JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice

A UK multicentre audit of the management of patients with primary hypercholesterolaemia or mixed dyslipidaemia with bempedoic acid against published lipid-lowering treatment targets

Background

Bempedoic acid, an adenosine triphosphate citrate lyase inhibitor, was introduced to UK practice via a pre-reimbursement access scheme for adults with primary hypercholesterolaemia or mixed dyslipidaemia who are at high risk of cardiovascular disease, in whom statins are either not tolerated or contraindicated, who have not achieved target cholesterol, despite being on ezetimibe therapy, and do not qualify for PCSK9 inhibitor treatment. This retrospective multicentre audit aimed to evaluate the achievement of lipid-lowering targets with bempedoic acid in UK patients based on recommendations in the Joint British Societies (JBS) guidelines for the prevention of cardiovascular disease.

Methods

Pseudo-anonymized medical record data for 221 adults treated with bempedoic acid as part of the UK scheme were entered into a bespoke data collection tool at four UK hospitals. Patient demographics, clinical characteristics, treatment pathways and lipid assessment results (against JBS lipid-lowering targets) were collected against pre-specified criteria.

Results

Overall, 54% (99/184) of patients achieved the JBS2 audit standard (total cholesterol (TC) <5 mmol/L and low-density lipoprotein cholesterol (LDL-C) <3 mmol/L or ≥25% reduction in TC and ≥30% reduction in LDL-C) at 12 weeks post-initiation. At week 12, the mean absolute change in LDL-C was -1.0 mmol/L; the mean percentage reduction from baseline was 22.0%. Additionally, 52% (96/185) of patients had an LDL-C of <3 mmol/L and 10% (18/185) an LDL-C of <1.8 mmol/L at 12 weeks (as per JBS3).

Conclusion

This audit highlights the role of bempedoic acid as part of combination therapy for a population with previously limited treatment options.

The cost-effectiveness of a uniform versus age-based threshold for one-off screening for prevention of cardiovascular disease

The objective of this article was to assess the cost-effectiveness of screening strategies for cardiovascular diseases (CVD). A decision analytic model was constructed to estimate the costs and benefits of one-off screening strategies differentiated by screening age, sex and the threshold for initiating statin therapy ("uniform" or "age-adjusted") from the Spanish NHS perspective. The age-adjusted thresholds were configured so that the same number of people at high risk would be treated as under the uniform threshold. Health benefit was measured in quality-adjusted life years (QALY). Transition rates were estimated from the European Prospective Investigation into Cancer and Nutrition (EPIC-CVD), a large multicentre nested case-cohort study with 12 years of follow-up. Unit costs of primary care, hospitalizations and CVD care were taken from the Spanish health system. Univariate and probabilistic sensitivity analyses were employed. The comparator was no systematic screening program. The base case model showed that the most efficient one-off strategy is to screen both men and women at 40 years old using a uniform risk threshold for initiating statin treatment (Incremental Cost-Effectiveness Ratio of €3,274/QALY and €6,085/QALY for men and women, respectively). Re-allocating statin treatment towards younger individuals at high risk for their age and sex would not offset the benefit obtained using those same resources to treat older individuals. Results are sensitive to assumptions about CVD incidence rates. To conclude, one-off screening for CVD using a uniform risk threshold appears cost-effective compared with no systematic screening. These results should be evaluated in clinical studies.

Evidence supporting the choice of a new cardiovascular risk equation for Australia

This article reviews the risk equations recommended for use in international cardiovascular disease (CVD) primary prevention guidelines and assesses their suitability for use in Australia against a set of a priori defined selection criteria. The review and assessment were commissioned by the National Heart Foundation of Australia on behalf of the Australian Chronic Disease Prevention Alliance to inform recommendations on CVD risk estimation as part of the 2023 update of the Australian CVD risk assessment and management guidelines. Selected international risk equations were assessed against eight selection criteria: development using contemporary data; inclusion of established cardiovascular risk factors; inclusion of ethnicity and deprivation measures; prediction of a broad selection of fatal and non-fatal CVD outcomes; population representativeness; model performance; external validation in an Australian dataset; and the ability to be recalibrated or modified. Of the ten risk prediction equations reviewed, the New Zealand PREDICT equation met seven of the eight selection criteria, and met additional usability criteria aimed at assessing the ability to apply the risk equation in practice in Australia.

Quality Appraisal of Screening Guidelines for Cardiovascular disease Prevention:a scoping review.. [DOI: 10.1101/2023.08.05.23293686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective

Each nation develops a guideline for managing and preventing cardiovascular disease (CVD) based on the available literature and the evidence-based consensus in their guideline’s recommendations. The goal of this review is to appraise the quality of many guidelines recommended by several international organizations for the early detection and prevention of CVD.

Methods

We conducted a scoping review using a few guideline-specific databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as the reporting guideline for this review. We used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to rate the methodological quality and rigorousness of the included guidelines for CVD prevention and early detection.

Results

Out of the 2,466 guidelines identified by our search, based on our eligibility criteria, we included a total of 20 distinct guidelines globally focused on screening for CVD prevention and early detection. (70%) of these guidelines were classified as "strongly recommended" while only (90%) were classified as just "recommended". The AGREE II appraisal domains with the highest median scores (percentile 25th, 75th) were “Clarity of Presentation”92% (81, 95.5), followed by Applicability88% (73, 93). The Rigour of Development and Editorial Independence were the lowest scores with a median of78% (66.5, 84) and75% (60.5, 92).

Conclusions

Using AGREE II quality appraisal tool, we provided a critical quality appraisal of several international CVD prevention guidelines and reveal opportunities to improve the CVD prevention guidelines’ quality.

What is already known in this review?

Each community develops a guideline for screening and managing CVD prevention based on the current evidence and evidence-based consensus.

AGREE II tool is an internationally standardized instrument to report the rigorousness of development, transparency, and methodological quality of the clinical practice guidelines.

What this review adds

This review provided a critical quality appraisal of several international CVD prevention guidelines.

The highest AGREE II domain median score was “Clarity of Presentation” while the least domains were “Editorial Independence” and “Rigour of Development”.

70%of these guidelines were classified as "strongly recommended".

How this review might affect research, practice, or policy

This review provided a critical quality appraisal of many CVD prevention guidelines and revealed opportunities to improve CVD prevention guidelines’ quality.

Comparison of Screening Guidelines for Cardiovascular disease Prevention and Early Detection:a scoping review.. [DOI: 10.1101/2023.08.05.23293697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Objective

Globally, cardiovascular disease (CVD) has a significant role in morbidity and early death. This review’s objective is to provide a summary of the strengths and weaknesses in the variety of screening guidelines made by several international organizations for the early identification and prevention of CVD.

Methods

As the reporting guideline for this review, we used Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). We performed a scoping review using a few guideline-specific databases. We tabulated the main key differences between the included screening guidelines for CVD prevention and early detection from different perspectives.

Results

We included a total of 20 unique guidelines that were developed by various organizations throughout the world and focused on screening for CVD prevention and early detection out of the 2,466 guidelines discovered by our search based on our eligibility criteria. We concluded that the target populations, CVD risk assessment techniques, outcomes, and categories of the chosen CVD prevention guidelines widely varied. Additionally, some guidelines adopted no grading scheme for their evidence, while others did not advocate the use of any imaging screening tools in their evaluation of the CVD risk.

Conclusions

This scoping review highlights the areas of each guideline’s strengths and weaknesses and conducts a systematic comparison of a number of worldwide guidelines for CVD prevention and early diagnosis.

What is already known in this review?

Based on the most recent evidence and consensus among experts, each nation creates its own set of guidelines for the early detection and prevention of CVD.

What this review adds

This review conducted a systematic comparison and summarized the strengths and weaknesses of the various screening guidelines made by numerous international organizations for the early detection and prevention of CVD.

• How this review might affect research, practice or policy

This review provided opportunities to improve the future development of the clinical practice guidelines for CVD prevention and early detection.

