Use of Framingham risk score and new biomarkers to predict cardiovascular mortality in older people: population based observational cohort study

Association of classic cardiovascular risk factors with myocardial infarction and ischemic stroke: A cross sectional analysis of the Shiraz Heart Study

Background

Myocardial infarction (MI) and ischemic stroke are the leading deadly clinical outcomes globally. This study aimed to investigate the association of classic cardiovascular risk factors with MI and ischemic stroke in a general population.

Methods

This cross-sectional study used the baseline data of the Shiraz Heart Study, a prospective cohort that investigate risk factors of coronary heart disease in a general population of Iran. Middle-aged citizens of 40-70 years old were included. Univariable and multivariable logistic regression analysis was performed to explore the association between sociodemographic, clinical, and metabolic factors and prevalent MI and stroke.

Results

Out of 7225 adults, 1.9 % (n = 135) had prior MI or stroke. Multiple logistic regression revealed that age≥60 years (aOR: 2.22, 95 % CI 1.45-3.20; P < 0.001), male sex (aOR: 3.82, 95 % CI 2.56-5.71; P < 0.001), history of hypertension (aOR: 1.71, 95 % CI 1.18-2.50; P < 0.005), history of hyperlipidemia (aOR: 2.42, 95 % CI 1.68-3.48; P < 0.001), having four 1st degree family members with sudden cardiac death (aOR: 26.28, 95 % CI 0.59-432.09; P < 0.022), and having a 1st degree family member with history of cardiovascular disease (aOR: 1.69, 95 % CI 1.13-2.54; P < 0.001) were associated with prior MI and stroke. Unlike high-density lipoprotein (P = 0.723) and triglyceride (P = 0.643), there were significant differences in the levels of fasting blood sugar (P < 0.001), total cholesterol (P < 0.001), and low-density lipoprotein (P < 0.001) between those with and without history of MI/stroke.

Conclusions

Being aged ≥60 years, history of hypertension and hyperlipidemia along with familial history of CVD and sudden cardiac death were in association with MI and stroke.

Steps to developing a DXA-based risk score for cardiovascular outcomes among older adults: the health, aging, and body composition study

Cardiovascular disease (CVD) is a major chronic disease worldwide and its risk factors have long been investigating in epidemiological studies. Our study aims to develop a body composition-based risk score and integrate it into the Framingham Risk Score (FRS) to improve CVD prediction among well-functioning older adults. We included 1882 older adults from the Health, Aging and Body Composition (Health ABC) study to screen body composition variables obtained from the Dual-energy X-ray absorptiometry (DXA). Three models were developed and compared: the 4-DXA model, the refit FRS, and the refit FRS plus 4-DXA model. C-statistics were 0.62 (95% CI: 0.59, 0.65) for the refit FRS, 0.58 (95% CI: 0.55, 0.61) for the 4-DXA model, and 0.63 (95% CI: 0.60, 0.66) for the refit FRS plus 4-DXA model. Compared to the refit FRS, the refit FRS plus 4-DXA model slightly improved CVD outcome prediction as the discrimination slope, net reclassification index, and the integrated discrimination index were 0.053 (95% CI: 0.041, 0.066), 0.098 (95% CI = - 0.0033, 0.20) and 0.013 (95% CI: 0.0069-0.019). This study provides a model for more accurate risk stratification and draws more attention on DXA-based indices in the clinical setting. It also encourages further research in validating the developed risk score in more diverse population and in investigating a broader range of CVD risk factors.

Optimizing Cardiovascular Health: A Comprehensive Review of Risk Assessment Strategies for Primary Prevention

Cardiovascular disease (CVD) is a leading global health concern, and effective primary prevention strategies are essential to mitigate its impact. This comprehensive review examines current risk assessment strategies for primary prevention of CVD, emphasizing the importance of early identification and intervention to reduce disease incidence. Traditional risk factors such as hypertension, hyperlipidemia, smoking, and lifestyle choices are discussed alongside emerging factors, including genetic predispositions and biomarkers. The review evaluates various risk assessment tools and models, such as the Framingham risk score, atherosclerotic CVD risk calculator, QRISK, and Reynolds risk score, highlighting their methodologies, strengths, and limitations. Additionally, the review explores lifestyle modifications, including dietary changes, physical activity, weight management, smoking cessation, and pharmacological interventions like statins and antihypertensives. Special considerations for different populations, including the elderly, women, and those with a family history of CVD, are addressed. Future directions in cardiovascular risk assessment are also discussed, focusing on technological advancements and personalized medicine. This review aims to enhance the implementation of effective primary prevention measures and improve cardiovascular health outcomes by providing a thorough analysis of risk assessment strategies.

From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion

Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.

Joint association of cardiovascular health and frailty with all-cause and cause-specific mortality: a prospective study

BACKGROUND

Poor cardiovascular health (CVH) and physical frailty were reported to increase mortality risk, but their joint effects have not been fully elucidated.

OBJECTIVES

We aimed to explore the separate and joint effects of CVH and frailty on mortality based on two perspectives of Life's Essential 8 (LE8) and Framingham Risk Score (FRS).

METHODS

21 062 participants in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018 were involved in this study. CVH was evaluated by the LE8 and FRS, and categorized into low, moderate and high CVH groups. Cox proportional hazard models were applied to estimate the separate and joint associations of CVH and frailty index (FI) with all-cause, cardiovascular disease (CVD) and cancer mortality.

RESULTS

Over a median follow-up period of 87 months (95% CI: 86.0-88.0), 2036 deaths occurred. The separate linear dose-response relationships between CVH, frailty and mortality were observed (nonlinear P > .05). The combination of low CVH/frailty was negatively associated with all-cause mortality [hazard ratio (HR) and 95%CI: low LE8*FI, 5.30 (3.74, 7.52); high FRS*FI, 4.34 (3.20, 5.88)], CVD mortality [low LE8*FI, 6.57 (3.54, 12.22); high FRS*FI, 7.29 (3.92, 13.55)] and cancer mortality [low LE8*FI, 1.99 (1.14, 3.25); high FRS*FI, 2.32 (1.30, 4.15)], with high CVH/fit group as reference. Further stratified analyses showed that the combined burden of mortality from frailty and low CVH was greater among the young and females.

CONCLUSIONS

Low CVH and frailty were independently and jointly correlated with greater risk of all-cause, CVD and cancer deaths, especially among the young and females.

A micronutrient supplement modulates homocysteine levels regardless of vitamin B biostatus in elderly subjects

Elevated homocysteine (Hcy) levels (≥15 μmol/L) in the elderly are frequently associated with a higher risk of cardiovascular disease and cognitive decline. Several studies have already shown an Hcy-lowering effect of B vitamin supplementation in cohorts deficient in these nutrients. The aim of this randomized, double-blinded 12-week intervention study was to investigate whether Hcy levels in healthy elderly subjects (75.4±4.5 years, n=133) could be lowered with a micronutrient supplement (i.e., 400 μg folic acid, 100 μg cobalamin). Difference in mean initial Hcy levels between intervention (17.6±7.1 μmol/L, n=65) and placebo group (18.9±6.1 μmol/L, n=68) was not significant. The prevalence of cobalamin and folate deficiency in the total study population was low: 27% had serum-cobalamin levels ≤150 pmol/L, 12% holo-transcobalamin (Holo-TC) levels ≤50 pmol/L, 13% low cobalamin status using the aggregated cobalamin marker 4cB12 and 10% red blood cell (RBC) folate ≤570 nmol/L. Nevertheless, the treated subjects still showed improved cobalamin and folate biostatus (serum cobalamin Δt12-t0: 63±48 pmol/L; Holo-TC Δt12-t0: 17±19 pmol/L; RBC folate Δt12-t0: 326±253 nmol/L) and Hcy levels (Δt12-t0: -3.6±5.7 μmol/L). The effects were statistically significant compared to the placebo group with p=0.005 (serum cobalamin), p=0.021 (Holo-TC), p=0.014 (RBC-folate) and p<0.001 (Hcy). The Hcy-lowering effect was dependent on the initial Hcy levels (p<0.001). Our findings suggest that elevated Hcy levels in elderly subjects can be lowered regardless of the initial cobalamin and folate biostatus.

Genetic, vascular and amyloid components of cerebral blood flow in a preclinical population

Aging-related cognitive decline can be accelerated by a combination of genetic factors, cardiovascular and cerebrovascular dysfunction, and amyloid-β burden. Whereas cerebral blood flow (CBF) has been studied as a potential early biomarker of cognitive decline, its normal variability in healthy elderly is less known. In this study, we investigated the contribution of genetic, vascular, and amyloid-β components of CBF in a cognitively unimpaired (CU) population of monozygotic older twins. We included 134 participants who underwent arterial spin labeling (ASL) MRI and [18F]flutemetamol amyloid-PET imaging at baseline and after a four-year follow-up. Generalized estimating equations were used to investigate the associations of amyloid burden and white matter hyperintensities with CBF. We showed that, in CU individuals, CBF: 1) has a genetic component, as within-pair similarities in CBF values were moderate and significant (ICC > 0.40); 2) is negatively associated with cerebrovascular damage; and 3) is positively associated with the interaction between cardiovascular risk scores and early amyloid-β burden, which may reflect a vascular compensatory response of CBF to early amyloid-β accumulation. These findings encourage future studies to account for multiple interactions with CBF in disease trajectory analyses.

