Systematic Coronary Risk Evaluation (SCORE): JACC Focus Seminar 4/8

Cardiovascular magnetic resonance reveals myocardial involvement in patients with active stage of inflammatory bowel disease

BACKGROUND

Active inflammatory bowel disease (A-IBD) but not remission (R-IBD) has been associated with an increased risk of cardiovascular death and hospitalization for heart failure.

OBJECTIVES

Using cardiovascular magnetic resonance (CMR), this study aims to assess adverse myocardial remodeling in patients with IBD in correlation with disease activity.

METHODS

Forty-four IBD patients without cardiovascular disease (24 female, median-age: 39.5 years, 26 A-IBD, 18 R-IBD) and 44 matched healthy volunteers (HV) were prospectively enrolled. The disease stage was determined by endoscopic and patient-reported criteria. Participants underwent CMR for cardiac phenotyping: cine imaging and strain analysis were performed to assess ventricular function. T1 mapping, extracellular volume and late-gadolinium enhanced images were obtained to assess focal and diffuse myocardial fibrosis. Simultaneous T1 and T2 elevation (T1 > 1049.3 ms, T2 > 54 ms) was considered to indicate a myocardial segment was inflamed.

RESULTS

16/44 (16.4%) IBD patients described dyspnea on exertion and 10/44 (22.7%) reported chest pain. A-IBD patients showed impaired ventricular function, indicated by reduced global circumferential and radial strain despite preserved left-ventricular ejection fraction. 16% of all IBD patients had focal fibrosis in a non-ischemic pattern. A-IDB patients had increased markers of diffuse left ventricular fibrosis (T1-values: A-IBD: 1022.0 ± 34.83 ms, R-IBD: 1010.10 ± 32.88 ms, HV: 990.61 ± 29.35 ms, p < .01). Significantly more participants with A-IDB (8/26, 30.8%) had at least one inflamed myocardial segment than patients in remission (0/18) and HV (1/44, 2.3%, p < .01). Markers of diffuse fibrosis correlated with disease activity.

CONCLUSION

This study, using CMR, provides evidence of myocardial involvement and patterns of adverse left ventricular remodeling in patients with IBD.

CLINICAL TRIAL REGISTRATION

ISRCTN30941346.

Cancer-associated thrombosis in hematologic malignancies

Patients with hematologic malignancies are often complicated not only by severe bleeding due to thrombocytopenia and disseminated intravascular coagulation but also by thromboembolic events, just like in patients with solid cancers, and these events can negatively impact patient outcomes. Nevertheless, the prevention and treatment of cancer-associated thrombosis (CAT) in hematologic malignancies has not been adequately investigated due to the limited size, heterogeneity, and unique pathophysiology of the patient population. This article summarizes the current understanding, risk factors, prediction models, and optimal prevention and treatment strategies of CAT in hematologic malignancies on a disease-by-disease basis, including acute leukemia, lymphoma, myeloma, and myeloproliferative neoplasms. Specific considerations of novel molecular targeted therapeutics introduced in recent years, such as immunomodulatory drugs and tyrosine kinase inhibitors, are also discussed based on the latest clinical trials.

Validation of SCORE2 on a sample from the Russian population and adaptation for the very high cardiovascular disease risk region

