Ankle-Brachial Index and cardiovascular events in atrial fibrillation

2016 ◽  
Vol 115 (04) ◽  
pp. 856-863 ◽  
Author(s):  
Giovanni Davi ◽  
Marco Proietti ◽  
Daniele Pastori ◽  
William R. Hiatt ◽  
Gino Roberto Corazza ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cardiovascular Events ◽  
Hazard Analysis ◽  
Ankle Brachial Index ◽  
Vascular Event ◽  
Vascular Events ◽  
Non Invasive ◽  
Vascular Death ◽  
Online Appendix ◽  
Male Patients

SummaryAtrial fibrillation (AF) patients are at high risk for thrombotic and vascular events related to their cardiac arrhythmia and underlying systemic atherosclerosis. Ankle-Brachial Index (ABI) is a non-invasive tool in evaluating systemic atherosclerosis, useful in predicting cardiovascular events in general population; no data are available in AF patients. ARAPACIS is a prospective multicentre observational study performed by the Italian Society of Internal Medicine, analysing association between low ABI (≤0.90) and vascular events in NVAF out- or in-patients, enrolled in 136 Italian centres. A total of 2,027 non-valvular AF (NVAF) patients aged > 18 years from both sexes followed for a median time of 34.7 (interquartile range: 22.0–36.0) months, yielding a total of 4,614 patient-years of observation. Mean age was 73 ± 10 years old with 55% male patients. A total of 176 patients (8.7%) experienced a vascular event, with a cumulative incidence of 3.81%/patient-year. ABI≤ 0.90 was more prevalent in patients with a vascular event compared with patients free of vascular events (32.2 vs 20.2%, p< 0.05). On Cox proportional hazard analysis, ABI≤ 0.90 was an independent predictor of vascular events (hazard ratio (HR): 1.394, 95% confidence interval (CI): 1.042–1.866; p=0.02), vascular death (HR: 2.047, 95% CI: 1.255-3.338; p=0.004) and MI (HR: 2.709, 95%> CI: 1.485-5.083; p=0.001). This latter association was also confirmed after excluding patients with previous MI (HR: 2.901, 95% CI: 1.408-5.990, p=0.004). No association was observed between low ABI and stroke/transient ischaemic attack (p=0.91). In conclusion, low ABI is useful to predict MI and vascular death in NVAF patients and may independently facilitate cardiovascular risk assessment in NVAF patients.Note: The review process for this paper was fully handled by C. Weber, Editor in Chief.Listed in the Supplementary Online Appendix Material which is available online at www.thrombosis-online.com.

Abstract 16732: Urinary 11-Dehydro-Thromboxane B2 is Associated With Vascular and Non-Vascular Events in Atrial Fibrillation Patients

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Daniele Pastori ◽  
Pasquale Pignatelli ◽  
Roberto Cangemi ◽  
William Hiatt ◽  
Alessio Farcomeni ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cardiovascular Events ◽  
Oral Anticoagulants ◽  
Cardiovascular Death ◽  
Cox Proportional Hazards ◽  
Thromboxane B2 ◽  
Vascular Events ◽  
Residual Cardiovascular Risk ◽  
Increased Risk ◽  
Anticoagulated Patients

Introduction: Non-Valvular Atrial Fibrillation (AF) patients show high residual cardiovascular risk despite oral anticoagulants. Urinary 11-dehydro-thromboxane B2 (TxB2) is associated with an increased risk of cardiovascular events, but its predictive value in anticoagulated AF patients is unknown. Hypothesis: Aim of this was to assess whether urinary 11-dehydro-TxB2 is a predictor of cardiovascular events in anticoagulated patients with AF. Methods: Prospective single-center cohort study, including 864 consecutive AF patients. Mean time of follow-up was 30.0 months yielding 2062 person-years of observation. Urinary 11-dehydro-TxB2 was measured at baseline. The primary end-point was the composite of myocardial infarction, ischemic stroke, cardiac revascularization, cardiovascular death and deaths from any cause. Results: Cardiovascular events occurred in 98 (11.3%), whilst 81 patients died (9.4%), including 55 from cardiovascular and 26 from non-cardiovascular causes. At baseline, urinary 11-dehydro-TxB2 levels were higher in patients who experienced a cardiovascular event (p<0.001). An increased rate of cardiovascular events, cardiovascular death and all-cause death was observed across tertiles of 11-dehydro-TxB2 (p<0.001). On Cox proportional hazards analysis, CHA2DS2-VASc score, second and third tertile of 11-dehydro-TxB2, compared to the first tertile, were significant predictors of vascular and non-vascular events. On a logistic regression analysis, 11-dehydro-TxB2 levels progressively increase with increasing CHA2DS2-VASc scores. Conclusions: Urinary 11-dehydro-TxB2 predicts residual risk of cardiovascular events in anticoagulated atrial fibrillation patients. Urinary 11-dehydro-TxB2 progressively increases with increasing CHA2DS2-VASc score suggesting that anticoagulated patients with high CHA2DS2-VASc score may need additional antithrombotic strategies.

