1
|
Helmink MAG, Peters SAE, Westerink J, Harris K, Tillmann T, Woodward M, van Sloten TT, van der Meer MG, Teraa M, Dorresteijn JAN, Ruigrok YM, Visseren FLJ, Hageman SHJ. Development and validation of a lifetime prediction model for incident type 2 diabetes in patients with established cardiovascular disease: the CVD2DM model. Eur J Prev Cardiol 2024:zwae096. [PMID: 38584392 DOI: 10.1093/eurjpc/zwae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/19/2024] [Accepted: 02/29/2024] [Indexed: 04/09/2024]
Abstract
AIMS Identifying patients with established cardiovascular disease (CVD) who are at high risk of type 2 diabetes (T2D) may allow for early interventions, reducing the development of T2D and associated morbidity. The aim of this study was to develop and externally validate the CVD2DM model to estimate the 10-year and lifetime risks of T2D in patients with established CVD. METHODS AND RESULTS Sex-specific, competing risk-adjusted Cox proportional hazard models were derived in 19 281 participants with established CVD and without diabetes at baseline from the UK Biobank. The core model's pre-specified predictors were age, current smoking, family history of diabetes mellitus, body mass index, systolic blood pressure, fasting plasma glucose, and HDL cholesterol. The extended model also included HbA1c. The model was externally validated in 3481 patients from the UCC-SMART study. During a median follow-up of 12.2 years (interquartile interval 11.3-13.1), 1628 participants with established CVD were diagnosed with T2D in the UK Biobank. External validation c-statistics were 0.79 [95% confidence interval (CI) 0.76-0.82] for the core model and 0.81 (95% CI 0.78-0.84) for the extended model. Calibration plots showed agreement between predicted and observed 10-year risk of T2D. CONCLUSION The 10-year and lifetime risks of T2D can be estimated with the CVD2DM model in patients with established CVD, using readily available clinical predictors. The model would benefit from further validation across diverse ethnic groups to enhance its applicability. Informing patients about their T2D risk could motivate them further to adhere to a healthy lifestyle.
Collapse
Affiliation(s)
- Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Sanne A E Peters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- The George Institute for Global Health, Imperial College London, London, UK
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Internal Medicine, Isala, Zwolle, The Netherlands
| | - Katie Harris
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Taavi Tillmann
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Mark Woodward
- The George Institute for Global Health, Imperial College London, London, UK
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Thomas T van Sloten
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ynte M Ruigrok
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| |
Collapse
|
2
|
Castelijns MC, Hageman SHJ, Teraa M, van der Meer MG, Westerink J, Ten Berg J, Visseren FLJ. Generalisability of trials on antithrombotic treatment intensification in patients with cardiovascular disease. Heart 2024; 110:482-490. [PMID: 38182277 DOI: 10.1136/heartjnl-2023-323519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/08/2023] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE Assessment of generalisability of guideline-informing trials on antithrombotic treatment intensification to real-world patients with cardiovascular disease (CVD). METHODS Inclusion and exclusion criteria of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS), Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management and Avoidance (CHARISMA), Prevention of Cardiovascular events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction (PEGASUS-TIMI) and Dual Antiplatelet Therapy (DAPT) study were applied to coronary artery disease (CAD) and/or peripheral artery disease (PAD) patients from Utrecht Cardiovascular Cohort-Second Manifestations of Arterial Disease (UCC-SMART) to determine real-world eligibility. Eligible and ineligible patients were compared on baseline characteristics, cardiovascular events, major bleeding and mortality. RESULTS Eligibility ranged from 11%-94% for CAD to 75%-90% for patients with PAD. Cardiovascular, bleeding and mortality risks were higher in COMPASS-eligible patients with CAD (rate ratios (RR) 1.98 (95% CI 1.74 to 2.26), 2.02 (95% CI 1.47 to 2.78) and 3.11 (95% CI 2.71 to 3.57), respectively) and CHARISMA-eligible patients (RR 1.51 (95% CI 1.12 to 2.06), 2.25 (95% CI 1.01 to 6.21) and 4.43 (95% CI 2.79 to 7.51), respectively), and lower in COMPASS-eligible patients with PAD (RR 0.45 (95% CI 0.36 to 0.56), 0.29 (95% CI 0.18 to 0.46) and 0.45 (95% CI 0.38 to 0.54), respectively) and DAPT-eligible patients with CAD (RR CVD 0.49 (95% CI 0.34 to 0.69) and mortality 0.67 (95% CI 0.48 to 0.94)) than ineligible patients. After adjustment for trial eligibility criteria, only higher cardiovascular and mortality risks in COMPASS-eligible patients with CAD and lower cardiovascular risks in CHARISMA-eligible and DAPT-eligible patients persisted with CAD. CONCLUSION A large proportion of contemporary CVD patients would be eligible for intensified antithrombotic treatment trials, with mostly similar adjusted event risks to ineligible patients. Trial-based guideline recommendations are largely applicable to real-world patients.
Collapse
Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Jurrien Ten Berg
- Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
3
|
Helmink MAG, Hageman SHJ, Eliasson B, Sattar N, Visseren FLJ, Dorresteijn JAN, Harris K, Peters SAE, Woodward M, Szentkúti P, Højlund K, Henriksen JE, Sørensen HT, Serné EH, van Sloten TT, Thomsen RW, Westerink J. Lifetime and 10-year cardiovascular risk prediction in individuals with type 1 diabetes: The LIFE-T1D model. Diabetes Obes Metab 2024. [PMID: 38456579 DOI: 10.1111/dom.15531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/09/2024]
Abstract
AIMS To develop and externally validate the LIFE-T1D model for the estimation of lifetime and 10-year risk of cardiovascular disease (CVD) in individuals with type 1 diabetes. MATERIALS AND METHODS A sex-specific competing risk-adjusted Cox proportional hazards model was derived in individuals with type 1 diabetes without prior CVD from the Swedish National Diabetes Register (NDR), using age as the time axis. Predictors included age at diabetes onset, smoking status, body mass index, systolic blood pressure, glycated haemoglobin level, estimated glomerular filtration rate, non-high-density lipoprotein cholesterol, albuminuria and retinopathy. The model was externally validated in the Danish Funen Diabetes Database (FDDB) and the UK Biobank. RESULTS During a median follow-up of 11.8 years (interquartile interval 6.1-17.1 years), 4608 CVD events and 1316 non-CVD deaths were observed in the NDR (n = 39 756). The internal validation c-statistic was 0.85 (95% confidence interval [CI] 0.84-0.85) and the external validation c-statistics were 0.77 (95% CI 0.74-0.81) for the FDDB (n = 2709) and 0.73 (95% CI 0.70-0.77) for the UK Biobank (n = 1022). Predicted risks were consistent with the observed incidence in the derivation and both validation cohorts. CONCLUSIONS The LIFE-T1D model can estimate lifetime risk of CVD and CVD-free life expectancy in individuals with type 1 diabetes without previous CVD. This model can facilitate individualized CVD prevention among individuals with type 1 diabetes. Validation in additional cohorts will improve future clinical implementation.
Collapse
Affiliation(s)
- Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Sciences, University of Glasgow, Glasgow, UK
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Katie Harris
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sanne A E Peters
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- The George Institute for Global Health, Imperial College London, London, UK
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, London, UK
| | - Péter Szentkúti
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kurt Højlund
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan Erik Henriksen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik H Serné
- Department of Vascular Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Thomas T van Sloten
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Isala, Zwolle, The Netherlands
| |
Collapse
|
4
|
van Trier TJ, Snaterse M, Boekholdt SM, Scholte op Reimer WJM, Hageman SHJ, Visseren FLJ, Dorresteijn JAN, Peters RJG, Jørstad HT. Validation of Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons in the EPIC-Norfolk prospective population cohort. Eur J Prev Cardiol 2024; 31:182-189. [PMID: 37793098 PMCID: PMC10809184 DOI: 10.1093/eurjpc/zwad318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 08/30/2023] [Accepted: 09/25/2023] [Indexed: 10/06/2023]
Abstract
AIMS The European Systematic Coronary Risk Evaluation 2 (SCORE2) and SCORE2-Older Persons (OP) models are recommended to identify individuals at high 10-year risk for cardiovascular disease (CVD). Independent validation and assessment of clinical utility is needed. This study aims to assess discrimination, calibration, and clinical utility of low-risk SCORE2 and SCORE2-OP. METHODS AND RESULTS Validation in individuals aged 40-69 years (SCORE2) and 70-79 years (SCORE2-OP) without baseline CVD or diabetes from the European Prospective Investigation of Cancer (EPIC) Norfolk prospective population study. We compared 10-year CVD risk estimates with observed outcomes (cardiovascular mortality, non-fatal myocardial infarction, and stroke). For SCORE2, 19 560 individuals (57% women) had 10-year CVD risk estimates of 3.7% [95% confidence interval (CI) 3.6-3.7] vs. observed 3.8% (95% CI 3.6-4.1) [observed (O)/expected (E) ratio 1.0 (95% CI 1.0-1.1)]. The area under the curve (AUC) was 0.75 (95% CI 0.74-0.77), with underestimation of risk in men [O/E 1.4 (95% CI 1.3-1.6)] and overestimation in women [O/E 0.7 (95% CI 0.6-0.8)]. Decision curve analysis (DCA) showed clinical benefit. Systematic Coronary Risk Evaluation 2-Older Persons in 3113 individuals (58% women) predicted 10-year CVD events in 10.2% (95% CI 10.1-10.3) vs. observed 15.3% (95% CI 14.0-16.5) [O/E ratio 1.6 (95% CI 1.5-1.7)]. The AUC was 0.63 (95% CI 0.60-0.65) with underestimation of risk across sex and risk ranges. Decision curve analysis showed limited clinical benefit. CONCLUSION In a UK population cohort, the SCORE2 low-risk model showed fair discrimination and calibration, with clinical benefit for preventive treatment initiation decisions. In contrast, in individuals aged 70-79 years, SCORE2-OP demonstrated poor discrimination, underestimated risk in both sexes, and limited clinical utility.