SCORE2 (Systematic COronary Risk Evaluation 2) is a risk assessment scale for cardiovascular events, presented in 2021 by the European Society of Cardiology. Both for training and validation of the SCORE2 model, representative samples from the Russian population were not used. Therefore, we aimed to validate SCORE2 on a such sample. For this purpose, we used a sample from the ESSE-RF epidemiological study consisting of 7251 participants aged 40-69 years without history of CVDs. We performed the validation by comparing SCORE2 risk estimates for ESSE-RF participants with the observed incidence of cardiovascular events in the study, adjusted for event information losses. The validation demonstrated that SCORE2 risk estimates were accurate for Russian men and inaccurate for Russian women. Together with the quantitative assessment of risk, SCORE2 offers its interpretation in terms of 10-year CVD risk group: low-moderate, high, and very high. For Russian men we considered the original interpretation of the SCORE2 estimates to be questionable because almost none of the men would be categorized as having "low-to-moderate" 10-year CVD risk. This problem would be typical for all countries of the very high CVD risk region. Therefore, we proposed a new interpretation of the SCORE2 risk estimates for men from the very high risk region. According to the proposed interpretation, the fraction of men in ESSE-RF in "low-to-moderate" 10-year CVD risk increased from 2% to 18% and the fraction of men in "very high" CVD risk decreased from 63% to 20% as compared to the original interpretation. The proposed interpretation would allow a more personalized approach to CVD treatment and optimize the burden on primary healthcare in the very high risk region countries.

Prediction of lifetime risk for cardiovascular disease, by risk factors level: the ATTICA epidemiological cohort study (2002-2022)

PURPOSE

We aimed to predict lifetime risk for cardiovascular disease (CVD).

METHODS

The sample consisted of 1988 participants with complete CVD data during the 20-year follow-up (50% men, 45 ± 14 years) of the ATTICA study. Lifetime risk for CVD was predicted at specific index ages (40, 50, and 60 years), based on the life-table method, with death free-of-CVD treated as a competing event.

RESULTS

718 participants experienced a fatal or nonfatal CVD event, corresponding to a crude CVD incidence of 36.1% (men: 40.2%, women: 32.1%, P-value < .001). Overall, women and men had similar lifetime CVD risk (P-value = .245); at index age of 40, the lifetime risk for CVD was 68% for men and 63% for women, with a progressive decline to 56% and 50% at the index age of 50, and to 55% for both men and women, at the index age of 60 years, respectively.

CONCLUSIONS

These results on lifetime risk for CVD can guide the allocation of resources to improve public health and preventive services, especially in ages below 50 years, in both men and women.

Bilateral Carotid Artery Molecular Calcification Assessed by [18F] Fluoride PET/CT: Correlation with Cardiovascular and Thromboembolic Risk Factors

Atherosclerosis, a leading cause of mortality and morbidity worldwide, involves inflammatory processes that result in plaque formation and calcification. The early detection of the molecular changes underlying these processes is crucial for effective disease management. This study utilized positron emission tomography/computed tomography (PET/CT) with [18F] sodium fluoride (NaF) as a tracer to visualize active calcification and inflammation at the molecular level. Our aim was to investigate the association between cardiovascular risk factors and [18F] NaF uptake in the left and right common carotid arteries (LCC and RCC). A cohort of 102 subjects, comprising both at-risk individuals and healthy controls, underwent [18F] NaF PET/CT imaging. The results revealed significant correlations between [18F] NaF uptake and cardiovascular risk factors such as age (β = 0.005, 95% CI 0.003-0.008, p < 0.01 in LCC and β = 0.006, 95% CI 0.004-0.009, p < 0.01 in RCC), male gender (β = -0.08, 95% CI -0.173--0.002, p = 0.04 in LCC and β = -0.13, 95% CI -0.21--0.06, p < 0.01 in RCC), BMI (β = 0.02, 95% CI 0.01-0.03, p < 0.01 in LCC and β = 0.02, 95% CI 0.01-0.03, p < 0.01 in RCC), fibrinogen (β = 0.006, 95% CI 0.0009-0.01, p = 0.02 in LCC and β = 0.005, 95% CI 0.001-0.01, p = 0.01), HDL cholesterol (β = 0.13, 95% CI 0.04-0.21, p < 0.01 in RCC only), and CRP (β = -0.01, 95% CI -0.02-0.001, p = 0.03 in RCC only). Subjects at risk showed a higher [18F] NaF uptake compared to healthy controls (one-way ANOVA; p = 0.02 in LCC and p = 0.04 in RCC), and uptake increased with estimated cardiovascular risk (one-way ANOVA, p < 0.01 in LCC only). These findings underscore the potential of [18F] NaF PET/CT as a sensitive tool for the early detection of atherosclerotic plaque, assessment of cardiovascular risk, and monitoring of disease progression. Further research is needed to validate the technique's predictive value and its potential impact on clinical outcomes.