Effects of Long-Term Intervention with Losartan, Aspirin and Atorvastatin on Vascular Remodeling in Juvenile Spontaneously Hypertensive Rats

Hypertension in adolescents is associated with adverse cardiac and vascular events. In addition to lowering blood pressure, it is not clear whether pharmacological therapy in early life can improve vascular remodeling. This study aimed to evaluate the effects of long-term administration of losartan, aspirin, and atorvastatin on vascular remodeling in juvenile spontaneously hypertensive rats (SHRs). Losartan, aspirin, and atorvastatin were administered via gavage at doses of 20, 10, and 10 mg/kg/day, respectively, on SHRs aged 6-22 weeks. Paraffin sections of the blood vessels were stained with hematoxylin-eosin (H&E) and Sirius Red to evaluate the changes in the vascular structure and the accumulation of different types of collagen. The plasma levels of renin, angiotensin II (Ang II), aldosterone (ALD), endothelin-1 (ET-1), interleukin-6 (IL-6), and neutrophil elastase (NE) were determined using ELISA kits. After the 16-week treatment with losartan, aspirin, and atorvastatin, the wall thickness of the thoracic aorta and carotid artery decreased. The integrity of the elastic fibers in the tunica media was maintained in an orderly manner, and collagen deposition in the adventitia was retarded. The plasma levels of renin, ALD, ET-1, IL-6, and NE in the SHRs also decreased. These findings suggest that losartan, aspirin, and atorvastatin could improve vascular remodeling beyond their antihypertensive, anti-inflammatory, and lipid-lowering effects. Many aspects of the protection provided by pharmacological therapy are important for the prevention of cardiovascular diseases in adults and older adults.

A peer support dietary change intervention for encouraging adoption and maintenance of the Mediterranean diet in a non-Mediterranean population (TEAM-MED): lessons learned and suggested improvements

Peer support interventions for dietary change may offer cost-effective alternatives to interventions led by health professionals. This process evaluation of a trial to encourage the adoption and maintenance of a Mediterranean diet in a Northern European population at high CVD risk (TEAM-MED) aimed to investigate the feasibility of implementing a group-based peer support intervention for dietary change, positive elements of the intervention and aspects that could be improved. Data on training and support for the peer supporters; intervention fidelity and acceptability; acceptability of data collection processes for the trial and reasons for withdrawal from the trial were considered. Data were collected from observations, questionnaires and interviews, with both peer supporters and trial participants. Peer supporters were recruited and trained to result in successful implementation of the intervention; all intended sessions were run, with the majority of elements included. Peer supporters were complimentary of the training, and positive comments from participants centred around the peer supporters, the intervention materials and the supportive nature of the group sessions. Attendance at the group sessions, however, waned over the intervention, with suggested effects on intervention engagement, enthusiasm and group cohesion. Reduced attendance was reportedly a result of meeting (in)frequency and organisational concerns, but increased social activities and group-based activities may also increase engagement, group cohesion and attendance. The peer support intervention was successfully implemented and tested, but improvements can be suggested and may enhance the successful nature of these types of interventions. Some consideration of personal preferences may also improve outcomes.

Antiplatelet and anticoagulant therapy in patients with submacular hemorrhage caused by neovascular age-related macular degeneration

Purpose

Patients with extensive submacular hemorrhage (SMH) caused by age-related macular degeneration (AMD) have a poor visual prognosis despite surgical intervention. Systemic blood-thinning drugs, which are commonly prescribed in the same age group, are known to increase the risk of severe hemorrhage in many parts of the body. This study aimed to investigate whether systemic blood-thinning drugs have an impact on the severity of SMH and if there are differences between the different types of blood-thinning medication.

Methods

We reviewed the medical records of patients who suffered from surgically treated SMH between 2020 and 2022. All patients received a full ophthalmologic examination upon presentation including best-corrected visual acuity (BCVA) and optical coherence tomography. Other characteristics that were recorded included size of hemorrhage, blood-thinning therapy, and reason for intake.

Results

A total of 115 patients with a mean age of 82 years were included in this retrospective analysis. Eighty-three patients (72.2%) were on blood-thinning therapy. The mean size of SMH was 32.01 mm2. Mean BCVA at initial presentation was 1.63 logMAR and 1.59 logMAR 1 year after surgery. The size of SMH was significantly larger in patients on blood-thinning medication (35.92 mm2 vs. 21.91 mm2) (p = 0.001) and their BCVA postoperatively was worse with 1.68 logMAR compared to 1.30 logMAR after 1 year (p = 0.503). Patients with vitamin K antagonists had larger SMH size and worse outcomes regarding BCVA compared to direct oral anticoagulants.

Conclusion

Blood thinners in patients with AMD affect the severity of SMH. Consequently, the indication for their intake should be critically evaluated.

Does Cardiovascular Disease Risk Decrease after Smoking Cessation in Occupational Risk Groups?

Objectives

Smoking cessation is very important for workers due to the possibility of exposure to additional environmental risks in the workplace environment. This study was performed to determine the changes in the Framingham Risk Score (FRS) and 10-year risk of cardiovascular disease (CVD) of employees before smoking cessation and after 6 months.

Materials and Methods

Five hundred and sixty-two employees who want to quit smoking were included in the study. In this prospective study, the baseline and 6-month FRS, and 10-year risk of CVD of workers were calculated. Furthermore, the Hospital Anxiety and Depression Scale was used for assessments of employees' anxiety and depression symptoms.

Results

After 6 months, 37% of the participants quit smoking. It was determined that 11.9% of employees have a high CVD risk and 10.6% moderate CVD risk. After 6 months, there was a statistically significant reduction in FRS who quit smoking (P < 0.001). In addition, within the 6 months after smoking cessation, 10-year coronary heart disease risk reduction was higher in quitters than those who cannot quit smoking (47.6% decrease in quitters and 14.9% in nonquitters, P < 0.001). Significant decreases in fasting blood glucose levels were determined after smoking cessation (P = 0.003).

Conclusions

The FRS and CVD risk of smoker employees were decreased 6 months after smoking cessation. In 6 months, CVD risk is reduced in almost half of those who quit smoking. Even in the short term, it is possible to reduce the CVD risk of a worker who quits smoking.

Adherence to secondary prevention recommendations after coronary artery bypass graft surgery

OBJECTIVE

This study was undertaken to assess and evaluate adherence to secondary prevention recommendations and risk factor modifications among a patient cohort at a single-tertiary centre in Ireland, following coronary artery bypass grafting (CABG).

METHODS

This is a retrospective observational study analysing patients who had CABG from 2015 to 2020, identified via the Adult Cardiac Surgery Database. Patients were asked a number of questions either over the phone or via postal survey, regarding blood pressure, cholesterol control, adherence to medication, attendance at cardiac-rehab and lifestyle factors. Any repeat interventions following CABG were noted.

RESULTS

A total of 540 patients were invited to take part in this study. One hundred seventy-three patients consented to participate, ranging from 47 to 86 years old. Postoperatively, 59% of participants attended cardiac rehab. 90.2% of patients report taking a statin, 91.3% report taking an antiplatelet, 77.4% report taking a β-blocker and 75.7% take an antihypertensive. 93.1% of patients questioned in this study reported full compliance with their daily medications. Sixteen patients continue to have hypertension despite their current regimen. Thirteen patients continue to have hypercholesterolemia despite their current prescription. 62.4% of participants have quit smoking with only 4.6% remaining current smokers. No patients required re-operation, and eight patients required stenting. Compliance with diet and exercise modifications was suboptimal.

CONCLUSION

In this patient population, adherence to medication and control of risk factors is acceptable. However, there is room for improvement in terms of attendance at cardiac rehab (59%) and maintenance of a healthy lifestyle post-CABG.