Effect of exercise engagement and cardiovascular risk on neuronal injury

INTRODUCTION

Neuronal health as a potential underlying mechanism of the beneficial effects of exercise has been understudied in humans. Furthermore, there has been limited consideration of potential moderators (e.g., cardiovascular health) on the effects of exercise.

METHODS

Clinically normal middle-aged and older adults completed a validated questionnaire about exercise engagement over a 10-year period (n = 75; age 63 ± 8 years). A composite estimate of neuronal injury was formulated that included cerebrospinal fluid-based measures of visinin-like protein-1, neurogranin, synaptosomal-associated protein 25, and neurofilament light chain. Cardiovascular risk was estimated using the Framingham Risk Score.

RESULTS

Cross-sectional analyses showed that greater exercise engagement was associated with less neuronal injury in the group with lower cardiovascular risk (p = 0.008), but not the group with higher cardiovascular risk (p = 0.209).

DISCUSSION

Cardiovascular risk is an important moderator to consider when examining the effects of exercise on cognitive and neural health, and may be relevant to personalized exercise recommendations.

HIGHLIGHTS

We examined the association between exercise engagement and neuronal injury. Vascular risk moderated the association between exercise and neuronal injury. Cardiovascular risk may be relevant to personalized exercise recommendations.

Cholesterol alone or in combination is associated with frailty among community-dwelling older adults: A cross-sectional study

BACKGROUND

Biological markers contribute to the precise intervention across the continuum of frailty severity. Few studies have explored the advantages of biological markers collected as part of primary care data among community-dwelling older adult population and controversy remains regarding the classic biological markers for frailty.

METHODS

We recruited a total of 8791 adults with a mean age of 71.95 years who met the inclusion and exclusion criteria in Guancheng District and Dalang Town, Dongguan, China. Frailty was assessed by a Chinese frailty evaluation scale. Frailty status was classified with 33-item modified frailty index and latent class analysis was applied to explore the latent classes (subtypes) of frailty. We measured biological markers on blood samples collected. We identify association between specific biological markers or patterns and frailty by logistic regression and association rule mining (ARM) based on the Apriori algorithm.

RESULTS

Multivariable analysis of our data showed that an elevated white blood cell (WBC) count and high cholesterol (CHOL) level were associated with pre-frailty (adjusted odds ratio [aOR] = 1.231, 95 % confidence interval [CI] = 1.009-1.501; aOR = 0.703, 95 % CI = 0.623-0.793) and frailty (aOR = 1.500, 95 % CI = 1.130-1.993; aOR = 0.561, 95 % CI = 0.461-0.684) compared with the normal groups. Importantly, significantly high level of CHOL was associated with a lower risk of four frailty subtypes compared with relatively healthy participants with the most power of association in the multi-frail group (aOR = 0.182, 95 % CI = 0.086-0.386). Based on ARM technique to develop correlation analysis to identify important high-risk clusters among older adult transitions from non-frail to frailty, patterns for normal level of CHOL co-occurred with an elevated creatinine (CREA) level have a significant association with the risk of frailty (aOR = 7.787, 95 % CI = 1.978-30.648) after adjusting for targeted confounders.

CONCLUSIONS

Our study highlights the correlation between classic biological markers, especially CHOL and frailty status and subtypes among community-dwelling older adult, in the primary care setting. Further large-scale prospective studies are still needed to confirm the role of classic biological markers in frailty.

The outcome of frailty in older people with diabetes as a function of glycaemic control and hypoglycaemic therapy: a review

INTRODUCTION

Frailty is an emerging and newly recognized complication of diabetes in older people. However, frailty is not thoroughly investigated in diabetes outcome studies.

AREAS COVERED

This manuscript reviews the effect of glycemic control and hypoglycemic therapy on the incidence of frailty in older people with diabetes.

EXPERT OPINION

Current studies show that both low glycemia and high glycemia are associated with frailty. However, most of the studies, especially low glycemia studies, are cross-sectional or retrospective, suggesting association, rather than causation, of frailty. In addition, frail patients in the low glycemia studies are characterized by lower body weight or lower body mass index (BMI), contrary to those in the high glycemia studies, who are either overweight or obese. This may suggest that frailty has a heterogeneous metabolic spectrum, starting with an anorexic malnourished (AM) phenotype at one end, which is associated with low glycemia and a sarcopenic obese (SO) phenotype on the other end, which is associated with high glycemia. The current little evidence suggests that poor glycemic control increases the risk of frailty, but there is a paucity of evidence to suggest that tight glycemic control would reduce the risk of incident frailty. Metformin is the only well-studied hypoglycemic agent, so far, to have a protective effect against frailty independent of glycemic control in the non-frail older people with diabetes. However, once frailty is developed, the choice of the best hypoglycemic agent for these patients will be affected by the metabolic phenotype of frailty. For example, sodium glucose transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) are appropriate in the SO phenotype due to their weight losing properties, while insulin therapy may be considered early in the AM phenotype due to its anabolic and weight gaining benefits. Future studies are still required to further investigate the metabolic effects of frailty on older people with diabetes, determine the most appropriate HbA1c target, and explore the most suitable hypoglycemic agent in each metabolic phenotype of frailty.

Can spirometry improve the performance of cardiovascular risk model in high-risk Eastern European countries?

Aims

Impaired lung function has been strongly associated with cardiovascular disease (CVD) events. We aimed to assess the additive prognostic value of spirometry indices to the risk estimation of CVD events in Eastern European populations in this study.

Methods

We randomly selected 14,061 individuals with a mean age of 59 ± 7.3 years without a previous history of cardiovascular and pulmonary diseases from population registers in the Czechia, Poland, and Lithuania. Predictive values of standardised Z-scores of forced expiratory volume measured in 1 s (FEV1), forced vital capacity (FVC), and FEV1 divided by height cubed (FEV1/ht3) were tested. Cox proportional hazards models were used to estimate hazard ratios (HRs) of CVD events of various spirometry indices over the Framingham Risk Score (FRS) model. The model performance was evaluated using Harrell's C-statistics, likelihood ratio tests, and Bayesian information criterion.

Results

All spirometry indices had a strong linear relation with the incidence of CVD events (HR ranged from 1.10 to 1.12 between indices). The model stratified by FEV1/ht3 tertiles had a stronger link with CVD events than FEV1 and FVC. The risk of CVD event for the lowest vs. highest FEV1/ht3 tertile among people with low FRS was higher (HR: 2.35; 95% confidence interval: 1.96-2.81) than among those with high FRS. The addition of spirometry indices showed a small but statistically significant improvement of the FRS model.

Conclusions

The addition of spirometry indices might improve the prediction of incident CVD events particularly in the low-risk group. FEV1/ht3 is a more sensitive predictor compared to other spirometry indices.

Impact of modifiable risk factors on prediction of 10-year cardiovascular disease utilizing framingham risk score in Southwest Iran

BACKGROUND

This cohort study was conducted to examine the association between modifiable risk factors, including hypertension, smoking, physical activity, diabetes, cholesterol, and high-density lipoprotein with Framingham risk score in the prediction of 10-year-risk of cardiovascular diseases (CVD) between men and women in an Arab community of Southwest Iran, Hoveyzeh.

MATERIALS AND METHODS

A total of 8,526 people aged 35-70 participated in this cohort study. Framingham was used to estimate the 10-year risk of CVD. Also, the linear regression models were used to assess the relationship between modifiable risk factors and the 10-year risk of CVD. Finally, the area under the receiver operating characteristic curve (AUC) was used to measure the ability of modifiable risk factors to predict the 10-year risk of CVD.

RESULTS

Our results of linear regression models showed that hypertension, smoking, PA, diabetes, cholesterol, and HDL were independently associated with the CVD risk in men and women. Also, AUC analysis showed that hypertension and diabetes have the largest AUC in men 0.841; 0.778 and in women 0.776; 0.715, respectively. However, physical activity had the highest AUC just in women 0.717.

CONCLUSION

Hypertension and diabetes in both gender and physical activity in women are the most important determinant for the prediction of CVD risk in Hoveyzeh. Our cohort study may be useful for adopting strategies to reduce CVD progression through lifestyle changes.