Collapse
Affiliation(s)
- Tinka J van Trier
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Marjolein Snaterse
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Wilma J M Scholte op Reimer
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- HU University of Applied Sciences Utrecht, Research Group Chronic Diseases, Padualaan 99, 3584 CH Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ron J G Peters
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Harald T Jørstad
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
5
|
Hageman SHJ, Dorresteijn JAN, Pennells L, van Smeden M, Bots ML, Di Angelantonio E, Visseren FLJ. The relevance of competing risk adjustment in cardiovascular risk prediction models for clinical practice. Eur J Prev Cardiol 2023; 30:1741-1747. [PMID: 37338108 DOI: 10.1093/eurjpc/zwad202] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/17/2023] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Many models developed for predicting the risk of cardiovascular disease (CVD) are adjusted for the competing risk of non-CVD mortality, which has been suggested to reduce potential overestimation of cumulative incidence in populations where the risk of competing events is high. The objective was to evaluate and illustrate the clinical impact of competing risk adjustment when deriving a CVD prediction model in a high-risk population. METHODS AND RESULTS Individuals with established atherosclerotic CVD were included from the Utrecht Cardiovascular Cohort-Secondary Manifestations of ARTerial disease (UCC-SMART). In 8355 individuals, followed for a median of 8.2 years (IQR 4.2-12.5), two similar prediction models for the estimation of 10-year residual CVD risk were derived: with competing risk adjustment using a Fine and Gray model and without competing risk adjustment using a Cox proportional hazards model. On average, predictions were higher from the Cox model. The Cox model predictions overestimated the cumulative incidence [predicted-observed ratio 1.14 (95% CI 1.09-1.20)], which was most apparent in the highest risk quartiles and in older persons. Discrimination of both models was similar. When determining treatment eligibility on thresholds of predicted risks, more individuals would be treated based on the Cox model predictions. If, for example, individuals with a predicted risk > 20% were considered eligible for treatment, 34% of the population would be treated according to the Fine and Gray model predictions and 44% according to the Cox model predictions. INTERPRETATION Individual predictions from the model unadjusted for competing risks were higher, reflecting the different interpretations of both models. For models aiming to accurately predict absolute risks, especially in high-risk populations, competing risk adjustment must be considered.
Collapse
Affiliation(s)
- Steven H J Hageman
- Department of Vascular Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Postbus 85500 3508 GA Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Postbus 85500 3508 GA Utrecht, The Netherlands
| | - Lisa Pennells
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Papworth Road, Trumpington, Cambridge CB2 0BB, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Papworth Road, Trumpington, Cambridge CB2 0BB, UK
| | - Maarten van Smeden
- Julius Centre for Health Science and Primary Care, University Medical Centre Utrecht, University of Utrecht, Heidelberglaan 100, Postbus 85500 3508 GA Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Centre for Health Science and Primary Care, University Medical Centre Utrecht, University of Utrecht, Heidelberglaan 100, Postbus 85500 3508 GA Utrecht, The Netherlands
| | - Emanuele Di Angelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Papworth Road, Trumpington, Cambridge CB2 0BB, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Papworth Road, Trumpington, Cambridge CB2 0BB, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, CB2 0BB Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, CB2 0BB Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, CB10 1SA Cambridge, UK
- Health Data Science Research Centre, Human Technopole, 20157 Milan, Italy
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Postbus 85500 3508 GA Utrecht, The Netherlands
| |
Collapse
|
6
|
Helmink MAG, Hageman SHJ, Visseren FLJ, de Ranitz-Greven WL, de Valk HW, van Sloten TT, Westerink J. Variability in benefit from intensive insulin therapy on cardiovascular events in individuals with type 1 diabetes: A post hoc analysis of the DCCT/EDIC study. Diabet Med 2023; 40:e15183. [PMID: 37470718 DOI: 10.1111/dme.15183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
AIM To evaluate presence of treatment effect heterogeneity of intensive insulin therapy (INT) on occurrence of major adverse cardiovascular events (MACE) in individuals with type 1 diabetes. METHODS In participants from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study, individual treatment effect of INT (≥3 daily insulin injections/insulin pump therapy) versus conventional therapy (once/twice daily insulin) on the risk of MACE was estimated using a penalized Cox regression model including treatment-by-covariate interaction terms. RESULTS In 1441 participants, 120 first MACE events were observed and 1279 individuals (89%) were predicted to benefit from INT with regard to MACE risk reduction. The study population was divided into four groups based on predicted treatment effect: one group with no predicted benefit and three tertiles with predicted treatment benefit. The median absolute reduction in 30-year risk of MACE across groups of predicted treatment effect ranged from -0.2% (i.e. risk increase; interquartile range [IQR] -0.1% to -0.3%) in the group with no predicted benefit to 6.6% (i.e. risk reduction; IQR 3.8%-10.9%; number needed to treat 15) in the highest tertile of predicted benefit. The observed benefit of preventing microvascular complications was stable across all subgroups of predicted MACE benefit. CONCLUSIONS Although INT reduces the risk of MACE in the majority of individuals with type 1 diabetes, benefit varies substantially. These individual differences in the effect of INT underline the necessity for a better understanding of the individual response to intensive treatment.
Collapse
Affiliation(s)
- Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Harold W de Valk
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas T van Sloten
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Isala Clinics, Zwolle, The Netherlands
| |
Collapse
|
7
|
Hageman SHJ, Petitjean C, Pennells L, Kaptoge S, Pajouheshnia R, Tillmann T, Blaha MJ, McClelland RL, Matsushita K, Nambi V, Klungel OH, Souverein PC, van der Schouw YT, Verschuren WMM, Lehmann N, Erbel R, Jöckel KH, Di Angelantonio E, Visseren FLJ, Dorresteijn JAN. Improving 10-year cardiovascular risk prediction in apparently healthy people: flexible addition of risk modifiers on top of SCORE2. Eur J Prev Cardiol 2023; 30:1705-1714. [PMID: 37264679 PMCID: PMC10600319 DOI: 10.1093/eurjpc/zwad187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/03/2023]
Abstract
AIMS In clinical practice, factors associated with cardiovascular disease (CVD) like albuminuria, education level, or coronary artery calcium (CAC) are often known, but not incorporated in cardiovascular risk prediction models. The aims of the current study were to evaluate a methodology for the flexible addition of risk modifying characteristics on top of SCORE2 and to quantify the added value of several clinically relevant risk modifying characteristics. METHODS AND RESULTS Individuals without previous CVD or DM were included from the UK Biobank; Atherosclerosis Risk in Communities (ARIC); Multi-Ethnic Study of Atherosclerosis (MESA); European Prospective Investigation into Cancer, The Netherlands (EPIC-NL); and Heinz Nixdorf Recall (HNR) studies (n = 409 757) in whom 16 166 CVD events and 19 149 non-cardiovascular deaths were observed over exactly 10.0 years of follow-up. The effect of each possible risk modifying characteristic was derived using competing risk-adjusted Fine and Gray models. The risk modifying characteristics were applied to individual predictions with a flexible method using the population prevalence and the subdistribution hazard ratio (SHR) of the relevant predictor. Risk modifying characteristics that increased discrimination most were CAC percentile with 0.0198 [95% confidence interval (CI) 0.0115; 0.0281] and hs-Troponin-T with 0.0100 (95% CI 0.0063; 0.0137). External validation was performed in the Clinical Practice Research Datalink (CPRD) cohort (UK, n = 518 015, 12 675 CVD events). Adjustment of SCORE2-predicted risks with both single and multiple risk modifiers did not negatively affect calibration and led to a modest increase in discrimination [0.740 (95% CI 0.736-0.745) vs. unimproved SCORE2 risk C-index 0.737 (95% CI 0.732-0.741)]. CONCLUSION The current paper presents a method on how to integrate possible risk modifying characteristics that are not included in existing CVD risk models for the prediction of CVD event risk in apparently healthy people. This flexible methodology improves the accuracy of predicted risks and increases applicability of prediction models for individuals with additional risk known modifiers.
