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Liang J, Jackson RT, Pylypchuk R, Choi Y, Chung C, Crengle S, Gao P, Grey C, Harwood M, Holt A, Kerr A, Mehta S, Wells S, Poppe K. Treatment drop-in in a contemporary cohort used to derive cardiovascular risk prediction equations. Heart 2024; 110:1083-1089. [PMID: 38960588 DOI: 10.1136/heartjnl-2024-324179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/11/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND No routinely recommended cardiovascular disease (CVD) risk prediction equations have adjusted for CVD preventive medications initiated during follow-up (treatment drop-in) in their derivation cohorts. This will lead to underestimation of risk when equations are applied in clinical practice if treatment drop-in is common. We aimed to quantify the treatment drop-in in a large contemporary national cohort to determine whether equations are likely to require adjustment. METHODS Eight de-identified individual-level national health administrative datasets in Aotearoa New Zealand were linked to establish a cohort of almost all New Zealanders without CVD and aged 30-74 years in 2006. Individuals dispensing blood-pressure-lowering and/or lipid-lowering medications between 1 July 2006 and 31 December 2006 (baseline dispensing), and in each 6-month period during 12 years' follow-up to 31 December 2018 (follow-up dispensing), were identified. Person-years of treatment drop-in were determined. RESULTS A total of 1 399 348 (80%) out of the 1 746 695 individuals in the cohort were not dispensed CVD medications at baseline. Blood-pressure-lowering and/or lipid-lowering treatment drop-in accounted for 14% of follow-up time in the group untreated at baseline and increased significantly with increasing predicted baseline 5-year CVD risk (12%, 31%, 34% and 37% in <5%, 5-9%, 10-14% and ≥15% risk groups, respectively) and with increasing age (8% in 30-44 year-olds to 30% in 60-74 year-olds). CONCLUSIONS CVD preventive treatment drop-in accounted for approximately one-third of follow-up time among participants typically eligible for preventive treatment (≥5% 5-year predicted risk). Equations derived from cohorts with long-term follow-up that do not adjust for treatment drop-in effect will underestimate CVD risk in higher risk individuals and lead to undertreatment. Future CVD risk prediction studies need to address this potential flaw.
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Affiliation(s)
- Jingyuan Liang
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Rodney T Jackson
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Romana Pylypchuk
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Yeunhyang Choi
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Claris Chung
- Accounting and Information Systems, University of Canterbury, Christchurch, New Zealand
| | - Sue Crengle
- Ngāi Tahu Māori Health Research Unit, University of Otago, Dunedin, New Zealand
| | - Pei Gao
- Department of Epidemiology and Biostatistics, Peking University, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Corina Grey
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Matire Harwood
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Anders Holt
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Andrew Kerr
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Suneela Mehta
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Susan Wells
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Katrina Poppe
- Section of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
- School of Medicine, University of Auckland, Auckland, New Zealand
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Xu Z, Usher-Smith J, Pennells L, Chung R, Arnold M, Kim L, Kaptoge S, Sperrin M, Di Angelantonio E, Wood AM. Age and sex specific thresholds for risk stratification of cardiovascular disease and clinical decision making: prospective open cohort study. BMJ MEDICINE 2024; 3:e000633. [PMID: 39175920 PMCID: PMC11340247 DOI: 10.1136/bmjmed-2023-000633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/12/2024] [Indexed: 08/24/2024]
Abstract
Objective To quantify the potential advantages of using 10 year risk prediction models for cardiovascular disease, in combination with risk thresholds specific to both age and sex, to identify individuals at high risk of cardiovascular disease for allocation of statin treatment. Design Prospective open cohort study. Setting Primary care data from the UK Clinical Practice Research Datalink GOLD, linked with hospital admissions from Hospital Episode Statistics and national mortality records from the Office for National Statistics in England, 1 January 2006 to 31 May 2019. Participants 1 046 736 individuals (aged 40-85 years) with no cardiovascular disease, diabetes, or a history of statin treatment at baseline using data from electronic health records. Main outcome measures 10 year risk of cardiovascular disease, calculated with version 2 of the QRISK cardiovascular disease risk algorithm (QRISK2), with two main strategies to identify individuals at high risk: in strategy A, estimated risk was a fixed cut-off value of ≥10% (ie, as per the UK National Institute for Health and Care Excellence guidelines); in strategy B, estimated risk was ≥10% or ≥90th centile of age and sex specific risk distributions. Results Compared with strategy A, strategy B stratified 20 241 (149.8%) more women aged ≤53 years and 9832 (150.2%) more men aged ≤47 years as having a high risk of cardiovascular disease; for all other ages the strategies were the same. Assuming that treatment with statins would be initiated in those identified as high risk, differences in the estimated gain in cardiovascular disease-free life years from statin treatment for strategy B versus strategy A were 0.14 and 0.16 years for women and men aged 40 years, respectively; among individuals aged 40-49 years, the numbers needed to treat to prevent one cardiovascular disease event for strategy B versus strategy A were 39 versus 21 in women and 19 versus 15 in men, respectively. Conclusions This study quantified the potential gains in cardiovascular disease-free life years when implementing prevention strategies based on age and sex specific risk thresholds instead of a fixed risk threshold for allocation of statin treatment. Such gains should be weighed against the costs of treating more younger people with statins for longer.
