Statin related muscular AE was noted in three patients. There were no cases of rhabdomyolysis, or statin related nonmuscular AEs in a median observation period of 5 years. In patients newly started on statins during cohort follow‐up (n = 7) there was no change in disease activity after statin initiation. Long term outcomes were not different between statin and nonstatin IIM control groups.

Conclusion

Statins were well tolerated in patients with non‐HMGCR positive IIM. Given the accelerated atherosclerotic risk in IIM patients, further prospective studies of statin safety in IIM patients are warranted.

Prediction of individualized lifetime benefit from cholesterol lowering, blood pressure lowering, antithrombotic therapy, and smoking cessation in apparently healthy people

AIMS

The benefit an individual can expect from preventive therapy varies based on risk-factor burden, competing risks, and treatment duration. We developed and validated the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model for the estimation of individual-level 10 years and lifetime treatment-effects of cholesterol lowering, blood pressure lowering, antithrombotic therapy, and smoking cessation in apparently healthy people.

METHODS AND RESULTS

Model development was conducted in the Multi-Ethnic Study of Atherosclerosis (n = 6715) using clinical predictors. The model consists of two complementary Fine and Gray competing-risk adjusted left-truncated subdistribution hazard functions: one for hard cardiovascular disease (CVD)-events, and one for non-CVD mortality. Therapy-effects were estimated by combining the functions with hazard ratios from preventive therapy trials. External validation was performed in the Atherosclerosis Risk in Communities (n = 9250), Heinz Nixdorf Recall (n = 4177), and the European Prospective Investigation into Cancer and Nutrition-Netherlands (n = 25 833), and Norfolk (n = 23 548) studies. Calibration of the LIFE-CVD model was good and c-statistics were 0.67-0.76. The output enables the comparison of short-term vs. long-term therapy-benefit. In two people aged 45 and 70 with otherwise identical risk-factors, the older patient has a greater 10-year absolute risk reduction (11.3% vs. 1.0%) but a smaller gain in life-years free of CVD (3.4 vs. 4.5 years) from the same therapy. The model was developed into an interactive online calculator available via www.U-Prevent.com.

CONCLUSION

The model can accurately estimate individual-level prognosis and treatment-effects in terms of improved 10-year risk, lifetime risk, and life-expectancy free of CVD. The model is easily accessible and can be used to facilitate personalized-medicine and doctor-patient communication.

ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research

Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.

Strengthening community-clinical linkages to reduce cardiovascular disease risk in rural NC: feasibility phase of the CHANGE study

BACKGROUND

Community Health Workers (CHW) are recommended for delivery of interventions to prevent cardiovascular disease, but there is insufficient evidence to guide implementation of CHW interventions in rural, medically underserved areas.

METHODS

Using a hybrid implementation-effectiveness design, we evaluated the implementation and effectiveness of an adapted, evidence-based cardiovascular disease risk reduction intervention among rural high-risk adults. CHWs at a community health center and local health department recruited, enrolled and counseled participants during 4 monthly home visits and 3 brief phone contacts. Participant data collection included pre- and post-intervention measurements of blood pressure, weight, and dietary and physical activity behaviors. We evaluated implementation with measures of intervention reach and delivery fidelity. Statistical analyses included descriptive statistics and paired t-tests.

RESULTS

Study participants (n = 105) had a mean age of 62 years and included 88% Non-Hispanic Blacks and 82% females. Recruitment strategies resulted in the enrollment of 38% of interested and eligible participants who received 80% of the planned intervention visits and phone contacts. Mean differences in pre-/post-intervention measures showed significant mean reductions in blood pressure (- 5.4 mmHg systolic, p = .006; - 2.3 mmHg diastolic, p = .04) and body weight (- 3.8 lb., p = .02). Self-reported dietary and physical activity behaviors also improved significantly.

CONCLUSION

This feasibility study demonstrated preliminary implementation and program effectiveness of a CHW-delivered intervention to reduce cardiovascular disease risk factors. Additionally, it identified areas for future refinements to strategies that strengthen community-clinical linkages with an integrated role of CHWs in rural health care delivery. If results from this feasibility study can be enhanced in a larger sample, there would be significant potential to positively impact the excess burden of chronic diseases that adversely impact rural, low-income, and medically underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03582696.