Prevalence of major electrocardiographic abnormalities in patients with hypertension in a primary care clinic in Hong Kong

Background

Hypertension is strongly associated with cardiovascular events. Studies have shown that electrocardiographic (ECG) abnormalities were associated with increased risks for cardiovascular events. However local data is limited. The objectives of this study were: (1) to determine the prevalence of major electrocardiographic abnormalities in patients with hypertension in primary care in Hong Kong, and (2) to determine the association of major electrocardiographic abnormalities with patients’ socio-economical background, cardiovascular disease and cardiovascular risk factors.

Methods

This was a cross-sectional study. Subjects were hypertensive patients aged between 18 and 80 who were enrolled in the Risk Assessment and Management Programme (RAMP) in a general outpatient clinic in Hong Kong. Outcome measures were prevalence of probable ischaemic heart disease (IHD), complete left bundle branch block (LBBB), left ventricular hypertrophy (LVH) and atrial fibrillation (AF) in patients with hypertension. The Pearson Chi-square test, independent t-test and Mantel–Haenszel test were used to measure the association between socioeconomic characteristics and cardiovascular risk factors, and ECG abnormalities.

Results

504 hypertensive patients aged 18–80 were recruited in a general outpatient clinic. 6.3% had probable IHD, 0.4% had complete LBBB, 4.0% had LVH and 1.0% had AF. Probable IHD was associated with smoking (P = 0.032), hypercholesterolaemia (P = 0.037) and higher 10-year CV risk (P = 0.04). Complete LBBB was associated with smoking (P = 0.021) and hypercholesterolaemia (P = 0.022). LVH was associated with male gender (P = 0.001) and longer duration of hypertension (P = 0.035). AF was not significantly associated with any of the clinical or sociodemographic parameters.

Conclusions

This study showed that a significant proportion of patients with hypertension at the primary care setting in Hong Kong had probable ischaemic heart disease, left ventricular hypertrophy and atrial fibrillation. This finding is consistent with both overseas data and historic data in Hong Kong. The detection of electrocardiographic abnormalities is helpful in hypertension management by improving risk stratification.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02662-1.

Contemporary Review of Risk Scores in Prediction of Coronary and Cardiovascular Deaths

PURPOSE OF REVIEW

Explore the current literature supporting risk stratification scores for prediction of coronary and cardiovascular disease deaths.

RECENT FINDINGS

Accurate risk prediction remains the foundation of management choice in primary prevention. When applied to new populations, the calibration of a predictive model will deteriorate, although discrimination changes minimally. One of the approaches with better performance and validation is the initial use of pooled cohort equation to identify low and high-risk patients, followed by coronary artery calcium scoring in those with borderline to intermediate risk. It is important to utilize a risk stratification tool that has been validated in a patient population that resembles the one used to develop the original tool to maintain adequate calibration. It is likely that the future of mortality risk prediction will develop in combined clinical risk predictors and cardiovascular imaging, such coronary artery calcium (CAC) scoring that renders the highest predictive accuracy.

Cardiovascular risk prediction equations underestimate risk in people living with HIV: Comparison and cut-point redefinition for 19 cardiovascular risk equations

BACKGROUND

Rates of cardiovascular disease are higher in people living with HIV. Early detection of high-risk subjects (applying cardiovascular risk equations) would allow preventive actions. D:A:D, ASCVD and FRS:CVD equations are the most recommended. However, controversies surround these equations and cut-points, which have the greatest capacity to discriminate high-risk subjects.

OBJECTIVES

The study aims (i) to assess the association/agreement between cardiovascular risk levels obtained with D:A:D and fifteen other cardiovascular risk equations, (ii) to detect cardiovascular risk equations capability to detect high-risk subjects, and (iii) to specify the optimal cardiovascular risk equation´s cut points for the prediction of carotid plaque presence, as a surrogate of high cardiovascular risk.

METHODS

86 adults with HIV were submitted to the clinical, laboratory and cardiovascular risk evaluation (including carotid ultrasound measurements). Cardiovascular risk was evaluated through multiple risk equations (e.g., D.A.D, ASCVD and FRS equations). Association and agreement between equations (Correlation, Bland-Altman, Williams´test) and equations capacity to detect plaque presence (ROC curves, sensitivity, specificity) were evaluated.

RESULTS

Cardiovascular risk equations showed a significant and positive correlation with plaque presence. Higher high-cardiovascular risk detection capability was obtained for ASCVD and D:A:D. Full D:A:D5y>0.88%, ASCVD>2.80% and FRS:CVD>2.77% correspond to a 80% sensitivity.

CONCLUSION

All cardiovascular risk equations underestimate the true risk in HIV subjects. The cut-points for high cardiovascular risk were found to vary greatly from recommended in clinical guidelines.

Statin treatment effectiveness and the SLCO1B1*5 reduced function genotype: long-term outcomes in women and men

Objective

To estimate the effect of rs4149056 (SLCO1B1*5) genotype (decreases statin transport) on cholesterol control and treatment duration in male and female primary care patients prescribed common statin medications.

Methods and Analysis

This study comprised 69 185 European‐ancestry UK Biobank cohort participants prescribed simvastatin or atorvastatin (aged 40‐79 years at first prescription, treatment duration 1 month to 29 years, mean 5.7 years). Principal outcomes were clinically high total cholesterol (>5 mmol/L) at baseline, plus treatment discontinuation.

Results

A total of 48.4% of 591 females homozygous for SLCO1B1*5 decreased function genotype had raised cholesterol vs 41.7% of those with functioning SLCO1B1 (odds ratio 1.31, 95% confidence interval [CI] 1.1‐1.55, P = .001). Fewer males had high cholesterol and the genotype effect was attenuated. In primary care prescribing, females homozygous for SLCO1B1*5 were more likely to stop receiving these statins (29.5%) than women with normal SLCO1B1 (25.7%) (hazard ratio [HR] 1.19, 95% CI 1.03‐1.37, P = .01), amounting to five discontinuations per 100 statin‐years in the SLCO1B1*5 group vs four in the normal SLCO1B1 function group. This remained significant after the first year of treatment (HR for discontinuing >1 year after first prescription 1.3, 95% CI 1.08‐1.56, P = .006). In men SLCO1B1*5 was only associated with treatment discontinuation in the first year.

Conclusions

In this large community sample of patients on commonly prescribed statins, the SLCO1B1*5 decreased function variant had much larger effects on cholesterol control and treatment duration in women than in men. Efforts to improve the effectiveness of statin therapy in women may need to include SLCO1B1*5 genotype‐guided statin selection.

Aspirin for cardiovascular disease prevention among adults in the United States: Trends, prevalence, and participant characteristics associated with use

OBJECTIVE

: Aspirin has been widely utilized over several decades for atherosclerotic cardiovascular disease (ASCVD) prevention among adults in the United States. We examined trends in aspirin use among adults aged ≥40 years from 1998 to 2019 and assessed factors associated with its use for primary and secondary ASCVD prevention.

METHODS

: Using 1998-2019 Behavioral Risk Factor Surveillance System data, we obtained weighted prevalence of aspirin use among adults aged ≥40 years for each year and examined trends in use over this period. Using multivariable logistic regression and utilizing data from 54,388 respondents aged ≥40 years in the 2019 data, we assessed factors associated with aspirin use for secondary prevention and for primary prevention stratified by the number of traditional ASCVD risk factors reported (hypertension, diabetes mellitus, high cholesterol, overweight/obesity, and cigarette smoking).

RESULTS

: Aspirin use prevalence increased from 29.0%(95%CI, 27.9%-30.2%) in 1998 to 37.5%(36.9%-38.0%) in 2009. However, use has slightly declined over the last decade: 35.6%(34.6%-36.6%) in 2011 to 33.5%(32.5%-34.6%) in 2019. In 2019, among respondents without cardiovascular disease (CVD), 27.5%(26.4%-28.6%) reported primary prevention aspirin use while 69.7%(67.0%-72.2%) of respondents with CVD reported secondary prevention aspirin use. Of concern, 45.6%(43.5%-47.7%) of adults aged ≥70 years without CVD reported primary prevention aspirin use. Additionally, among individuals without any self-reported traditional ASCVD risk factor, males (adjusted odds ratio(aOR):1.60, 95%CI:1.12-2.27), persons aged ≥70 years (aOR:3.22, 95%CI:2.27-4.55), and individuals with healthcare coverage (aOR:2.28, 95%CI:1.17-4.44) had higher odds of primary prevention aspirin use compared to females, persons aged 40-69 years, and individuals without healthcare coverage, respectively. Females were less likely than males to report secondary prevention aspirin use (aOR:0.64, 95%CI:0.50-0.82).