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Affiliation(s)
- Zhe Xu
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Pennells
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ryan Chung
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew Arnold
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lois Kim
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Stephen Kaptoge
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Emanuele Di Angelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Health Data Science Research Centre, Human Technopole, Milan, Italy
| | - Angela M Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Cambridge Centre of Artificial Intelligence in Medicine, Cambridge, UK
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Siriyotha S, Lukkunaprasit T, Looareesuwan P, Kunakorntham P, Anothaisintawee T, Nimitphong H, McKay GJ, Attia J, Thakkinstian A. Individual treatment effects of sodium-glucose co-transporter-2 inhibitors on the risk of chronic kidney disease in patients with type 2 diabetes: A counterfactual prediction model based on real-world data. Diabetes Obes Metab 2024. [PMID: 39039709 DOI: 10.1111/dom.15793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/18/2024] [Accepted: 06/28/2024] [Indexed: 07/24/2024]
Abstract
AIM To estimate individual treatment effects (ITEs) of sodium-glucose co-transporter-2 inhibitors (SGLT2is) on lowering the risk of developing chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) and to identify those most probable to benefit from treatment. METHODS This study followed a T2D cohort from Ramathibodi Hospital, Thailand, from 2015 to 2022. A counterfactual model was constructed to predict factual and counterfactual risks of CKD if patients did/did not receive SGLT2is. ITEs were estimated by subtracting the factual risk from the counterfactual risk of CKD. RESULTS There were 1619 and 15 879 patients included in the SGLT2i and non-SGLT2i groups, respectively. The estimated ITEs varied from -1.19% to -17.51% with a median of -4.49%, that is, 50% of patients had a 4.49% or greater lower CKD risk if they received an SGLT2i. Patients who gained the greatest benefit from SGLT2is were more probable to be male, aged at least 60 years, with a history of diabetes duration of at least 3 months, hypertension, peripheral arterial disease, diabetic retinopathy and low high-density lipoprotein cholesterol. CONCLUSIONS Our prediction model provides individualized information that helps target T2D patients who may benefit more from SGLT2is. This could help clinical decision making and implementation of personalized medicine in clinical practice, especially in resource-limited settings.
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Affiliation(s)
- Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thitiya Lukkunaprasit
- Department of Pharmacy Administration, College of Pharmacy, Rangsit University, Pathum Thani, Thailand
| | - Panu Looareesuwan
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patratorn Kunakorntham
- Department of Information Technology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thunyarat Anothaisintawee
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hataikarn Nimitphong
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gareth J McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, Newcastle, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Abbasi AF, Asim MN, Ahmed S, Vollmer S, Dengel A. Survival prediction landscape: an in-depth systematic literature review on activities, methods, tools, diseases, and databases. Front Artif Intell 2024; 7:1428501. [PMID: 39021434 PMCID: PMC11252047 DOI: 10.3389/frai.2024.1428501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Survival prediction integrates patient-specific molecular information and clinical signatures to forecast the anticipated time of an event, such as recurrence, death, or disease progression. Survival prediction proves valuable in guiding treatment decisions, optimizing resource allocation, and interventions of precision medicine. The wide range of diseases, the existence of various variants within the same disease, and the reliance on available data necessitate disease-specific computational survival predictors. The widespread adoption of artificial intelligence (AI) methods in crafting survival predictors has undoubtedly revolutionized this field. However, the ever-increasing demand for more sophisticated and effective prediction models necessitates the continued creation of innovative advancements. To catalyze these advancements, it is crucial to bring existing survival predictors knowledge and insights into a centralized platform. The paper in hand thoroughly examines 23 existing review studies and provides a concise overview of their scope and limitations. Focusing on a comprehensive set of 90 most recent survival predictors across 44 diverse diseases, it delves into insights of diverse types of methods that are used in the development of disease-specific predictors. This exhaustive analysis encompasses the utilized data modalities along with a detailed analysis of subsets of clinical features, feature engineering methods, and the specific statistical, machine or deep learning approaches that have been employed. It also provides insights about survival prediction data sources, open-source predictors, and survival prediction frameworks.
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Affiliation(s)
- Ahtisham Fazeel Abbasi
- Department of Computer Science, Rhineland-Palatinate Technical University of Kaiserslautern-Landau, Kaiserslautern, Germany
- Smart Data & Knowledge Services, Deutsches Forschungszentrum für Künstliche Intelligenz (DFKI), Kaiserslautern, Germany
| | - Muhammad Nabeel Asim
- Smart Data & Knowledge Services, Deutsches Forschungszentrum für Künstliche Intelligenz (DFKI), Kaiserslautern, Germany
| | - Sheraz Ahmed
- Smart Data & Knowledge Services, Deutsches Forschungszentrum für Künstliche Intelligenz (DFKI), Kaiserslautern, Germany
| | - Sebastian Vollmer
- Department of Computer Science, Rhineland-Palatinate Technical University of Kaiserslautern-Landau, Kaiserslautern, Germany
- Smart Data & Knowledge Services, Deutsches Forschungszentrum für Künstliche Intelligenz (DFKI), Kaiserslautern, Germany
| | - Andreas Dengel
- Department of Computer Science, Rhineland-Palatinate Technical University of Kaiserslautern-Landau, Kaiserslautern, Germany
- Smart Data & Knowledge Services, Deutsches Forschungszentrum für Künstliche Intelligenz (DFKI), Kaiserslautern, Germany
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Keogh RH, Van Geloven N. Prediction Under Interventions: Evaluation of Counterfactual Performance Using Longitudinal Observational Data. Epidemiology 2024; 35:329-339. [PMID: 38630508 PMCID: PMC11332371 DOI: 10.1097/ede.0000000000001713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/10/2024] [Indexed: 04/19/2024]
Abstract
Predictions under interventions are estimates of what a person's risk of an outcome would be if they were to follow a particular treatment strategy, given their individual characteristics. Such predictions can give important input to medical decision-making. However, evaluating the predictive performance of interventional predictions is challenging. Standard ways of evaluating predictive performance do not apply when using observational data, because prediction under interventions involves obtaining predictions of the outcome under conditions that are different from those that are observed for a subset of individuals in the validation dataset. This work describes methods for evaluating counterfactual performance of predictions under interventions for time-to-event outcomes. This means we aim to assess how well predictions would match the validation data if all individuals had followed the treatment strategy under which predictions are made. We focus on counterfactual performance evaluation using longitudinal observational data, and under treatment strategies that involve sustaining a particular treatment regime over time. We introduce an estimation approach using artificial censoring and inverse probability weighting that involves creating a validation dataset mimicking the treatment strategy under which predictions are made. We extend measures of calibration, discrimination (c-index and cumulative/dynamic AUCt) and overall prediction error (Brier score) to allow assessment of counterfactual performance. The methods are evaluated using a simulation study, including scenarios in which the methods should detect poor performance. Applying our methods in the context of liver transplantation shows that our procedure allows quantification of the performance of predictions supporting crucial decisions on organ allocation.