Reprint of: Impact of Lipids on Cardiovascular Health: JACC Health Promotion Series

People who maintain ideal cardiovascular heath have a low lifetime risk of cardiovascular disease. Therefore, encouraging people to achieve ideal cardiovascular health represents an important opportunity to improve the prevention of cardiovascular disease. However, preventing cardiovascular disease by promoting ideal cardiovascular health requires shifting the focus from treating disease after it develops to preventing cardiovascular events before they happen by slowing the progression of atherosclerosis. Because atherogenic lipoproteins play a central causal role in the initiation and progression of atherosclerosis, maintaining optimal lipid levels is necessary to achieve ideal cardiovascular health. This review describes the cumulative effect of lipid-carrying lipoproteins on the risk of cardiovascular disease, estimates the magnitude of the clinical benefit that can be achieved by maintaining optimal lipid levels, identifies the most effective timing for implementing strategies designed to achieve optimal lipid levels, and provides a clinical pathway to help people achieve the lipid levels necessary for ideal cardiovascular health.

Estimating individual lifetime benefit and bleeding risk of adding rivaroxaban to aspirin for patients with stable cardiovascular disease: results from the COMPASS trial

Aims 

Adding rivaroxaban to aspirin in patients with stable atherosclerotic disease reduces the recurrence of cardiovascular disease (CVD) but increases the risk of major bleeding. The aim of this study was to estimate the individual lifetime treatment benefit and harm of adding low-dose rivaroxaban to aspirin in patients with stable cardiovascular disease.

Methods and results 

Patients with established CVD from the COMPASS trial (n = 27 390) and SMART prospective cohort study (n = 8139) were used. Using the pre-existing lifetime SMART-REACH model for recurrent CVD, and a newly developed Fine and Gray competing risk-adjusted lifetime model for major bleeding, individual treatment effects from adding low-dose rivaroxaban to aspirin in patients with stable CVD were estimated, expressed in terms of (i) life-years free of stroke or myocardial infarction (MI) gained; and (ii) life-years free from major bleeding lost. Calibration of the SMART-REACH model for prediction of recurrent CVD events in the COMPASS study was good. The major bleeding risk model as derived in the COMPASS trial showed good external calibration in the SMART cohort. Predicted individual gain in life expectancy free of stroke or MI from added low-dose rivaroxaban had a median of 16 months (range 1–48 months), while predicted individualized lifetime lost in terms of major bleeding had a median of 2 months (range 0–20 months).

Conclusion 

There is a wide distribution in lifetime gain and harm from adding low-dose rivaroxaban to aspirin in individual patients with stable CVD. Using these lifetime models, benefits and bleeding risk can be weighed for each individual patient, which could facilitate treatment decisions in clinical practice.

Dynamic risk prediction for diabetes using biomarker change measurements

Background

Dynamic risk models, which incorporate disease-free survival and repeated measurements over time, might yield more accurate predictions of future health status compared to static models. The objective of this study was to develop and apply a dynamic prediction model to estimate the risk of developing type 2 diabetes mellitus.

Methods

Both a static prediction model and a dynamic landmark model were used to provide predictions of a 2-year horizon time for diabetes-free survival, updated at 1, 2, and 3 years post-baseline i.e., predicting diabetes-free survival to 2 years and predicting diabetes-free survival to 3 years, 4 years, and 5 years post-baseline, given the patient already survived past 1 year, 2 years, and 3 years post-baseline, respectively. Prediction accuracy was evaluated at each time point using robust non-parametric procedures. Data from 2057 participants of the Diabetes Prevention Program (DPP) study (1027 in metformin arm, 1030 in placebo arm) were analyzed.

Results

The dynamic landmark model demonstrated good prediction accuracy with area under curve (AUC) estimates ranging from 0.645 to 0.752 and Brier Score estimates ranging from 0.088 to 0.135. Relative to a static risk model, the dynamic landmark model did not significantly differ in terms of AUC but had significantly lower (i.e., better) Brier Score estimates for predictions at 1, 2, and 3 years (e.g. 0.167 versus 0.099; difference − 0.068 95% CI − 0.083 to − 0.053, at 3 years in placebo group) post-baseline.

Conclusions

Dynamic prediction models based on longitudinal, repeated risk factor measurements have the potential to improve the accuracy of future health status predictions.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0812-y) contains supplementary material, which is available to authorized users.