Collapse
Affiliation(s)
- Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Carmen Petitjean
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Lisa Pennells
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Stephen Kaptoge
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Romin Pajouheshnia
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Taavi Tillmann
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, USA
| | | | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Vijay Nambi
- Center for Cardiovascular Disease Prevention, Michael E DeBakey Veterans Affairs Hospital, Houston, USA
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - W M Monique Verschuren
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Nils Lehmann
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Raimund Erbel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Emanuele Di Angelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- Health Data Science Research Centre, Human Technopole, Milan, Italy
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| |
Collapse
|
8
|
Helmink MAG, Westerink J, Hageman SHJ, Koopman M, van der Meer MG, Teraa M, Ruigrok YM, Visseren FLJ. Effect of adipose tissue quantity and dysfunction on the risk of cancer in individuals with and without type 2 diabetes. Obes Res Clin Pract 2023; 17:383-389. [PMID: 37777400 DOI: 10.1016/j.orcp.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/18/2023] [Accepted: 09/08/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE To determine the role of waist circumference and metabolic dysfunction in the risk of cancer in individuals with type 2 diabetes (T2D) and to compare this to individuals without T2D. METHODS Individuals with (n = 1925) and without T2D (n = 10,204) were included from the UCC-SMART cohort. Incident cancer diagnoses were obtained by linkage with the Netherlands Cancer Registry. Metabolic dysfunction was defined as ≥ 3 adapted NCEP ATP-III metabolic syndrome criteria. The effects of waist circumference and metabolic dysfunction on cancer were assessed using Cox proportional hazards models, adjusted for confounders. RESULTS During a median follow-up of 8.3 years (IQR 4.2-13.1), 1740 individuals were diagnosed with cancer. Incidence rates of total cancer were 19.3 and 15.5/1000 person-years for individuals with and without T2D, respectively. In individuals without T2D, a higher waist circumference was associated with an increased risk of colorectal (per standard deviation: HR 1.23; 95%CI 1.03-1.46), urinary tract (HR 1.28; 95%CI 1.05-1.56) and total cancer (HR 1.06; 95%CI 1.02-1.13). Metabolic dysfunction was related to an increased risk of colorectal (HR 1.35; 95%CI 1.01-1.82), lung (HR 1.37; 95%CI 1.07-1.75) and total cancer (HR 1.13; 95%CI 1.01-1.25) in individuals without T2D. In individuals with T2D, no significant associations were found. CONCLUSION Incidence rates of cancer are higher among individuals with T2D. However, higher waist circumference and metabolic dysfunction are only associated with an increased cancer risk in patients without T2D. These findings provide novel insights into the role of metabolic dysfunction in the occurrence of cancer.
Collapse
Affiliation(s)
- Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands; Department of Internal Medicine, Isala Clinics Zwolle, PO Box 10400, 8000 GK Zwolle, the Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Ynte M Ruigrok
- Department of Neurology, University Medical Center Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.
| |
Collapse
|
9
|
Pennells L, Kaptoge S, Østergaard HB, Read SH, Carinci F, Franch-Nadal J, Petitjean C, Taylor O, Hageman SHJ, Xu Z, Shi F, Spackman S, Gualdi S, Holman N, Da Providencia E Costa RB, Bonnet F, Brenner H, Gillum RF, Kiechl S, Lawlor DA, Potier L, Schöttker B, Sofat R, Völzke H, Willeit J, Baltane Z, Fava S, Janos S, Lavens A, Pildava S, Poljicanin T, Pristas I, Rossing P, Sascha R, Scheidt-Nave C, Stotl I, Tibor G, Urbančič-Rovan V, Vanherwegen AS, Vistisen D, Du Y, Walker MR, Willeit P, Ference B, De Bacquer D, Halle M, Huculeci R, McEvoy JW, Timmis A, Vardas P, Dorresteijn JAN, Graham I, Wood A, Eliasson B, Herrington W, Danesh J, Mauricio D, Benedetti MM, Sattar N, Visseren FLJ, Wild S, Di Angelantonio E, Balkau B, Bonnet F, Fumeron F, Stocker H, Holleczek B, Schipf S, Schmidt CO, Dörr M, Tilg H, Leitner C, Notdurfter M, Taylor J, Dale C, Prieto-Merino D, Gillum RF, Lavens A, Vanherwegen AS, Poljicanin T, Pristas I, Buble T, Ivanko P, Rossing P, Carstensen B, Heidemann C, Du Y, Scheidt-Nave C, Gall T, Sandor J, Baltane Z, Pildava S, Lepiksone J, Magri CJ, Azzopardi J, Stotl I, Real J, Vlacho B, Mata-Cases M. SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe. Eur Heart J 2023; 44:2544-2556. [PMID: 37247330 PMCID: PMC10361012 DOI: 10.1093/eurheartj/ehad260] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 05/31/2023] Open
Abstract
AIMS To develop and validate a recalibrated prediction model (SCORE2-Diabetes) to estimate the 10-year risk of cardiovascular disease (CVD) in individuals with type 2 diabetes in Europe. METHODS AND RESULTS SCORE2-Diabetes was developed by extending SCORE2 algorithms using individual-participant data from four large-scale datasets comprising 229 460 participants (43 706 CVD events) with type 2 diabetes and without previous CVD. Sex-specific competing risk-adjusted models were used including conventional risk factors (i.e. age, smoking, systolic blood pressure, total, and HDL-cholesterol), as well as diabetes-related variables (i.e. age at diabetes diagnosis, glycated haemoglobin [HbA1c] and creatinine-based estimated glomerular filtration rate [eGFR]). Models were recalibrated to CVD incidence in four European risk regions. External validation included 217 036 further individuals (38 602 CVD events), and showed good discrimination, and improvement over SCORE2 (C-index change from 0.009 to 0.031). Regional calibration was satisfactory. SCORE2-Diabetes risk predictions varied several-fold, depending on individuals' levels of diabetes-related factors. For example, in the moderate-risk region, the estimated 10-year CVD risk was 11% for a 60-year-old man, non-smoker, with type 2 diabetes, average conventional risk factors, HbA1c of 50 mmol/mol, eGFR of 90 mL/min/1.73 m2, and age at diabetes diagnosis of 60 years. By contrast, the estimated risk was 17% in a similar man, with HbA1c of 70 mmol/mol, eGFR of 60 mL/min/1.73 m2, and age at diabetes diagnosis of 50 years. For a woman with the same characteristics, the risk was 8% and 13%, respectively. CONCLUSION SCORE2-Diabetes, a new algorithm developed, calibrated, and validated to predict 10-year risk of CVD in individuals with type 2 diabetes, enhances identification of individuals at higher risk of developing CVD across Europe.
Collapse
|
10
|
Castelijns MC, Hageman SHJ, Teraa M, van der Meer MG, Westerink J, Costa F, Ten Berg JM, Visseren FLJ. External validation of bleeding risk models for the prediction of long-term bleeding risk in patients with established cardiovascular disease. Am Heart J 2023; 260:72-81. [PMID: 36841319 DOI: 10.1016/j.ahj.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE The long-term predictive performance of existing bleeding risk models in patients with various manifestations of cardiovascular disease (CVD) is not well known. This study aims to assess and compare the performance of relevant existing bleeding risk models in estimating the long-term risk of major bleeding in a cohort of patients with established CVD. METHODS Seven existing bleeding risk models (PRECISE-DAPT, DAPT, Ducrocq et al, de Vries et al, S2TOP-BLEED, Intracranial B2LEED3S and HAS-BLED) were identified and externally validated in 7,249 patients with established CVD included in the Utrecht Cardiovascular Cohort-second manifestations of arterial disease study. Predictive performance was assessed in terms of discrimination and calibration, both at 10 years and the original prediction horizon of the models. Major bleeding was defined as Bleeding Academic Research Consortium type 3 or 5. RESULTS After a median follow-up of 8.4 years (interquartile range 4.5-12.5), a total of 233 (3.2%) major bleeding events occurred. C-statistics for discrimination at 10 years ranged from 0.53 (95%CI 0.49-0.57) to 0.64 (95%CI 0.60-0.68). Calibration plots after recalibration to 10 years showed best agreement between predicted and observed bleeding risk for De Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. CONCLUSIONS The performance of existing bleeding risk models to predict long-term bleeding in patients with CVD varied. Discrimination and calibration were best for the models of de Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. Of these, recalibrated models requiring the least predictors may be preferred for use to personalize prevention with antithrombotic therapy.
Collapse
Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Internal Medicine, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Francesco Costa
- Department of Cardiology, G. Martino University Hospital Messina, Messina, Italy
| | - Jurriën M Ten Berg
- Department of Cardiology and Platelet Function Research, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
11
|
Castelijns MC, Helmink MAG, Hageman SHJ, Asselbergs FW, de Borst GJ, Bots ML, Cramer MJ, Dorresteijn JAN, Emmelot-Vonk MH, Geerlings MI, de Jong PA, van der Kaaij NP, Kappelle LJ, Lely AT, van der Meer MG, Mol BM, Nathoe HM, Onland-Moret NC, van Petersen RB, Ruigrok YM, van Smeden M, Teraa M, Vandersteen A, Verhaar MC, Westerink J, Visseren FLJ. Cohort profile: the Utrecht Cardiovascular Cohort-Second Manifestations of Arterial Disease (UCC-SMART) Study-an ongoing prospective cohort study of patients at high cardiovascular risk in the Netherlands. BMJ Open 2023; 13:e066952. [PMID: 36806141 PMCID: PMC9944278 DOI: 10.1136/bmjopen-2022-066952] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
PURPOSE The Utrecht Cardiovascular Cohort-Second Manifestations of Arterial Disease (UCC-SMART) Study is an ongoing prospective single-centre cohort study with the aim to assess important determinants and the prognosis of cardiovascular disease progression. This article provides an update of the rationale, design, included patients, measurements and findings from the start in 1996 to date. PARTICIPANTS The UCC-SMART Study includes patients aged 18-90 years referred to the University Medical Center Utrecht, the Netherlands, for management of cardiovascular disease (CVD) or severe cardiovascular risk factors. Since September 1996, a total of 14 830 patients have been included. Upon inclusion, patients undergo a standardised screening programme, including questionnaires, vital signs, laboratory measurements, an ECG, vascular ultrasound of carotid arteries and aorta, ankle-brachial index and ultrasound measurements of adipose tissue, kidney size and intima-media thickness. Outcomes of interest are collected through annual questionnaires and adjudicated by an endpoint committee. FINDINGS TO DATE By May 2022, the included patients contributed to a total follow-up time of over 134 000 person-years. During follow-up, 2259 patients suffered a vascular endpoint (including non-fatal myocardial infarction, non-fatal stroke and vascular death) and 2794 all-cause deaths, 943 incident cases of diabetes and 2139 incident cases of cancer were observed up until January 2020. The UCC-SMART cohort contributed to over 350 articles published in peer-reviewed journals, including prediction models recommended by the 2021 European Society of Cardiology CVD prevention guidelines. FUTURE PLANS The UCC-SMART Study guarantees an infrastructure for research in patients at high cardiovascular risk. The cohort will continue to include about 600 patients yearly and follow-up will be ongoing to ensure an up-to-date cohort in accordance with current healthcare and scientific knowledge. In the near future, UCC-SMART will be enriched by echocardiography, and a food frequency questionnaire at baseline enabling the assessment of associations between nutrition and CVD and diabetes.