General Factors That Reduce Cardiovascular Risk in People With Schizophrenia: A Systematic Review

BACKGROUND

The life expectancy of individuals with schizophrenia in the United States is 20% shorter than that of the general population owing to cardiovascular disease (CVD). It is crucial to identify the factors that reduce CVD risk in these individuals.

OBJECTIVE

In this systematic review, we examined the factors associated with CVD in people with schizophrenia.

METHODS

We searched 3 electronic databases for English articles published before April 2023. Investigators assessed the factors associated with 2 cardiovascular health outcomes among people with schizophrenia: the 10-year coronary heart disease (CHD)/CVD risk and peak oxygen uptake (VO2Peak/max).

RESULTS

We retrieved 17 studies from the search. Investigators examined factors affecting 10-year CHD/CVD risk in 11 studies and VO2Peak/max in 6 studies among people with schizophrenia. We found that individuals who had low metabolic symptoms (ie, hypertension and hyperglycemia), did not smoke, engaged in continuous CVD risk assessments, had a shorter duration of the diagnosis and hospitalization, and were of normal weight had a lower 10-year CHD/CVD risk. Furthermore, individuals who engaged in specific physical activity had a higher VO2Peak/max. Finally, those taking antipsychotic medications had a higher 10-year CHD/CVD risk and a lower VO2Peak/max.

CONCLUSIONS

The CVD risk factors observed in the general population are common among people with schizophrenia. When these risk factors are controlled, the 10-year CHD/CVD risk and VO2Peak/max of these individuals may be improved. Given the elevated CVD risk associated with antipsychotic medications, future researchers should examine modifying CVD risk factors to mitigate the additional risks associated with medication use in this population.

Impact of Social Support on Cardiovascular Risk Prediction Models: A Systematic Review

Cardiovascular diseases (CVD) stand as the primary causes of both mortality and morbidity on a global scale. Social factors such as low social support can increase the risk of developing heart diseases and have shown poor prognosis in cardiac patients. Resources such as PubMed and Google Scholar were searched using a boolean algorithm for articles published between 2003 and 2023. Eligible articles showed an association between social support and cardiovascular risks. A systematic review was conducted using the guidance published in the Cochrane Prognosis Method Group and the PRISMA checklist, for reviews of selected articles. A total of five studies were included in our final analysis. Overall, we found that participants with low social support developed cardiovascular events, and providing a good support system can decrease the risk of readmission in patients with a history of CVD. We also found that integrating social determinants in the cardiovascular risk prediction model showed improvement in accessing the risk. Population with good social support showed low mortality and decreased rate of readmission. There are various prediction models, but the social determinants are not primarily included while calculating the algorithms. Although it has been proven in multiple studies that including the social determinants of health (SDOH) improves the accuracy of cardiovascular risk prediction models. Hence, the inclusion of SDOH should be highly encouraged.

Added Predictive Value of Female-Specific Factors and Psychosocial Factors for the Risk of Stroke in Women Under 50

BACKGROUND AND OBJECTIVES

Female-specific factors and psychosocial factors may be important in the prediction of stroke but are not included in prediction models that are currently used. We investigated whether addition of these factors would improve the performance of prediction models for the risk of stroke in women younger than 50 years.

METHODS

We used data from the Stichting Informatievoorziening voor Zorg en Onderzoek, population-based, primary care database of women aged 20-49 years without a history of cardiovascular disease. Analyses were stratified by 10-year age intervals at cohort entry. Cox proportional hazards models to predict stroke risk were developed, including traditional cardiovascular factors, and compared with models that additionally included female-specific and psychosocial factors. We compared the risk models using the c-statistic and slope of the calibration curve at a follow-up of 10 years. We developed an age-specific stroke risk prediction tool that may help communicating the risk of stroke in clinical practice.