CONCLUSION

: Aspirin use has slightly declined over the last decade. A significant proportion of adults aged ≥70 years reported primary prevention aspirin use in 2019. Since current guidelines do not recommend primary prevention aspirin use among adults aged ≥70 years, such use should be discouraged.

Cardiovascular Risk Stratification Based on Oxidative Stress for Early Detection of Pathology

Aims: Current cardiovascular (CV) risk prediction algorithms are able to quantify the individual risk of CV disease. However, CV risk in young adults is underestimated due to the high dependency of age in biomarker-based algorithms. Because oxidative stress is associated with CV disease, we sought to examine CV risk stratification in young adults based on oxidative stress to approach the discovery of new markers for early detection of pathology. Results: Young adults were stratified into (i) healthy controls, (ii) subjects with CV risk factors, and (iii) patients with a reported CV event. Plasma samples were analyzed using FASILOX, a novel approach to interrogate the dynamic thiol redox proteome. We also analyzed irreversible oxidation by targeted searches using the Uniprot database. Irreversible oxidation of cysteine (Cys) residues was greater in patients with reported CV events than in healthy subjects. These results also indicate that oxidation is progressive. Moreover, we found that glutathione reductase and glutaredoxin 1 proteins are differentially expressed between groups and are proteins involved in antioxidant response, which is in line with the impaired redox homeostasis in CV disease. Innovation: This study, for the first time, describes the oxidative stress (reversible and irreversible Cys oxidation) implication in human plasma according to CV risk stratification. Conclusion: The identification of redox targets and the quantification of protein and oxidative changes might help to better understand the role of oxidative stress in CV disease, and aid stratification for CV events beyond traditional prognostic and diagnostic markers. Antioxid. Redox Signal. 35, 602-617.

Analyses and Declarations of Omega-3 Fatty Acids in Canned Seafood May Help to Quantify Their Dietary Intake

The American Heart Association (AHA) recently confirmed common recommendations of one to two fish dishes per week in order to prevent cardiovascular disease (CVD). Nevertheless, the natural fluctuations of lipids and fatty acids (FA) in processed seafood caught little public attention. Moreover, consumers of unprocessed seafood in general do not know how much omega-3 fatty acids (omega-3 FA) within servings they actually ingest. The few studies published until today considering this aspect have been re-evaluated in today's context. They included four observational studies with canned fatty coldwater fish (mackerel and herring from the same region, season, producer and research group). Their outcomes were similar to those conducted in the following years using supplements. Cans containing seafood (especially fatty coldwater fish) with declared content of omega-3 FA are ready-to-use products. Human studies have shown a higher bioavailability of omega-3 FA by joint uptake of fat. Canned fatty coldwater fish contain omega-3 FA plus plenty of fat in one and the same foodstuff. That suggests a new dietary paradigm with mixed concepts including several sources with declared content of omega-3 FA for reducing the cardiovascular risk and other acknowledged indications.

Arterial evaluation of systemic sclerosis patients with Doppler ultrasound: What did we find?

AIM

The aim of this study was to detect macrovascular findings in systemic sclerosis (SSc) by means of color Doppler ultrasonography (CDUS) and to evaluate the relationship between the laboratory and clinical findings in the setting of the disease.

METHODS

This was a cross-sectional study. Eighty-eight patients were included in the study. CDUS examinations of the bilateral carotid, vertebral, and peripheral arteries were performed. The presence of macrovascular involvement was investigated and recorded, and its relationships with the clinical, laboratory, and cardiovascular risk factors were evaluated.

RESULTS

An atheromatous plaque was found in 67.7% of the 1936 arteries examined by CDUS. Of these 1936 arteries, 37.4% demonstrated a narrowing of the intraluminal diameter. On the other hand, the carotid intima-media thickness (CIMT) was found to have increased in 55.7% of the patients. This increase was found to be statistically correlated with disease duration, the modified Rodnan Skin Thickness Score, and the Medsger Disease Activity Score. But no relation existed with the disease subtype, age, or cardiovascular risk factors. Arterial occlusion was detected in 10 patients. An association was found between the CIMT values and arterial occlusion.

CONCLUSIONS

In this study, we examined the arteries by means of CDUS, and we detected structural alterations in the peripheral and carotid arteries. We witnessed that these macrovascular changes had a close association with certain features of SSc. We think there is a need for broader prospective studies in order to evaluate the contribution of these factors to the macrovascular changes stated in the article.

Pharmacogenetic association of diabetes-associated genetic risk score with rapid progression of coronary artery calcification following treatment with HMG-CoA-reductase inhibitors -results of the Heinz Nixdorf Recall Study

HMG-CoA-Reductase inhibitors (HMGRIs) are currently the most widely used group of drugs in patients with coronary artery disease (CAD) and are given preemptively to patients with high levels of cholesterol, including those with diabetes mellitus (DM). However, intake of HMGRIs also increases the progression of coronary artery calcification (CAC) and the risk of developing DM. This study aimed to investigate whether HMGRI intake interacts with the diabetes-associated genetic risk score (GRS) to affect CAC progression using data from the population-based Heinz Nixdorf Recall (HNR) study. CAC was measured in 3157 participants using electron-beam computed tomography twice, at baseline (CAC_b) and 5 years later (CAC_5y). CAC progression was classified as slow, expected, or rapid based on predicted values. Weighted DM GRS was constructed using 100 diabetes mellitus-associated single nucleotide polymorphisms (SNPs). We used log-linear regression to evaluate the interaction of HMGRI intake with diabetes-associated GRS and individual SNPs on CAC progression (rapid vs. expected/slow), adjusting for age, sex, and log(CAC_b + 1). The prevalence of rapid CAC progression in the HNR study was 19.6%. We did not observe any association of the weighted diabetes mellitus GRS with the rapid progression of CAC (relative risk (RR) [95% confidence interval (95% CI)]: 1.01 [0.94; 1.10]). Furthermore, no indication of an interaction between GRS and HMGRI intake was observed (1.08 [0.83; 1.41]). Our analyses showed no indication that the impact of HMGRIs on CAC progression is significantly more severe in patients with a high genetic risk of developing DM than in those with a low GRS.

Risk of Depression among Early Onset Type 2 Diabetes Mellitus Patients

<b><i>Methodology:</i></b> Biochemically confirmed type 2 diabetes mellitus (T2DM) patients (<i>n</i> = 1,114) were recruited from the outpatient department of 2 tertiary care hospitals in Dhaka, Bangladesh. Face-to-face interview was conducted using a semi-structured questionnaire containing sociodemographic parameters and relevant information about depression and diabetes. Biochemical test results and treatment-related information were taken from patients’ records. The Hospital Anxiety and Depression Scale (HADS) was used to screen all patients for psychiatric manifestation. Those diagnosed by HADS were subsequently reassessed using structured clinical interview for DSM-5 Disorders – Clinician Version. T2DM diagnosed at age &#x3c;40 years were considered as early onset T2DM. Association between age of onset category and depression was assessed using multivariable mixed-effect logistic regression adjusting for random variation of the area of residence and plausible confounders. <b><i>Results:</i></b> Around a third of the participants (32.5%) were diagnosed with T2DM before the age of 40 years. Early onset T2DM patients were found to have 57% increase in the risk of developing depression (OR 1.57; 95% CI 1.13–2.28; <i>p</i> = 0.011) in comparison to those with usual onset T2DM (≥40 years). Among other factors a positive family history for diabetes (OR 1.33; 95% CI 1.03–1.78; <i>p</i> = 0.038), poor glycemic control (OR 1.31; 95% CI 1.03–1.68; <i>p</i> = 0.028), presence of 1, or more diabetic complications (OR 1.37; 95% CI 1.03–1.78; <i>p</i> = 0.011) also showed increased risk of depression. <b><i>Conclusion:</i></b> Early onset T2DM patients are at greater risk of developing depression. The finding is likely to help in setting preventive strategies aiming to reduce the presence of concomitant depression symptoms among diabetes.

