Abstract MP41: Implications of the Use of the New ACC/AHA Guidelines for Cardiovascular Disease Prevention in a Brazilian Cohort - The Elsa Brasil Study

Introduction: The 2013 American College of Cardiology / American Heart Association (ACC/AHA) guidelines developed a new prediction model for cardiovascular disease (CVD) and suggested the use of a lower threshold of 7.5% 10 year hard CVD risk for primary prevention. The implications of the use of this model in other cohort and admixed races has not yet been tested. The current study sought to evaluate the potential impact of its use in a large Brazilian cohort. Methods: We have included 15105 participants of the (Brazilian Longitudinal Study of Adult Health) ELSA-Brasil study, a multicenter prospective study that enrolled civil servants aged 35 to 74 years in 6 different urban areas in brazil. We have calculated the both the Framingham risk score (FRS) and the new risk prediction model to the entire cohort, and estimated the impact of changing current recommendations based on the FRS and lipid targets to the new recommendations based on the absolute risk estimated by the new model. Results: The mean age was 52±9.1 years, with 8218 (54%) women. The race distribution included 52% white, 16% black, 28% mixed (brown), and 4% of other. While 19.2% (95% CI: 18.4 to 19.6) of the cohort would require statins for primary prevention accordion to prior recommendations, the new guidelines would recommend treatment for approximately 40.2% (95%CI: 39.4 to 41.0) of the cohort. A substantial increase in the population in whom statins are recommended occurred for males, from 23.3% (95%CI: 22.6 to 24.0%) to 55.7% (95%CI: 54.9 to 56.5), as well as females, from 16.6 (95%CI: 16.0 to 17.2) to 27.1 (95%CI: 26.4 to 27.8), and across all races and age levels (figure). Conclusion: The new ACC/AHA guidelines for primary prevention would approximately double the proportion of Brazilian adults in whom statins are indicated, mostly among older individuals. The epidemiological and economical impact of this changes are not yet known.

Download Full-text

Urbanization and market integration have strong, nonlinear effects on cardiometabolic health in the Turkana

Science Advances ◽

10.1126/sciadv.abb1430 ◽

2020 ◽

Vol 6 (43) ◽

pp. eabb1430

Author(s):

Amanda J. Lea ◽

Dino Martins ◽

Joseph Kamau ◽

Michael Gurven ◽

Julien F. Ayroles

Keyword(s):

Cardiovascular Disease ◽

Urban Areas ◽

Market Integration ◽

Nonlinear Effects ◽

Cardiometabolic Health ◽

Adult Health ◽

Way Of Life ◽

Cvd Risk ◽

Subsistence Level ◽

Refined Carbohydrates

The “mismatch” between evolved human physiology and Western lifestyles is thought to explain the current epidemic of cardiovascular disease (CVD) in industrialized societies. However, this hypothesis has been difficult to test because few populations concurrently span ancestral and modern lifestyles. To address this gap, we collected interview and biomarker data from individuals of Turkana ancestry who practice subsistence-level, nomadic pastoralism (the ancestral way of life for this group), as well as individuals who no longer practice pastoralism and live in urban areas. We found that Turkana who move to cities exhibit poor cardiometabolic health, partially because of a shift toward “Western diets” high in refined carbohydrates. We also show that being born in an urban area independently predicts adult health, such that life-long city dwellers will experience the greatest CVD risk. By focusing on a substantial lifestyle gradient, our work thus informs the timing, magnitude, and evolutionary causes of CVD.

Download Full-text

Abstract P307: The Impact of Aspirin Primary Prevention Treatment Guidelines, 2007-2015: Aspirin Use Stratified by Cardiovascular Disease Risk

Circulation ◽

10.1161/circ.133.suppl_1.p307 ◽

2016 ◽

Vol 133 (suppl_1) ◽

Author(s):

Jeremy R Van’t Hof ◽

Sue Duval ◽

Adrienne Walts ◽

Russell V Luepker ◽

Alan T Hirsch

Keyword(s):