RESULTS

We included 409,026 women with a total of 3,990,185 person-years of follow-up. Stroke occurred in 2,751 women (incidence rate 6.9 [95% CI 6.6-7.2] per 10,000 person-years). Models with only traditional cardiovascular factors performed poorly to moderately in all age groups: 20-29 years: c-statistic: 0.617 (95% CI 0.592-0.639); 30-39 years: c-statistic: 0.615 (95% CI 0.596-0.634); and 40-49 years: c-statistic: 0.585 (95% CI 0.573-0.597). After adding the female-specific and psychosocial risk factors to the reference models, the model discrimination increased moderately, especially in the age groups 30-39 (Δc-statistic: 0.019) and 40-49 years (Δc-statistic: 0.029) compared with the reference models, respectively.

DISCUSSION

The addition of female-specific factors and psychosocial risk factors improves the discriminatory performance of prediction models for stroke in women younger than 50 years.

The predictive role of laboratory parameters in cardiovascular risk assessment in obese

The significance of cardiovascular diseases in mortality is indisputable. It is well-established that cardiovascular diseases are more prevalent among individuals with obesity. This study aimed to determine the predictive value of easily accessible hematological and biochemical parameters in assessing cardiovascular risk among obese patients. The study was designed as an observational retrospective. Department of Family Medicine, study was carried out between 25/06/2022 to 30/10/2022. The data of 439 obese patients were analyzed retrospectively. Using the online Heart Score system, the patients were classified into low, medium, high, and very high cardiovascular risk categories. The hemogram and certain biochemistry values of the patients at the time of admission were examined. Receiver operating characteristic (ROC) analyses were conducted to discriminate cardiovascular risk classes based on laboratory values. Markers with high diagnostic value, including a high area under the curve (AUC) value, sensitivity, and specificity, were presented. Significant differences were observed between the groups in terms of age, systolic blood pressure, diastolic blood pressure, total cholesterol, low-density lipoprotein, glucose, HbA1c, hemoglobin, platelet count, neutrophil (NEU) count, and platelet-lymphocyte ratio parameters (P < .05). The white blood cell count and NEU count of patients in the high-risk groups were found to have significantly higher AUC values compared to the moderate-risk group (AUC values of .737 and .779, respectively). The white blood cell and NEU parameters were found to have a positive predictive value in estimating the degree of cardiovascular risk. These parameters can potentially serve as biomarkers in identifying individuals at high risks for cardiovascular diseases.

The Biggest Unmet Needs in Cardiovascular Disease Prevention in 2023

BACKGROUND

While the major causes of atherosclerotic cardiovascular disease (CVD) are known, clinical audits continue to show inadequate risk factor control, even in the highest risk subjects. More effective risk estimation methods may help, and advances in this field are outlined. There exist excellent guidelines on CVD prevention, but their very length and complexity may limit their use. Other factors inhibiting guideline implementation are explored.

SUMMARY

While new medications continue to be developed, the real challenges to effective CVD prevention are societal and political. Both nationally and at European levels, cohesive, integrated strategies with defined responsibilities and accountability are needed, together with empowerment of people to understand the concept of risk and what they can do about it.

KEY MESSAGES

There are profound health inequalities between and within countries that need to be addressed.

Machine learning-based mRNA signature in early acute myocardial infarction patients: the perspective toward immunological, predictive, and personalized

