Traditional risk factors and a Genetic Risk Score are associated with age of first acute coronary syndrome

Wellens Syndrome: prevalence, risk factors and coronary angiographic variation. A cross-sectional study

BACKGROUND

Wellens syndrome complicates acute coronary syndrome and, if unmanaged, can lead to immanent myocardial infarction. This study aimed towards determining the prevalence of Wellens syndrome among acute coronary syndrome patients while focusing on both types and identifying the associated risk factors, then exploring the variation in affected coronary arteries within patients fulfilling Wellens syndrome criteria.

METHODS

Implementing a descriptive cross sectional hospital based observational study design, at Ahmed Gasim Teaching Hospital for Cardiac Surgery and Renal Transplantation in Khartoum North, Sudan, the study was conducted following using a non probability convenience sampling of patients fitting the inclusion criteria. Data was collected using closed ended structured questionnaires. Ethical clearance was obtained from relevant authorities. Statistical analysis was done using descriptive and comparative data analysis with the aid of the SPSS software, and STROBE guidelines were followed.

RESULTS

A total of 120 patients were included, 70 males and 50 females, majority in their fifth decade. 14 patients had no documented risk factors. 42.5% had STEMI, 34.2% had NSTEMI and 23.3% had unstable angina. Patients fulfilling Wellens syndrome criteria were 18 (15%), 55.6% of them were type A and 44.4% were type B. Most frequently encountered risk factor among Wellens syndrome patients was Diabetes (50%). Out of 16 Wellens syndrome patients who underwent coronary angiography, 50% had mid LAD involvement, most were type A; 25% had proximal LAD involvement and 25% had normal coronary angiography. There was some association between Wellens syndrome and NSTEMI, but no significant association with any specific risk factor.

CONCLUSION

Wellens syndrome complicates 15% of acute coronary syndrome patients with a 55.6% possibility of becoming type A, it can present even without a specific predisposing risk factor and coronary angiographic variation other than the proximal part of the LAD artery may occur, including multiple vessels involvement. This is a descriptive cross sectional study conducted at Ahmed Gasim Teaching Hospital in Sudan, to determine the prevalence and risk factors of Wellens syndrome. Data was collected using questionnaires and analyzed with the SPSS software. Out of 120 patients, 14 patients had no documented risk factors. 34.2% had NSTEMI and 23.3% had unstable angina. Patients fulfilling Wellens syndrome criteria were 18 (15%). The commonest risk factor among Wellens syndrome patients was Diabetes (50%). 50% of Wellens syndrome patients had mid LAD involvement. The study concluded that Wellens syndrome is not rare, it can present without specific risk factor and coronary angiographic variation other than the proximal LAD artery can occur.

In-hospital risk stratification algorithm of Asian elderly patients

Limited research has been conducted in Asian elderly patients (aged 65 years and above) for in-hospital mortality prediction after an ST-segment elevation myocardial infarction (STEMI) using Deep Learning (DL) and Machine Learning (ML). We used DL and ML to predict in-hospital mortality in Asian elderly STEMI patients and compared it to a conventional risk score for myocardial infraction outcomes. Malaysia's National Cardiovascular Disease Registry comprises an ethnically diverse Asian elderly population (3991 patients). 50 variables helped in establishing the in-hospital death prediction model. The TIMI score was used to predict mortality using DL and feature selection methods from ML algorithms. The main performance metric was the area under the receiver operating characteristic curve (AUC). The DL and ML model constructed using ML feature selection outperforms the conventional risk scoring score, TIMI (AUC 0.75). DL built from ML features (AUC ranging from 0.93 to 0.95) outscored DL built from all features (AUC 0.93). The TIMI score underestimates mortality in the elderly. TIMI predicts 18.4% higher mortality than the DL algorithm (44.7%). All ML feature selection algorithms identify age, fasting blood glucose, heart rate, Killip class, oral hypoglycemic agent, systolic blood pressure, and total cholesterol as common predictors of mortality in the elderly. In a multi-ethnic population, DL outperformed the TIMI risk score in classifying elderly STEMI patients. ML improves death prediction by identifying separate characteristics in older Asian populations. Continuous testing and validation will improve future risk classification, management, and results.