Abstract 162: Processes of Care that are Associated With Reduced Risk of Recurrent Vascular Events Among Patients With a Transient Ischemic Attack and Minor Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Dawn Bravata ◽  
Laura Myers ◽  
Mat Reeves ◽  
Eric Cheng ◽  
Fitsum Baye ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Carotid Artery ◽  
Recurrent Events ◽  
Vascular Event ◽  
Fiscal Year ◽  
Minor Stroke ◽  
Vascular Events ◽  
Processes Of Care ◽  
Free Care ◽  
Reduced Risk

Background: Interventions that emphasize early evaluation and management of patients with TIA and minor stroke have demonstrated reductions in recurrent vascular events. Objective: To identify processes of care that were associated with reduced risk of recurrent vascular events after TIA or minor stroke. Methods: We identified patients with a TIA or minor stroke cared for in a Department of Veterans Affairs (VA) Emergency Department or inpatient ward (fiscal year 2011). Recurrent vascular events included ischemic stroke, myocardial infarction, heart failure, arrhythmia or death within 90-days and 1-year of discharge. 32 processes of care were examined. Defect-free care was assessed for a set of 6 processes (brain imaging, carotid artery imaging, hypertension management, high or moderate potency statin, antithrombotics, and anticoagulation for atrial fibrillation); patients who received all processes for which they were eligible passed the defect-free measure. Multivariable logistic regression with a random facility effect was used to model recurrent events. Clinically important potential confounders were forced into all models; other significant covariates were identified by backward selection. Results: Among 8107 patients, 14.0% had a recurrent vascular event within 90-days; 26.5% within 1-year. Three processes were associated with lower 90-day events after adjustment for 24 covariates: carotid artery imaging (adjusted OR, 0.74 [95%CI, 0.65-0.85], lipid measurement (0.80 [0.68-0.94]), and anticoagulation quality for atrial fibrillation (0.56 [0.35-0.88]). Three processes were associated with reduced 1-year events: carotid artery imaging (0.80 [0.71-0.89]), lipid measurement (0.85 [0.75-0.97]), and timely carotid stenosis intervention (0.49 [0.26-0.94]). The defect-free care rate, observed in 17.4%, was also associated with a reduction in recurrent vascular event risk both within 90-days (0.78 [0.65-0.93]) and 1-year (0.82 [0.71-0.94]). Conclusions: The delivery of a comprehensive set of clinical processes was associated with clinically meaningful reductions in short and longer-term risk of recurrent vascular events. Widespread implementation of these processes should be strongly considered.

P945Abnormalities in ankle-brachial indices are independently associated with new-onset atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Tseng ◽  
M Girardo ◽  
D Atwal ◽  
C Firth ◽  
J Shipman ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Hazard Analysis ◽  
Chronic Kidney Disease Stage ◽  
Ankle Brachial Index ◽  
Arterial Disease ◽  
Disease Stage ◽  
Chronic Obstructive ◽  
Increased Risk ◽  
Onset Atrial Fibrillation ◽  
New Onset