Patients diagnosed with stable coronary artery disease (CAD) are at continued risk of experiencing acute myocardial infarction (AMI). This study aims to unravel the pivotal biomarkers and dynamic immune cell changes, from an immunological, predictive, and personalized viewpoint, by implementing a machine-learning approach and a composite bioinformatics strategy. Peripheral blood mRNA data from different datasets were analyzed, and CIBERSORT was used for deconvoluting human immune cell subtype expression matrices. Weighted gene co-expression network analysis (WGCNA) in single-cell and bulk transcriptome levels was conducted to explore possible biomarkers for AMI, with a particular emphasis on examining monocytes and their involvement in cell-cell communication. Unsupervised cluster analysis was performed to categorize AMI patients into different subtypes, and machine learning methods were employed to construct a comprehensive diagnostic model to predict the occurrence of early AMI. Finally, RT-qPCR on peripheral blood samples collected from patients validated the clinical utility of the machine learning-based mRNA signature and hub biomarkers. The study identified potential biomarkers for early AMI, including CLEC2D, TCN2, and CCR1, and found that monocytes may play a vital role in AMI samples. Differential analysis revealed that CCR1 and TCN2 exhibited elevated expression levels in early AMI compared to stable CAD. Machine learning methods showed that the glmBoost+Enet [alpha=0.9] model achieved high predictive accuracy in the training set, external validation sets, and clinical samples in our hospital. The study provided comprehensive insights into potential biomarkers and immune cell populations involved in the pathogenesis of early AMI. The identified biomarkers and the constructed comprehensive diagnostic model hold great promise for predicting the occurrence of early AMI and can serve as auxiliary diagnostic or predictive biomarkers.

Cardiovascular Risk Prediction in Men and Women Aged Under 50 Years Using Routine Care Data

Background Prediction models for risk of cardiovascular events generally do not include young adults, and cardiovascular risk factors differ between women and men. Therefore, this study aimed to develop prediction models for first-ever cardiovascular event risk in men and women aged 30 to 49 years. Methods and Results We included patients aged 30 to 49 years without cardiovascular disease from a Dutch routine care database. Outcome was defined as first-ever cardiovascular event. Our reference models were sex-specific Cox proportional hazards models based on traditional cardiovascular predictors, which we compared with models using 2 predictor subsets with the 20 or 50 most important predictors based on the Cox elastic net model regularization coefficients. We assessed the C-index and calibration curve slopes at 10 years of follow-up. We stratified our analyses based on 30- to 39-year and 40- to 49-year age groups at baseline. We included 542 141 patients (mean age 39.7, 51% women). During follow-up, 10 767 cardiovascular events occurred. Discrimination of reference models including traditional cardiovascular predictors was moderate (women: C-index, 0.648 [95% CI, 0.645-0.652]; men: C-index, 0.661 [95%CI, 0.658-0.664]). In women and men, the Cox proportional hazard models including 50 most important predictors resulted in an increase in C-index (0.030 and 0.012, respectively), and a net correct reclassification of 3.7% of the events in women and 1.2% in men compared with the reference model. Conclusions Sex-specific electronic health record-derived prediction models for first-ever cardiovascular events in the general population aged <50 years have moderate discriminatory performance. Data-driven predictor selection leads to identification of nontraditional cardiovascular predictors, which modestly increase performance of models.

Undertreatment and Underachievement of LDL-C Target among Individuals with High and Very High Cardiovascular Risk in the Malaysian Community

Dyslipidaemia is a major cause of morbidity and mortality. The aims of this study are to determine the prevalence of dyslipidaemia subtypes, the proportions of lipid-lowering therapy (LLT) use, and the achievement of low-density lipoprotein cholesterol (LDL-C) treatment targets for high-risk (HR) and very high-risk (VHR) Malaysians. This cross-sectional study involves 5279 participants across 11 states in Malaysia. The data were obtained through a standardised questionnaire, anthropometric measurements, venous glucose and lipid profile. The participants with existing cardiovascular disease (CVD) or diabetes with at least one of the other major risk factors (smoking, hypertension or dyslipidaemia) were grouped into the VHR category. Other participants were risk-categorised using the Framingham General CVD Risk Score (FRS-CVD). The prevalence of elevated LDL-C, LLT use and LDL-C target were set according to respective risk categories. Pearson's chi-squared test was used to test the difference in the proportions. The mean ± standard deviation (SD) age was 41.1 ± 14.8 years, and 62.2% (3283/5279) of the group were females. Within the participant group, 51.5% were found to have elevated total cholesterol, 28.8% had low HDL-C, and 33.8% had high triglyceride. As for elevated LDL-C, 9.8% were in VHR, 8.6% in HR, 5.8% in MR and 34.9% in LR categories. Among the VHR group, 75.8% were not on LLT, and only 15.9% achieved the LDL-C target. As for the HR category, 87.7% were not on LLT, and only 16.1% achieved the LDL-C target. Dyslipidaemia is highly prevalent among Malaysians. The majority of VHR and HR participants were not on LLT and did not achieve LDL-C treatment targets. Proactive programs are warranted to combat dyslipidaemia-associated CVD events in these groups.