Association between lipid fractions and age of first myocardial infarction

OBJECTIVE

Dyslipidemia is a major cause of early coronary heart disease (CHD). Low-density-lipoprotein cholesterol (LDL-C), remnant cholesterol (remnant-C) and high-density lipoprotein cholesterol (HDL-C) have all been shown to be associated with risk of CHD. We aimed to compare the association of these lipid fractions with age at first myocardial infarction(MI). Design. Multicenter study of consecutive patients hospitalized with a first MI. Linear regression models were used to assess the independent association of LDL-C, remnant-C and HDL-C with age at first MI. Results. The study included 1744 patients. In univariate analyses, LDL-C, remnant-C, and HDL-C were all significantly associated with age at first MI. However, in multivariate analyses only LDL-C [-2.5 years (95%CI: -3.1 to -1.8) per 1 SD increase] and to a lesser extent remnant-C [-0.9 years (95% CI: -1.5 to -0.3)] continued to be associated with age of MI, while HDL-C [0.5 years (95%CI: -0.2 to 1.2)] was not. Conclusions. LDL-C is the lipid fraction strongest associated with younger age of presentation of first MI. These results support the importance of controlling and treating LDL-C in prevention of premature MI.

Genetic Risk Prediction for Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease: an Update

PURPOSE OF REVIEW

This review aims to summarize the research on genetic risk scores and their ability to improve risk prediction in both a primary and a secondary prevention population.

RECENT FINDINGS

Several groups have examined the role of genetic scores in different patient populations. Recent studies have capitalized on the growing number of identified genetic variants to construct polygenic risk scores that include hundreds and sometimes thousands of SNPs. Also, recent studies have demonstrated that individuals with high genetic risk scores can attenuate their risk with lifestyle modifications and with statins, for which the benefit of treatment may be greater in those at highest genetic risk. Genetic risk scores when added to existing clinical models appear to improve risk prediction, particularly in the setting of incident cardiovascular disease and may provide actionable information to optimize prevention early in life. Future research will need to establish how to best use this genetic risk information either as a means to further individualize treatment decisions or to better identify high-risk populations.

Polygenic Contribution in Individuals With Early-Onset Coronary Artery Disease

BACKGROUND

Despite evidence of high heritability, monogenic disorders are identified in a minor fraction of individuals with early-onset coronary artery disease (EOCAD). We hypothesized that some individuals with EOCAD carry a high number of common genetic risk variants, with a combined effect similar to Mendelian forms of coronary artery disease, such as familial hypercholesterolemia.

METHODS AND RESULTS

To confirm the polygenic contribution to EOCAD (age of ≤40 years for men and ≤45 years for women), we calculated in 111 418 British participants from the UK Biobank cohort a genetic risk score (GRS) based on the presence of 182 independent variants associated with coronary artery disease (GRS182). Participants with a diagnosis of EOCAD who underwent a revascularization procedure (n=96) had a significantly higher GRS182 (P=3.21×10^-9) than those without EOCAD. An increase of 1 SD in GRS182 corresponded to an odds ratio of 1.84 (1.52-2.24) for EOCAD. The prevalence of a polygenic contribution that increased EOCAD risk similar to what is observed in heterozygous familial hypercholesterolemia was estimated at 1 in 53. In a local cohort of individuals with EOCAD (n=30), GRS182 was significantly increased compared with UK Biobank controls (P=0.001). Seven participants (23%) had a GRS182 corresponding to an estimated 2-fold increase in EOCAD risk; none had a rare mutation involved in monogenic dyslipidemia or EOCAD.

CONCLUSIONS

These results suggest a significant polygenic contribution in individuals presenting with EOCAD, which could be more prevalent than familial hypercholesterolemia. Determination of the polygenic risk component could be included in the diagnostic workup of patients with EOCAD.

Prevalence of Conventional Cardiovascular Risk Factors in Patients with Acute Coronary Syndromes in Slovakia

BACKGROUND

Acute coronary syndrome (ACS) is a major health problem and the leading cause of death and disability in Slovakia. This is the first study to describe the prevalence rate of conventional cardiovascular risk factors in patients hospitalized for ACS.

METHODS

Hypertension, diabetes mellitus, hyperlipidemia and cigarette smoking were documented in 1,567 cases (mean age, SD: 66.1±12.0 years, 34.8% of females) enrolled in the SLOVAKS registry from August 2011 through September 2011.