Collapse
Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Mirjam I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A Titia Lely
- Department of Gynaecology and Obstetrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Barend M Mol
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N Charlotte Onland-Moret
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rutger B van Petersen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ynte M Ruigrok
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Angela Vandersteen
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
12
|
van Trier TJ, Snaterse M, Hageman SHJ, Ter Hoeve N, Sunamura M, Moll van Charante E, Galenkamp H, Deckers JW, Martens FMAC, Visseren FLJ, Scholte Op Reimer WJM, Peters RJG, Jørstad HT. Unexploited potential of risk factor treatment in patients with atherosclerotic cardiovascular disease. Eur J Prev Cardiol 2023; 30:601-610. [PMID: 36757680 DOI: 10.1093/eurjpc/zwad038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/03/2023] [Accepted: 02/07/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Most patients with atherosclerotic cardiovascular disease remain at (very) high risk for recurrent events due to suboptimal risk factor control. AIM This study aimed to quantify the potential of maximal risk factor treatment on ten-year and lifetime risk of recurrent atherosclerotic cardiovascular events in patients one year after a coronary event. METHODS Pooled data from six studies: RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS. Patients aged ≥45 years at ≥6 months after coronary event were included. The SMART-REACH score was used to estimate ten-year and lifetime risk of recurrent atherosclerotic cardiovascular events with current treatment, and potential risk reduction and gains in event-free years with maximal treatment (lifestyle and pharmacological). RESULTS In 3,230 atherosclerotic cardiovascular disease patients (24% women), at median (IQR) 1.1 years (1.0-1.8) after index event, ten-year risk was median (IQR) 20% (15%-27%) and lifetime risk 54% (47-63). Whereas 70% used conventional medication, 82% had ≥1 drug-modifiable risk factor not on target. Furthermore, 91% had ≥1 lifestyle-related risk factor not on target. Maximising therapy was associated with a potential reduction of median (IQR) ten-year risk to 6% (4%-8%) and of lifetime risk to 20% (15%-27%), and a median (IQR) gain of 7.3 (5.4-10.4) ASCVD event-free years. CONCLUSIONS Among patients with atherosclerotic cardiovascular disease, maximising current, guideline-based preventive therapy has the potential to mitigate a large part of their risk of recurrent events and to add a clinically important number of event-free years to their lifetime.
Collapse
Affiliation(s)
- Tinka J van Trier
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marjolein Snaterse
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nienke Ter Hoeve
- Capri Cardiac Rehabilitation Rotterdam, Rotterdam, The Netherlands.,Department of Rehabilitation Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Madoka Sunamura
- Capri Cardiac Rehabilitation Rotterdam, Rotterdam, The Netherlands.,Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Eric Moll van Charante
- Department of General Practice, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Henrike Galenkamp
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Jaap W Deckers
- Department of Cardiology, Thoraxcenter, Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilma J M Scholte Op Reimer
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,HU University of Applied Sciences Utrecht, Research Group Chronic Diseases, Utrecht, The Netherlands
| | - Ron J G Peters
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Harald T Jørstad
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Østergaard HB, Hageman SHJ, Read SH, Taylor O, Pennells L, Kaptoge S, Petitjean C, Xu Z, Shi F, McEvoy JW, Herrington W, Visseren FLJ, Wood A, Eliasson B, Sattar N, Wild S, Di Angelantonio E, Dorresteijn JAN. Estimating individual lifetime risk of incident cardiovascular events in adults with Type 2 diabetes: an update and geographical calibration of the DIAbetes Lifetime perspective model (DIAL2). Eur J Prev Cardiol 2023; 30:61-69. [PMID: 36208182 DOI: 10.1093/eurjpc/zwac232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/20/2022] [Accepted: 10/05/2022] [Indexed: 01/14/2023]
Abstract
AIMS The 2021 European Society of Cardiology cardiovascular disease (CVD) prevention guidelines recommend the use of (lifetime) risk prediction models to aid decisions regarding intensified preventive treatment options in adults with Type 2 diabetes, e.g. the DIAbetes Lifetime perspective model (DIAL model). The aim of this study was to update the DIAL model using contemporary and representative registry data (DIAL2) and to systematically calibrate the model for use in other European countries. METHODS AND RESULTS The DIAL2 model was derived in 467 856 people with Type 2 diabetes without a history of CVD from the Swedish National Diabetes Register, with a median follow-up of 7.3 years (interquartile range: 4.0-10.6 years) and comprising 63 824 CVD (including fatal CVD, non-fatal stroke and non-fatal myocardial infarction) events and 66 048 non-CVD mortality events. The model was systematically recalibrated to Europe's low- and moderate-risk regions using contemporary incidence data and mean risk factor distributions. The recalibrated DIAL2 model was externally validated in 218 267 individuals with Type 2 diabetes from the Scottish Care Information-Diabetes (SCID) and Clinical Practice Research Datalink (CPRD). In these individuals, 43 074 CVD events and 27 115 non-CVD fatal events were observed. The DIAL2 model discriminated well, with C-indices of 0.732 [95% confidence interval (CI) 0.726-0.739] in CPRD and 0.700 (95% CI 0.691-0.709) in SCID. CONCLUSION The recalibrated DIAL2 model provides a useful tool for the prediction of CVD-free life expectancy and lifetime CVD risk for people with Type 2 diabetes without previous CVD in the European low- and moderate-risk regions. These long-term individualized measures of CVD risk are well suited for shared decision-making in clinical practice as recommended by the 2021 CVD ESC prevention guidelines.
Collapse
Affiliation(s)
- Helena Bleken Østergaard
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Stephanie H Read
- Usher Institute, University of Edinburgh, Craigour House, 450 Old Dalkeith Rd, Edinburgh EH16 4SS, UK
- On behalf of the Scottish Diabetes Research Network epidemiology group, Diabetes Support Unit, Level 8, Ninewells Hospital, DundeeDD1 9SY, UK
| | - Owen Taylor
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Lisa Pennells
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Carmen Petitjean
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Zhe Xu
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Fanchao Shi
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | | | - William Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Blå stråket 5 B Wallenberglab, SU41345 Göteborg, Sweden
| | - Naveed Sattar
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, G12 8TA Glasgow, UK
| | - Sarah Wild
- Usher Institute, University of Edinburgh, Craigour House, 450 Old Dalkeith Rd, Edinburgh EH16 4SS, UK
- On behalf of the Scottish Diabetes Research Network epidemiology group, Diabetes Support Unit, Level 8, Ninewells Hospital, DundeeDD1 9SY, UK
| | - Emanuele Di Angelantonio
- Department of Public Health and Primary Care, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
- Health Data Science Centre, Human Technopole, V.le Rita Levi-Montalcini, 1, 20157 Milano MI, Italy
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| |
Collapse
|
14
|
Castelijns MC, Hageman SHJ, Ruigrok YM, van der Meer MG, Teraa M, Westerink J, Visseren FLJ. Visceral adipose tissue quantity and dysfunction and the occurrence of major bleeding in patients with established cardiovascular disease. Obes Res Clin Pract 2023; 17:40-46. [PMID: 36464615 DOI: 10.1016/j.orcp.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVES To determine the association between both visceral fat quantity and adipose tissue dysfunction, and major bleeding in patients with established cardiovascular disease. METHODS Patients from the Second Manifestations of ARTerial disease study with established cardiovascular disease were included. Visceral fat was measured using ultrasound and adipose tissue dysfunction was depicted using metabolic syndrome criteria (revised National Cholesterol Education Program). Cox regression models were fitted to study the relation with major bleeding defined as Bleeding Academic Research Consortium (BARC) type 3 or 5, or International Society on Thrombosis and Haemostasis (ISTH) major bleeding. Sensitivity analyses were performed using C-reactive protein levels to reflect adipose tissue dysfunction. RESULTS In 6927 patients during a median follow up of 9.2 years, a total of 237 BARC type 3 or 5 bleedings and 224 ISTH major bleedings were observed. Visceral fat quantity was not related to major bleeding (HR 1.01, 95%CI 0.88-1.16 for BARC type 3 or 5 bleeding and HR 1.00, 95%CI 0.87-1.15 for ISTH major bleeding), nor was metabolic syndrome (HR 0.97, 95%CI 0.75-1.26 for BARC type 3 or 5 bleeding and HR 0.98, 95%CI 0.75-1.28 for ISTH major bleeding). Sensitivity analyses using C-reactive protein levels showed similar results. No effect modification was observed by sex, antithrombotic therapy, presence of metabolic syndrome or diabetes. CONCLUSION In patients with cardiovascular disease, no association was found between visceral fat quantity measured with ultrasound or measures of adipose tissue dysfunction and the risk of major bleeding, irrespective of antithrombotic agent use.