The association of peak systolic velocity in the carotid artery with coronary heart disease: A study based on portable ultrasound

Cardiovascular disease (CVD) is the highest cause of death globally with more people dying annually from it than from any other cause. CVD is associated with modifiable risk factors (dyslipidaemia, hypertension and diabetes) and treating each of these factors lowers the risk of CVD. It is impossible to estimate the benefit of risk factor modification in the individual patient and extrapolating data from multiple trials is difficult. It would be useful to have a marker of risk that accurately estimates real time risk by measuring blood flow factors associated with the pathogenesis of atheroma. The aim of this preliminary study was to validate a low-cost measurement technique for obtaining blood flow velocity profiles and assess whether any of the measured and calculated factors, based on computational fluid dynamics (CFD) simulation, known to be associated with atheroma was associated with coronary heart disease (CHD), thus establishing its feasibility and acceptability as a clinical tool and suggesting areas for future research. Our study identified (i) that mean peak systolic (PS) velocity being associated with CHD; individuals without CHD: mean (SD) = 62.8 (16.1) cm/s, with CHD: mean (SD)  = 53.6 (17.3) cm/s, p = 0.042; and (ii) that low-cost, portable ultrasound, which is routinely available in general practice, is a suitable assessment tool.

Starting Antihypertensive Drug Treatment With Combination Therapy: Controversies in Hypertension - Con Side of the Argument

Supplemental Digital Content is available in the text.

GPs' familiarity with and use of cardiovascular clinical prediction rules: a UK survey study

BACKGROUND

Clinical prediction rules (CPRs) can help general practitioners (GPs) address challenges in cardiovascular disease. A survey published in 2014 evaluated GPs' awareness and use of CPRs in the UK. However, many new CPRs have been published since and it is unknown which cardiovascular CPRs are currently recognised and used.

AIM

To identify cardiovascular CPRs recognised and used by GPs, and to assess how GPs' familiarity and use have changed over time.

DESIGN & SETTING

An online survey of GPs in the UK was undertaken.

METHOD

Using comparable methods to the 2014 survey, GPs were recruited from a network of doctors in the UK. They were asked how familiar they were with cardiovascular CPRs, how frequently they used them, and why they used them. The results were compared with the 2014 survey.

RESULTS

Most of 401 GPs were familiar with QRISK scores, ABCD scores, CHADS scores, HAS-BLED score, Wells scores for deep vein thrombosis, and Wells scores for pulmonary embolism. The proportions of GPs using these CPRs were 96.3%, 65.1%, 97.3%, 93.0%, 92.5%, and 82.0%, respectively. GPs' use increased by 31.2% for QRISK scores, by 13.5% for ABCD scores, by 54.6% for CHADS scores, by 33.2% for Wells scores for deep vein thrombosis, and by 43.6% for Wells scores for pulmonary embolism; and decreased by 45.9% for the Joint British Societies (JBS) risk calculator, by 38.7% for Framingham risk scores, and by 8.7% for New Zealand tables. GPs most commonly used cardiovascular CPRs to guide therapy and referral.

CONCLUSION

The study found GPs' familiarity and use of cardiovascular CPRs changed substantially. Integrating CPRs into guidelines and practice software might increase familiarity and use.

Efficacy of combination therapy with ezetimibe and statins versus a double dose of statin monotherapy in participants with hypercholesterolemia: a meta-analysis of literature

Background

The aim of this study was to compare and summarize the lipid-altering effects of combination therapy with ezetimibe and statins (E/S) and a double dose of statin (D/S) monotherapy on patients with hypercholesterolemia.

Methods

We conducted search on 2 medical databases, PubMed and EMBASE to identify all relevant studies. A meta-analysis was performed to clarify the efficacy in the two groups. Only double-blind Randomized controlled study (RCTs) of efficacy evaluation in the two groups with ezetimibe and statins and a double dose of statin in participants with hypercholesterolemia that examined low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and high-density lipoprotein (HDL) were included. Two reviewers extracted data from all primary studies independently. The primary data were the level of LDL-C, TC and HDL-C concentrations at the end point and are expressed as mean and standard deviation (SD).

Results

A total of 11 double-blind, active or placebo-controlled studies with 1926 hypercholesterolemia adults randomized to ezetimibe 10 mg added to ongoing statins (N = 994) or statin titration (doubling) (N = 932) were pooled for the global meta-analysis. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random- or fixed-effect model. The result showed that the participants in E/S group get obvious lower LDL-C [MD = -13.14 mg/dL, 95%CI (−16.83, -9.44), p = 0.00001] and TC concentration [MD = -23.79 mg/dL, 95%CI (−38.65, -8.93), p = 0.002] from baseline to follow-up, comparing to the D/S group. Besides, no significant between-group differences were observed for concentrations of HDL-C [MD = 0.46 mg/dL, 95%CI (− 1.14, 2.06), p = 0.57]. According to subgroup analysis, the combination of ezetimibe and atorvastatin (10 mg) [MD = -16.98 mg/dL, p < 0 .0001] or simvastatin (20 mg) [MD = -17.35 mg/dL, p < 0 .0001] showed stronger ability of reducing LDL-C than combination of ezetimibe and rosuvastatin (10 mg) [MD = -9.29 mg/dL, p = 0.05]. The efficacy of short-term (endpoint time between 6 to 16 week) and long-term (52 week) treatment in the LDL-C between two groups did not show significant differences. Besides, only participants from Asia treated with combination therapy were associated with a significant lower LDL-C concentration [MD = -14.7 mg/dL, p < 0 .0001].

Conclusions

The addition of ezetimibe to statin appears to be more effective on reducing LDL-C and TC concentrations than doubling the statin dose. Moreover, the ability to reduce cholesterol levels of combinations therapy with ezetimibe and different statins or to participants from different geographic location may vary, based on this meta-analysis, while more samples are needed to verify.

Prevalence and sociodemographic correlates of cardiovascular risk factors among patients with hypertension in South African primary care

OBJECTIVE

To determine the prevalence and sociodemographic correlates of cardiovascular risk factors among patients with hypertension at Johan Heyns Community Health Centre, Sedibeng district, South Africa.

METHODS

A total of 328 participants were systematically sampled. A researcher-administered questionnaire collected information on: socio-demography, presence of diabetes, family history of hypercholesterolaemia, family history of fatal cardiovascular (CV) events, and engagement in physical activities. Other measurements included: blood pressure (BP), weight, height, abdominal circumference and electrocardiography (ECG). Data analysis included descriptive statistics, chi-squared test and regression analysis. Main outcome measures included the proportions of participants with each CV risk and their significant sociodemographic determinants.

RESULTS

Participants' mean age was 57.7 years. Most participants were black (86.0%), female (79%) and pensioners (43.6%). The mean BP was 139/84 mmHg, and 60.7% had their BP controlled to targets. There was an average of 3.7 CV risk factors per participant and the prevalence of CV risk factors was: abdominal obesity (80.8%), physical inactivity (73.2%), diabetes (30.2%), alcohol use (28.0%), hypercholesterolaemia (26.5%), smoking (11.9%), past family history of fatal CV event (14.9%), and left ventricular hypertrophy (5.2%). Sociodemographic factors significantly associated with each CV risk factor were: obesity and being female (p = 0.00); alcohol use and young age (p = 0.00); smoking, being male and race other than black (p = 0.00 and p = 0.00, respectively); physical inactivity, being a pensioner and male (p = 0.02 and p = 0.02, respectively); diabetes and being male (p = 0.03); hypercholesterolaemia and race other than black (p = 0.03); family history of hypercholesterolaemia and race other than black (p = 0.00); and family history of fatal CV event and race other than black (p = 0.00).

