Cardiovascular mortality risk beyond 10 years in men and women; long-term follow-up from the EPIC-Norfolk prospective population study

Introduction

Current primary prevention strategies in cardiovascular (CV) disease focus on initiating preventive interventions in people at high 10-year risk of CV mortality. However, initiating such strategies should be beneficial not only in the first 10 years, but throughout life. Established risk algorithms estimate the risk of 10-year CV mortality, but limited evidence is available about the relationship between 10-year and longer-term CV mortality.

Purpose

To compare cumulative incidence of CV mortality in a population cohort at 10- and 20-years follow-up, stratified by sex.

Methods

We analysed CV mortality at 10-years and 20-years follow-up using Kaplan-Meier estimates among men and women aged 39–70 years without baseline CV disease or diabetes mellitus in the large, prospective population-based EPIC-Norfolk cohort. CV mortality included death with as underlying or contributing cause ischaemic heart disease, heart failure, cerebrovascular disease or peripheral artery disease.

Results

We analysed data from 20,453 participants (56% women), with a mean age of 56±8 years, and median (IQR) follow-up of 22 (21–23) years. At baseline, there were no clinically relevant differences in CV risk factors between men and women. Overall cumulative CV mortality rate was 1.9% (384 deaths) in the first 10 years, and 7.3% (995 deaths) at 20 years follow-up (ratio 3.8). Among men, 10-year CV mortality was 2.9% (249 deaths), and 9.6% (785 deaths) at 20 years follow-up (ratio 3.3). Among women, CV mortality was 1.2% (135 deaths) at 10 year and 5.5% (594 deaths) at 20 years follow-up (ratio 4.6).

Conclusion

We observed an incremental increase in CV mortality beyond the 10-year scope of current established CV risk algorithms. At 20 years follow-up, CV mortality rates were 3–5 times higher compared with the first decade, indicating that 20-year CV mortality risk for both men and women cannot simply be estimated based on extrapolation of 10-year risk.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EPIC-Norfolk is supported by programme grants from the Medical Research Council UK (MRC G0401527, MRC G0701863, MRC G1000143) and Cancer Research UK (CRUK 8257).

Let’s get active: patients with a recent coronary event are highly motivated to lose weight and increase physical activity levels

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NWO-grant

Title (Dutch): Het centraal stellen van behandelvoorkeuren van de individuele patiënt met een chronische hartziekte.

Subtitle: Persoonsgerichte zorg voor hartpatiënten

Introduction

Motivated patients are more likely to successfully improve unhealthy lifestyles. How patients perceive their risk factors and their willingness to improve is an integral part of this motivation. However, such preferences, and how they align with clinicians’ risk perception are seldom systematically assessed in patients with coronary artery disease (CAD).

Purpose

We aimed to investigate preferences in risk factor treatment in patients with CAD, and to compare this with clinicians’ perception of patients’ risks.

Methods

We administered a 10-item questionnaire on patients’ preferences on risk factor treatment in secondary prevention which was developed in consultation with end-users. We sent the questionnaire to approximately 450 patients who were referred to cardiac rehabilitation after recent (<3 months) admission to an acute coronary unit between Feb 2020 and Apr 2021. We demonstrate the results of 6 questions that covered the following subjects relevant to secondary prevention: Q1: risk factor perception, Q2: priority setting, Q3: wanting help, Q4: willingness to change, Q5: motivation to change, Q6: confidence to successfully change. We compared patients risk factor perception with clinicians’ report in the medical record.

Results

A total of 296 patients completed the survey (66% of eligible respondents) at mean (SD) age 64 (10) years on median (IQR) 38 (25-53) days after discharge. Physical activity was much more frequently reported as risk factor by patients (P 55%) compared to clinicians (C 31%), followed by other disparities such as for high cholesterol (P 48% vs. C 36%) and overweight (P 46% vs. C 59%) (Figure 1). Patients were asked which of their perceived risk factors on Q1 was most important to improve (Q2) and for which they wanted help (Q3). Top-3 risk factors chosen for improvement were overweight (87%), physical inactivity (81%), and stress (79%), for which 75% required help with any risk factor, again most frequently with increasing physical activity (64%), overweight (59%) and stress (51%) (Figure 2). Motivation and confidence for improvement of risk factors were high: 87% were willing to adapt their lifestyles, with motivation rates of median (IQR) 8 (7-9) out of 10, and estimated chance for successful improvement of median (IQR) 7 (6-8) out of 10.

Conclusion(s)

Patients who recently suffered from coronary event are highly motivated to lose weight and increase physical inactivity. The use of these patient preferences by the clinician will enable compliance and outcomes with respect to weight loss and improved physical activity.

Overall benefits of smoking cessation in patients with ASCVD are underestimated

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.

Lifetime versus 10-year risk of recurrent events in patients with cardiovascular disease: impact of age

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.