National Trends in Cessation Counseling, Prescription Medication Use, and Associated Costs Among US Adult Cigarette Smokers

IMPORTANCE

Cigarette smoking is the leading cause of preventable disease and death in the United States. When used separately or in combination, smoking cessation counseling and cessation medications have been associated with increased cessation rates.

OBJECTIVES

To present trends in self-reported receipt of physician advice to quit smoking and in use of prescription smoking cessation medication along with their associated expenditures among a nationally representative sample of active adult smokers in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study of US adults aged 18 years or older was conducted from July 5, 2018, through August 15, 2018. Data were collected between January 1, 2006, and December 31, 2015, from the Medical Expenditure Panel Survey, an annual US survey of individuals and families, health care personnel, and employers. Participants (n = 29 106) were noninstitutionalized civilians who were randomly drawn from the respondents of the previous year's National Health Interview Survey. Multivariable logistic regression models were used to examine the associations between sociodemographic factors and receipt of physician cessation advice and use of cessation prescription medication. A 2-part econometric model was used to assess health care expenditures.

MAIN OUTCOMES AND MEASURES

Trends in self-reported receipt of physician advice to quit and uptake of prescription smoking cessation medications with associated total and out-of-pocket expenditures.

RESULTS

The study sample consisted of 29 106 participants, with a mean (SD) age of 57 (10) years and a composition of 13 670 women (47.0%). The results were weighted to provide estimates for 31.2 million active adult cigarette smokers. The proportion of smokers who reported receiving physician advice to quit increased from 60.2% (95% CI, 58.5%-62.0%) in 2006 to 2007 to 64.9% (95% CI, 62.8%-66.9%) in 2014 to 2015, with a P for trend = .001. The odds of receiving physician cessation advice was statistically significantly higher in women (odds ratio [OR], 1.50; 95% CI, 1.39-1.59) and lower among uninsured participants (OR, 0.58; 95% CI, 0.52-0.65). Overall, prescription smoking cessation medication use decreased with a corresponding reduction in total expenditures from $146 million (out-of-pocket cost, $46 million) in 2006 to 2007 to $73 million (out-of-pocket cost, $9 million) in 2014 to 2015. Male (odds ratio [OR], 0.78; 95% CI, 0.66-0.91), uninsured (OR, 0.58; 95% CI, 0.41-0.83), and racial/ethnic minority (African American: OR, 0.51 [95% CI, 0.38-0.69]; Asian: OR, 0.31 [95% CI, 0.10-0.93]; Hispanic: OR, 0.53 [95% CI, 0.36-0.78]) participants were less likely to use prescription smoking cessation medications.

CONCLUSIONS AND RELEVANCE

The lower rates of delivery of physician advice to quit smoking and the lower uptake of known prescription smoking cessation medications among men, younger adults, uninsured individuals, racial/ethnic minority groups, and those without smoking-associated comorbidities may be associated with the higher smoking rates among these subgroups despite an all-time low prevalence of smoking in the United States; this finding calls for a more targeted implementation of smoking cessation guidelines.

A nomogram for the prediction of cerebrovascular disease among patients with brain necrosis after radiotherapy for nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

This study sought to develop and validate a nomogram to predict cerebrovascular disease (CVD) among patients with brain necrosis after radiotherapy for nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

A total of 346 eligible patients with brain necrosis after radiotherapy for NPC were divided into a training set (n = 231) and a validation set (n = 115). A multivariate Cox proportional hazards regression model was used to select the significant variables for CVD prediction in the training set. Then, a nomogram was developed based on the regression model. The performance of the nomogram was assessed with respect to discrimination and calibration. All patients were classified into high- or low-risk groups based on the risk scores derived from the nomogram. Moreover, a decision curve analysis was performed with the combined training and validation sets to evaluate the clinical usefulness of the nomogram.

RESULTS

Four significant predictors were identified: hypertension, statin treatment, serum level of high-density lipoprotein, and interval between radiotherapy and brain necrosis. The nomogram incorporating these four predictors showed favorable calibration and discrimination regarding the training set, with a C-index of 0.763 (95% CI, 0.694 to 0.832), which was confirmed using the validation set (C-index 0.768; 95% CI, 0.675 to 0.861). Furthermore, the nomogram successfully stratified patients into high- and low-risk groups. The decision curve indicated that our nomogram was clinically useful.