Inflammation biomarkers are associated with the incidence of cardiovascular disease: a meta-analysis

Background

Inflammation is a risk factor for cardiovascular disease (CVD), and particular inflammatory parameters can be used to predict the incidence of CVD. The aim of this study was to assess the association between fibrinogen (FIB), interleukin-6 (IL-6), C-reactive protein (CRP) and galectin-3 (Gal-3) and the risk of cardiovascular disease using meta-analysis.

Methods

PubMed, Embase, Scopus, and Web of Science databases were searched with the appropriate strategies to identify observational studies relevant to this meta-analysis. A random-effects model was used to combine inflammation factor-associated outcomes and cardiovascular disease outcomes, except in the case of galectin-3, where a fixed-effects model was used because of less heterogeneity. Location, age, type of cardiovascular disease, and sample size factors were used to explore heterogeneity in stratification and metaregression for subgroup analysis. A case-by-case literature exclusion approach was used for sensitivity analysis. The funnel plot and Begg's test were combined to assess publication bias.

Results

Thirty-three papers out of 11,456 were screened for inclusion in the analysis. Four inflammation biomarkers were significantly associated with the development of CVD: FIB (OR: 1.21, 95% CI: 1.15-1.27, P < 0.001; HR: 1.04, 95% CI: 1.00-1.07, P < 0.05), IL-6 (HR: 1.16, 95% CI: 1.10-1.22, P < 0.001), CRP (OR: 1.25, 95% CI: 1.15-1.35, P < 0.001; HR: 1.20, 95% CI: 1.14-1.25, P < 0.001) and Gal-3 (HR: 1.09, 95% CI: 1.05-1.14, P < 0.001). Location factors help explain the source of heterogeneity, and there is publication bias in the Gal-3 related literature.

Conclusion

Taken together, the current research evidence suggests that high levels of fibrinogen, interleukin-6, C-reactive protein and galectin-3 are risk factors for cardiovascular disease and can be used as biomarkers to predict the development of cardiovascular disease to some extent.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42023391844.

Is It Feasible to Predict Cardiovascular Risk among Healthy Vegans, Lacto-/Ovo-Vegetarians, Pescatarians, and Omnivores under Forty?

Guidelines for cardiovascular (CV) risk assessment among young adults are uncertain. Researchers are still looking for new tools for earlier diagnosis of cardiovascular diseases (CVD), the leading cause of mortality in the modern world. This study aimed to assess whether CV risk estimation is possible in groups of healthy individuals under the age of 40 on different dietary patterns (vegans-VEGAN (n = 48), lacto-/ovo-vegetarians-VEGE (n = 49), pescatarians-PESCA (n = 23), and omnivores-OMN (n = 35)) during the pandemic period. Four metrics containing selected risk classifiers were created, and participants were assessed using them. Groups including meat consumption showed increased CV risk predictions in the metrics assessment. The next analyzes showed statistically significant relationships between the results from the created metrics and selected non-basic biomarkers for ApoA1 (OMN group, p = 0.028), IL-6 (PESCA group, p = 0.048), HCY (VEGAN group, p = 0.05), and hsCRP (OMN + PESCA groups, p = 0.025). We found that predicting CV risk among healthy people under 40 adhering to different dietary patterns, taking into account basic and non-basic laboratory assessments and created metrics, is challenging but feasible. Furthermore, the OMN group appeared to be at the highest risk of increased CV risk in the future, while risk tended to be the lowest in the VEGAN group.

A Systematic Review and Meta-Analysis of Advanced Biomarkers for Predicting Incident Cardiovascular Disease among Asymptomatic Middle-Aged Adults

Cardiovascular disease (CVD) continues as the most important cause of mortality. Better risk screening and prediction are needed to reduce the cardiovascular disease burden. The aim of the study was to assess the role of serum biomarkers in the prediction of CVD among asymptomatic middle-aged adults with no prior CVD history. A systematic review and meta-analysis were carried out using literature from PubMed and following PRISMA reporting guidelines. Twenty-five studies met our inclusion criteria and were included in the systematic review. The most commonly studied biomarker was high-sensitivity C reactive protein (hs-CRP) (10 studies), which showed that higher hs-CRP levels are associated with an increased risk of subsequent CVD events and mortality. In addition, several less-studied biomarkers (N-terminal pro-brain natriuretic peptide (NT-proBNP), fibrinogen, gamma-glutamyl transferase (GGT), and others) also showed significant associations with greater future risk of CVD. A meta-analysis was possible to perform for hs-CRP and NT-proBNP, which showed statistically significant results for the ability of hs-CRP (hazard ratio (HR) 1.19, (95% CI: 1.09−1.30), p < 0.05) and NT-proBNP (HR 1.22, (1.13−1.32), p < 0.05) to predict incident CVD among middle-aged adults without a prior CVD history or symptoms. Several serum biomarkers, particularly hs-CRP and NT-proBNP, have the potential to improve primary CVD risk prevention among asymptomatic middle-aged adults.

Plasma homocysteine and macular thickness in older adults-the Rugao Longevity and Aging Study

OBJECTIVES

To determine the association of plasma homocysteine levels with retinal layer thickness in a large community cohort of older adults.

METHODS

The Rugao Longevity and Ageing Study is an observational, prospective and community-based cohort study. A total of 989 older adults who underwent spectral-domain optical coherence tomography (SD-OCT) were included and analyzed. Foveal, macular retinal nerve fibre layer (mRNFL) and ganglion cell layer plus inner plexiform layer (GC-IPL) thicknesses were measured by SD-OCT. Plasma homocysteine levels were measured using chemiluminescence immunoassay. Linear regression analyses were performed to evaluate the relationship between plasma homocysteine and retinal layer thickness while controlling for confounding factors.

RESULTS

Of the 989 participants, 500 (50.56%) were men. The mean age was 78.26 (4.58) years, and the mean plasma homocysteine level was 16.38 (8.05) μmol/L. In multivariable analyses, each unit increase in plasma homocysteine was associated with an 8.84 × 10^-2 (95% CI: -16.54 × 10^-2 to -1.15 × 10^-2, p = 0.032) μm decrease in the average inner thickness of the GC-IPL after controlling for confounding factors. The association remained significant even in participants without major cardiovascular disease or diabetes (β = -10.33 × 10^-2, 95% CI: -18.49 × 10^-2 to -2.18 × 10^-2, p = 0.013). No significant associations of plasma homocysteine levels with macular thickness or mRNFL were found in primary and sensitivity analyses (p > 0.05).

CONCLUSIONS

Increased plasma homocysteine levels are associated with a thinner GC-IPL. Plasma homocysteine may be a risk factor for thinner retinas in older adults.

Associations Between High-Sensitivity C-Reactive Protein and All-Cause Mortality Among Oldest-Old in Chinese Longevity Areas: A Community-Based Cohort Study

Background

The association between high-sensitivity C-reactive protein (hsCRP) levels and all-cause mortality for the oldest-old (aged 80 years or older) remains unclear. We aimed to investigate the associations between hsCRP concentrations and the risks of all-cause mortality, and further identify the potential modifying factors affecting these associations among the oldest-old.

Methods

This prospective, community-based cohort study included 2,206 participants aged 80 years or older (median age 93.0 years) from the Healthy Aging and Biomarkers Cohort Study. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) with 95% confidential intervals (95% CIs) for all-cause mortality according to hsCRP quartiles and recommendation for relative risk categories of hsCRP levels (< 1.0, 1.0–3.0, and > 3.0 mg/L), with adjustment for sociodemographic information, lifestyle, physical examination, medical history, and other potential confounders.

Results

During a median follow-up period of 3.1 years (IQR: 1.6–3.9 years), 1,106 deaths were verified. After full adjustment for potential confounders, a higher hsCRP concentration was positively associated with an increased risk of all-cause mortality (P for trend < 0.001). Compared with the lowest quartile, the fully adjusted HRs of the second, third, and fourth quartiles were 1.17 (95% CI: 0.94, 1.46), 1.28 (95% CI: 1.01, 1.61), and 1.49 (95% CI: 1.20, 1.87), respectively. The association of hsCRP with all-cause mortality was modified by smoking status (P for interaction = 0.011), an increased risk of hsCRP with all-cause mortality showed among non-current smokers (HR: 1.17; 95% CI: 1.07, 1.28), but no significance was observed in current smokers (HR: 0.83; 95% CI: 0.66, 1.18).

Conclusions

Our study indicated that elevated hsCRP concentrations were associated with a higher risk of all-cause mortality among Chinese oldest-old. Future studies investigating additional factors of disease and aging processes are needed to obtain a better understanding of the mechanisms.

Prevalence of hyperhomocysteinemia (HHcy) and its major determinants among hypertensive patients over 35 years of age

OBJECTIVE

Hyperhomocysteinemia (HHcy) and hypertension are associated with cardiovascular events. However, effects of Hcy-lowing interventions on cardiovascular outcome were conflicting. Serum folate level was proposed to be a possible determinant of efficacy of extra folate supplementation on cardiovascular outcome. The aims of the present study were to describe representative information on the levels of serum homocysteine and folate in hypertensive patients, and to explore the major determinants of HHcy.