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Affiliation(s)
- Ruth H. Keogh
- From the Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nan Van Geloven
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
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Lin L, Poppe K, Wood A, Martin GP, Peek N, Sperrin M. Making predictions under interventions: a case study from the PREDICT-CVD cohort in New Zealand primary care. FRONTIERS IN EPIDEMIOLOGY 2024; 4:1326306. [PMID: 38633209 PMCID: PMC11021700 DOI: 10.3389/fepid.2024.1326306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024]
Abstract
Background Most existing clinical prediction models do not allow predictions under interventions. Such predictions allow predicted risk under different proposed strategies to be compared and are therefore useful to support clinical decision making. We aimed to compare methodological approaches for predicting individual level cardiovascular risk under three interventions: smoking cessation, reducing blood pressure, and reducing cholesterol. Methods We used data from the PREDICT prospective cohort study in New Zealand to calculate cardiovascular risk in a primary care setting. We compared three strategies to estimate absolute risk under intervention: (a) conditioning on hypothetical interventions in non-causal models; (b) combining existing prediction models with causal effects estimated using observational causal inference methods; and (c) combining existing prediction models with causal effects reported in published literature. Results The median absolute cardiovascular risk among smokers was 3.9%; our approaches predicted that smoking cessation reduced this to a median between a non-causal estimate of 2.5% and a causal estimate of 2.8%, depending on estimation methods. For reducing blood pressure, the proposed approaches estimated a reduction of absolute risk from a median of 4.9% to a median between 3.2% and 4.5% (both derived from causal estimation). Reducing cholesterol was estimated to reduce median absolute risk from 3.1% to between 2.2% (non-causal estimate) and 2.8% (causal estimate). Conclusions Estimated absolute risk reductions based on non-causal methods were different to those based on causal methods, and there was substantial variation in estimates within the causal methods. Researchers wishing to estimate risk under intervention should be explicit about their causal modelling assumptions and conduct sensitivity analysis by considering a range of possible approaches.
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Affiliation(s)
- Lijing Lin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Katrina Poppe
- Schools of Population Health & Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Angela Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre of Artificial Intelligence in Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Glen P. Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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Tansawet A, Siribumrungwong B, Techapongsatorn S, Numthavaj P, Poprom N, McKay GJ, Attia J, Thakkinstian A. Delayed versus primary closure to minimize risk of surgical-site infection for complicated appendicitis: A secondary analysis of a randomized trial using counterfactual prediction modeling. Infect Control Hosp Epidemiol 2024; 45:322-328. [PMID: 37929568 PMCID: PMC10933508 DOI: 10.1017/ice.2023.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To evaluate the risk of surgical site infection (SSI) following complicated appendectomy in individual patients receiving delayed primary closure (DPC) versus primary closure (PC) after adjustment for individual risk factors. DESIGN Secondary analysis of randomized controlled trial (RCT) with prediction model. SETTING Referral centers across Thailand. PARTICIPANTS Adult patients who underwent appendectomy via a lower-right-quadrant abdominal incision due to complicated appendicitis. METHODS A secondary analysis of a published RCT was performed applying a counterfactual prediction model considering interventions (PC vs DPC) and other significant predictors. A multivariable logistic regression was applied, and a likelihood-ratio test was used to select significant predictors to retain in a final model. Factual versus counterfactual SSI risks for individual patients along with individual treatment effect (iTE) were estimated. RESULTS In total, 546 patients (271 PC vs 275 DPC) were included in the analysis. The individualized prediction model consisted of allocated intervention, diabetes, type of complicated appendicitis, fecal contamination, and incision length. The iTE varied between 0.4% and 7% for PC compared to DPC; ∼38.1% of patients would have ≥2.1% lower SSI risk following PC compared to DPC. The greatest risk reduction was identified in diabetes with ruptured appendicitis, fecal contamination, and incision length of 10 cm, where SSI risks were 47.1% and 54.1% for PC and DPC, respectively. CONCLUSIONS In this secondary analysis, we found that most patients benefited from early PC versus DPC. Findings may be used to inform SSI prevention strategies for patients with complicated appendicitis.