CONCLUSION

The nomogram showed favorable predictive accuracy for CVD among patients with brain necrosis after radiotherapy for NPC and might aid in clinical decision making.

General practitioners' reasoning on risk screening and primary prevention of stroke - a focus group study

BACKGROUND

By screening and modifying risk factors, stroke incidence can be reduced. Clinical guidelines states that primary prevention of stroke is a responsibility and task of primary health care, but research shows that this not always the case. The aim of the study was to explore and describe what characterizes GPs' reasoning around risk screening and primary prevention among persons at risk for stroke in primary health care.

METHODS

A qualitative design based in a grounded theory approach was chosen in order to investigate this unexplored research area. Data collection was done using focus group interviews and data was analysed using a constant comparative method. Twenty-two GPs were interviewed in four focus groups.

RESULTS

Findings showed that GPs perceived difficulties in prioritizing patients with an unhealthy lifestyle and described a lack of systematicity in their procedures, which complicated their clinical decisions concerning patients with stroke risk factors. The results showed a lack of systematic risk screening methods. Time constraints and the reimbursement system were described as hindering the preventive work.

CONCLUSION

There is a need for a more proactive, transparent and systematic approach in the distribution of GPs' time and reimbursement of prevention in primary health care. The findings suggest, by developing new methods and approaches such as digital clinical decision-making tools and by implementing inter-professional team-work, the quality of the primary prevention of stroke could be improved.

The prediction of therapy-benefit for individual cardiovascular disease prevention: rationale, implications, and implementation

PURPOSE OF REVIEW

We aim to outline the importance and the clinical implications of using predicted individual therapy-benefit in making patient-centered treatment decisions in cardiovascular disease (CVD) prevention. Therapy-benefit concepts will be illustrated with examples of patients undergoing lipid management.

RECENT FINDINGS

In both primary and secondary CVD prevention, the degree of variation in individual therapy-benefit is large. An individual's therapy-benefit can be estimated by combining prediction algorithms and clinical trial data. Measures of therapy-benefit can be easily integrated into clinical practice via a variety of online calculators. Lifetime estimates (e.g., gain in healthy life expectancy) look at therapy-benefit over the course of an individual's life, and are less influenced by age than short-term estimates (e.g., 10-year absolute risk reduction). Lifetime estimates can thus identify people who could substantially benefit from early initiation of CVD prevention. Compared with current guidelines, treatment based on predicted therapy-benefit would increase eligibility for therapy among young people with a moderate risk-factor burden and individuals with a high residual risk.

SUMMARY

The estimation of individual therapy-benefit is an important part of individualized medicine. Implementation tools allow for clinicians to readily estimate both short-term and lifetime therapy-benefit.

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current U.S. prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general U.S. clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (e.g., family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.

Use of a Metabolic Syndrome Severity Z Score to Track Risk During Treatment of Prediabetes: An Analysis of the Diabetes Prevention Program

OBJECTIVE

We assessed whether changes in metabolic syndrome (MetS) severity during the treatment of prediabetes are associated with reduced risk of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD).

RESEARCH DESIGN AND METHODS

We analyzed data from the Diabetes Prevention Program (DPP) for 2,476 adults in 1996-1999 with prediabetes randomized to receive treatment with lifestyle modification, metformin, or placebo for 2-3 years and followed through 2014 for T2DM and CVD outcomes. We calculated effect sizes from baseline in a MetS severity z score (MetS-Z) and the individual MetS components, and assessed relationships between 1-year effect size and incident T2DM and CVD using hazard ratios (HRs) and mediation analysis.

RESULTS

Baseline MetS-Z and its components were associated with risk of incident T2DM and CVD. During year 1 of intervention, MetS-Z and its components decreased most with lifestyle modification, followed by treatment with metformin and placebo. Risk of T2DM within 1-5 years was most strongly associated with 1-year changes in MetS-Z and waist circumference (both HRs for a 1 SD increase = 1.80), whereas the risk of CVD was associated with a 1-year change in MetS-Z, glucose, and systolic blood pressure. In mediation analyses, the effect of lifestyle modification on T2DM risk was mediated by 1-year changes in MetS-Z, waist circumference, glucose, and triglycerides, whereas the effect of metformin was mediated by MetS-Z and glucose.