Collapse
Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Ynte M Ruigrok
- Department of Neurology, University Medical Center Utrecht, the Netherlands
| | | | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.
| | | |
Collapse
|
15
|
Hageman SHJ, Lu W, Kaptoge S, Lall K, Bobak M, Pikhart H, Kubinova R, Pajak A, Tamosiunas A, Stang A, Schmidt B, Schramm S, Di Angelantonio E, Visseren FLJ, Dorresteijn JAN. Prediction of lifetime cardiovascular risk and individual lifetime treatment benefit in four European risk regions: geographic recalibration of the LIFE-CVD model. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The life expectancy free of cardiovascular disease (CVD) in individuals without previous CVD can be estimated with the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model, as recommended by the 2021 ESC CVD prevention guidelines. Our aim was to systematically recalibrate the LIFE-CVD model to four European risk regions using contemporary and representative registry data.
Methods and results
The LIFE-CVD model was systematically recalibrated to four distinct risk regions within Europe, using representative aggregate data on age- and sex-specific expected CVD and non-CVD mortality incidences and risk factor distributions. For external validation, 1,451,077 individuals without previous CVD were included from seven European cohorts, with 53,721 CVD events and 62,902 non-CVD deaths during follow up. After applying the recalibrated risk prediction models to external validation cohorts, C-indices (figure 1) ranged from 0.670 (95% CI 0.650–0.690) to 0.787 (95% CI 0.785–0.789). Predicted risks matched the observed risks in the CPRD data. With the recalibrated LIFE-CVD model, the estimated gain in CVD-free life expectancy from preventive therapy differed per region, for example a 50-year-old smoking women with a systolic blood pressure of 140mm Hg was estimated to gain 0.4 years of CVD-free life from 10 mm Hg SBP reduction in the low risk region, whereas this would be 1.5 years in the very high risk region (figure 2).
Interpretation
By taking into account geographical differences in CVD incidence, the recalibrated LIFE-CVD model provides a more accurate tool for the prediction of lifetime risk and CVD-free life expectancy for individuals without previous CVD, facilitating shared decision-making in cardiovascular prevention options as recommended by the 2021 European Prevention Guidelines.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- S H J Hageman
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - W Lu
- University College London, Department of Epidemiology and Public Health , London , United Kingdom
| | - S Kaptoge
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - K Lall
- University of Tartu, Estonian Genome Centre , Tartu , Estonia
| | - M Bobak
- University College London, Department of Epidemiology and Public Health , London , United Kingdom
| | - H Pikhart
- University College London, Department of Epidemiology and Public Health , London , United Kingdom
| | - R Kubinova
- National Institute of Public Health , Prague , Czechia
| | - A Pajak
- Institute of Public Health, Department of Epidemiology and Population Studies , Krakow , Poland
| | - A Tamosiunas
- Lithuanian University of Health Sciences, Institute of Cardiology , Kaunas , Lithuania
| | - A Stang
- Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - B Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - S Schramm
- Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - E Di Angelantonio
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - F L J Visseren
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| |
Collapse
|
16
|
Matsushita K, Kaptoge S, Hageman SHJ, Visseren FLJ, Pennells L, Coresh J. Including measures of chronic kidney disease to improve cardiovascular risk prediction by SCORE2 and SCORE2-OP. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The 2021 ESC guideline on cardiovascular disease (CVD) prevention qualitatively categorizes moderate and severe chronic kidney disease (CKD) as high and very-high CVD risk status regardless of other factors like age and does not include estimated glomerular filtration rate (eGFR) and albuminuria in its algorithms, SCORE2 and SCORE2-OP, to predict CVD risk.
Purpose
To develop and validate an “Add-on” to incorporate CKD measures into these algorithms, using a validated approach.
Methods
In 3,054,840 participants from 34 datasets, we developed three Add-ons (eGFR only, eGFR + urinary albumin-to-creatinine ratio [ACR] [the primary Add-on], and eGFR + dipstick proteinuria) for SCORE2 and SCORE2-OP. We validated c-statistics and net reclassification improvement (NRI), accounting for competing risk of non-CVD death, in 5,995,067 participants from 33 different datasets.
Results
In the target population of SCORE2 and SCORE2-OP without diabetes, the CKD Add-on (eGFR only) and CKD Add-on (eGFR + ACR) improved c-statistic by 0.006 (95% CI 0.005–0.008) and 0.018 (0.012–0.024), respectively, for SCORE2 and 0.012 (0.009–0.015) and 0.023 (0.013–0.032), respectively, for SCORE2-OP. Similar results were seen when we included individuals with diabetes and tested the CKD Add-on (eGFR + dipstick). In 57,485 European participants with CKD, SCORE2 or SCORE2-OP with a CKD Add-on showed a significant NRI (e.g., 0.100 [0.062–0.138] for SCORE2) compared to the qualitative approach in the ESC guideline.
Conclusion
Our Add-ons with CKD measures improved CVD risk prediction beyond SCORE2 and SCORE2-OP. This approach will help clinicians and patients with CKD refine risk prediction and further personalize preventive therapies for CVD.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): US National Kidney Foundation funding as well as US NIDDK
Collapse
Affiliation(s)
- K Matsushita
- Johns Hopkins Bloomberg School of Public Health , Baltimore , United States of America
| | - S Kaptoge
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - S H J Hageman
- University Medical Center Utrecht, Department of Vascular Medicine , Utrecht , The Netherlands
| | - F L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine , Utrecht , The Netherlands
| | - L Pennells
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - J Coresh
- Johns Hopkins Bloomberg School of Public Health , Baltimore , United States of America
| |
Collapse
|
17
|
Hageman SHJ, Pennells L, Pajouheshnia R, Tillmann T, Blaha MJ, McClelland RL, Matsushita K, Nambi V, Van Der Schouw YT, Verschuren WMM, Lehmann N, Jockel KH, Di Angelantonio E, Visseren FLJ, Dorresteijn JAN. The value of additional risk factors for improving 10-year cardiovascular risk prediction in apparently healthy people. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In clinical practice, factors known to be associated with cardiovascular disease (CVD) like albuminuria, education level, or coronary calcium score are not directly incorporated in cardiovascular risk prediction models. The aim of the current study was to quantify the added value of potential risk modifying characteristics when added to the SCORE2 algorithm for individuals without diabetes mellitus (DM) or prior CVD.
Methods and results
Individuals without previous CVD or DM were included from the ARIC, MESA, EPIC-NL and HNR studies (n=46,285) in whom 2,177 CVD events and 2,062 non-cardiovascular deaths were observed over exactly 10.0 years of follow-up. The effect of each possible risk modifying characteristic was derived using Fine and Gray models that included an offset term for the SCORE2 linear predictor. The risk modifying characteristics were applied to individual predictions using the “naïve approach”, which modifies predicted risks based on the population prevalence and the SHR of the relevant predictor. Subdistribution hazard ratios are presented in the table. External validation was performed in the CPRD cohort (UK, n=518,015, 12,675 CVD events). In the external validation, adjustment of SCORE2 predicted risks with both single and with all available risk modifiers did not negatively affect calibration (see figure) and led to a modest increase in discrimination (C-index 0.742 [95% CI 0.737–0.746] versus unimproved SCORE2 risk C-index 0.737 [95% CI 0.732–0.741]). The net reclassification index or adding all these predictors was +0.032 (95% CI 0.025; 0.028) for future events and −0.008 (95% CI −0.009; −0.007) for future non-events. The coronary calcium score was found to the single strongest added predictor.
Interpretation
The current analysis presents a method on how to integrate possible risk modifying characteristics that are not included in existing CVD risk models for the prediction of CVD event risk in apparently healthy people. This flexible methodology improves the accuracy of predicted risks and increases applicability of prediction models for individuals with additional risk known modifiers
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- S H J Hageman
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - L Pennells
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - R Pajouheshnia
- Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology , Utrecht , The Netherlands
| | - T Tillmann
- University of Tartu, Institute of Family Medicine and Public Health , Tartu , Estonia
| | - M J Blaha
- The Johns Hopkins Hospital, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease , Baltimore , United States of America
| | - R L McClelland
- University of Washington, Department of Biostatistics , Seattle , United States of America
| | - K Matsushita
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology , Baltimore , United States of America
| | - V Nambi
- Baylor College of Medicine, Department of Medicine , Houston , United States of America
| | - Y T Van Der Schouw
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , The Netherlands
| | - W M M Verschuren
- National Institute for Public Health and the Environment (RIVM), Centre for Nutrition, Prevention and Health Services , Bilthoven , The Netherlands
| | - N Lehmann
- University hospital Essen, Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - K H Jockel
- University hospital Essen, Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - E Di Angelantonio
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - F L J Visseren
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| |
Collapse
|
18
|
Van Trier T, Snaterse M, Hageman SHJ, Ter Hoeve N, Sunamura M, Moll Van Charante EP, Galenkamp H, Deckers JW, Visseren FLJ, Scholte Op Reimer WJM, Peters RJG, Jorstad HT. Overall benefits of smoking cessation in patients with ASCVD are underestimated. Eur J Prev Cardiol 2022. [DOI: 10.1093/eurjpc/zwac056.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
New risk prediction models estimate and employ individual ‘treatment benefit’, which can be used to motivate patients with atherosclerotic cardiovascular disease (ASCVD) to quit smoking and to adhere to beneficial pharmacological interventions. However, this treatment benefit is usually calculated for a limited set of cardiovascular outcomes, i.e. years gained without myocardial infarction or stroke, while ignoring non-cardiovascular health benefits and pharmacological side- and adverse effects. Importantly, treatment effect size of medication is smaller in persistent smokers compared to non-smokers, because of the higher overall mortality of the smokers. By disregarding non-cardiovascular outcomes, the overall benefit of smoking cessation will be underestimated.