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Affiliation(s)
- Amarit Tansawet
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Suphakarn Techapongsatorn
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pawin Numthavaj
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Napaphat Poprom
- Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gareth J. McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - John Attia
- School of Medicine and Public Health, and Hunter Medical Research Institute, University of Newcastle, New Lambton, New South Wales, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Yang G, Mason AM, Wood AM, Schooling CM, Burgess S. Dose-Response Associations of Lipid Traits With Coronary Artery Disease and Mortality. JAMA Netw Open 2024; 7:e2352572. [PMID: 38241044 PMCID: PMC10799266 DOI: 10.1001/jamanetworkopen.2023.52572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/01/2023] [Indexed: 01/22/2024] Open
Abstract
Importance Apolipoprotein B (apoB), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG) are associated with coronary artery disease (CAD). However, trial evidence for the association of intensive LDL-C lowering and TG lowering with mortality is less definitive. Objectives To investigate the associations of apoB, LDL-C, and TG with CAD and mortality, both overall and by sex and age, and to characterize the shapes of these associations. Design, Setting, and Participants This genetic association study used linear and nonlinear mendelian randomization (MR) to analyze a population-based cohort of individuals of European ancestry from the UK Biobank, which recruited participants from 2006 to 2010 with follow-up information updated until September 2021. Data analysis occurred from December 2022 to November 2023. Exposures Genetically predicted apoB, LDL-C, and TG. Main Outcomes and Measures The primary outcomes were CAD, all-cause mortality, and cause-specific mortality. Genetic associations with CAD were calculated using logistic regression, associations with all-cause mortality using Cox proportional hazards regression, and associations with cause-specific mortality using cause-specific Cox proportional hazards regression with censoring for other causes of mortality. Results This study included 347 797 participants (mean [SD] age, 57.2 [8.0] years; 188 330 female [54.1%]). There were 23 818 people who developed CAD and 23 848 people who died. Genetically predicted apoB was positively associated with risk of CAD (odds ratio [OR], 1.65 per SD increase; 95% CI 1.57-1.73), all-cause mortality (hazard ratio [HR], 1.11; 95% CI, 1.06-1.16), and cardiovascular mortality (HR, 1.36; 95% CI, 1.24-1.50), with some evidence for larger associations in male participants than female participants. Findings were similar for LDL-C. Genetically predicted TG was positively associated with CAD (OR, 1.60; 95% CI 1.52-1.69), all-cause mortality (HR, 1.08; 95% CI, 1.03-1.13), and cardiovascular mortality (HR, 1.21; 95% CI, 1.09-1.34); however, sensitivity analyses suggested evidence of pleiotropy. The association of genetically predicted TG with CAD persisted but it was no longer associated with mortality outcomes after controlling for apoB. Nonlinear MR suggested that all these associations were monotonically increasing across the whole observed distribution of each lipid trait, with no diminution at low lipid levels. Such patterns were observed irrespective of sex or age. Conclusions and relevance In this genetic association study, apoB (or, equivalently, LDL-C) was associated with increased CAD risk, all-cause mortality, and cardiovascular mortality, all in a dose-dependent way. TG may increase CAD risk independent of apoB, although the possible presence of pleiotropy is a limitation. These insights highlight the importance of apoB (or, equivalently, LDL-C) lowering for reducing cardiovascular morbidity and mortality across its whole distribution.
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Affiliation(s)
- Guoyi Yang
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
| | - Amy M. Mason
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, United Kingdom
| | - Angela M. Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - C. Mary Schooling
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Graduate School of Public Health and Health Policy, City University of New York, New York
| | - Stephen Burgess
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, United Kingdom
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
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Delabays B, de La Harpe R, Vollenweider P, Fournier S, Müller O, Strambo D, Graham I, Visseren FLJ, Nanchen D, Marques-Vidal P, Vaucher J. Comparison of the European and US guidelines for lipid-lowering therapy in primary prevention of cardiovascular disease. Eur J Prev Cardiol 2023; 30:1856-1864. [PMID: 37290056 DOI: 10.1093/eurjpc/zwad193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023]
Abstract
AIMS Population-wide impacts of new guidelines in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) should be explored in independent cohorts. Assess and compare the lipid-lowering therapy eligibility and predictive classification performance of 2016 and 2021 European Society of Cardiology (ESC), 2019 American Heart Association/American College of Cardiology (AHA/ACC), and 2022 US Preventive Services Task Force (USPSTF) guidelines. METHODS AND RESULTS Participants from the CoLaus|PsyCoLaus study, without ASCVD and not taking lipid-lowering therapy at baseline. Derivation of 10-year risk for ASCVD using Systematic COronary Risk Evaluation (SCORE1), SCORE2 [including SCORE2-Older Persons (SCORE2-OP)], and pooled cohort equation. Computation of the number of people eligible for lipid-lowering therapy based on each guideline and assessment of discrimination and calibration metrics of the risk models using first incident ASCVD as an outcome. Among 4,092 individuals, 158 (3.9%) experienced an incident ASCVD during a median follow-up of 9 years (interquartile range, 1.1). Lipid-lowering therapy was recommended or considered in 40.2% (95% confidence interval, 38.2-42.2), 26.4% (24.6-28.2), 28.6% (26.7-30.5), and 22.6% (20.9-24.4) of women and in 62.1% (59.8-64.3), 58.7% (56.4-61.0), 52.6% (50.3-54.9), and 48.4% (46.1-50.7) of men according to the 2016 ESC, 2021 ESC, 2019 AHA/ACC, and 2022 USPSTF guidelines, respectively. 43.3 and 46.7% of women facing an incident ASCVD were not eligible for lipid-lowering therapy at baseline according to the 2021 ESC and 2022 USPSTF, compared with 21.7 and 38.3% using the 2016 ESC and 2019 AHA/ACC, respectively. CONCLUSION Both the 2022 USPSTF and 2021 ESC guidelines particularly reduced lipid-lowering therapy eligibility in women. Nearly half of women who faced an incident ASCVD were not eligible for lipid-lowering therapy.