CONCLUSIONS

There is a high burden of CV risk factors among patients with hypertension in South African primary care, signifying a substantial risk of cardiovascular disease (CVD) in this setting. Interventions aimed at CVD risk reduction need to take cognisance of the sociodemographic correlates of CV risk factors.

Perspective: Clinical relevance of the dichotomous classification of Alzheimer's disease biomarkers: Should there be a "gray zone"?

The 2018 National Institute on Aging and the Alzheimer's Association (NIA-AA) research framework recently redefined Alzheimer's disease (AD) as a biological construct, based on in vivo biomarkers reflecting key neuropathologic features. Combinations of normal/abnormal levels of three biomarker categories, based on single thresholds, form the AD signature profile that defines the biological disease state as a continuum, independent of clinical symptomatology. While single thresholds may be useful in defining the biological signature profile, we provide evidence that their use in studies with cognitive outcomes merits further consideration. Using data from the Alzheimer's Disease Neuroimaging Initiative with a focus on cortical amyloid binding, we discuss the limitations of applying the biological definition of disease status as a tool to define the increased likelihood of the onset of the Alzheimer's clinical syndrome and the effects that this may have on trial study design. We also suggest potential research objectives going forward and what the related data requirements would be.

Impact of wearable physical activity monitoring devices with exercise prescription or advice in the maintenance phase of cardiac rehabilitation: systematic review and meta-analysis

BACKGROUND

Physical activity (PA) is a component of cardiac rehabilitation (CR). However, life-long engagement in PA is required to maintain benefits gained. Wearable PA monitoring devices (WPAM) are thought to increase PA. There appear to be no reviews which investigate the effect of WPAM in cardiac populations. We firstly aimed to systematically review randomised controlled trials within the cardiac population that investigated the effect WPAM had through the maintenance phase of CR. We specifically examined the effect on cardiorespiratory fitness (CRF), amount and intensity of daily PA, and sedentary time. Secondly, we aimed to collate outcome measures reported, reasons for drop out, adverse events, and psychological impact from utilising a WPAM.

METHODS

A systematic search (up to January 2019) of relevant databases was completed, followed by a narrative synthesis, meta-analysis and qualitative analysis.

RESULTS

Nine studies involving 1,352 participants were included. CRF was improved to a greater extent in participants using WPAM with exercise prescription or advice compared with controls (MD 1.65 mL/kg/min;95% confidence interval [CI; 0.64-2.66]; p = 0.001; I2 = 0%). There was no significant between group difference in six-minute walk test distance. In 70% of studies, step count was greater in participants using a WPAM with exercise prescription or advice, however the overall effect was not significant (SMD 0.45;95% [CI; - 0.17-1.07] p = 0.15; I2 = 81%). A sensitivity analysis resulted in significantly greater step counts in participants using a WPAM with exercise prescription or advice and reduced the heterogeneity from 81 to 0% (SMD 0.78;95% [CI;0.54-1.02]; p < 0.001; I2 = 0%). Three out of four studies reporting on intensity, found significantly increased time spent in moderate and moderate-vigorous intensity PA. No difference between groups was found for sedentary time. Three of six studies reported improved psychological benefits.No cardiac adverse events related to physical activity were reported and 62% of non-cardiac adverse events were primarily musculoskeletal injuries. Reasons for dropping out included medical conditions, lack of motivation, loss of interest, and technical difficulties.

CONCLUSIONS

Our meta-analysis showed WPAM with exercise prescription or advice are superior to no device in improving CRF in the maintenance phase of CR and no cardiac adverse events were reported with WPAM use. Our qualitative analysis showed evidence in favour of WPAM with exercise prescription or advice for both CRF and step count. WPAM with exercise prescription or advice did not change sedentary time. Psychological health and exercise intensity may potentially be enhanced by WPAM with exercise prescription or advice, however further research would strengthen this conclusion.

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42019106591.

Do patients actually do what we ask: patient fidelity and persistence to the Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups blood pressure self-management intervention

OBJECTIVE

Self-management of hypertension can reduce and control blood pressure (BP) compared with clinic monitoring. However, self-management relies on patients following an algorithm, which may be variably adhered to. This study reports fidelity of high-risk patients to the self-management algorithm set by the TASMIN-SR trial.

METHODS

Patients with hypertension, above target clinic BP and one or more of stroke, diabetes, coronary heart disease or chronic kidney disease, were invited to self-monitor following an individualized self-titration algorithm. Home BP readings and medication change details were submitted monthly for 12 months. Readings downloaded from patients' electronic monitors were compared with written submissions, and protocol fidelity was assessed.

RESULTS

Two hundred and seventy-six patients were randomized to self-management and 225 (82%) completed the required training sessions. Of these, 166 (74%) completed self-management. A total of 11385 (89.6%) submitted readings were accurate compared with corresponding downloaded monitor readings. Mean error rate was 5.2% per patient, which increased with age but not comorbidities. Patients made 475 of 683 (69.5%) algorithm-recommended medication changes, equating to nearly three medication changes per patient. Mean SBP for patients who completed training and made all recommended changes dropped from 141 mmHg (95% CI 138.26-144.46) to 121 mmHg (95% CI 118.30-124.17 mmHg) compared with 129 mmHg (95% CI 125.27-136.73 mmHg) for patients who made none.

CONCLUSION

Most patients randomized to self-management completed training; however, 36% of these had dropped out by 12 months. Self-monitoring was largely undertaken properly and accurately recorded. Fidelity with self-management was associated with lower achieved SBP. Successful implementation of self-management into daily practice requires careful training and should be accompanied by monitoring of fidelity.

Statin use in cancer survivors versus the general population: cohort study using primary care data from the UK clinical practice research datalink

BACKGROUND

Cancer survivors may be at increased risk of cardiovascular diseases, but little is known about whether prescribing guidelines for the primary prevention of cardiovascular disease are adequately implemented in these patients. We compared levels of statin initiation and cessation among cancer survivors compared to the general population to determine differences in uptake of pharmaceutical cardiovascular risk prevention measures in these groups.

METHODS

The study population included individuals aged ≥40 during 2005-13 within the UK Clinical Practice Research Datalink primary care database. Within this population we identified cancer survivors who were alive and under follow-up at least 1 year after diagnosis, and controls with no cancer history. Follow-up time prior to cancer diagnosis was included in the control cohort. Using logistic regression, we compared these groups with respect to uptake of statins within 1 month of a first high recorded cardiovascular risk score. Then, we used Cox modelling to compare persistence on statin therapy (time to statin cessation) between cancer survivors and controls from the main study population who had initiated on a statin.

RESULTS

Among 4202 cancer survivors and 113,035 controls with a record indicating a high cardiovascular risk score, 23.0% and 23.5% respectively initiated a statin within 1 month (adjusted odds ratio 0.98 [91.8-1.05], p = 0.626). Cancer survivors appeared more likely to discontinue statin treatment than controls (adjusted hazard ratio 1.07 [1.01-1.12], p = 0.02). This greater risk of discontinuing was only evident after the first year of therapy (p-interaction < 0.001).

INTERPRETATION

Although cardiovascular risk is thought to be higher in cancer survivors compared to the general population, cancer survivors were no more likely to receive statins, and marginally more likely to cease long-term therapy, than general population controls. There may be an opportunity to mitigate the suspected higher cardiovascular risk in the growing population of cancer survivors by improving uptake of lipid-lowering treatment and persistence on therapy.

Registry report on prediction by Pocock cardiovascular score of cerebral microemboli acutely following carotid endarterectomy

Background

Cerebral microemboli may lead to ischaemic neurological complications after carotid endarterectomy (CEA). The association between classical cardiovascular risk factors and acute cerebral microemboli following carotid surgery has not been studied. The aim of this study was to explore whether an established cardiovascular risk score (Pocock score) predicts the presence of cerebral microemboli acutely after CEA.