Cardiovascular Disease ◽

Primary Care ◽

Primary Prevention ◽

Health System ◽

Absolute Difference ◽

Risk Category ◽

Global Risk ◽

Cvd Risk ◽

Ischemic Event ◽

The Impact

Background: Current national cardiovascular disease primary prevention (PP) guidelines recommend low dose aspirin (ASA) to prevent a first heart attack or stroke in appropriate candidates. The 2009 United States Preventive Services Task Force (USPSTF) ASA primary prevention recommendation was not widely implemented, and minimal data exist to define the efficacy of this “A” level recommendation. This study was designed to evaluate the impact of this recommendation on PP ASA use in primary care clinics in a large, regional health system over a 9 year period (2007-2015) stratifying patients by their 10 year global risk for a primary ischemic event. Methods: Bi-annual, cross-sectional electronic medical record (EMR) data were collected from 2007 to 2015 to evaluate documented ASA use for all office-based encounters involving a primary care provider within the Fairview Health System (Minnesota). PP candidates were defined as individuals within the USPSTF guideline target population (men ages 45-79 and women ages 55-79 years) with no documented history of an atherosclerotic syndrome. Appropriate ASA use candidates were defined as PP individuals with no ASA use contraindications (peptic ulcer disease, gastrointestinal bleeding or use of other antithrombotic medications). Ten year cardiovascular disease (CVD) risk was calculated using the ACC/AHA 2013 global risk calculator. ASA use was evaluated bi-annually in the total PP population and a stratified subset characterized by <10%, 10-20% and >20% ten year risk of an ischemic event. Secondary prevention (SP) ASA use was assessed as a reference standard for ideal penetration of guideline recommended ASA use. Results: Over 270,000 unique encounters were evaluated over the 9 year study period. Of those, 88,055 were PP ASA candidates with data for risk score calculation. Appropriate PP ASA use rates did not improve throughout the study period, with an average of 43% PP ASA use compared to 77% in the SP population. When stratified by <10%, 10-20% and >20% ten year CVD risk, average appropriate PP ASA use was 41%, 63% and 73% respectively, representing an absolute difference of 36%, 14% and 4% respectively compared to SP ASA use. Appropriate PP ASA use did not increase in any risk category following the publication of the 2009 USPSTF guidelines. Documented contraindications to ASA use were very low (6%) in the PP population. Conclusion: Appropriate PP ASA use in primary care settings increases as CVD risk increases. PP ASA use in the highest risk population is similar to the rate in the SP cohort. A large primary prevention aspirin treatment gap exists in the medium and low CVD risk categories. Publication of the 2009 USPSTF recommendation was not associated with improved aspirin use in any risk category. Public health interventions to safely and effectively disseminate this PP ASA recommendation, involving both the public and health care providers, are warranted.

Download Full-text

Preventive Pharmacotherapy for Cardiovascular Disease: A Modelling Study Considering Health Gain, Costs, and Cost-Effectiveness when Stratifying by Absolute Risk

Scientific Reports ◽

10.1038/s41598-019-55372-8 ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Nhung Nghiem ◽

Josh Knight ◽

Anja Mizdrak ◽

Tony Blakely ◽

Nick Wilson

Keyword(s):

Cardiovascular Disease ◽

Absolute Risk ◽

Health Gain ◽

Risk Level ◽

Cvd Risk ◽

Male Population ◽

Lifetime Horizon ◽

Individual Level ◽

Risk Stratum ◽

The Impact

AbstractCardiovascular disease (CVD) is the leading cause of death internationally. We aimed to model the impact of CVD preventive double therapy (a statin and anti-hypertensive) by clinician-assessed absolute risk level. An established and validated multi-state life-table model for the national New Zealand (NZ) population was adapted. The new version of the model specifically considered the 60–64-year-old male population which was stratified by risk using a published NZ-specific CVD risk equation. The intervention period of treatment was for five years, but a lifetime horizon was used for measuring benefits and costs (a five-year horizon was also implemented). We found that for this group offering double therapy was highly cost-effective in all absolute risk categories (eg, NZ$1580 per QALY gained in the >20% in 5 years risk stratum; 95%UI: Dominant to NZ$3990). Even in the lowest risk stratum (≤5% risk in 5 years), the cost per QALY was only NZ$25,500 (NZ$28,200 and US$19,100 in 2018). At an individual level, the gain for those who responded to the screening offer and commenced preventive treatment ranged from 0.6 to 4.9 months of quality-adjusted life gained (or less than a month gain with a five-year horizon). Nevertheless, at the individual level, patient considerations are critical as some people may decide that this amount of average health gain does not justify taking daily medication.

Download Full-text

Consumption of dairy products and cardiovascular disease risk: results from the French prospective cohort NutriNet-Santé

British Journal Of Nutrition ◽

10.1017/s0007114521001422 ◽

2021 ◽

pp. 1-37

Author(s):

Laury Sellem ◽

Bernard Srour ◽

Kim G. Jackson ◽

Serge Hercberg ◽

Pilar Galan ◽

...