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Affiliation(s)
- Benoît Delabays
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Roxane de La Harpe
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Peter Vollenweider
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Stephane Fournier
- Heart and Vessel Department, Division of Cardiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Olivier Müller
- Heart and Vessel Department, Division of Cardiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Davide Strambo
- Department of Clinical Neurosciences, Division of Neurology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Ian Graham
- School of Medicine, Trinity College Dublin, The University of Dublin, College Green, Dublin 2 D02 PN40, Ireland
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht and Utrecht University, Heidelberglaan 100, Utrecht 3584 CX, Netherlands
| | - David Nanchen
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Rue du Bugnon 44, Lausanne 1011, Switzerland
| | - Pedro Marques-Vidal
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
| | - Julien Vaucher
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne 1011, Switzerland
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Helmink MAG, Hageman SHJ, Visseren FLJ, de Ranitz-Greven WL, de Valk HW, van Sloten TT, Westerink J. Variability in benefit from intensive insulin therapy on cardiovascular events in individuals with type 1 diabetes: A post hoc analysis of the DCCT/EDIC study. Diabet Med 2023; 40:e15183. [PMID: 37470718 DOI: 10.1111/dme.15183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
AIM To evaluate presence of treatment effect heterogeneity of intensive insulin therapy (INT) on occurrence of major adverse cardiovascular events (MACE) in individuals with type 1 diabetes. METHODS In participants from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study, individual treatment effect of INT (≥3 daily insulin injections/insulin pump therapy) versus conventional therapy (once/twice daily insulin) on the risk of MACE was estimated using a penalized Cox regression model including treatment-by-covariate interaction terms. RESULTS In 1441 participants, 120 first MACE events were observed and 1279 individuals (89%) were predicted to benefit from INT with regard to MACE risk reduction. The study population was divided into four groups based on predicted treatment effect: one group with no predicted benefit and three tertiles with predicted treatment benefit. The median absolute reduction in 30-year risk of MACE across groups of predicted treatment effect ranged from -0.2% (i.e. risk increase; interquartile range [IQR] -0.1% to -0.3%) in the group with no predicted benefit to 6.6% (i.e. risk reduction; IQR 3.8%-10.9%; number needed to treat 15) in the highest tertile of predicted benefit. The observed benefit of preventing microvascular complications was stable across all subgroups of predicted MACE benefit. CONCLUSIONS Although INT reduces the risk of MACE in the majority of individuals with type 1 diabetes, benefit varies substantially. These individual differences in the effect of INT underline the necessity for a better understanding of the individual response to intensive treatment.
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Affiliation(s)
- Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Harold W de Valk
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas T van Sloten
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Isala Clinics, Zwolle, The Netherlands
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11
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Pennells L, Kaptoge S, Østergaard HB, Read SH, Carinci F, Franch-Nadal J, Petitjean C, Taylor O, Hageman SHJ, Xu Z, Shi F, Spackman S, Gualdi S, Holman N, Da Providencia E Costa RB, Bonnet F, Brenner H, Gillum RF, Kiechl S, Lawlor DA, Potier L, Schöttker B, Sofat R, Völzke H, Willeit J, Baltane Z, Fava S, Janos S, Lavens A, Pildava S, Poljicanin T, Pristas I, Rossing P, Sascha R, Scheidt-Nave C, Stotl I, Tibor G, Urbančič-Rovan V, Vanherwegen AS, Vistisen D, Du Y, Walker MR, Willeit P, Ference B, De Bacquer D, Halle M, Huculeci R, McEvoy JW, Timmis A, Vardas P, Dorresteijn JAN, Graham I, Wood A, Eliasson B, Herrington W, Danesh J, Mauricio D, Benedetti MM, Sattar N, Visseren FLJ, Wild S, Di Angelantonio E, Balkau B, Bonnet F, Fumeron F, Stocker H, Holleczek B, Schipf S, Schmidt CO, Dörr M, Tilg H, Leitner C, Notdurfter M, Taylor J, Dale C, Prieto-Merino D, Gillum RF, Lavens A, Vanherwegen AS, Poljicanin T, Pristas I, Buble T, Ivanko P, Rossing P, Carstensen B, Heidemann C, Du Y, Scheidt-Nave C, Gall T, Sandor J, Baltane Z, Pildava S, Lepiksone J, Magri CJ, Azzopardi J, Stotl I, Real J, Vlacho B, Mata-Cases M. SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe. Eur Heart J 2023; 44:2544-2556. [PMID: 37247330 PMCID: PMC10361012 DOI: 10.1093/eurheartj/ehad260] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 05/31/2023] Open
Abstract
AIMS To develop and validate a recalibrated prediction model (SCORE2-Diabetes) to estimate the 10-year risk of cardiovascular disease (CVD) in individuals with type 2 diabetes in Europe. METHODS AND RESULTS SCORE2-Diabetes was developed by extending SCORE2 algorithms using individual-participant data from four large-scale datasets comprising 229 460 participants (43 706 CVD events) with type 2 diabetes and without previous CVD. Sex-specific competing risk-adjusted models were used including conventional risk factors (i.e. age, smoking, systolic blood pressure, total, and HDL-cholesterol), as well as diabetes-related variables (i.e. age at diabetes diagnosis, glycated haemoglobin [HbA1c] and creatinine-based estimated glomerular filtration rate [eGFR]). Models were recalibrated to CVD incidence in four European risk regions. External validation included 217 036 further individuals (38 602 CVD events), and showed good discrimination, and improvement over SCORE2 (C-index change from 0.009 to 0.031). Regional calibration was satisfactory. SCORE2-Diabetes risk predictions varied several-fold, depending on individuals' levels of diabetes-related factors. For example, in the moderate-risk region, the estimated 10-year CVD risk was 11% for a 60-year-old man, non-smoker, with type 2 diabetes, average conventional risk factors, HbA1c of 50 mmol/mol, eGFR of 90 mL/min/1.73 m2, and age at diabetes diagnosis of 60 years. By contrast, the estimated risk was 17% in a similar man, with HbA1c of 70 mmol/mol, eGFR of 60 mL/min/1.73 m2, and age at diabetes diagnosis of 50 years. For a woman with the same characteristics, the risk was 8% and 13%, respectively. CONCLUSION SCORE2-Diabetes, a new algorithm developed, calibrated, and validated to predict 10-year risk of CVD in individuals with type 2 diabetes, enhances identification of individuals at higher risk of developing CVD across Europe.