RESULTS

Overall, 83.5% (95% CI, 81.6-85.2%) of the patients with ACS had hypertension, 65.0% (62.5-67.2%) had a hyperlipidemic profile, 32.6% (30.3-34.9%) were diagnosed with diabetes, and 27.6% (25.1-29.8%) were smokers at the time of a heart-related event. Only 5% of patients with ACS lacked any of the 4 conventional risk factors. Higher prevalence rates of all major risk factors, except smoking, were detected in women than in men, in older (≥65 years of age) than younger patients, and in rural (<2,000 inhabitants) than in urban areas. Premature ACS (<45 years of age) was associated with smoking in men, and smoking and hypertension in women. Smoking, in all risk factor combinations, reduced the age at the time of a heart-related event, on average, by 10.0 years in men and by 12.4 years in women.

CONCLUSION

The results of this study suggest an appreciable burden of major cardiovascular risk factors and also highlight differences that may aid the targeting of public health interventions.

Association Between Family History, a Genetic Risk Score, and Severity of Coronary Artery Disease in Patients With Premature Acute Coronary Syndromes

Objective—

A genetic risk score (GRS) for coronary artery disease has recently been shown to be independent of family history (FHx) in predicting future cardiovascular events. We sought to determine whether the presence of these risk factors, either individually or together, was associated with a higher burden of angiographic coronary artery disease.

Approach and Results—

We included 763 patients with premature acute coronary syndrome (median age, 50 [46–53] years; 30.8% women) with at least 1 major epicardial vessel stenosis enrolled in the Gender and Sex Determinants of Cardiovascular Disease From Bench to Beyond in Premature Acute Coronary Syndrome (GENESIS-PRAXY) study, a multicentre prospective cohort study of premature patients with acute coronary syndrome (aged ≤55 years). The prevalence of multivessel disease (ie, ≥2 vessels with >50% stenosis) in individuals with FHx was 49.7% as compared with 37.9% in those without FHx ( P <0.01 for comparison). In adjusted models for age, sex, traditional risk factors, and GRS, FHx was associated with a higher prevalence of 3-vessel disease (odds ratio [OR], 1.42; 95% confidence interval, 0.91–2.21; P =0.12 for 2-vessel disease and OR, 2.26; 95% confidence interval, 1.29–3.95; P =0.005 for 3-vessel disease). Individuals with a high GRS were also more likely to have multivessel disease (OR, 1.41; 95% confidence interval, 1.01–1.99; P =0.047) after adjustment for traditional risk factors, including FHx. Individuals with both a FHx and a high GRS as compared with those with neither had the highest ORs for multivessel disease (adjusted OR, 2.14; 95% confidence interval, 1.24–3.69; P =0.0064).

Conclusions—

In patients with premature acute coronary syndrome, the presence of either a high GRS or FHx is associated with greater severity of coronary artery disease at angiography. Whether preventive strategies targeted to genetically predisposed individuals will reduce the burden of early acute coronary syndrome warrants further study.

Translating Genomic Advances to Physical Therapist Practice: A Closer Look at the Nature and Nurture of Common Diseases

The Human Genome Project and the International HapMap Project have yielded new understanding of the influence of the human genome on health and disease, advancing health care in significant ways. In personalized medicine, genetic factors are used to identify disease risk and tailor preventive and therapeutic regimens. Insight into the genetic bases of cellular processes is revealing the causes of disease and effects of exercise. Many diseases known to have a major lifestyle contribution are highly influenced by common genetic variants. Genetic variants are associated with increased risk for common diseases such as cardiovascular disease and osteoarthritis. Exercise response also is influenced by genetic factors. Knowledge of genetic factors can help clinicians better understand interindividual differences in disease presentation, pain experience, and exercise response. Family health history is an important genetic tool and encourages clinicians to consider the wider client-family unit. Clinicians in this new era need to be prepared to guide patients and their families on a variety of genomics-related concerns, including genetic testing and other ethical, legal, or social issues. Thus, it is essential that clinicians reconsider the role of genetics in the preservation of wellness and risk for disease to identify ways to best optimize fitness, health, or recovery. Clinicians with knowledge of the influence of genetic variants on health and disease will be uniquely positioned to institute individualized lifestyle interventions, thereby fulfilling roles in prevention and wellness. This article describes how discoveries in genomics are rapidly evolving the understanding of health and disease by highlighting 2 conditions: cardiovascular disease and osteoarthritis. Genetic factors related to exercise effects also are considered.