Risk Factors for Heart Disease in Working Railwaymen

Heart diseases are the most common non-communicable diseases worldwide. We examined the prevalence of risk factors for heart disease among a sub-population of working men. In total, 11,059 railway crew workers of the Russian Railways Company were included in the study. We also asked participants to answer several questions based on the WHO STEPwise approach to surveillance (STEPS) translated into Russian. Only 30% of drivers had normal body mass index (BMI), whereas 70% were overweight or obese. In 12% of subjects, total cholesterol was higher than 5 mmol/L. In 15% of participants, glucose level was higher than 5.5 mmol/L. 38% of drivers reported smoking. Physical inactivity was registered in 54% of persons. Only 29% ate according to the key principles of good diet quality. 24% of respondents had a family history of heart disease. MANOVA demonstrated that BMI was determined by age, profession, smoking, physical inactivity, and diet quality. As age increased, the number of people with normal cholesterol levels decreased. It was demonstrated that a correlation existed between glucose levels and BMI. In the total group, the correlation was 0.46 (p < .05). The correlation between those parameters increased due to age, from 0.33 in the <30 years of age group up to 0.52 in the >50 years of age group. This study demonstrated that there is a high prevalence of risk factors for heart disease in train drivers in the Russian Federation.

New Way to "SCORE" Risk: Updates on the ESC Scoring System and Incorporation into ESC Cardiovascular Prevention Guidelines

PURPOSE OF REVIEW

Prior European Society of Cardiology (ESC) guidelines endorsed the SCORE 10-year cardiovascular disease (CVD) risk calculator to inform the total risk approach to CVD prevention, including the use of preventive interventions like lipid lowering therapies. However, SCORE was released in 2003, did not allow for estimation of fatal and non-fatal CVD events, and was limited to adults aged 40 to 70 years. The ESC's Cardiovascular Risk Collaboration (CRC) was tasked with updating SCORE (SCORE2) and with extending the upper age range of adults eligible for risk estimation (SCORE2-OP). This review summarises these two deliverables.

RECENT FINDINGS

Published in 2021, these updated risk scores allow for estimation of 10 year total (fatal + non-fatal) risks of a first atherosclerotic cardiovascular event in adults (SCORE2) and older persons (SCORE2-OP), calibrated for use in four European risk regions. The models account for competing risk of non-CVD death. These were extensively validated with excellent calibration and C-statistics ranging from 0.67 to 0.81. SCORE2 and SCORE2-OP have informed the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. In addition to endorsing these two updated risk calculators, these guidelines have, for the first time, recommended the use of age-related risk categories. This change was motivated to prevent overreliance on age when making CVD prevention decisions.

[Sports cardiology : Which sport can be recommended for heart diseases?]