Abstract Introduction Lower extremity physiologic studies are an important non-invasive diagnostic tool in peripheral arterial disease (PAD). PAD and atrial fibrillation (AF) are associated with increased cardiovascular and all-cause mortality. Purpose To evaluate the association between PAD and new-onset AF and the risk of stroke. Methods We performed a study of all patients without AF undergoing ankle-brachial index (ABI) for any indication between January 1996 to June 2018. The ABI cut-off were as follows: abnormal ABI (0–0.99), normal ABI (1.00–1.39) and poor vessel compressibility (PC) (1.40+). Demographic, comorbidity, and outcome variables were extracted using the electronic medical record. Results Overall, 34,441 patients (mean age 66.8±14.3, 57.3% male, 88.2% white) were included in the study with a median follow-up of 7.2 years (interquartile range, 3.0–12.9 years). Multivariate Cox proportional hazard analysis showed increased risk of new-onset AF for male sex, older age, hypertension, coronary artery disease, cerebrovascular disease, chronic kidney disease stage III or greater, congestive heart failure, chronic obstructive pulmonary disease, and cancer (all p<0.0001). After adjustment, ABI results were significantly associated with new-onset AF, particularly poorly-compressible vessels (adjusted HR: 1.42 (1.30–1.55), p<0.0001) compared to abnormal ABI (adjusted HR: 1.12 (1.05–1.20), p=0.0012). Patients with atrial fibrillation were more likely to experience ischemic stroke (39.2% versus 16.1%, p<0.0001). Conclusion Abnormalities in ABI results, particularly poorly-compressible vessels, are independently associated with new-onset atrial fibrillation in a large ambulatory cohort. While the mechanism cannot be assessed, common inflammatory mechanisms and increased vascular stiffness may play an important role. Identification of AF in these at-risk patients may improve cardiovascular outcomes.

Abstract TP180: Ankle-brachial Index and Recurrent Stroke Risk: a Meta-analysis

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Thomas Liman ◽  
Ja Bin Hong ◽  
Christopher Leonards ◽  
Bob Siegerink ◽  
Matthias Endres
Keyword(s):  
Recurrent Stroke ◽  
Meta Analysis ◽  
Ankle Brachial Index ◽  
Stroke Recurrence ◽  
Significant Heterogeneity ◽  
Vascular Events ◽  
Vascular Death ◽  
Atherosclerotic Burden ◽  
Increased Risk

Background and Purpose: The ankle-brachial index (ABI) is a fast, cheap, non-invasive indicator of atherosclerotic burden that may also be indicative of stroke recurrence. In this systematic review and meta-analysis, we sought to explore ABI’s merit as a marker for stroke recurrence and vascular risk by synthesizing the data currently available in the stroke literature. Methods: We searched Embase, MEDLINE, and Pubmed databases for prospective cohort studies that included consecutive stroke and/or transient ischemic attack (TIA) patients, measured ABI at baseline, and performed a follow-up assessment at least 12 months following initial stroke/TIA. The following endpoints were chosen for our analysis: (1) recurrent stroke and (2) combined vascular endpoint (recurrent vascular event or vascular death). Crude risk ratios and adjusted Cox proportional hazard ratios (HRs) were combined separately using the random-effects model. Study level characteristics (e.g. percent of cohort with a history of hypertension, average cohort age, and mean follow-up duration) were included as meta-regression covariates. Results: We included 11 studies (5374 patients). Low ABI was associated with an increased risk of recurrent stroke (pooled estimated HR 1.70, 95% CI 1.10-2.64) and vascular events or vascular death, following stroke (pooled estimated HR 2.22, 95% CI 1.67-2.97). No significant heterogeneity was observed in the meta-analysis. Conclusion: Our results confirm the prognostic value of ABI for the recurrence of stroke. It is likely that the inclusion of ABI in risk calculation models will help in improving accuracy of existing models.

scholarly journals Atherosclerotic Burden and Vascular Risk in Stroke Patients With Atrial Fibrillation

Stroke ◽  
2021 ◽  
Author(s):  
Jong-Ho Park ◽  
Jong-Won Chung ◽  
Oh Young Bang ◽  
Gyeong-Moon Kim ◽  
Kang-Ho Choi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cardiovascular Events ◽  
Hazard Ratio ◽  
Adjusted Hazard Ratio ◽  
Major Adverse Cardiovascular Events ◽  
Atherosclerotic Vascular Disease ◽  
Stroke Patients ◽  
Vascular Events ◽  
Atherosclerotic Burden ◽  
Artery Disease