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12
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de Winter MA, Büller HR, Carrier M, Cohen AT, Hansen JB, Kaasjager KAH, Kakkar AK, Middeldorp S, Raskob GE, Sørensen HT, Visseren FLJ, Wells PS, Dorresteijn JAN, Nijkeuter M. Recurrent venous thromboembolism and bleeding with extended anticoagulation: the VTE-PREDICT risk score. Eur Heart J 2023; 44:1231-1244. [PMID: 36648242 PMCID: PMC10079391 DOI: 10.1093/eurheartj/ehac776] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/23/2022] [Accepted: 12/07/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Deciding to stop or continue anticoagulation for venous thromboembolism (VTE) after initial treatment is challenging, as individual risks of recurrence and bleeding are heterogeneous. The present study aimed to develop and externally validate models for predicting 5-year risks of recurrence and bleeding in patients with VTE without cancer who completed at least 3 months of initial treatment, which can be used to estimate individual absolute benefits and harms of extended anticoagulation. METHODS AND RESULTS Competing risk-adjusted models were derived to predict recurrent VTE and clinically relevant bleeding (non-major and major) using 14 readily available patient characteristics. The models were derived from combined individual patient data from the Bleeding Risk Study, Hokusai-VTE, PREFER-VTE, RE-MEDY, and RE-SONATE (n = 15,141, 220 recurrences, 189 bleeding events). External validity was assessed in the Danish VTE cohort, EINSTEIN-CHOICE, GARFIELD-VTE, MEGA, and Tromsø studies (n = 59 257, 2283 recurrences, 3335 bleeding events). Absolute treatment effects were estimated by combining the models with hazard ratios from trials and meta-analyses. External validation in different settings showed agreement between predicted and observed risks up to 5 years, with C-statistics ranging from 0.48-0.71 (recurrence) and 0.61-0.68 (bleeding). In the Danish VTE cohort, 5-year risks ranged from 4% to 19% for recurrent VTE and 1% -19% for bleeding. CONCLUSION The VTE-PREDICT risk score can be applied to estimate the effect of extended anticoagulant treatment for individual patients with VTE and to support shared decision-making.
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Affiliation(s)
- Maria A de Winter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam UMC, Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Rd, K1H8L6 Ottawa, Ontario, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas’ Hospitals, King's College London, Westminster Bridge Road, London, SE1 7EH, UK
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø and Thrombosis Research Center (TREC), Division of internal medicine, University hospital of North Norway, 9038, Tromsø, Norway
| | - Karin A H Kaasjager
- Department of Acute Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Ajay K Kakkar
- Thrombosis Research Institute London, 1B Manresa Road Chelsea, SW3 6LR, London, UK
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, The Netherlands
| | - Gary E Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, 801 N.E. 13th Street, Oklahoma City, OK 73104, USA
| | - Henrik T Sørensen
- Department of Clinical Medicine - Department of Clinical Epidemiology, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Philip S Wells
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Rd, K1H8L6 Ottawa, Ontario, Canada
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Mathilde Nijkeuter
- Department of Acute Internal Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
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13
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Tanaka JRV, Sousa KHJF, Alves PJP, Guerra MJJ, Gonçalves PDB. Educational Technology on Urinary Incontinence during Pregnancy: Development and Validation of an Online Course for the Brazilian Population. AQUICHAN 2023. [DOI: 10.5294/aqui.2023.23.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Objective: To describe the development and validation process of an online course on urinary incontinence during pregnancy in Brazil. Materials and methods: This methodological study followed an online course’s literature search, development, and validation steps. A total of 22 specialists participated in the validation step, and the content validity index (CVI) was used. Fifty-one Physical Therapy students (target audience) also participated in the Suitability Assessment of Materials. Results: The synthesis reached in the integrative review provided the basis for the course’s theoretical content, which was regarded as suitable by the specialists regarding its content, language, presentation, stimulation/motivation, and cultural adequacy (CVI = 0.99). The target audience considered the course organized, easily understandable, engaging, and motivational, with a positive response index ranging from 84.3 % to 100 %. Conclusions: The Brazilian version of the online course was considered sufficiently adequate in content and interface quality by both specialists and the target audience.