Innerhalb der Kardiologie hat der Bereich der Sportkardiologie in den letzten 10 Jahren sukzessive an Bedeutung zugenommen. Dies liegt v. a. daran, dass sich das Spektrum der Fragestellungen zu körperlichem Training in der Prävention und Sekundärprävention jenseits der klassischen kardiovaskulären Rehabilitation erweitert hat. Dieses Spektrum betrifft v. a. Jugendliche und junge Erwachsene, die bei manifester kardialer Erkrankung weiterhin körperlich aktiv sein wollen und zum Teil Freizeit- und Leistungssport anstreben. Ergänzend wird der Kreis der Patient*innen mit kardialen Erkrankungen, die auch noch im höheren Alter sportliche Höchstleistungen anstreben und Beratung suchen, immer größer. In diesen Fällen geht es dann darum, auf der einen Seite ein körperliches Training als Therapiestrategie zu empfehlen, aber auf der anderen Seite auch das kardiovaskuläre System zu schützen. Empfehlungen zu körperlichem Training sollten deshalb auch individuelle Aspekte berücksichtigen. Zusätzlich wird im ambitionierten Freizeit- und Leistungssport die Empfehlung zur Freigabe von Wettkampfsport adressiert. So fragen Patient*innen nach Sport- und Trainingsempfehlungen bei kardiovaskulären Risikofaktoren wie arterieller Hypertonie, Pathologien der Koronararterien im Sinne des Fehlabgangs der Koronarien, Muskelbrücke oder koronarer Herzkrankheit, Kardiomyopathien, Myokarditis sowie Herzrhythmusstörungen und Herzklappenfehlern. In diesem Artikel werden diese Erkrankungen mit entsprechenden sportkardiologischen Spezifika diskutiert und jeweils Empfehlungen zu körperlichem Training und Wettkampfsport gegeben.

Impact of Outcome Definitions on Cardiovascular Risk Prediction in a Contemporary Primary Prevention Population

BACKGROUND

Estimation of an individual's cardiovascular disease (CVD) risk may enhance risk discussion and treatment decisions. Yet, common cardiovascular outcomes such as heart failure or coronary revascularization are not included in the estimation of atherosclerotic cardiovascular disease (ASCVD) risk. Our objective was to determine the incidence of ASCVD in a contemporary primary prevention population with more than 10 years of follow-up, and how incidence estimates change when incorporating additional cardiovascular endpoints.

METHODS

We used the population-level CANHEART (Cardiovascular Health in Ambulatory Care Research Team) database of all Ontario residents alive January 1, 2008, aged 30-99 years, and with no prior history of cardiovascular disease. Individuals were followed to December 31, 2019 for incident first and recurrent cardiovascular events. ASCVD outcomes were defined by hospitalizations for myocardial infarction, stroke and circulatory death, while global CVD outcomes also included hospitalizations for unstable angina, transient ischemic attacks, peripheral arterial disease, out-of-hospital cardiac arrests, heart failure and coronary revascularization.

RESULTS

Among 7496 165 individuals free of cardiovascular disease, their mean age was 50 years (SD: 13.9 years) and 52.3% were women. After 11 years of follow-up, the rate of an incident ASCVD event was 3.95 per 1000 person-years while the rate of a global CVD event was almost doubled at 6.67 per 1000 person-years. The most common additional first manifestations of CVD were heart failure which accounted for 12.0% of additional events and coronary revascularization which accounted for 12.7%. When considering first and recurrent events, the rate of ASCVD was 5.20 per 1000 person-years while the rate of all global CVD events was more than double at 10.90 per 1000 person-years. This was mainly due to a higher proportion of recurrent heart failure (13.7%) and coronary revascularization (23.2%) events.

CONCLUSIONS

ASCVD accounts for just over half of all preventable first cardiovascular events and even fewer first and recurrent cardiovascular events in contemporary practice. Estimating broader CVD endpoints may enhance risk-discussions with patients and improve informed decision-making.

Risk Factors for Locomotive Crew Members Depending on Their Place of Work

PURPOSE

The purpose of this study is to examine the prevalence of workplace exposure, behavior, and individual health conditions, along with resulting medical activity among locomotive crew members depending on their place of work.

PATIENTS AND METHODS

Participants included 5585 train drivers and 3723 train drivers' assistants (7% of the total train operators in the Russian Federation). Measured height and weight were used to calculate body mass index (BMI), and waist circumference, pulse rate, and blood pressure were also measured. The risk assessment was conducted using the STEPS tool. The level of commitment to a Healthy Lifestyle was assessed based on World Health Organization recommendations. Occupational risk factors were surveyed. Morbidity was analyzed over the past year.