Background and Purpose: Data on the effect on vascular outcomes of concomitant atherosclerotic vascular disease (ASVD) with atrial fibrillation (AF) after stroke are limited. This study evaluated the effect of ASVD with AF versus AF only on the risk of vascular events. Methods: We retrospectively analyzed a prospectively registered multicenter database involving 3213 stroke patients with AF. ASVD included extracranial atherosclerosis measured in the proximal portion of the internal carotid artery, intracranial atherosclerosis (all ≥50% stenosis), coronary artery disease, and peripheral artery disease and was categorized into 4 strata depending on the number of ASVDs (0, 1, 2, and 3–4). The independent associations of ASVD with major adverse cardiovascular events, stroke, and all-cause death were assessed. Results: A total of 2670 patients were included (mean age, 73.5±9.8 years; median CHA 2 DS 2 -VASc score, 5; interquartile range, 4−6). During the follow-up (mean, 1.7 years), a total of 672 (25.2%) major adverse cardiovascular events, 170 (6.4%) stroke events, and 501 (18.8%) all-cause deaths were noted. The adjusted hazard ratio for major adverse cardiovascular events versus no ASVD was 1.25 (95% CI, 1.00–1.56) for ASVD 1, 1.34 (95% CI, 1.02–1.76) for ASVD 2, and 1.93 (95% CI, 1.24–2.99) for ASVD 3–4. The adjusted hazard ratio for all-cause death versus no ASVD was 1.32 (1.01–1.74), 1.47 (1.06–2.03), and 2.39 (1.47–3.89), respectively. Among ASVD components, the presence of symptomatic or asymptomatic extracranial atherosclerosis was a more potent predictor of major adverse cardiovascular events (1.27 [1.05–1.54]) and all-cause death (1.45 [1.17–1.81]). Conclusions: ASVD burden with AF can be a cumulative marker of a high risk for untoward vascular outcomes. Among ASVD components, extracranial atherosclerosis seems to have a predominant effect.

Abstract 91: Small Perivascular Spaces as Vascular Risk Factors

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Jose Gutierrez ◽  
Chuanhui Dong ◽  
Sandino Cespedes ◽  
Tatjana Rundek ◽  
Ralph Sacco ◽  
...  
Keyword(s):  
Risk Factors ◽  
Population Based ◽  
Vascular Risk Factors ◽  
Vascular Event ◽  
Perivascular Spaces ◽  
Vascular Risk ◽  
Vascular Events ◽  
High Burden ◽  
Lacunar Infarcts ◽  
Vascular Death

Introduction: Small perivascular spaces (SPVS) are gaining momentum as imaging biomarkers of cerebrovascular health. Hypothesis: SPVS confer vascular risks and the coexistence of SPVS with lacunar infarcts (LI) heightens these risks. Methods: Stroke-free participants in the population-based Northern Manhattan Study were followed for incident stroke (ischemic and hemorrhagic), MI, all death, vascular death, and any vascular event. Lesions with diameter of 3 mm or less and absence of FLAIR rim were classified as SPVS on a semi-quantitative scale (range 0 to 28). We defined “high SPVS burden” as the upper quintile and compared the rate of vascular events in this group to individuals in the lower 4 quintiles combined. LI were defined as lesions greater than 3 mm with associated FLAIR rim, round shape, and typical location. Cox models were used to calculate risks of outcomes after adjusting for confounders. Results: This analysis includes 1208 NOMAS participants (40% male, 65% Hispanic; mean age 71 ± 9 years at time of MRI) followed a mean of 6 ± 2 years. SPVS were present in 91% of the sample (median SPVS scale score 5). Compared to participants with a lesser burden of SPVS, participants with a high SPVS burden had a higher incidence rate per 1000 person-years of death (48 vs 34), vascular death (20 vs 11), ischemic stroke (12 vs 7) and any vascular event (37 vs 24). After adjusting for demographics and vascular risk factors, participants with a high burden of SPVS had a higher risk of death (HR 1.35, 1.00-1.78), vascular death (HR 1.55, 0.96-2.51), any stroke (HR 1.53, 0.91-2.57), MI (HR 1.29, 0.69-2.41), and any vascular event (HR 1.50, 1.07-2.11). The presence of lacunar infarcts was an effect modifier such that those with LI and a high SPVS burden had a greater risk of vascular death (B=0.63, P=0.03), any stroke (B=0.72, P=0.03) and any vascular event (B=0.54, P=0.02) compared to those without LI. Conclusions: In this multi-ethnic, population-based study, participants with a high burden of SPVS had increased incidence rates of vascular events. Furthermore, the joint presence of SPVS and LI heighten the risk of vascular death, any stroke and any vascular event. The presence of SPVS may help select subjects for randomized trials to assess intervention strategies.