Subjects and methods

Pocock scores were assessed for the 670 patients from the Carotid Surgery Registry (age 71±1 (SEM) years, 474 (71%) male, 652 (97%) Caucasian) managed from January 2002 to December 2012 in the Regional Vascular Centre at University Hospitals Coventry and Warwickshire NHS Trust, which serves a population of 950 000. CEA was undertaken in 474 (71%) patients for symptomatic carotid stenosis and in 196 (25%) asymptomatic patients during the same period. 74% of patients were hypertensive, 71% were smokers and 49% had hypercholesterolaemia.

Results

A high Pocock score (≥2.3%) was significantly associated with evidence of cerebral microemboli acutely following CEA (P=0.039, Mann-Whitney (MW) test). A Pocock score (≥2.3%) did not predict patients who required additional antiplatelet therapy (microemboli signal (MES) rate >50 hour^-1: P=0.164, MW test). Receiver operating characteristic analysis also showed that the Pocock score predicts acute postoperative microemboli (area under the curve (AUC) 0.546, 95% CI 0.502 to 0.590, P=0.039) but not a high rate of postoperative microemboli (MES >50 hour⁻¹: AUC 0.546, 95% CI 0.482 to 0.610, P=0.164). A Pocock score ≥2.3% showed a sensitivity of 74% for the presence of acute postoperative cerebral microemboli. A Pocock score ≥2.3% also showed a sensitivity of 77% and a negative predictive value of 90% for patients who developed a high microembolic rate >50 hour⁻¹ after carotid surgery.

Conclusion

These findings demonstrate that the Pocock score could be used as a clinical tool to identify patients at high risk of developing acute postoperative microemboli.

Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines?

A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.

Trial to Encourage Adoption and Maintenance of a Mediterranean Diet (TEAM-MED): Protocol for a Randomised Feasibility Trial of a Peer Support Intervention for Dietary Behaviour Change in Adults at High Cardiovascular Disease Risk

Adoption of a Mediterranean diet (MD) reduces cardiovascular disease (CVD) risk. However, interventions to achieve dietary behaviour change are typically resource intensive. Peer support offers a potentially low-cost approach to encourage dietary change. The primary objective of this randomised controlled trial is to explore the feasibility of peer support versus a previously tested dietetic-led intervention to encourage MD behaviour change, and to test recruitment strategies, retention and attrition in order to inform the design of a definitive trial. A total of 75 overweight adults at high CVD risk who do not follow a MD (Mediterranean Diet Score (MDS ≤ 3)) will be randomly assigned to either: a minimal intervention (written materials), a proven intervention (dietetic support, written materials and key MD foods), or a peer support intervention (group-based community programme delivered by lay peers) for 12 months. The primary end-point is change in MDS from baseline to 6 months (adoption of MD). Secondary end-points include: change in MDS from 6 to 12 months (maintenance of MD), effects on nutritional biomarkers and CVD risk factors, fidelity of implementation, acceptability and feasibility of the peer support intervention. This study will generate important data regarding the feasibility of peer support for ease of adoption of MD in an 'at risk' Northern European population. Data will be used to direct a larger scale trial, where the clinical efficacy and cost-effectiveness of peer support will be tested.

Potential role of new molecular plasma signatures on cardiovascular risk stratification in asymptomatic individuals

The evaluation of cardiovascular (CV) risk is based on equations derived from epidemiological data in individuals beyond the limits of middle age such as the Framingham and SCORE risk assessments. Lifetime Risk calculator (QRisk^®), estimates CV risk throughout a subjects’ lifetime, allowing those. A more aggressive and earlier intervention to be identified and offered protection from the consequences of CV and renal disease. The search for molecular profiles in young people that allow a correct stratification of CV risk would be of great interest to adopt preventive therapeutic measures in individuals at high CV risk. To improve the selection of subjects susceptible to intervention with aged between 30–50 years, we have employed a multiple proteomic strategy to search for new markers of early CV disease or reported CV events and to evaluate their relationship with Lifetime Risk. Blood samples from 71 patients were classified into 3 groups according to their CV risk (healthy, with CV risk factors and with a previously reported CV event subjects) and they were analyzed using a high through quantitative proteomics approach. This strategy allowed three different proteomic signatures to be defined, two of which were related to CV stratification and the third one involved markers of organ damage.

Polycystic Ovary Syndrome and Periodontal disease: Underlying Links- A Review

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age, which negatively affects various health systems. There is an extensive literature regarding the association of PCOS and other systemic conditions such as diabetes mellitus, cardiovascular disease, and psychological disorders. However, there is a lack of literature in associating PCOS and periodontal disease. Hence, PubMed search was done for various articles related to PCOS and its association with other comorbidities, including periodontal diseases. Analysis was done and data were synthesized and compiled in a sequential and presentable paradigm. This literature review of the pathophysiological mechanisms linking the two diseases suggests a positive relation between the two comorbidities. However, multicenter studies, with larger sample sizes, are to be conducted to establish a clearer and stronger association.

Correlation of the anterior ocular segment biometry with HbA1c level in type 2 diabetes mellitus patients

Objectives

To compare the anterior ocular segment biometry among Type 2 diabetes mellitus (DM) with no diabetic retinopathy (DR) and non-proliferative diabetic retinopathy (NPDR), and to evaluate the correlation of anterior ocular segment biometry with HbA1c level.

Methods

A cross-sectional study was conducted in Hospital Universiti Sains Malaysia, Kelantan from November 2013 till May 2016 among Type 2 DM patients (DM with no DR and DM with NPDR). The patients were evaluated for anterior ocular segment biometry [central corneal thickness (CCT), anterior chamber width (ACW), angle opening distance (AOD) and anterior chamber angle (ACA)] by using Anterior Segment Optical Coherence Tomography (AS-OCT). Three ml venous blood was taken for the measurement of HbA1c.

Results

A total of 150 patients were included in this study (DM with no DR: 50 patients, DM with NPDR: 50 patients, non DM: 50 patients as a control group). The mean CCT and ACW showed significant difference among the three groups (p < 0.001 and p = 0.015 respectively). Based on post hoc result, there were significant mean difference of CCT between non DM and DM with NPDR (mean difference 36.14 μm, p < 0.001) and also between non DM and DM with no DR (mean difference 31.48 μm, p = 0.003). The ACW was significantly narrower in DM with NPDR (11.39 mm SD 0.62) compared to DM with no DR (11.76 mm SD 0.53) (p = 0.012). There were no significant correlation between HbA1c and all the anterior ocular segment biometry.

Conclusion

Diabetic patients have significantly thicker CCT regardless of retinopathy status whereas ACW was significantly narrower in DM with NPDR group compared to DM with no DR. There was no significant correlations between HbA1c and all anterior ocular segment biometry in diabetic patients regardless of DR status.

Cardiovascular outcomes and safety with antidiabetic drugs

Type 2 diabetes is a debilitating disease that impacts the life expectancy, quality of life, and health of an individual. Cardiovascular disease (CVD) is a common diabetes-associated complication and a principal cause for death in diabetic patients. This review aims to investigate and summarize the effect of Type 2 diabetes mellitus (T2DM) medications on CVD issues. A comprehensive literature review mainly from level 1 evidence was performed. Thirty-seven articles were extracted from Google Scholar, ScienceDirect, ProQuest, and PubMed Database using a combination of keywords. The findings suggest that different glucose-lowering agents have been tested for their efficacy and safety in T2DM with CVD. Some of the recent trials such as the "United Kingdom Prospective Diabetes Study," "Empagliflozin (EMPA) Cardiovascular (CV) Outcome Event Trial in T2DM Patients-Removing Excess Glucose" (EMPA-REG OUTCOME), "Liraglutide Effect and Action in Diabetes: Evaluation of CV Outcome Results," and "Trial to Evaluate CV and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes" (SUSTAIN6) have shed important light on this vital clinical concern, thus demonstrating a convincing effect of liraglutide, semaglutide, and EMPA on CVD outcomes, while metformin is thought to be the first-line optimal oral agent to manage Type 2 diabetics. Some classes of drugs demonstrate CV protection, some of them may be a result of a class effect, and some differences might be based on the population enrolled individually. Most of the trials failed to show a significant benefit with regard to mortality and morbidity in spite of intensive glycemic control. This study, therefore, enabled us to develop a guide of potential antidiabetic medication that can influence or promote CV health. Health professionals in future should weigh the CV risk against possible advantages while prescribing antidiabetic medications.