Purpose
We estimated and compared the treatment benefits – expressed as ‘gain in years without major cardiovascular events’ – of smoking cessation versus persistent smoking with targeted pharmaceutical interventions in patients with established ASCVD treated with anti-platelet agents, statins and anti-hypertensive drugs.
Methods
We pooled individual-level risk factors data from six large, recent prospective studies: RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS. We included patients aged ≥45 years who persisted in smoking ≥6 months after acute coronary syndrome or revascularisation. The primary outcome was SMART-REACH estimated treatment benefit expressed as gain in years without a myocardial infarction or stroke. We compared the cardiovascular treatment benefit of smoking cessation versus the use of one or more pharmaceutical treatments: bempedoic acid, colchicine and PCSK9 inhibitors.
Results
We included 989 smokers with established ASCVD (23% female), with mean age of 60 (SD 8) years at median 1.2 (IQR 1.0-2.0) years post-index event. A mean of 4.81 (95%CI 4.73-4.89) event-free years would be gained through smoking cessation. Persistent smoking with maximal pharmaceutical treatment resulted in a comparable gain of 4.83 (95% CI 4.72-4.93) event-free years.(Figure)
Conclusion
The estimated lifetime treatment benefit of smoking cessation appeared to be comparable to the use of several pharmaceutical treatments combined, even when the analysis was limited to major cardiovascular events. This substantial health benefit underscores smoking cessation to be one of the most important actions to improve the overall health of patients with established ASCVD. To accurately compare treatment options, overall benefits and harms should be considered, in addition to the patients’ preferences, in a shared decision making process.
Collapse
Affiliation(s)
- T Van Trier
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - M Snaterse
- Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, Netherlands (The)
| | - SHJ Hageman
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands (The)
| | - N Ter Hoeve
- Capri Cardiac Rehabilitation, Rotterdam, Netherlands (The)
| | - M Sunamura
- Capri Cardiac Rehabilitation, Rotterdam, Netherlands (The)
| | - EP Moll Van Charante
- Amsterdam UMC - Location Academic Medical Center, Department of General Practice, Amsterdam, Netherlands (The)
| | - H Galenkamp
- Amsterdam UMC - Location Academic Medical Center, Department of Public and Occupational Health, Amsterdam, Netherlands (The)
| | - JW Deckers
- Erasmus University Medical Centre, Department of Cardiology, Rotterdam, Netherlands (The)
| | - FLJ Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands (The)
| | - WJM Scholte Op Reimer
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - RJG Peters
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - HT Jorstad
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| |
Collapse
|
19
|
Van Trier T, Snaterse M, Hageman SHJ, Hoeve N, Sunamura M, Moll Van Charante EP, Galenkamp H, Deckers JW, Visseren FLJ, Scholte Op Reimer WJM, Peters RJG, Jorstad HT. Lifetime versus 10-year risk of recurrent events in patients with cardiovascular disease: impact of age. Eur J Prev Cardiol 2022. [DOI: 10.1093/eurjpc/zwac056.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Most risk models for patients with established atherosclerotic cardiovascular disease (ASCVD) calculate short-term risk of recurrent events and death, typically for a duration of 10 years. However, lifetime risk estimates may better support the healthcare professional in selecting patients for intensified preventive treatment (1). Also, a cross-sectional study suggested that communicating lifetime risk to ASCVD patients enhances risk perception and willingness for therapy (2). In the new ESC prevention guideline, however, 10-year risk estimates remain standard for ASCVD patients but the additional use of lifetime risk is recommended for communication in the shared decision-making process (3).
Purpose
We therefore aimed to compare estimates of 10-year with lifetime risk of recurrent ASCVD events or death, stratified by age.
Methods
We pooled individual-level data on risk factors from six large, recent prospective studies (RESPONSE 1 and 2, OPTICARE, EUROASPIRE IV and V and HELIUS). We included Dutch patients aged ≥45 years with a follow-up of ≥6 months after acute coronary syndrome or revascularisation. The SMART-REACH models were used to estimate the difference between 10-year and lifetime risk of recurrent myocardial infarction, stroke, or cardiovascular death, stratified by age (<55, 55-65, 65-75, ≥75 years).
Results
In 3,230 ASCVD patients (24% women), mean age 61±8 years, at median follow-up 1.1 (IQR 1.0-1.8) years after index event, SMART-REACH 10-year risk was 23±11% versus lifetime 56±11%. (Figure 1) We found a considerable difference between 10-year and lifetime risk in patients aged 45-55 years (18±8% vs. 61±10%). Discrepancies decreased with increasing age, with similar estimates in the highest (75-85) age group. (Figure 2).
Conclusion
Lifetime risk of a limited set of cardiovascular outcomes rather than 10-year risk may provide a more complete estimate of future ASCVD disease burden, as especially in younger patients 10-year risk is usually low, even in the presence of risk factors.
Collapse
Affiliation(s)
- T Van Trier
- Amsterdam University Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - M Snaterse
- Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, Netherlands (The)
| | - SHJ Hageman
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands (The)
| | - N Hoeve
- Capri Cardiac Rehabilitation, Rotterdam, Netherlands (The)
| | - M Sunamura
- Capri Cardiac Rehabilitation, Rotterdam, Netherlands (The)
| | - EP Moll Van Charante
- Amsterdam University Medical Center, Department of General Practice, Amsterdam, Netherlands (The)
| | - H Galenkamp
- Amsterdam University Medical Center, Department of Public and Occupational Health, Amsterdam, Netherlands (The)
| | - JW Deckers
- Erasmus University Medical Centre, Department of Cardiology, Rotterdam, Netherlands (The)
| | - FLJ Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands (The)
| | - WJM Scholte Op Reimer
- Amsterdam University Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - RJG Peters
- Amsterdam University Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - HT Jorstad
- Amsterdam University Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| |
Collapse
|
20
|
Hageman SHJ, McKay AJ, Ueda P, Gunn LH, Jernberg T, Hagström E, Bhatt DL, Steg PG, Läll K, Mägi R, Gynnild MN, Ellekjær H, Saltvedt I, Tuñón J, Mahíllo I, Aceña Á, Kaminski K, Chlabicz M, Sawicka E, Tillman T, McEvoy JW, Di Angelantonio E, Graham I, De Bacquer D, Ray KK, Dorresteijn JAN, Visseren FLJ. Estimation of recurrent atherosclerotic cardiovascular event risk in patients with established cardiovascular disease: the updated SMART2 algorithm. Eur Heart J 2022; 43:1715-1727. [PMID: 35165703 PMCID: PMC9312860 DOI: 10.1093/eurheartj/ehac056] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/30/2021] [Accepted: 01/18/2022] [Indexed: 11/19/2022] Open
Abstract
AIMS The 10-year risk of recurrent atherosclerotic cardiovascular disease (ASCVD) events in patients with established ASCVD can be estimated with the Secondary Manifestations of ARTerial disease (SMART) risk score, and may help refine clinical management. To broaden generalizability across regions, we updated the existing tool (SMART2 risk score) and recalibrated it with regional incidence rates and assessed its performance in external populations. METHODS AND RESULTS Individuals with coronary artery disease, cerebrovascular disease, peripheral artery disease, or abdominal aortic aneurysms were included from the Utrecht Cardiovascular Cohort-SMART cohort [n = 8355; 1706 ASCVD events during a median follow-up of 8.2 years (interquartile range 4.2-12.5)] to derive a 10-year risk prediction model for recurrent ASCVD events (non-fatal myocardial infarction, non-fatal stroke, or cardiovascular mortality) using a Fine and Gray competing risk-adjusted model. The model was recalibrated to four regions across Europe, and to Asia (excluding Japan), Japan, Australia, North America, and Latin America using contemporary cohort data from each target region. External validation used data from seven cohorts [Clinical Practice Research Datalink, SWEDEHEART, the international REduction of Atherothrombosis for Continued Health (REACH) Registry, Estonian Biobank, Spanish Biomarkers in Acute Coronary Syndrome and Biomarkers in Acute Myocardial Infarction (BACS/BAMI), the Norwegian COgnitive Impairment After STroke, and Bialystok PLUS/Polaspire] and included 369 044 individuals with established ASCVD of whom 62 807 experienced an ASCVD event. C-statistics ranged from 0.605 [95% confidence interval (CI) 0.547-0.664] in BACS/BAMI to 0.772 (95% CI 0.659-0.886) in REACH Europe high-risk region. The clinical utility of the model was demonstrated across a range of clinically relevant treatment thresholds for intensified treatment options. CONCLUSION The SMART2 risk score provides an updated, validated tool for the prediction of recurrent ASCVD events in patients with established ASCVD across European and non-European populations. The use of this tool could allow for a more personalized approach to secondary prevention based upon quantitative rather than qualitative estimates of residual risk.