Is aspirin still the drug of choice for management of patients with peripheral arterial disease?

VASA ◽  
2013 ◽  
Vol 42 (2) ◽  
pp. 88-95 ◽  
Author(s):  
Pavel Poredos ◽  
Mateja K. Jezovnik
Keyword(s):  
Cardiovascular Events ◽  
Meta Analysis ◽  
Ankle Brachial Index ◽  
Arterial Disease ◽  
Antiplatelet Drugs ◽  
Antiplatelet Drug ◽  
Diabetic Patients ◽  
Vascular Events ◽  
Artery Disease ◽  
Peripheral Arterial

Antiplatelet drugs represent one of the basic options for management of patients with different atherosclerotic diseases. Aspirin is the oldest and most often prescribed antiplatelet drug. The efficacy of aspirin depends on the clinical characteristics of the treated population and probably also on the type or location of atherosclerotic disease. It seems that it is most effective in coronary patients with clinically unstable disease, less effective in prevention of cerebrovascular incidents, and its efficacy is uncertain in peripheral artery disease (PAD) patients. One of the first meta-analyses (Antithrombotic Trialists’ Collaboration - ATC) indicated that antiplatelet drugs also significantly reduce cardiovascular events in patients with PAD. However, only one third of the PAD patients included were treated with aspirin, while the rest received other anti-platelet drugs. The latest ATC meta-analysis of randomized control trials of aspirin therapy involving patients with diabetes and PAD demonstrated no benefit of aspirin in reducing cardiovascular events. Also in patients with preclinical PAD (pathological ankle brachial index) aspirin did not result in a significant reduction of vascular events. The new anti-platelet drugs prasugrel, ticagrelor and picotamide seem to be more effective than aspirin in PAD patients, particularly in diabetic patients with PAD. In conclusion, antiplatelet drugs are effective in prevention of cardiovascular events in different atherosclerotic diseases, including PAD. However, recent studies indicated that in PAD patients aspirin is less effective than in coronary artery disease. New anti-platelet drugs showed marginal superiority over aspirin without definite advantages. Aspirin thus remains the first line of antiplatelet drug for secondary prevention of cardiovascular events in PAD patients and clopidogrel as its effective alternative. Further, new studies on PAD patients are necessary to better define the role of anti-platelet agents in these patients and one of the promising ways of access to anti-platelet treatment would be personalized anti-platelet therapy.

Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation

2013 ◽  
Vol 110 (12) ◽  
pp. 1189-1198 ◽  
Author(s):  
Pilar Gallego ◽  
Vanessa Roldan ◽  
Francisco Marín ◽  
Marta Romera ◽  
Mariano Valdés ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Oral Anticoagulation ◽  
Cardiovascular Events ◽  
Vitamin K Antagonists ◽  
Bleeding Risk ◽  
Vascular Events ◽  
Coronary Syndrome ◽  
Independent Risk Factors