METHODS

11,007 participants with hypertension were analyzed in this cross-sectional study. Blood pressure and serum levels of biochemical indicators were measured. Multivariate logistic regression model was used to assess the associated factors of HHcy.

RESULTS

Geometric mean of serum total homocysteine was 14.1 (95% CI: 13.9, 14.4) μmol/L and prevalence of HHcy was 36.1 (95% CI: 34.0, 38.1) % in hypertensive patients. HHcy was strongly associated with factors including male sex, older age, elevated serum creatinine (SCr), lower serum folate and vitamin B12, and uncontrolled blood pressure in hypertensive patients. Elevated SCr attributed to HHcy with the etiologic fraction of 0.29. The change of the odds ratio of HHcy associated with folate was significantly higher in patients with elevated SCr compared with that of patients with normal SCr.

CONCLUSION

The results suggested the protection of female sex and higher levels of folate and vitamin B12 from HHcy and attribution of older age and elevated SCr to HHcy. Restoring renal function deserved attention for hypertensive patients to benefit from Hcy-lowing measures.

The interaction of hypertension and homocysteine increases the risk of mortality among middle-aged and older population in the United States

OBJECTIVES

To investigate the interaction of hypertension and total plasma homocysteine (tHcy) levels on risk of all-cause and cardiovascular disease (CVD) mortality among middle-aged and older population.

METHODS

This observational cohort study analyzed data from the National Health and Nutrition Examination Survey database (1999-2002 survey cycle). A generalized additive model (GAM) based on Cox proportional hazards models was applied to estimate the relationship of tHcy level with all-cause and CVD mortality. Stratification analyses by sex and renal function were performed.

RESULTS

Among 5724 individuals aged 40-85, 704 (12.3%) died, with 339 CVD deaths after a median follow-up period of 5.58 years. Mean age was 60.7 ± 13.4 years (49.6% men). In the fully adjusted model, we found that per 1 μmol/l increment of plasma tHcy was associated with 8% increased risk of all-cause mortality and 7% increased risk of CVD mortality in hypertensive participants. The adjusted hazard ratio (95% CIs) for all-cause and CVD mortality were 1.08 (1.06-1.10) and 1.07 (1.04-1.10), respectively. There were pronounced interactive effects between hypertension and tHcy levels on risk of all-cause mortality (P for interaction = 0.031).

CONCLUSION

Hypertension and tHcy levels can interactively affect the risk of all-cause mortality among middle-aged and older population. Conceivably, hypertension may further enhance the ability of elevated tHcy to provoke the risk of all-cause mortality.

Noninvasive Aortic Ultrafast Pulse Wave Velocity Associated With Framingham Risk Model: in vivo Feasibility Study

Background

Aortic pulse wave velocity (PWV) enables the direct assessment of aortic stiffness, which is an independent risk factor of cardiovascular (CV) events. The aim of this study is to evaluate the association between aortic PWV and CV risk model classified into three groups based on the Framingham risk score (FRS), i.e., low-risk (&lt;10%), intermediate-risk (10~20%) and high-risk (&gt;20%).

Methods

To noninvasively estimate local PWV in an abdominal aorta, a high-spatiotemporal resolution PWV measurement method (&gt;1 kHz) based on wide field-of-view ultrafast curved array imaging (ufcPWV) is proposed. In the ufcPWV measurement, a new aortic wall motion tracking algorithm based on adaptive reference frame update is performed to compensate errors from temporally accumulated out-of-plane motion. In addition, an aortic pressure waveform is simultaneously measured by applanation tonometry, and a theoretical PWV based on the Bramwell-Hill model (bhPWV) is derived. A total of 69 subjects (aged 23–86 years) according to the CV risk model were enrolled and examined with abdominal ultrasound scan.

Results

The ufcPWV was significantly correlated with bhPWV (r = 0.847, p &lt; 0.01), and it showed a statistically significant difference between low- and intermediate-risk groups (5.3 ± 1.1 vs. 8.3 ± 3.1 m/s, p &lt; 0.01), and low- and high-risk groups (5.3 ± 1.1 vs. 10.8 ± 2.5 m/s, p &lt; 0.01) while there is no significant difference between intermediate- and high-risk groups (8.3 ± 3.1 vs. 10.8 ± 2.5 m/s, p = 0.121). Moreover, it showed a significant difference between two evaluation groups [low- (&lt;10%) vs. higher-risk group (≥10%)] (5.3 ± 1.1 vs. 9.4 ± 3.1 m/s, p &lt; 0.01) when the intermediate- and high-risk groups were merged into a higher-risk group.

Conclusion

This feasibility study based on CV risk model demonstrated that the aortic ufcPWV measurement has the potential to be a new approach to overcome the limitations of conventional systemic measurement methods in the assessment of aortic stiffness.

Absolute Cardiovascular Disease Risk Assessed in Old Age Predicts Disability and Mortality: A Retrospective Cohort Study of Community-Dwelling Older Adults

Background

Evidence is limited on the predictive validity of absolute cardiovascular disease (CVD) risk, estimated by multivariable assessments in old age, for disability and mortality. We aimed to examine the longitudinal associations of absolute CVD risk assessed using region‐specific risk estimation charts with disability and mortality among community‐dwelling people aged ≥65 years.

Methods and Results

This retrospective cohort study included 7456 community‐dwelling people aged ≥65 years (mean age, 73.7 years) without CVD and functional decline at baseline. They lived in either Obu City or Midori Ward of Nagoya City, Aichi Prefecture, Japan. We estimated absolute CVD risk using the revised World Health Organization CVD risk estimation charts and stratified risk levels into 3 categories: low (<10%), mid (10% to <20%), and high (≥20%). We followed up the functional disability incidence and all‐cause mortality monthly for 5 years. The prevalence of each CVD risk level based on the laboratory‐based model was as follows: low CVD risk, 1096 (14.7%); mid CVD risk, 5510 (73.9%); and high CVD risk, 850 (11.4%). During follow‐up, the incidence rates of disability and mortality were 33.4 per 1000 and 12.4 per 1000 person‐years, respectively. Cox regression analysis showed that the adjusted hazard ratios (95% CIs) for disability incidence were 1.32 (1.13–1.56) and 1.44 (1.18–1.77) in mid and high CVD risk levels, respectively (reference: low CVD risk level); for mortality incidence, they were 1.53 (1.16–2.01) and 2.02 (1.45–2.80) in mid and high CVD risk levels, respectively (reference: low CVD risk level).

Conclusions

Absolute CVD risk was associated with both disability and mortality in people aged ≥65 years. Estimated CVD risk levels may be useful surrogate markers for disability and mortality risks even when assessed in old age.

Homocysteine, hypertension, and risks of cardiovascular events and all-cause death in the Chinese elderly population: a prospective study

BACKGROUND

Increased homocysteine levels are associated with the risk of cardiovascular disease (CVD) and death. However, their prevention has not been effective in decreasing CVD risk. This study investigated the individual and combined associations of hyperhomocysteinemia and hypertension with incident CVD events and all-cause death in the Chinese elderly population without a history of CVD.

METHODS

This prospective study was conducted among 1,257 elderly participants (mean age: 69 years). A questionnaire survey, physical examinations, and laboratory tests were conducted to collect baseline data. Hyperhomocysteinemia was defined as homocysteine level ≥ 15 µmol/L. H-type hypertension was defined as concomitant hypertension and hyperhomocysteinemia. Multivariate Cox regression analysis was used to evaluate individual and combined associations of hyperhomocysteinemia and hypertension with the risks of incident CVD events and all-cause death.

RESULTS

Over a median of 4.84-year follow-up, hyperhomocysteinemia was independently associated with incident CVD events and all-cause death. The hazard ratios (HRs) were 1.45 (95% CI: 1.01−2.08) for incident CVD events and 1.55 (95% CI: 1.04−2.30) for all-cause death. After adjustment for confounding factors, H-type hypertension had the highest HRs for incident CVD events and all-cause death. The fully adjusted HRs were 2.44 for incident CVD events (95% CI: 1.28−4.65), 2.07 for stroke events (95% CI: 1.01−4.29), 8.33 for coronary events (95% CI: 1.10−63.11), and 2.31 for all-cause death (95% CI: 1.15−4.62).

CONCLUSIONS

Hyperhomocysteinemia was an independent risk factor, and when accompanied by hypertension, it contributed to incident CVD events and all-cause death in the Chinese elderly population without a history of CVD.