Collapse
Affiliation(s)
- Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ailsa J McKay
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Laura H Gunn
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Department of Public Health Sciences and School of Data Science, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Ph. Gabriel Steg
- French Alliance for Cardiovascular Trials, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, INSERM Unité, 1148 Paris, France
| | - Kristi Läll
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Reedik Mägi
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU—Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatrics, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - José Tuñón
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Autónoma University, Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Ignacio Mahíllo
- Department of Epidemiology, Fundación Jiménez Díaz, Madrid, Spain
| | - Álvaro Aceña
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Autónoma University, Madrid, Spain
| | - Karol Kaminski
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
| | - Malgorzata Chlabicz
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Emilia Sawicka
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
- Department of Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Taavi Tillman
- Centre for Non-Communicable Disease, Institute for Global Health, University College London, London, UK
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, Galway, Ireland
- Galway Campus, National University of Ireland Galway, Galway, Ireland
| | - Emanuele Di Angelantonio
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ian Graham
- School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Dirk De Bacquer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
- Corresponding author. Tel: +31 88 7555161, Fax: +31 30 2523741,
| |
Collapse
|
21
|
Gynnild MN, Hageman SHJ, Spigset O, Lydersen S, Saltvedt I, Dorresteijn JAN, Visseren FLJ, Ellekjær H. Use of lipid-lowering therapy after ischaemic stroke and expected benefit from intensification of treatment. Open Heart 2022; 9:openhrt-2022-001972. [PMID: 35459718 PMCID: PMC9036470 DOI: 10.1136/openhrt-2022-001972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/05/2022] [Indexed: 12/27/2022] Open
Abstract
Objectives Elevated low-density lipoprotein cholesterol (LDL-C) increases the risk of recurrent cardiovascular disease (CVD) events. We examined use of lipid-lowering therapy (LLT) following ischaemic stroke, and estimated benefits from guideline-based up-titration of LLT. Methods The Norwegian COgnitive Impairment After STroke (Nor-COAST) study, a multicentre prospective cohort study, collected data on LLT use, dose intensity and LDL-C levels for 462 home-dwelling patients with ischaemic stroke. We used the Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health (SMART-REACH) model to estimate the expected benefit of up-titrating LLT. Results At discharge, 92% received LLT (97% statin monotherapy). Patients with prestroke dementia and cardioembolic stroke aetiology were less likely to receive LLT. Older patients (coefficient −3 mg atorvastatin per 10 years, 95% CI −6 to −0.5) and women (coefficient −5.1 mg atorvastatin, 95% CI −9.2 to −0.9) received lower doses, while individuals with higher baseline LDL-C, ischaemic heart disease and large artery stroke aetiology received higher dose intensity. At 3 months, 45% reached LDL-C ≤1.8 mmol/L, and we estimated that 81% could potentially reach the target with statin and ezetimibe, resulting in median 5 (IQR 0–12) months of CVD-free life gain and median 2% 10-year absolute risk reduction (IQR 0–4) with large interindividual variation. Conclusion Potential for optimisation of conventional LLT use exists in patients with ischaemic stroke. Awareness of groups at risk of undertreatment and objective estimates of the individual patient’s benefit of intensification can help personalise treatment decisions and reduce residual cholesterol risk. Trial registration number NCT02650531.
Collapse
Affiliation(s)
- Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Trondheim, Norway .,Department of Stroke, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Trondheim, Norway.,Department of Geriatrics, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | | | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
22
|
Van Trier TJ, Snaterse M, Ter Hoeve N, Sunamura M, Moll Van Charante EP, Galenkamp H, Deckers JW, Hageman SHJ, Visseren FLJ, Scholte Op Reimer WJM, Peters RJG, Jorstad HT. Modifiable lifetime risk for recurrent major cardiovascular events: observations in a contemporary pooled cohort. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The major modifiable risk factors for atherosclerosis – lifestyle, hypertension, diabetes and cholesterol – collectively account for 80 to 90% of disease burden. Currently, the majority of coronary patients does not meet the guideline-directed treatment targets for these risk factors, resulting in high levels of residual risk. An increasing number of novel preventive drugs aims to reduce this residual risk, but are not considered cost-effective when added routinely to all patients. Quantifying the potential lifetime risk reduction one year after an acute coronary syndrome (ACS) may aid in optimum use of available treatment and value-based use of novel drugs.
Purpose
The purpose of this analysis was to quantify the loss of lifetime risk reduction due to suboptimal modifiable risk factor control in patients with prior ACS or revascularisation.
Methods
We pooled six recent prospective studies (Response 1 [1] and 2 [2], Opticare [3], EuroAspire IV [4] and V [5] and HELIUS [6]) with Dutch patients (n=3,230, 24% women) at mean age 61±8 years and follow-up at median 1.1 [IQR 1.0–1.8] years after an ACS or revascularisation. We investigated individual lifestyle- and drug-modifiable risk factors at guideline-directed targets. Using the SMART-REACH model [7], we calculated % reduction of individual residual lifetime risk for myocardial infarction, stroke, or cardiovascular death and event free years gained by the change from current treatment to a (simulated) guideline-directed optimal situation.
Results
Risk factor control was far from optimal: only 7% met all lifestyle-related risk targets, whereas 10% met none: 30% persist smoking, 79% was overweight (BMI ≥25 kg/m2), of which 40% obese (BMI ≥30 kg/m2), and 45% reported insufficient physical activity (<150 minutes per week). Systolic blood pressure ≥140 mmHg was found in 40%, and LDL-cholesterol ≥1.8 mmol/L or ≥2.5 mmol/L (depending on the target at that time) in 65%. Basic preventive medication use was, however, common: 87% used antithrombotic agents, 85% lipid lowering drugs and 86% any blood pressure lowering drugs. By the change from current to optimal guideline-directed treatment, residual lifetime risk for cardiovascular events and cardiovascular death would decrease from a mean of 54±11% to 25±10% (Figure 1), and a median of 7.4 [IQR 5.2–10.6] event free years would be gained (Figure 2).
Conclusion
Suboptimal risk factor control resulted in avoidable high residual lifetime risk of myocardial infarction, stroke, or cardiovascular death and loss of event free years in patients with prior ACS or revascularisation. This finding highlights the unexploited potential of optimised use of available lifestyle- and drug treatment to significantly reduce residual lifetime risk.
Funding Acknowledgement
Type of funding sources: None. Figure 1. Modifiable residual lifetime riskFigure 2. Lifetime benefit in CVD event free years
Collapse
Affiliation(s)
- T J Van Trier
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - M Snaterse
- Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, Netherlands (The)
| | - N Ter Hoeve
- Capri Cardiac Rehabilitation, Rotterdam, Netherlands (The)
| | - M Sunamura
- Capri Cardiac Rehabilitation, Rotterdam, Netherlands (The)
| | - E P Moll Van Charante
- Amsterdam UMC - Location Academic Medical Center, Department of General Practice, Amsterdam, Netherlands (The)
| | - H Galenkamp
- Amsterdam UMC - Location Academic Medical Center, Department of Public and Occupational Health, Amsterdam, Netherlands (The)
| | - J W Deckers
- Erasmus University Medical Centre, Department of Cardiology, Thoraxcenter, Rotterdam, Netherlands (The)
| | - S H J Hageman
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands (The)
| | - F L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands (The)
| | - W J M Scholte Op Reimer
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - R J G Peters
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| | - H T Jorstad
- Amsterdam UMC - Location Academic Medical Center, Department of Cardiology, Amsterdam, Netherlands (The)
| |
Collapse
|
23
|
Gynnild MN, Hageman SHJ, Dorresteijn JAN, Spigset O, Lydersen S, Wethal T, Saltvedt I, Visseren FLJ, Ellekjær H. Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention. Clin Epidemiol 2021; 13:813-823. [PMID: 34566434 PMCID: PMC8456548 DOI: 10.2147/clep.s322779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/20/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Suboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets. Patients and Methods The SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated. Results In total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55–0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32–54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63–76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2–3.4) event-free life years if guideline targets were met. Conclusion Secondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.
Collapse
Affiliation(s)
- Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Torgeir Wethal
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Geriatrics, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
24
|
de Vries TI, Cooney MT, Selmer RM, Hageman SHJ, Pennells LA, Wood A, Kaptoge S, Xu Z, Westerink J, Rabanal KS, Tell GS, Meyer HE, Igland J, Ariansen I, Matsushita K, Blaha MJ, Nambi V, Peters R, Beckett N, Antikainen R, Bulpitt CJ, Muller M, Emmelot-Vonk MH, Trompet S, Jukema W, Ference BA, Halle M, Timmis AD, Vardas PE, Dorresteijn JAN, De Bacquer D, Di Angelantonio E, Visseren FLJ, Graham IM. SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. Eur Heart J 2021; 42:2455-2467. [PMID: 34120185 PMCID: PMC8248997 DOI: 10.1093/eurheartj/ehab312] [Citation(s) in RCA: 165] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/09/2021] [Accepted: 05/07/2021] [Indexed: 12/21/2022] Open
Abstract
AIMS The aim of this study was to derive and validate the SCORE2-Older Persons (SCORE2-OP) risk model to estimate 5- and 10-year risk of cardiovascular disease (CVD) in individuals aged over 70 years in four geographical risk regions. METHODS AND RESULTS Sex-specific competing risk-adjusted models for estimating CVD risk (CVD mortality, myocardial infarction, or stroke) were derived in individuals aged over 65 without pre-existing atherosclerotic CVD from the Cohort of Norway (28 503 individuals, 10 089 CVD events). Models included age, smoking status, diabetes, systolic blood pressure, and total- and high-density lipoprotein cholesterol. Four geographical risk regions were defined based on country-specific CVD mortality rates. Models were recalibrated to each region using region-specific estimated CVD incidence rates and risk factor distributions. For external validation, we analysed data from 6 additional study populations {338 615 individuals, 33 219 CVD validation cohorts, C-indices ranged between 0.63 [95% confidence interval (CI) 0.61-0.65] and 0.67 (0.64-0.69)}. Regional calibration of expected-vs.-observed risks was satisfactory. For given risk factor profiles, there was substantial variation across the four risk regions in the estimated 10-year CVD event risk. CONCLUSIONS The competing risk-adjusted SCORE2-OP model was derived, recalibrated, and externally validated to estimate 5- and 10-year CVD risk in older adults (aged 70 years or older) in four geographical risk regions. These models can be used for communicating the risk of CVD and potential benefit from risk factor treatment and may facilitate shared decision-making between clinicians and patients in CVD risk management in older persons.