Early-stage atherosclerosis in poloxamer 407-induced hyperlipidemic mice: pathological features and changes in the lipid composition of serum lipoprotein fractions and subfractions

Background

The aims of this study were to evaluate the effect of poloxamer 407 administration on atherogenic serum lipoprotein fractions and subfractions associated with cholesterol, triglycerides and phospholipids, as well as the onset of early atherosclerosis, in mice.

Methods

Mice were administered either sterile saline or poloxamer 407 (to induce a dose-controlled hyperlipidemia) for 1 month and then sacrificed at 1, 4 and 10 days after the last dose of poloxamer 407. Systolic and diastolic blood pressure, the activity of a cysteine protease (cathepsin B) in cardiac and liver tissue, and histological/morphological examination of heart and liver specimens was performed for each group of mice at each time point. Lastly, small angle X-ray scattering was utilized to analyze the lipoprotein fractions and subfractions associated with cholesterol, triglycerides and phospholipids for both groups of mice at each time point. Statistical analysis was performed using one-way, analysis-of-variance with post hoc analysis to determine significantly different mean values, while correlation analysis employed the Spearman test.

Results

Poloxamer 407-treated mice revealed significant hyperlipidemia, moderately elevated blood pressure, general lipidosis in liver cells, increased cysteine protease activity in heart tissue, and contractile-type changes in cardiomyocytes. Similar to humans, the onset of atherosclerosis in poloxamer 407-treated mice was characterized by a steady increase in serum low-density, intermediate-density and very-low-density lipoprotein fractions, as well as very-low-density lipoprotein subfractions.

Conclusions

We would propose that the sustained elevation of serum atherogenic lipoprotein fractions and subfractions induced by the administration of poloxamer 407 to mice resulted in the morphological changes we observed in both heart and liver cells, which are suggested to precede atherosclerosis, since this is a well-established mouse model of atherosclerosis. Since most of the cellular, biochemical and physiological changes documented in the present study using poloxamer 407-treated mice are related to the symptoms of early atherosclerosis in humans, it is suggested that the poloxamer 407-induced mouse model of hyperlipidemia and atherosclerosis might prove beneficial as an experimental animal model with which to evaluate the pathological features observed in early-stage atherosclerosis.

Meta-Analysis Comparing Rosuvastatin and Atorvastatin in Reducing Concentration of C-Reactive Protein in Patients With Hyperlipidemia

We conducted a meta-analysis of 13 randomized trials comparing the efficacy of rosuvastatin versus atorvastatin in reducing concentrations of C-reactive protein (CRP). We searched PubMed, Ovid, and Elsevier databases until June 2014. Search terms included C-reactive protein or CRP, rosuvastatin, atorvastatin, randomized, randomly, and randomization; 13 trials (3798 patients) were included. Funnel plots for CRP were inspected to assess publication bias. The pooled analysis demonstrated the benefit of rosuvastatin over atorvastatin therapy for all 13 trials (mean difference [MD] = −0.11, which is standardized mean with no unit although the raw data before pooling is mg/L, 95% confidence interval −0.15 to −0.07, P < .0001) with no evidence of significant publication bias (I2 = 6.9%, P = .377). Subgroup analysis indicated a significant benefit of rosuvastatin over atorvastatin regarding the 1/1 dose ratio (MD = −0.14, 95% CI −0.21 to −0.06) and 1/2 dose ratio (MD= −0.11, 95% CI −0.16 to −0.05). Cumulative and influence analyses showed accuracy and stability for the estimation mentioned earlier. Our meta-analysis shows that rosuvastatin produces better reduction in CRP concentrations than atorvastatin at a dose ratio of 1/1 and 1/2 (rosuvastatin/atorvastatin), respectively.

Coronary artery disease in the military patient

Ischaemic heart disease is the most common cause of sudden death in the UK, and the most common cardiac cause of medical discharge from the Armed Forces. This paper reviews current evidence pertaining to the diagnosis and management of coronary artery disease from a military perspective, encompassing stable angina and acute coronary syndromes. Emphasis is placed on the limitations inherent in the management of acute coronary syndromes in the deployed environment. Occupational issues affecting patients with coronary artery disease are reviewed. Consideration is also given to the potential for coronary artery disease screening in the military, and the management of modifiable cardiovascular disease risk factors, to help decrease the prevalence of coronary artery disease in the military population.