Malnutrition risk and its association with adverse outcomes in a Belgian cohort of community-dwelling adults aged 80 years and over

Objectives: To investigate the prevalence of malnutrition risk and its association with adverse outcomes in a Belgian cohort of community-dwelling adults aged ≥80 years, a worldwide growing age-group.Methods: In the BELFRAIL cohort, malnutrition risk was evaluated with the Mini Nutritional Assessment (MNA total score <24) and prealbumin levels (<20 mg/dl). Agreement between them was assessed with Kohen's kappa coefficient. Association with first unplanned hospitalization (3.0 ± 0.25 years follow-up) and mortality (5.1 ± 0.25 years follow-up) was investigated with survival analysis and Cox multivariate regression.Results: Out of 567 BELFRAIL participants, 556 (98.1%) had MNA and 545 (96.1%) prealbumin levels. Sixty-eight (12.2%) were at risk of malnutrition based on MNA and 69 (12.7%) based on prealbumin, with very poor agreement between them (Kappa = 0.024, 95% CI -0.064, 0.112). For both MNA and prealbumin, participants with malnutrition risk had lower physical and cognitive performance tests' scores. They had no higher risk for first hospitalization compared to those without malnutrition risk, but higher risk for all-cause mortality even after adjustment for multimorbidity, inflammation, physical and mental functioning (HR 1.35 95%CI 0.92-1.97 for MNA; HR 1.46; 95%CI 1.01-2.12 for prealbumin).Conclusion: Malnutrition risk based on MNA or prealbumin was low in a Belgian cohort of community-dwelling adults aged ≥80 years. Physical and cognitive performance was lower in those with malnutrition risk, but malnutrition risk was not independently associated with hospitalization and mortality (except for malnutrition risk by prealbumin). Further research needs to investigate the best tool to assess malnutrition risk in this age group.

Prediction of Cardiovascular Disease Risk Accounting for Future Initiation of Statin Treatment

Cardiovascular disease (CVD) risk-prediction models are used to identify high-risk individuals and guide statin initiation. However, these models are usually derived from individuals who might initiate statins during follow-up. We present a simple approach to address statin initiation to predict “statin-naive” CVD risk. We analyzed primary care data (2004–2017) from the UK Clinical Practice Research Datalink for 1,678,727 individuals (aged 40–85 years) without CVD or statin treatment history at study entry. We derived age- and sex-specific prediction models including conventional risk factors and a time-dependent effect of statin initiation constrained to 25% risk reduction (from trial results). We compared predictive performance and measures of public-health impact (e.g., number needed to screen to prevent 1 event) against models ignoring statin initiation. During a median follow-up of 8.9 years, 103,163 individuals developed CVD. In models accounting for (versus ignoring) statin initiation, 10-year CVD risk predictions were slightly higher; predictive performance was moderately improved. However, few individuals were reclassified to a high-risk threshold, resulting in negligible improvements in number needed to screen to prevent 1 event. In conclusion, incorporating statin effects from trial results into risk-prediction models enables statin-naive CVD risk estimation and provides moderate gains in predictive ability but had a limited impact on treatment decision-making under current guidelines in this population.

Cardiovascular risk in the elderly population of Spain. The EPICARDIAN risk score

BACKGROUND AND OBJECTIVES

Cardiovascular risk estimation in people over 70 years of age is problematic. Most scores have been created based on cohorts of middle-aged people, with an underrepresentation of older adults. The predictive power of classical cardiovascular risk factors declines with age. The aim of this work is to develop a specific score for estimating cardiovascular risk among the elderly population in Spain.

METHODS

This work is a population-based cohort established in 1995.

SETTING

Three geographical areas of Spain (Madrid, Ávila, and Lugo).

PARTICIPANTS

3,729 people older than 64 years with no cardiovascular diseases (CVD) at baseline.

MEASUREMENTS

Suspected fatal and nonfatal CVD (both coronary heart disease and stroke) were investigated annually and confirmed using the WHO-MONICA criteria. All participants were followed-up on until occurrence of a first CVD event, until death, or until December 31, 2015.

RESULTS

Age was the strongest predictor of CVD at 10 years in both men and women. In men, variables associated with CVD were high blood pressure treatment (HR: 1.35; 95% CI: 1.067-1.710), diabetes (HR: 1.359; 95% CI: 0.997-1.852), and smoking (HR: 1.207; 95% CI: 0.945-1.541) and in women, the variables were smoking (HR: 1.881; 95% CI: 1.356-2.609) and diabetes (HR: 1.285; 95% CI: 0.967-1.707). Total cholesterol did not increase the risk of CVD in men or women. However, total cholesterol levels >200 mg/dL were inversely associated with 10-year risk of CVD in men and women.

CONCLUSIONS

In elderly Spanish men, total CVD at 10 years is significantly increased by age, diabetes, and antihypertensive treatment and in elderly Spanish women by diabetes and smoking. Total cholesterol levels did not increase the risk of CVD, particularly in males.

Preclinical carotid atherosclerosis as an indicator of polyvascular disease: a narrative review

Carotid atherosclerotic lesions are correlated with atherosclerotic deterioration of the arterial wall in other vascular territories and with cardiovascular events. The detection of pre-symptomatic carotid lesions like intima-media thickness (IMT) and asymptomatic carotid plaques is possible by non-invasive ultrasound duplex scanning. Current measurement guidelines suggest an average measurement of IMT within 10 mm of the segment of the common carotid artery. The thickening of intima-media appears in a long subclinical period of atherosclerosis. Therefore, the determination of IMT has emerged as one of the methods for determining early structural deterioration of the arterial wall. A close interrelationship was shown between IMT and risk factors of atherosclerosis, their duration, and intensity. Different studies demonstrated that increased IMT is a powerful predictor of coronary, cerebrovascular, and peripheral arterial occlusive disease and their complication. A recent meta-analysis indicated a minimal improvement in the risk estimation of cardiovascular events after adding IMT to the Framingham Risk Score. These findings influenced the latest ACC/AHA guidelines which again recommend the use of carotid IMT measurement for individual risk assessment. The presence of atherosclerotic plaques indicates that the atherosclerotic process is already ongoing. The findings of different studies are equivocal that carotid plaques independently predict cardiovascular events and improve risk predictions for coronary artery disease when added to the Framingham Risk Score. However, besides the size of plaque and grade of stenosis, the structure of plaque calcification, vascularization, lipid core, and the surface of plaques are important indicators of related risks for cardiovascular events.

Usefulness of Relative Handgrip Strength as a Simple Indicator of Cardiovascular Risk in Middle-Aged Koreans

BACKGROUND

Reduced muscular strength, measured by handgrip strength, has been associated with increased risk for cardiovascular disease (CVD) and mortality. However, the prognostic significance of handgrip strength has been less well-studied in the middle-aged Korean population. This study determined whether handgrip strength predicted 10-year CVD risk in this population and whether there is a sex-specific difference.

METHODS

The data were derived from the 2015 Korean National Health and Nutrition Examination Survey that included total of 2776 participants aged 40-69 years without prior history of CVD (men: 1184; women: 1592). Isometric relative handgrip strength was calculated by dividing absolute handgrip strength by body mass index. Participants were classified into three groups by their 10-year Framingham cardiovascular risk score: low (<10%), intermediate (10-19%), and high (≥20%).

RESULTS

In men, relative handgrip strength was higher in the absence of hypertension, dyslipidemia, and diabetes compared with in the presence of these CVD risk factors. In women, a higher relative handgrip strength was observed in the absence of hypertension and dyslipidemia but not in the absence of diabetes compared with their counterparts. Advanced age was inversely associated with relative handgrip strength for both sexes. Multivariate logistic regression analysis demonstrated that an increased relative handgrip strength was a significant and independent predictor of low 10-year CVD risk among middle-aged women (odds ratio range 0.09-0.49, p < 0.001), but not among men.

CONCLUSIONS

Handgrip strength is a simple and effective screening tool for risk stratification for CVD in middle-aged Korean women.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Analysis of Global Oxidative Status Using Multimarker Scores Reveals a Specific Association Between Renal Dysfunction and Diuretic Therapy in Older Adults

Aging and chronic kidney disease (CKD) are important interrelated cardiovascular risk (CVR) factors linked to oxidative stress, but this relationship has not been well studied in older adults. We assessed the global oxidative status in an older population with normal to severely impaired renal function. We determined the oxidative status of 93 older adults (mean age 85 years) using multimarker scores. OxyScore was computed as index of systemic oxidative damage by analyzing carbonyl groups, oxidized low-density lipoprotein, 8-hydroxy-2'-deoxyguanosine, and xanthine oxidase activity. AntioxyScore was computed as index of antioxidant defense by analyzing catalase and superoxide dismutase (SOD) activity and total antioxidant capacity. OxyScore and AntioxyScore were higher in subjects with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 than in peers with eGFR >60 mL/min/1.73 m2, with protein carbonyls, catalase, and SOD activity as major drivers. Older adults with a recent cardiovascular event had similar OxyScore and AntioxyScore as peers with eGFR >60 mL/min/1.73 m2. Multivariate linear regression analysis revealed that both indices were associated with decreased eGFR independently of traditional CVR factors. Interestingly, AntioxyScore was also associated with diuretic treatment, and a more pronounced increase was seen in subjects receiving combination therapy. The associations of AntioxyScore with diuretic treatment and eGFR were mutually independent. In conclusion, eGFR is the major contributor to the imbalance in oxidative stress in this older population. Given the association between oxidative stress, CKD, and CVR, the inclusion of renal function parameters in CVR estimators for older populations, such as the SCORE-OP, might improve their modest performance.