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Hageman SHJ, McKay AJ, Ueda P, Gunn LH, Jernberg T, Hagström E, Bhatt DL, Steg PG, Läll K, Mägi R, Gynnild MN, Ellekjær H, Saltvedt I, Tuñón J, Mahíllo I, Aceña Á, Kaminski K, Chlabicz M, Sawicka E, Tillman T, McEvoy JW, Di Angelantonio E, Graham I, De Bacquer D, Ray KK, Dorresteijn JAN, Visseren FLJ. Estimation of recurrent atherosclerotic cardiovascular event risk in patients with established cardiovascular disease: the updated SMART2 algorithm. Eur Heart J 2022; 43:1715-1727. [PMID: 35165703 PMCID: PMC9312860 DOI: 10.1093/eurheartj/ehac056] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/30/2021] [Accepted: 01/18/2022] [Indexed: 11/19/2022] Open
Abstract
AIMS The 10-year risk of recurrent atherosclerotic cardiovascular disease (ASCVD) events in patients with established ASCVD can be estimated with the Secondary Manifestations of ARTerial disease (SMART) risk score, and may help refine clinical management. To broaden generalizability across regions, we updated the existing tool (SMART2 risk score) and recalibrated it with regional incidence rates and assessed its performance in external populations. METHODS AND RESULTS Individuals with coronary artery disease, cerebrovascular disease, peripheral artery disease, or abdominal aortic aneurysms were included from the Utrecht Cardiovascular Cohort-SMART cohort [n = 8355; 1706 ASCVD events during a median follow-up of 8.2 years (interquartile range 4.2-12.5)] to derive a 10-year risk prediction model for recurrent ASCVD events (non-fatal myocardial infarction, non-fatal stroke, or cardiovascular mortality) using a Fine and Gray competing risk-adjusted model. The model was recalibrated to four regions across Europe, and to Asia (excluding Japan), Japan, Australia, North America, and Latin America using contemporary cohort data from each target region. External validation used data from seven cohorts [Clinical Practice Research Datalink, SWEDEHEART, the international REduction of Atherothrombosis for Continued Health (REACH) Registry, Estonian Biobank, Spanish Biomarkers in Acute Coronary Syndrome and Biomarkers in Acute Myocardial Infarction (BACS/BAMI), the Norwegian COgnitive Impairment After STroke, and Bialystok PLUS/Polaspire] and included 369 044 individuals with established ASCVD of whom 62 807 experienced an ASCVD event. C-statistics ranged from 0.605 [95% confidence interval (CI) 0.547-0.664] in BACS/BAMI to 0.772 (95% CI 0.659-0.886) in REACH Europe high-risk region. The clinical utility of the model was demonstrated across a range of clinically relevant treatment thresholds for intensified treatment options. CONCLUSION The SMART2 risk score provides an updated, validated tool for the prediction of recurrent ASCVD events in patients with established ASCVD across European and non-European populations. The use of this tool could allow for a more personalized approach to secondary prevention based upon quantitative rather than qualitative estimates of residual risk.
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Affiliation(s)
- Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ailsa J McKay
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Laura H Gunn
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Department of Public Health Sciences and School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Ph. Gabriel Steg
- French Alliance for Cardiovascular Trials, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, INSERM Unité, 1148 Paris, France
| | - Kristi Läll
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Reedik Mägi
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatrics, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - José Tuñón
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Autónoma University, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Ignacio Mahíllo
- Department of Epidemiology, Fundación Jiménez Díaz, Madrid, Spain
| | - Álvaro Aceña
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Autónoma University, Madrid, Spain
| | - Karol Kaminski
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
| | - Malgorzata Chlabicz
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Emilia Sawicka
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
- Department of Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Taavi Tillman
- Centre for Non-Communicable Disease, Institute for Global Health, University College London, London, UK
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, Galway, Ireland
- Galway Campus, National University of Ireland Galway, Galway, Ireland
| | - Emanuele Di Angelantonio
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ian Graham
- School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Dirk De Bacquer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
- Corresponding author. Tel: +31 88 7555161, Fax: +31 30 2523741,
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15
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Gynnild MN, Hageman SHJ, Dorresteijn JAN, Spigset O, Lydersen S, Wethal T, Saltvedt I, Visseren FLJ, Ellekjær H. Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention. Clin Epidemiol 2021; 13:813-823. [PMID: 34566434 PMCID: PMC8456548 DOI: 10.2147/clep.s322779] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/20/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Suboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets. PATIENTS AND METHODS The SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated. RESULTS In total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55-0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32-54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63-76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2-3.4) event-free life years if guideline targets were met. CONCLUSION Secondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.
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Affiliation(s)
- Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
| | - Torgeir Wethal
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatrics, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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de Vries TI, Cooney MT, Selmer RM, Hageman SHJ, Pennells LA, Wood A, Kaptoge S, Xu Z, Westerink J, Rabanal KS, Tell GS, Meyer HE, Igland J, Ariansen I, Matsushita K, Blaha MJ, Nambi V, Peters R, Beckett N, Antikainen R, Bulpitt CJ, Muller M, Emmelot-Vonk MH, Trompet S, Jukema W, Ference BA, Halle M, Timmis AD, Vardas PE, Dorresteijn JAN, De Bacquer D, Di Angelantonio E, Visseren FLJ, Graham IM. SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. Eur Heart J 2021; 42:2455-2467. [PMID: 34120185 PMCID: PMC8248997 DOI: 10.1093/eurheartj/ehab312] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/09/2021] [Accepted: 05/07/2021] [Indexed: 12/21/2022] Open
Abstract
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.