Collapse
|
25
|
Hageman SHJ, Dorresteijn JAN, Bots ML, Asselbergs FW, Westerink J, van der Meulen MP, Mosterd A, Visseren FLJ, Asselbergs FW, Nathoe HM, de Borst GJ, Bots ML, Geerlings MI, Emmelot MH, de Jong PA, Leiner T, Lely AT, van der Kaaij NP, Kappelle LJ, Ruigrok YM, Verhaar MC, Visseren FLJ, Westerink J. Residual cardiovascular risk reduction guided by lifetime benefit estimation in patients with symptomatic atherosclerotic disease: effectiveness and cost-effectiveness. Eur J Prev Cardiol 2021; 29:635-644. [PMID: 34009323 DOI: 10.1093/eurjpc/zwab028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/07/2020] [Indexed: 12/22/2022]
Abstract
AIMS To determine the (cost)-effectiveness of blood pressure lowering, lipid-lowering, and antithrombotic therapy guided by predicted lifetime benefit compared to risk factor levels in patients with symptomatic atherosclerotic disease. METHODS AND RESULTS For all patients with symptomatic atherosclerotic disease in the UCC-SMART cohort (1996-2018; n = 7697) two treatment strategies were compared. The lifetime benefit-guided strategy was based on individual estimation of gain in cardiovascular disease (CVD)-free life with the SMART-REACH model. In the risk factor-based strategy, all patients were treated the following: low-density lipoprotein cholesterol (LDL-c) < 1.8 mmol/L, systolic blood pressure <140 mmHg, and antithrombotic medication. Outcomes were evaluated for the total cohort using a microsimulation model. Effectiveness was evaluated as total gain in CVD-free life and events avoided, cost-effectiveness as incremental cost-effectivity ratio (ICER). In comparison to baseline treatment, treatment according to lifetime benefit would lead to an increase of 24 243 CVD-free life years [95% confidence interval (CI) 19 980-29 909] and would avoid 940 (95% CI 742-1140) events in the next 10 years. For risk-factor based treatment, this would be an increase of 18 564 CVD-free life years (95% CI 14 225-20 456) and decrease of 857 (95% CI 661-1057) events. The ICER of lifetime benefit-based treatment with a treatment threshold of ≥1 year additional CVD-free life per therapy was €15 092/QALY gained and of risk factor-based treatment €9933/QALY gained. In a direct comparison, lifetime benefit-based treatment compared to risk factor-based treatment results in 1871 additional QALYs for the price of €36 538/QALY gained. CONCLUSION Residual risk reduction guided by lifetime benefit estimation results in more CVD-free life years and more CVD events avoided compared to the conventional risk factor-based strategy. Lifetime benefit-based treatment is an effective and potentially cost-effective strategy for reducing residual CVD risk in patients with clinical manifest vascular disease.
Collapse
Affiliation(s)
- Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Miriam P van der Meulen
- Julius Center for Health Sciences and Primary Care, Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arend Mosterd
- Julius Center for Health Sciences and Primary Care, Utrecht, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Cardiology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Hageman SHJ, Dorresteijn JAN, Visseren FLJ. Comment to: Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE risk model. Eur J Prev Cardiol 2021; 29:e139-e140. [PMID: 33792666 DOI: 10.1093/eurjpc/zwab033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, PO Box 85500, 3508 GA Utrecht, The Netherlands
| |
Collapse
|
27
|
Hageman SHJ, de Borst GJ, Dorresteijn JAN, Bots ML, Westerink J, Asselbergs FW, Visseren FLJ. Cardiovascular risk factors and the risk of major adverse limb events in patients with symptomatic cardiovascular disease. Heart 2020; 106:1686-1692. [DOI: 10.1136/heartjnl-2019-316088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 01/24/2023] Open
Abstract
AimTo determine the relationship between non-high-density lipoprotein cholesterol (non-HDL-c), systolic blood pressure (SBP) and smoking and the risk of major adverse limb events (MALE) and the combination with major adverse cardiovascular events (MALE/MACE) in patients with symptomatic vascular disease.MethodsPatients with symptomatic vascular disease from the Utrecht Cardiovascular Cohort - Secondary Manifestations of ARTerial disease (1996–2017) study were included. The effects of non-HDL-c, SBP and smoking on the risk of MALE were analysed with Cox proportional hazard models stratified for presence of peripheral artery disease (PAD). MALE was defined as major amputation, peripheral revascularisation or thrombolysis in the lower limb.ResultsIn 8139 patients (median follow-up 7.8 years, IQR 4.0–11.8), 577 MALE (8.7 per 1000 person-years) and 1933 MALE/MACE were observed (29.1 per 1000 person-years). In patients with PAD there was no relation between non-HDL-c and MALE, and in patients with coronary artery disease (CAD), cerebrovascular disease (CVD) or abdominal aortic aneurysm (AAA) the risk of MALE was higher per 1 mmol/L non-HDL-c (HR 1.14, 95% CI 1.01 to 1.29). Per 10 mm Hg SBP, the risk of MALE was higher in patients with PAD (HR 1.06, 95% CI 1.01 to 1.12) and in patients with CVD/CAD/AAA (HR 1.15, 95% CI 1.08 to 1.22). The risk of MALE was higher in smokers with PAD (HR 1.45, 95% CI 0.97 to 2.14) and CAD/CVD/AAA (HR 7.08, 95% CI 3.99 to 12.57).ConclusionsThe risk of MALE and MALE/MACE in patients with symptomatic vascular disease differs according to vascular disease location and is associated with non-HDL-c, SBP and smoking. These findings confirm the importance of MALE as an outcome and underline the importance of risk factor management in patients with vascular disease.
Collapse
|
28
|
Hageman SHJ, Dorresteijn JAN, Bots ML, Westerink J, Asselbergs FW, De Borst GJ, Visseren FLJ. P1540Major adverse limb events (MALE) and the relation with classical risk factors in patients with symptomatic cardiovascular disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with symptomatic cardiovascular disease are at high risk for recurrent major adverse cardiovascular events (MACE). Major adverse limb events (MALE) are only rarely reported as a (primary) outcome in trials and cohorts although MALE often lead to significant morbidity and disability.
Purpose
The aim of this study was to determine the incidence of MALE in patients with coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD) or abdominal aortic aneurysm (AAA) and to assess to what extent the classical modifiable risk factors systolic blood pressure (SBP), smoking and non-high density lipoprotein cholesterol (non-HDL-c) affect the risk of MALE.
Methods
Patients with symptomatic vascular disease were included from the ongoing UCC-SMART cohort (1996–2017, n=8139). MALE was defined as a major amputation, peripheral revascularization or thrombolysis of the lower limb. A major amputation included all amputations at the level of the forefoot or higher due to a vascular cause. For non-HDL-c, smoking (per category: non-smoking, former smoking and current smoking) and SBP, the risk for MALE was analyzed with Cox proportional hazard models adjusted for potential confounders. All results were stratified for the presence of PAD/AAA or CAD/CVD at baseline. To calculate the population attributable fraction, non-HDL-c was dichotomized at 1.8 mmol/L and SBP at 140 mmHg.
Results
A total of 577 MALE were observed in 65,402 person-years (median follow up 7.6 years, IQR 3.9–11.7 years) (figure 1A), of which 32 major amputations. In PAD/AAA patients 413 MALE were observed (incidence rate 24.9/1000 person-years). In the CAD/CVD patients 164 MALE were observed (incidence rate 3.4/1000 person-years). The MALE risk per 1 mmol/L higher non-HDL-c was not elevated: HR 1.01 (95% CI 0.94–1.09) for patients with PAD/AAA and HR 1.03 (95% CI 0.91–1.18) for patients with CAD/CVD (figure 1B). The MALE risk per 10mmHg higher SBP was HR 1.10 (95% CI 1.05–1.15) for PAD/AAA patients and HR 1.14 (95% CI 1.06–1.22) for CAD/CVD patients. In patients with PAD/AAA the risk for MALE by former smoking was HR 1.34 (95% CI 0.92–1.97) and for current smoking HR 1.66 (95% CI 1.14–2.44). In CAD/CVD patients, this was for former smoking HR 2.98 (95% CI 1.65–5.39) and for current smoking HR 6.81 (95% CI 3.72–12.45). The population attributable fraction was 0.13 (95% CI −0.07–0.32) for non-HDL-c, 0.21 (95% CI 0.13–0.28) for SBP and 0.28 (95% CI 0.22–0.33) for current smoking.
Figure 1
Conclusions
The incidence of MALE is high in patients with PAD/AAA, and much lower in patients with CAD or CVD. Systolic blood pressure and smoking increase the risk of MALE in PAD/AAA and CAD/CVD patients, Non-HDL-c was not related to the risk of MALE. These findings confirm the importance of MALE as an outcome in patients with clinical manifest vascular disease and underline the importance of the management of classical risk factors to prevent these disabling clinical events.
Acknowledgement/Funding
None
Collapse
Affiliation(s)
- S H J Hageman
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| | - M L Bots
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands (The)
| | - J Westerink
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| | - F W Asselbergs
- University Medical Center Utrecht, Department of cardiology, Utrecht, Netherlands (The)
| | - G J De Borst
- University Medical Center Utrecht, Department of Vascular Surgery, Utrecht, Netherlands (The)
| | - F L J Visseren
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| |
Collapse
|