Dyslipidemia and prevention of atherosclerotic cardiovascular disease in the elderly

The atherosclerotic cardiovascular disease (ASCVD) represents the leading cause of death and disability in the elderly. The study of atherosclerosis and the strategies to control ASCVD are evolving. All strategies emphasize the need to lower LDL cholesterol (LDL-C) through an appropriate lifestyle and the use of lipid-lowering drugs, mainly statins. Available evidence coming from clinical trials is useful to inform clinical choices but the older people are poorly represented in those trials. Thus evidence supporting the benefit of statin therapy for primary and secondary prevention of fatal and nonfatal ASCVD events in adults aged 75 years and older are limited. The pharmacological therapy of dyslipidemia is recommended by guidelines provided by international expert panels in adults, while in the elderly it is still a matter of debate. Statins are generally well tolerated drugs but their use in the elderly, especially in fragile ones or with multi-pathology that take many other drugs, requires a careful evaluation of the risk-benefit ratio and a shared decision-making process between doctor and patient.

Cardiovascular risk profiles and 20-year mortality in older people: gender differences in the Pro.V.A. study

The age- and gender-related cardio-metabolic changes may limit the applicability of guidelines for the prevention of cardiovascular diseases (CVD) in older people. We investigated the association of cardiovascular risk profile with 20-year all-cause and CVD-mortality in older adults, focusing on age- and gender-specific differences. This prospective study involved 2895 community-dwelling individuals aged ≥65 years who participated in the Pro.V.A study. The sum of achieved target levels (smoking, diet, physical activity, body weight, blood pressure, lipids, and diabetes) recommended by the European Society of Cardiology 2016 guidelines was assessed in each participant. From this sum, cardiovascular risk profile was categorised as very high (0–2), high (3), medium (4), low (5), and very low (6–7 target levels achieved). All-cause and CV mortality data over 20 years were obtained from health registers. At Cox regression, lower cardiovascular risk profile was associated with reduced 20-year all-cause mortality in both genders, with stronger results for women (HR = 0.42 [95%CI:0.25–0.69] and HR = 0.61 [95%CI:0.42–0.89] for very low vs. very high cardiovascular risk profile in women and men, respectively). This trend was more marked for CVD mortality. Lower cardiovascular risk profile was associated with reduced all-cause and CVD mortality only in men < 75 years, while the associations persisted in the oldest old women. A lower cardiovascular risk profile, as defined by current guidelines, may reduce all-cause and CVD mortality in older people, with stronger and longer benefits in women. These findings suggest that personalised and life-course approaches considering gender and age differences may improve the delivery of preventive actions in older people.

Clinical Characteristics and Prognosis of Young Middle Eastern Adults with ST-Elevation Myocardial Infarction: One-Year Follow-Up

AIMS

Few studies have investigated premature ST-elevation myocardial infarction (STEMI) in the Middle East. We aimed to compare the clinical characteristics and one-year prognosis of young (<45 years) and older (≥45 years) Middle Eastern adults with STEMI.

METHODS AND MATERIAL

A total of 706 patients with STEMI, who were prospectively enrolled in the First Jordanian Percutaneous Coronary Intervention Registry, were stratified into two groups (<45 or ≥45 years). Baseline clinical variables and one-year major adverse cardiovascular events (MACE) were evaluated.

RESULTS

Young patients (<45 years) comprised 17.4% of STEMI patients (123 of 706). Compared with older patients (≥45 years), young patients were mostly male (96% vs 82%, P<0.001), smokers (86% vs 49%, P<0.001) and less likely to have multi-vessel disease (26% vs 44%, P=0.001). Anterior STEMI was the most common diagnosis and left anterior descending artery was the most common culprit vessel in both groups. There were no significant differences between the younger and older patients in in-hospital (20% vs 19%, P=0.12) and one-year MACE (24% vs 26%, P=0.68). However, none (0%) of the young died during one-year follow-up while 21 (4%) of the older patients died (P=0.036).

CONCLUSIONS

Young adult patients in the Middle East with STEMI are more likely to be smoking men with multiple risk factors and single vessel disease by angiography. Although, younger patients had similar one-year MACE to older patients, their mortality rate appears to be better. A larger study is warranted to investigate this vulnerable group of patients to prevent future events.

Identification of Mortality Risks in the Advancement of Old Age: Application of Proportional Hazard Models Based on the Stepwise Variable Selection and the Bayesian Model Averaging Approach

Identifying factors that affect mortality requires a robust statistical approach. This study’s objective is to assess an optimal set of variables that are independently associated with the mortality risk of 433 older comorbid adults that have been discharged from the geriatric ward. We used both the stepwise backward variable selection and the iterative Bayesian model averaging (BMA) approaches to the Cox proportional hazards models. Potential predictors of the mortality rate were based on a broad range of clinical data; functional and laboratory tests, including geriatric nutritional risk index (GNRI); lymphocyte count; vitamin D, and the age-weighted Charlson comorbidity index. The results of the multivariable analysis identified seven explanatory variables that are independently associated with the length of survival. The mortality rate was higher in males than in females; it increased with the comorbidity level and C-reactive proteins plasma level but was negatively affected by a person’s mobility, GNRI and lymphocyte count, as well as the vitamin D plasma level.

Progress in the risk assessment of hydroxychloroquine in frail elderly people

Hydroxychloroquine (HCQ) is an antimalarial drug also known to have anti-inflammatory and antiviral effects. The antiviral action of HCQ has been a point of interest for many researchers because of its mechanism of action and the potential use it could have during the current COVID-19 pandemic. However, HCQ can cause QT interval prolongation. The current therapies used in COVID-19 are changing as the pandemic develops. The aim of this article is to promote a validated risk score for QT prolongation in multidimensional assessment of COVID-19 patients, especially in elderly and polypathological patients.

The incremental value of angiographic features for predicting recurrent cardiovascular events: Insights from the Duke Databank for Cardiovascular Disease

BACKGROUND AND AIMS

Identifying patient subgroups with cardiovascular disease (CVD) at highest risk for recurrent events remains challenging. Angiographic features may provide incremental value in risk prediction beyond clinical characteristics.

METHODS

We included all cardiac catheterization patients from the Duke Databank for Cardiovascular Disease with significant coronary artery disease (CAD; 07/01/2007-12/31/2012) and an outpatient follow-up visit with a primary care physician or cardiologist in the same health system within 3 months post-catheterization. Follow-up occurred for 3 years for the primary major adverse cardiovascular event endpoint (time to all-cause death, myocardial infarction [MI], or stroke). A multivariable model to predict recurrent events was developed based on clinical variables only, then adding angiographic variables from the catheterization. Next, we compared discrimination of clinical vs. clinical plus angiographic risk prediction models.

RESULTS

Among 3366 patients with angiographically-defined CAD, 633 (19.2%) experienced cardiovascular events (death, MI, or stroke) within 3 years. A multivariable model including 18 baseline clinical factors and initial revascularization had modest ability to predict future atherosclerotic cardiovascular disease events (c-statistic = 0.716). Among angiographic predictors, number of diseased vessels, left main stenosis, left anterior descending stenosis, and the Duke CAD Index had the highest value for secondary risk prediction; however, the clinical plus angiographic model only slightly improved discrimination (c-statistic = 0.724; delta 0.008). The net benefit for angiographic features was also small, with a relative integrated discrimination improvement of 0.05 (95% confidence interval: 0.03-0.08).

CONCLUSIONS

The inclusion of coronary angiographic features added little incremental value in secondary risk prediction beyond clinical characteristics.

Cardiovascular Risk Prediction using JBS3 Tool: A Kerala based Study

Background:

Accuracy of Joint British Society calculator3 (JBS3) cardiovascular (CV) risk assessment tool may vary across the Indian states, which is not verified in south Indian, Kerala based population.

Objectives:

To evaluate the traditional risk factors (TRFs) based CV risk estimation done in Kerala based population.

Methods:

This cross-sectional study uses details of 977 subjects aged between 30 and 80 years, recorded from the medical archives of clinical locations at Ernakulum district, in Kerala. The risk categories used are Low (<7.5%), Intermediate (≥7.5% and <20%), and High (≥20%) 10-year risk classifications. The lifetime classifications are Low lifetime (≤39%) and High lifetime (≥40%) are used. The study evaluated using statistical analysis; the Chi-square test was used for dependent and categorical CV risk variable comparisons. A multivariate ordinal logistic regression analysis for the 10-year risk and odds logistic regression analysis for the lifetime risk model identified the significant risk variables.