SummaryBleeding risk (often perceived, rather than actual) is a common reason for cessation of oral anticoagulation with Vitamin K antagonists (VKA). We investigate clinical outcomes in a consecutive population of VKA naïve atrial fibrillation (AF) patients, who initiated VKA therapy in our clinic. We included consecutive VKA-naíve patients with non valvular AF, initiated on VKA therapy in our anticoagulation outpatient clinic in 2009. During follow-up, adverse events [thrombotic/vascular events (stroke, acute coronary syndrome, acute heart failure and cardiac death), major bleeding and death], and VKA cessation were recorded. At the end of the follow-up, we determined time within therapeutic range (TTR), using a linear approximation (Rosendaal method). We studied 529 patients (49% male, median age 76), median follow-up 835 days (IQR 719−954). During this period 114 patients stopped VKA treatment. 63 patients suffered a thrombotic/cardiovascular event (5.17%/year, 27 thrombotic/ischaemic strokes), 51 major bleeding (4.19%/year) and 48 died (3.94%/year). Median TTR was 54% (34a57). On multivariate analysis (adjusted by CHA2DS2-VASc score), VKA cessation was associated with death [Hazard Ratio (HR) 3.43; p<0.001], stroke [4.21; p=0.001] and thrombotic/cardiovascular events [2.72; p<0.001]. Independent risk factors for major bleeding were age [1.08; p<0.001], previous stroke [1.85; p=0.049], and TTR [0.97; p=0.001], but not VKA cessation. In conclusion, in AF patients AF, VKA cessation is independently associated with mortality stroke and cardiovascular events. Specifically, VKA cessation independently increased the risk of stroke, even after adjusting for CHA2DS2-VASc score. TTR was an independent risk factor for major bleeding following initiation of VKA therapy.Note: The editorial process for this paper was fully handled by Prof Christian Weber, Editor in Chief.

Combining risk markers improves cardiovascular risk prediction in women

2013 ◽  
Vol 126 (2) ◽  
pp. 139-146 ◽  
Author(s):  
Suzanne Holewijn ◽  
Martin den Heijer ◽  
Lambertus A. Kiemeney ◽  
Anton F. H. Stalenhoef ◽  
Jacqueline de Graaf
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Risk Stratification ◽  
Cardiovascular Events ◽  
Ankle Brachial Index ◽  
Individual Risk ◽  
Intermediate Risk ◽  
Risk Markers ◽  
Cardiovascular Risk Stratification ◽  
Non Invasive

Cardiovascular risk stratification could be improved by adding measures of atherosclerosis to current risk scores, especially in intermediate-risk individuals. We prospectively evaluated the additive value of different non-invasive risk markers (both individual and combined) for gender-specific cardiovascular risk stratification on top of traditional risk factors in a middle-aged population-based cohort. Carotid-plaques, IMT (intima–media thickness), ABI (ankle–brachial index), PWV (pulse–wave velocity), AIx (augmentation index), CAP (central augmented pressure) and CSP (central-systolic pressure) were measured in 1367 CVD (cardiovascular disease)-free participants aged 50–70 years old. Cardiovascular events were validated after a mean follow-up of 3.8 years. AUC (area-under-the-curve) and NRI (net reclassification improvement) analyses (total-NRI for all and clinical-NRI for intermediate-risk groups) were used to determine the additive value of individual and combined risk markers. Cardiovascular events occurred in 32 women and 39 men. Traditional cardiovascular risk factors explained 6.2% and 12.5% of the variance in CVD in women and men respectively. AUCs did not substantially increase by adding individual or combined non-invasive risk markers. Individual risk markers only improved reclassification in intermediate-risk women and more than in men; clinical-NRIs ranged between 48.0 and 173.1% in women and 8.9 and 20% in men. Combined non-invasive-risk markers improved reclassification in all women and even more in those at intermediate risk; ‘IMT-presence-thickness-of-plaques’ showed largest reclassification [total-NRI=33.8%, P=0.012; IDI (integrated-discrimination-improvement)=0.048, P=0.066; clinical-NRI=168.0%]. In men, combined non-invasive risk markers improved reclassification only in those at intermediate risk; ‘PWV-AIx-CSP-CAP-IMT’ showed the largest reclassification (total-NRI=14.5%, P=0.087; IDI=0.016, P=0.148; clinical-NRI=46.0%). In all women, cardiovascular risk stratification improved by adding combinations and in women at intermediate risk also by adding individual non-invasive risk markers. The additive value of individual and combined non-invasive risk markers in men is limited to men at intermediate risk only, and to a lesser extent than in women.

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