Hypercholesterolaemia - practical information for non-specialists

Hypercholesterolaemia is amongst the most common conditions encountered in the medical profession. It remains one of the key modifiable cardiovascular risk factors and there have been recent advances in the risk stratification methods and treatment options available. In this review, we provide a background into hypercholesterolaemia for non-specialists and consider the merits of the different risk assessment tools available. We also provide detailed considerations as to: i) when to start treatment, ii) what targets to aim for and iii) the role of low density lipoprotein cholesterol.

PARS risk charts: A 10-year study of risk assessment for cardiovascular diseases in Eastern Mediterranean Region

This study was designed to develop a risk assessment chart for the clinical management and prevention of the risk of cardiovascular disease (CVD) in Iranian population, which is vital for developing national prevention programs. The Isfahan Cohort Study (ICS) is a population-based prospective study of 6504 Iranian adults ≥35 years old, followed-up for ten years, from 2001 to 2010. Behavioral and cardiometabolic risk factors were examined every five years, while biennial follow-ups for the occurrence of the events was performed by phone calls or by verbal autopsy. Among these participants, 5432 (2784 women, 51.3%) were CVD free at baseline examination and had at least one follow-up. Cox proportional hazard regression was used to predict the risk of ischemic CVD events, including sudden cardiac death due to unstable angina, myocardial infarction, and stroke. The model fit statistics such as area under the receiver-operating characteristic (AUROC), calibration chi-square and the overall bias were used to assess the model performance. We also tested the Framingham model for comparison. Seven hundred and five CVD events occurred during 49452.8 person-years of follow-up. The event probabilities were calculated and presented color-coded on each gender-specific PARS chart. The AUROC and Harrell's C indices were 0.74 (95% CI, 0.72-0.76) and 0.73, respectively. In the calibration, the Nam-D'Agostino χ2 was 10.82 (p = 0.29). The overall bias of the proposed model was 95.60%. PARS model was also internally validated using cross-validation. The Android app and the Web-based risk assessment tool were also developed as to have an impact on public health. In comparison, the refitted and recalibrated Framingham models, estimated the CVD incidence with the overall bias of 149.60% and 128.23% for men, and 222.70% and 176.07% for women, respectively. In conclusion, the PARS risk assessment chart is a simple, accurate, and well-calibrated tool for predicting a 10-year risk of CVD occurrence in Iranian population and can be used in an attempt to develop national guidelines for the CVD management.

A cross-sectional survey of cardiovascular health and lifestyle habits of hospital staff in the UK: Do we look after ourselves?

Background

A high prevalence of stress-related disorders is well known among healthcare professionals. We set out to assess the prevalence of cardiovascular risk factors and compliance with national dietary and physical activity recommendations in NHS staff in the UK with comparison between clinical and non-clinical staff, and national surveys.

Design

A multi-centre cross-sectional study.

Methods

A web-based questionnaire was developed to include anonymised data on demographics, job role, cardiovascular risk factors and diseases, dietary habits, physical activity and barriers towards healthy lifestyle. This was distributed to staff in four NHS hospitals via emails.

Results

A total of 1158 staff completed the survey (response rate 13%) with equal distribution between the clinical and non-clinical groups. Most staff were aged 26–60 years and 79% were women. Half of the staff were either overweight or obese (51%) with no difference between the groups (P = 0.176), but there was a lower prevalence of cardiovascular risk factors compared to the general population. The survey revealed a low compliance (17%) with the recommended intake of five-a-day portions of fruit and vegetables, and that of moderate or vigorous physical activity (56%), with no difference between the clinical and non-clinical staff (P = 0.6). However, more clinical staff were exceeding the alcohol recommendations (P = 0.02). Lack of fitness facilities and managerial support, coupled with long working hours, were the main reported barriers to a healthy lifestyle.

Conclusions

In this survey of UK NHS staff, half were found to be overweight or obese with a lower prevalence of cardiovascular risk factors compared to the general population. There was a low compliance with the five-a-day fruit and vegetables recommendation and physical activity guidelines, with no difference between the clinical and non-clinical staff.

Statin initiations and QRISK2 scoring in UK general practice: a THIN database study

BACKGROUND

Statin prescribing should be based on cardiovascular disease (CVD) risk, but evidence suggests overtreatment of low-risk groups and undertreatment of high-risk groups.

AIM

To investigate the relationship between CVD risk scoring in primary care and initiation of statins for the primary prevention of CVD, and the effect of changes to the National Institute for Health and Care Excellence (NICE) guidance in 2014.

DESIGN AND SETTING

Historical cohort study using UK electronic primary care records.

METHOD

A cohort was created of statin-naïve patients without CVD between 1 January 2000 and 31 December 2015. CVD risk scores (calculated using QRISK2 available from 2012) and statin initiations were identified. Rates of CVD risk score recording were calculated and relationships between CVD risk category (low-, intermediate-, and high-risk: <10%, 10-19.9%, and ≥20% 10-year CVD risk) and statin initiation were analysed.

RESULTS

A total of 1.4 million patients were identified from 248 practices. Of these, 151 788 had a recorded CVD risk score since 2012 (10.67%) and 217 860 were initiated on a statin (15.31%). Among patients initiated on a statin after 2012, 27.1% had a documented QRISK2 score: 2.7% of low-risk, 13.8% of intermediate-risk, and 35.0% of high-risk patients were initiated on statins. Statin initiation rates halved from a peak in 2006. After the 2014 NICE guidelines, statin initiation rates declined in high-risk patients but increased in intermediate-risk patients.

CONCLUSION

Most patients initiated on statins had no QRISK2 score recorded. Most patients at high risk of CVD were not initiated on statins. One in six statin initiations were to low-risk patients indicating significant overtreatment. Initiations of statins in intermediate-risk patients rose after NICE guidelines were updated in 2014.

A content analysis of the representation of statins in the British newsprint media

OBJECTIVE

This study reviewed the news media coverage of statins, seeking to identify specific trends or differences in viewpoint between media outlets and examine common themes.

DESIGN

The study is a content analysis of the frequency and content of the reporting of statins in a selection of the British newsprint media. It involved an assessment of the number, timing and thematic content of articles followed by a discourse analysis examining the underlying narratives. The sample was the output of four UK newspapers, covering a broad-spectrum readership, over a six month timeframe 1 October 2013 to 31 March 2014.

RESULTS

A total of 67 articles included reference to statins. The majority (39, 58%) were reporting or responding to publication of a clinical study. The ratio of negative to positive coverage was greater than 2:1 overall. In the more politically right-leaning newspapers, 67% of coverage was predominantly negative (30/45 articles); 32% in the more left-leaning papers (7/22 articles). Common themes were the perceived 'medicalisation' of the population; the balance between lifestyle modification and medical treatments in the primary prevention of heart disease; side effects and effectiveness of statins; pharmaceutical sponsorship and implications for the reliability of evidence; trust between the public and government, institutions, research organisations and the medical profession.

CONCLUSIONS

Newsprint media coverage of statins was substantially influenced by the publication of national guidance and by coverage in the medical journals of clinical studies and comment. Statins received a predominantly negative portrayal, notably in the more right-leaning press. There were shared themes: concern about the balance between medication and lifestyle change in the primary prevention of heart disease; the adverse effects of treatment; and a questioning of the reliability of evidence from research institutions, scientists and clinicians in the light of their potential allegiances and funding.