Results:

The mean age of the study population is 52.56±11.43 years. With 39.1% in low, 25.0% in intermediate, and 35.9% has high 10-year risk. Low lifetime risk with 41.1%, the high lifetime risk has 58.9% subjects. The intermediate 10-year risk category shows the highest reclassifications to High lifetime risk. The Hosmer-Lemeshow goodness-of-fit statistics indicates a good model fit.

Conclusion:

Timely interventions using risk predictions can aid in appropriate therapeutic and lifestyle modifications useful for primary prevention. Precaution to avoid short-term incidences and reclassifications to a high lifetime risk can reduce the CVD related mortality rates.

Cardiovascular Risk Calculators and their Applicability to South Asians

BACKGROUND

Estimation of absolute cardiovascular disease (CVD) risk and tailoring therapies according to the estimated risk is a fundamental concept in the primary prevention of CVD is assessed in this study. Numerous CVD risk scores are currently available for use in various populations but unfortunately, none exist for South Asians who have much higher CVD risk as compared to their western counterparts.

METHODS

A literature search was done using PubMed and Google search engines to prepare a narrative review on this topic.

RESULTS

Various currently available CVD risk scores and their pros and cons are summarized. The studies performed in native as well as migrant South Asians evaluating the accuracy of these risk scores for estimation of CVD risk are also summarized. The findings of these studies have generally been inconsistent, but it appears that the British risk scores (e.g. QRISK versions) may be more accurate because of inclusion of migrant South Asians in the derivation of these risk scores. However, the lack of any prospective study precludes our ability to draw any firm conclusions. Finally, the potential solution to these challenges, including the role of recalibration and subclinical atherosclerosis imaging, is also discussed.

CONCLUSION

This review highlights the need to develop large, representative, prospectively followed databases of South Asians providing information on various CVD risk factors and their contribution to incident CVD. Such databases will not only allow the development of validated CVD risk scores for South Asians but will also enable application of machine-learning approaches to provide personalized solutions to CVD risk assessment and management in these populations.

Cardiovascular risk prediction using physical performance measures in COPD: results from a multicentre observational study

OBJECTIVES

Although cardiovascular disease (CVD) is a common comorbidity associated with chronic obstructive pulmonary disease (COPD), it is unknown how to improve prediction of cardiovascular (CV) risk in individuals with COPD. Traditional CV risk scores have been tested in different populations but not uniquely in COPD. The potential of alternative markers to improve CV risk prediction in individuals with COPD is unknown. We aimed to determine the predictive value of conventional CVD risk factors in COPD and to determine if additional markers improve prediction beyond conventional factors.

DESIGN

Data from the Evaluation of the Role of Inflammation in Chronic Airways disease cohort, which enrolled 729 individuals with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage II-IV COPD were used. Linked hospital episode statistics and survival data were prospectively collected for a median 4.6 years of follow-up.

SETTING

Five UK centres interested in COPD.

PARTICIPANTS

Population-based sample including 714 individuals with spirometry-defined COPD, smoked at least 10 pack years and who were clinically stable for >4 weeks.

INTERVENTIONS

Baseline measurements included aortic pulse wave velocity (aPWV), carotid intima-media thickness (CIMT), C reactive protein (CRP), fibrinogen, spirometry and Body mass index, airflow Obstruction, Dyspnoea and Exercise capacity (BODE) Index, 6 min walk test (6MWT) and 4 m gait speed (4MGS) test.

PRIMARY AND SECONDARY OUTCOME MEASURES

New occurrence (first event) of fatal or non-fatal hospitalised CVD, and all-cause and cause-specific mortality.

RESULTS

Out of 714 participants, 192 (27%) had CV hospitalisation and 6 died due to CVD. The overall CV risk model C-statistic was 0.689 (95% CI 0.688 to 0.691). aPWV and CIMT neither had an association with study outcome nor improved model prediction. CRP, fibrinogen, GOLD stage, BODE Index, 4MGS and 6MWT were associated with the outcome, independently of conventional risk factors (p<0.05 for all). However, only 6MWT improved model discrimination (C=0.727, 95% CI 0.726 to 0.728).

CONCLUSION

Poor physical performance defined by the 6MWT improves prediction of CV hospitalisation in individuals with COPD.

TRIAL REGISTRATION NUMBER

ID 11101.

Functional principal component based landmark analysis for the effects of longitudinal cholesterol profiles on the risk of coronary heart disease

Patients' longitudinal biomarker changing patterns are crucial factors for their disease progression. In this research, we apply functional principal component analysis techniques to extract these changing patterns and use them as predictors in landmark models for dynamic prediction. The time-varying effects of risk factors along a sequence of landmark times are smoothed by a supermodel to borrow information from neighbor time intervals. This results in more stable estimation and more clear demonstration of the time-varying effects. Compared with the traditional landmark analysis, simulation studies show our proposed approach results in lower prediction error rates and higher area under receiver operating characteristic curve (AUC) values, which indicate better ability to discriminate between subjects with different risk levels. We apply our method to data from the Framingham Heart Study, using longitudinal total cholesterol (TC) levels to predict future coronary heart disease (CHD) risk profiles. Our approach not only obtains the overall trend of biomarker-related risk profiles, but also reveals different risk patterns that are not available from the traditional landmark analyses. Our results show that high cholesterol levels during young ages are more harmful than those in old ages. This demonstrates the importance of analyzing the age-dependent effects of TC on CHD risk.

Prospective associations between ECG abnormalities and death or myocardial infarction in a cohort of 980 employed, middle-aged Swedish men

Background

In 1993, 1000 randomly selected employed Swedish men aged 45–50 years were invited to a nurse-led health examination with a survey on life style, fasting lab tests, and a 12-lead ECG. A repeat examination was offered in 1998. The ECGs were classified according to the Minnesota Code. Upon ethical approval, endpoints in terms of MI and death over 25 years were collected from Swedish national registers with the purpose of analyzing the independent association of ECG abnormalities as risk factors for myocardial infarction and death.

Results

Seventy-nine of 977 participants had at least one ECG abnormality 1993 or 1998.

One hundred participants had a first MI over the 25 years. Odds ratio for having an MI in the group that had one or more ECG abnormality compared with the group with two normal ECGs was estimated to 3.16. 95%CI (1.74; 5.73), p value 0.0001.

One hundred fifty-seven participants had died before 2019. For death, similarly no statistically significant difference was shown, OR 1.52, 95%CI (0.83; 2.76).

Conclusions

Our study suggests that presence of ST- and R-wave changes is associated with an independent 3–4-fold increased risk of MI after 25 years follow-up, but not of death. A 12-lead resting ECG should be included in any MI risk calculation on an individual level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43044-020-00114-9.

Lipoprotein(a) and cardiovascular death in oldest-old (≥80 years) patients with acute myocardial infarction: A prospective cohort study

BACKGROUND AND AIMS

Compared with what is known about the prognostic value of lipoprotein(a) [Lp(a)] in middle-aged patients with atherosclerotic cardiovascular disease (ASCVD), less is understood concerning the role of Lp(a) in oldest-old (≥80 years old) with ASCVD. The aim of the present study was to investigate the relationship between Lp(a) and cardiovascular death (CD) among the oldest-old with acute myocardial infarction (AMI).

METHODS

A total of 1008 patients with AMI, older than 80 years, were consecutively enrolled between January 2012 and August 2018. The clinical characteristics were collected and Lp(a) concentrations were measured by the immunoturbidimetric method at baseline. The relationship between plasma Lp(a) concentration (≤10 mg/dL, 10-30 mg/dL, >30 mg/dL) and CD was evaluated by Kaplan-Meier analysis and Cox proportional hazard models.

RESULTS

During an average of 36.26 months of follow-up, 287 CD occurred. Data showed that patients with high Lp(a) levels (>30 mg/dL) had the highest rate of CD (p < 0.05). Kaplan-Meier analysis showed that the high Lp(a) group had the lowest event-free survival rate in the oldest-old with AMI (p = 0.030). In addition, subjects with Lp(a) > 30 mg/dL had a 1.5-fold (95% confidence interval: 1.083-2.132) higher risk of CD compared with those with Lp(a) ≤10 mg/dL in fully adjusted Cox proportional hazards model.

CONCLUSIONS

The current data firstly showed that plasma Lp(a) concentration was associated with the risk of CD in oldest-old with AMI, suggesting that Lp(a) could be a useful adjunctive measurement in the evaluation of CD in this population.