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Hageman S, Pennells L, Ojeda F, Kaptoge S, Kuulasmaa K, de Vries T, Xu Z, Kee F, Chung R, Wood A, McEvoy JW, Veronesi G, Bolton T, Achenbach S, Aleksandrova K, Amiano P, Sebastian DS, Amouyel P, Andersson J, Bakker SJL, Da Providencia Costa RB, Beulens JWJ, Blaha M, Bobak M, Boer JMA, Bonet C, Bonnet F, Boutron-Ruault MC, Braaten T, Brenner H, Brunner F, Brunner EJ, Brunström M, Buring J, Butterworth AS, Capkova N, Cesana G, Chrysohoou C, Colorado-Yohar S, Cook NR, Cooper C, Dahm CC, Davidson K, Dennison E, Di Castelnuovo A, Donfrancesco C, Dörr M, Doryńska A, Eliasson M, Engström G, Ferrari P, Ferrario M, Ford I, Fu M, Gansevoort RT, Giampaoli S, Gillum RF, Gómez de la Cámara A, Grassi G, Hansson PO, Huculeci R, Hveem K, Iacoviello L, Ikram MK, Jørgensen T, Joseph B, Jousilahti P, Wouter Jukema J, Kaaks R, Katzke V, Kavousi M, Kiechl S, Klotsche J, König W, Kronmal RA, Kubinova R, Kucharska-Newton A, Läll K, Lehmann N, Leistner D, Linneberg A, Pablos DL, Lorenz T, Lu W, Luksiene D, Lyngbakken M, Magnussen C, Malyutina S, Ibañez AM, Masala G, Mathiesen EB, Matsushita K, Meade TW, Melander O, Meyer HE, Moons KGM, Moreno-Iribas C, Muller D, Münzel T, Nikitin Y, Nordestgaard BG, Omland T, Onland C, Overvad K, Packard C, Pająk A, Palmieri L, Panagiotakos D, Panico S, Perez-Cornago A, Peters A, Pietilä A, Pikhart ,H, Psaty BM, Quarti-Trevano F, Garcia JRQ, Riboli E, Ridker PM, Rodriguez B, Rodriguez-Barranco M, Rosengren A, Roussel R, Sacerdote C, Sans S, Sattar N, Schiborn C, Schmidt B, Schöttker B, Schulze M, Schwartz JE, Selmer RM, Shea S, Shipley MJ, Sieri S, Söderberg S, Sofat R, Tamosiunas A, Thorand B, Tillmann T, Tjønneland A, Tong TYN, Trichopoulou A, Tumino R, Tunstall-Pedoe H, Tybjaerg-Hansen A, Tzoulaki J, van der Heijden A, van der Schouw YT, Verschuren WMM, Völzke H, Waldeyer C, Wareham NJ, Weiderpass E, Weidinger F, Wild P, Willeit J, Willeit P, Wilsgaard T, Woodward M, Zeller T, Zhang D, Zhou B, Dendale P, Ference BA, Halle M, Timmis A, Vardas P, Danesh J, Graham I, Salomaa V, Visseren F, De Bacquer D, Blankenberg S, Dorresteijn J, Di Angelantonio E. SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe. Eur Heart J 2021; 42:2439-2454. [PMID: 34120177 PMCID: PMC8248998 DOI: 10.1093/eurheartj/ehab309] [Citation(s) in RCA: 475] [Impact Index Per Article: 158.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/08/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022] Open
Abstract
AIMS The aim of this study was to develop, validate, and illustrate an updated prediction model (SCORE2) to estimate 10-year fatal and non-fatal cardiovascular disease (CVD) risk in individuals without previous CVD or diabetes aged 40-69 years in Europe. METHODS AND RESULTS We derived risk prediction models using individual-participant data from 45 cohorts in 13 countries (677 684 individuals, 30 121 CVD events). We used sex-specific and competing risk-adjusted models, including age, smoking status, systolic blood pressure, and total- and HDL-cholesterol. We defined four risk regions in Europe according to country-specific CVD mortality, recalibrating models to each region using expected incidences and risk factor distributions. Region-specific incidence was estimated using CVD mortality and incidence data on 10 776 466 individuals. For external validation, we analysed data from 25 additional cohorts in 15 European countries (1 133 181 individuals, 43 492 CVD events). After applying the derived risk prediction models to external validation cohorts, C-indices ranged from 0.67 (0.65-0.68) to 0.81 (0.76-0.86). Predicted CVD risk varied several-fold across European regions. For example, the estimated 10-year CVD risk for a 50-year-old smoker, with a systolic blood pressure of 140 mmHg, total cholesterol of 5.5 mmol/L, and HDL-cholesterol of 1.3 mmol/L, ranged from 5.9% for men in low-risk countries to 14.0% for men in very high-risk countries, and from 4.2% for women in low-risk countries to 13.7% for women in very high-risk countries. CONCLUSION SCORE2-a new algorithm derived, calibrated, and validated to predict 10-year risk of first-onset CVD in European populations-enhances the identification of individuals at higher risk of developing CVD across Europe.
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