CONCLUSIONS

Changes in these risk indicators of MetS severity during intervention in the DPP reflect altered disease risk and may help in tracking earlier responses to treatment and in motivating patients.

Medicare, Metrics and Trust in the Future

System improvements to Medicare are critical to ensure a stable and sustainable future. Measures and outcomes in Medicare are collaborative in foundation and have the potential to become even stronger. Utilization research, comparative effectiveness research and regulatory considerations must strive for best practice for the Medicare population. Government, regulatory, industry and academia should continue to work together for cost effective approaches that yield evidence-based interventions for positive health outcomes. Recommendations for improvements to the Medicare program are abundant and show strong potential to positively impact all of healthcare. These improvements will establish and maintain an even greater trust and positive view on what many consider a popular, vital social healthcare program in the U.S.

Unfavorable and favorable changes in modifiable risk factors and incidence of coronary heart disease: The Whitehall II cohort study

BACKGROUND

Few studies have examined long-term associations of unfavorable and favorable changes in vascular risk factors with incident coronary heart disease (CHD). We examined this issue in a middle-aged disease-free population.

METHODS

We used repeat data from the Whitehall II cohort study. Five biomedical, behavioral and psychosocial examinations of 8335 participants without CHD produced up to 20,357 person-observations to mimic a non-randomized pseudo-trial. After measurement of potential change in 6 risk factors twice (total cholesterol, blood pressure, smoking, overweight, psychological distress, problems in social relationships), a 5-year follow-up of CHD was undertaken.

RESULTS

Incidence of CHD was 7.4/1000 person-years. Increases from normal to high cholesterol (hazard ratio, HR = 1.59, 95% CI 1.26-2.00) and from normal to high blood pressure (HR = 1.64, 95% CI 1.33-2.03), as compared to remaining at the normal level, were associated with increased risk of CHD. In contrast, decreases from high to low levels of cholesterol (HR = 0.73, 95% CI 0.58-0.91), psychological distress (HR = 0.68, 95% CI 0.51-0.90), and problems in social relationships (HR = 0.65, 95% CI 0.50-0.85), and quitting smoking (HR = 0.49, 95% CI 0.29-0.82) were associated with a reduced CHD risk compared to remaining at high risk factor levels. The highest absolute risk was associated with persistent exposure to both high cholesterol and hypertension (incidence 18.1/1000 person-years) and smoking and overweight (incidence 17.7/1000 person-years).

CONCLUSIONS

While persistent exposures and changes in biological and behavioral risk factors relate to the greatest increases and reductions in 5-year risk of CHD, also favorable changes in psychosocial risk factors appear to reduce CHD risk.

Precision medicine screening using whole-genome sequencing and advanced imaging to identify disease risk in adults

Advances in technology are enabling evaluation for prevention and early detection of age-related chronic diseases associated with premature mortality, such as cancer and cardiovascular diseases. These diseases kill about one-third of men and one-quarter of women between the ages of 50 and 74 years old in the United States. We used whole-genome sequencing, advanced imaging, and other clinical testing to screen 209 active, symptom-free adults. We identified a broad set of complementary age-related chronic disease risks associated with premature mortality.

Reducing premature mortality associated with age-related chronic diseases, such as cancer and cardiovascular disease, is an urgent priority. We report early results using genomics in combination with advanced imaging and other clinical testing to proactively screen for age-related chronic disease risk among adults. We enrolled active, symptom-free adults in a study of screening for age-related chronic diseases associated with premature mortality. In addition to personal and family medical history and other clinical testing, we obtained whole-genome sequencing (WGS), noncontrast whole-body MRI, dual-energy X-ray absorptiometry (DXA), global metabolomics, a new blood test for prediabetes (Quantose IR), echocardiography (ECHO), ECG, and cardiac rhythm monitoring to identify age-related chronic disease risks. Precision medicine screening using WGS and advanced imaging along with other testing among active, symptom-free adults identified a broad set of complementary age-related chronic disease risks associated with premature mortality and strengthened WGS variant interpretation. This and other similarly designed screening approaches anchored by WGS and advanced imaging may have the potential to extend healthy life among active adults through improved prevention and early detection of age-related chronic diseases (and their risk factors) associated with premature mortality.