Reduction in Chronic Disease Risk and Burden in a 70-Individual Cohort Through Modification of Health Behaviors

Introduction

Health risk factors, including lifestyle risks and health literacy, are known to contribute to the chronic disease epidemic. According to the Centers for Disease Control and Prevention (CDC), chronic diseases account for 90% of healthcare costs, morbidity, and mortality. In the United States, healthcare providers attempt to modulate a limited set of risks. However, chronic diseases continue to proliferate despite expansion of wellness programs and drugs to manage and prevent chronic conditions. Pandemics, exemplified by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), show that people in good health suffer mortality rates at 10% the rate compared to those with pre-existing chronic conditions. Healthcare costs and morbidity rates often parallel mortality rates. New root-cause risk and health tools that accommodate low health literacy and are linked to personalized health improvement care plans are needed to reverse the chronic disease epidemic. Reported here is a study on 70 manufacturing employees in the Midwest US using a personalized and group approach to chronic disease reversal and prevention which may also find utility in pandemic severity and policy decisions.

Methods

Health, lifestyle, behavior, and motivation data were collected on 70 individuals at the beginning of a nine-month disease reversal and prevention program. The data were updated every two to six months over the period. Inputs included information from a novel health risk assessment, serum biomarkers specific for chronic disease, and traditional medical information. Using all these data we generated robust, personalized, and modifiable care plans that were implemented by the participant and guided by a care team including health coaches and medical providers. Periodic renewal of profile data and biomarkers facilitated adjustment of care plans to optimize the path toward health goals set mutually by the participant and the care team.

Results

Ninety percent of participants experienced a favorable reduction in chronic disease biomarkers. The reduction in serum biomarkers coincided with a reduction in disease and risk attributes based on medical chart data and before and after interviews. Hemoglobin A1C, for example, lowered in all but one participant concomitant with reported improved energy and reduced need for medications in the majority of participants. Markers of inflammation lowered across the population. Most importantly each individual reported improvement in their overall health.

Conclusions

This simple, inexpensive, root-cause based risk and health approach generates a “do no harm” action plan that guides a care team, including the participant, on a path to improved health. The data demonstrate that changes in a novel risk calculator score coincide with changes in sensitive biomarkers for chronic disease. When the risks of an individual are reduced, the biomarkers reflect that change with self-reported wellbeing also improved. This program and process may be of value to society plagued with escalating levels of chronic disease and merits further study and implementation.

Quantification of homocysteine thiolactone in human saliva and urine by gas chromatography-mass spectrometry

Homocysteine thiolactone (HTL) is a chemically reactive thioester that has been implicated in cardiovascular disease. So far, its presence has been documented in human and mouse plasma and urine. Here, using a new method, we show that HTL is present in human saliva. The assay involves chloroform-methanol extraction of HTL, lyophilization, and derivatization with N-trimethylsilyl-N-methyl trifluoroacetamide (MSTFA) and trimethylchlorosilane (TMCS). The method is based on a gas chromatography coupled with mass spectrometry (GC-MS) and quantifies HTL in a linear range from 0.05 to 1 µmol L^-1 saliva and urine. The limit of quantification (LOQ) was 0.05 µmol L^-1. With respect to saliva specimen, the accuracy was 98.7-112.6%, and 90.2-100.5%, while the precision was 7.1-13.5% and 12.5-15.0% for the intra- and inter-day variation, respectively. In relation to urine samples, the accuracy was 91.9-110.9% and 91.2-103.3%, while the precision varied from 2.2% to 14.5% and 7.4% to 14.3% for intra- and inter-day measurements, respectively. Using this method, we show that in apparently healthy individuals (n = 18), HTL levels in saliva are not positively correlated with urinary HTL levels. Undoubtedly, larger population should be investigated to get more meaningful results.

High-Sensitivity Cardiac Troponin I Improves Cardiovascular Risk Prediction in Older Men: HIMS (The Health in Men Study)

Background

The Framingham Risk Score estimates the 10‐year risk of cardiovascular events. However, it performs poorly in older adults. We evaluated the incremental benefit of adding high‐sensitivity cardiac troponin I (hs‐cTnI) to the Framingham Risk Score.

Methods and Results

The HIMS (Health in Men Study) is a cohort study of community‐dwelling men aged 70 to 89 years in Western Australia. Participants were identified from the electoral roll, with a subset undergoing plasma analysis. Hs‐cTnI (Abbott Architect i2000SR) was measured in 1151 men without prior cardiovascular disease. The Western Australia Data Linkage System was used to identify incident cardiovascular events. After 10 years of follow‐up, 252 men (22%) had a cardiovascular event (CVE+) and 899 did not (CVE–). The Framingham Risk Score placed 148 (59%) CVE+ and 415 (46%) CVE– in the high‐risk category. In CVE– men, adding hs‐cTnI affected the risk categories of 244 (27.2%) men, with 64.8% appropriately reclassified to a lower and 35.2% to a higher category, which decreased the number of high‐risk men in the CVE– to 39%. In CVE+ men, adding hs‐cTnI affected the risk categories of 61 (24.2%), with 50.8% appropriately reclassified to a higher and 49.2% to a lower category and 82.5% remaining above the 15% risk treatment threshold. The net reclassification index was 0.305 (P<0.001). Adding hs‐cTnI increased the C‐statistic modestly from 0.588 (95% CI, 0.552–0.624) to 0.624 (95% CI, 0.589–0.659) and improved model fit (likelihood ratio test, P<0.001).

Conclusions

Adding hs‐cTnI to the Framingham Risk Score provided incremental prognostic benefit in older men, especially aiding reclassification of individuals into a lower risk category.

A novel colorimetric and fluorometric probe for biothiols based on MnO2 NFs-Rhodamine B system

Herein, a novel bimodal ratiometric probe for sensitive and selective detection of biothiols (including glutathione (GSH), cysteine (Cys) and homocysteine (Hcys)) was constructed, which was based on the redox reaction between manganese dioxide nanoflakes (MnO₂ NFs) and rhodamine (RhB) and biothiols. When MnO₂ NFs was added into RhB solution, RhB was oxidized to a series of derivatives, accompanying with the colorimetric color changing from purple to light pink and fluorescence changing from red to green. In the presence of GSH, Cys or Hcys, they could reduce MnO₂ NFs to Mn²⁺, thereby preventing the following oxidization of RhB and the corresponding color and fluorescence changes. The absorption intensity ratio and fluorescence intensity ratio showed good linear relationships with the concentrations of biothiols. The colorimetric detection limits for GSH, Cys and Hcys were 0.057 μM, 0.140 μM and 0.087 μM, respectively. And the fluorescence detection limits were 0.177 μM, 0.282 μM and 0.161 μM. More importantly, this probe was successfully applied to monitor the concentration of GSH/Cys/Hcys in human serum samples, with satisfactory recovery. Thus, this MnO₂ NFs-RhB platform can potentially be a candidate for the detection of biothiols.

Biomarkers versus traditional risk factors to predict cardiovascular events in very old adults: cross-validated prospective cohort study

OBJECTIVES

To test new cardiovascular (CV) risk models in very old adults with and without a history of CV disease (CVD), based on traditional risk factors and biomarkers.

DESIGN

Cross-validated prospective cohort study. The models were tested in the BELFRAIL Study and externally validated in the Leiden 85-plus Study.

SETTING

General practice, Belgium and The Netherlands.

PARTICIPANTS

The BELFRAIL cohort consisted of 266 patients aged 80 years or older without a history of CVD and 260 with a history of CVD. The Leiden 85-plus Study consisted of 264 patients aged 85 years without a history of CVD and 282 with a history of CVD.

OUTCOME MEASURES

The model with traditional risk factors and biomarkers, as well as the model using only biomarkers, was compared with the model with only traditional risk factors to predict 3-year CV morbidity and mortality. A competing-risk analysis was performed, and the continuous net reclassification improvement (NRI), integrated discrimination improvement (IDI) and net benefit were used to compare the predictive value of the different models.

RESULTS

Traditional risk factors poorly predicted CV mortality and morbidity. In participants without a history of CVD, adding N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) improved the prediction (NRI 0.56 (95% CI 0.16 to 0.99) and relative IDI 4.01 (95% CI 2.19 to 6.28)). In participants with a history of CVD, the NRI with the addition of NT-pro-BNP and high-sensitivity C reactive protein was 0.38 (95% CI 0.09 to 0.70), and the relative IDI was 0.53 (95% CI 0.23 to 0.90). Moreover, in participants without a history of CVD, NT-pro-BNP performed well as a stand-alone predictor (NRI 0.32 (95% CI -0.12 to 0.74) and relative IDI 3.44 (95% CI 1.56 to 6.09)).

CONCLUSIONS

This study tested new risk models to predict CV morbidity and mortality in very old adults. Especially, NT-pro-BNP showed a strong added predictive value. This opens perspectives for clinicians who are in need of an easily applicable strategy for CV risk prediction in very old adults.