RESULTS

The lowest frequency of work exposure risk factors was found for employees of the Trans-Baikal railway; the highest was among Krasnoyarsk, North, and South-East. The participants from the Far East and October Railways had the lowest self-reported frequency of behavioral risk factors. The participants from the Eastern Siberian, October, and Southern Urals railways had the lowest occurrence of individual health conditions. The participants from the East Siberian, Far East, Kuibyshev, and Sverdlovsk railways were the least likely to visit their doctor, take temporary disability leave, or be hospitalized. The total assessed Healthy Lifestyle commitment index was higher for participants from the Far Eastern and Southern Urals railways. The participants from the Moscow and October railways were the least committed to a Healthy Lifestyle.

CONCLUSIONS

Significant differences exist between risk factors and Healthy Lifestyle commitment between railways. Future research should examine changes due to a new corporate health program introduced in 2020.

Heart rate variability and cognitive performance in adults with cardiovascular risk

BACKGROUND

Heart rate variability (HRV), a measure of autonomic function, has been associated with both cardiovascular disease and cognitive dysfunction. In turn, cardiovascular risk has been linked to an increased risk of dementia onset. However, whether autonomic dysfunction may represent an early marker of cognitive decline in individuals with high cardiovascular risk is still an open issue.

METHODS

We performed a complete 24-hour HRV analysis in 50 middle-aged and elderly subjects with cardiovascular risk as assessed with the European Society of Cardiology Systematic Coronary Risk Evaluation (ESC SCORE). Cognitive performance was evaluated by Montreal Cognitive Assessment (MoCA), Free and Cued Selective Reminding Test (FCSRT) and Stroop Color and Word Test. Stepwise regression was used to identify significant associations between 24-hour ambulatory ECGs parameters and cognitive performances.

RESULTS

There were 30 women and 20 men with mean age of 64.9 years (range 51-77) and the mean ESC SCORE was 6%. Four subjects were diagnosed with mild cognitive impairment. Associations were found between measures of HRV and measures of cognition. Ultra-low frequency (ULF) band power of HRV significantly correlated with MoCA (r = 0.424, p = 0.003), also after adjustment for demographics and education. A significant association was also found between the ESC SCORE and ULF band power (r = -0.470, p = 0.0009).

CONCLUSIONS

Ultra-low frequency band power of HRV is associated with cognitive performance of middle-aged and elderly subjects with cardiovascular risk. This finding may indicate that autonomic nervous system dysregulation plays a role in developing cardiovascular risk and cognitive decline.

Editor-in-Chief's Top Picks From 2021

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Artificial Intelligence & Machine Learning (NEW section), Basic & Translational Research, Biomarkers (NEW section), Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Cardiovascular Disease in Women, Coronary Disease & Interventions, Congenital Heart Disease, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Vascular Medicine, and Valvular Heart Disease.^1-100.

Score2: A New Updated Algorithm to Predict Cardiovascular Disease Risk in Europe

The recently published guidelines of the European Society of Cardiology for the prevention of cardiovascular diseases presented in August 2021 at the virtual European Society of Cardiology congress recommend the use of the SCORE2 risk index instead of the classic SCORE risk index to calculate the cardiovascular risk (specifically, ten-year fatal and nonfatal risk) in a healthy population under the age of 70 years, with a level of evidence IB. This new risk index was developed with the collaboration of about 200 investigators, including 45 cohorts in 13 countries with 700,000 participants, and covers the known risk factors for heart and circulatory diseases such as age, sex, lipid levels, blood pressure, and smoking. In addition, it divides the countries into four groups of risk and uses a competing risk model, adjusting the risk for the probability of having another event, which enables better estimation of the risk of fatal and nonfatal events in a younger population (40-69 years).