Keyword(s):

Cardiovascular Disease ◽

Dairy Products ◽

Disease Risk ◽

Heart Diseases ◽

Cardiovascular Disease Risk ◽

Dietary Intakes ◽

Cvd Risk ◽

Dairy Consumption ◽

Fermented Dairy ◽

The Impact

Abstract In France, dairy products contribute to dietary saturated fat intake, of which reduced consumption is often recommended for cardiovascular disease (CVD) prevention. Epidemiological evidence on the association between dairy consumption and CVD risk remains unclear, suggesting either null or inverse associations. This study aimed to investigate the associations between dairy consumption (overall and specific foods) and CVD risk in a large cohort of French adults. This prospective analysis included participants aged ≥ 18 years from the NutriNet-Santé cohort (2009–2019). Daily dietary intakes were collected using 24h-dietary records. Total dairy, milk, cheese, yogurts, fermented and reduced-fat dairy intakes were investigated. CVD cases (n=1,952) included cerebrovascular (n=878 cases) and coronary heart diseases (CHD, n=1,219 cases). Multivariable Cox models were performed to investigate associations. This analysis included n=104,805 French adults (mean age at baseline 42.8 years (SD 14.6)), mean follow-up 5.5 years (SD 3.0, i.e. 579,155 persons years). There were no significant associations between dairy intakes and total CVD or CHD risks. However, the consumption of at least 160 g/d of fermented dairy (e.g. cheese and yogurts) was associated with a reduced risk of cerebrovascular diseases compared to intakes below 57 g/d (HR=0.81 [0.66-0.98], p-trend=0.01). Despite being a major dietary source of saturated fats, dairy consumption was not associated with CVD or CHD risks in this study. However, fermented dairy was associated with a lower cerebrovascular disease risk. Robust randomized controlled trials are needed to further assess the impact of consuming different dairy foods on CVD risk and potential underlying mechanisms.

Download Full-text

Management of High Blood Pressure in Those without Overt Cardiovascular Disease Utilising Absolute Risk Scores

International Journal of Hypertension ◽

10.4061/2011/595791 ◽

2011 ◽

Vol 2011 ◽

pp. 1-3

Author(s):

Mark R. Nelson

Keyword(s):

Blood Pressure ◽

Cardiovascular Disease ◽

Cardiovascular Events ◽

Absolute Risk ◽

Risk Scores ◽

Cvd Risk ◽

Adverse Cardiovascular Event ◽

Single Measure ◽

Usual Practice ◽

Single Risk Factor

Increasing blood pressure has a continuum of adverse risk for cardiovascular events. Traditionally this single measure was used to determine who to treat and how vigorously. However, estimating absolute risk rather than measurement of a single risk factor such as blood pressure is a superior method to identify who is most at risk of having an adverse cardiovascular event such as stroke or myocardial infarction, and therefore who would most likely benefit from therapeutic intervention. Cardiovascular disease (CVD) risk calculators must be used to estimate absolute risk in those without overt CVD as physician estimation is unreliable. Incorporation into usual practice and limitations of the strategy are discussed.

Download Full-text

Patterns of Immune Activation in HIV and Non HIV Subjects and Its Relation to Cardiovascular Disease Risk

Frontiers in Immunology ◽

10.3389/fimmu.2021.647805 ◽

2021 ◽

Vol 12 ◽

Author(s):

Alinda G. Vos ◽

Caitlin N. Dodd ◽

Eveline M. Delemarre ◽

Stefan Nierkens ◽

Celicia Serenata ◽

...

Keyword(s):

Risk Factors ◽

Cardiovascular Disease ◽

Immune Activation ◽

Hiv Positive ◽

Inflammation Markers ◽

Cvd Risk Factors ◽

Immune Markers ◽

Cvd Risk ◽

The Impact ◽

Hiv Negative

IntroductionInsight into inflammation patterns is needed to understand the pathophysiology of HIV and related cardiovascular disease (CVD). We assessed patterns of inflammation related to HIV infection and CVD risk assessed with carotid intima media thickness (CIMT).MethodsA cross-sectional study was performed in Johannesburg, South Africa, including participants with HIV who were virally suppressed on anti-retroviral therapy (ART) as well as HIV-negative participants who were family members or friends to the HIV-positive participants. Information was collected on CVD risk factors and CIMT. Inflammation was measured with the Olink panel ‘inflammation’, allowing to simultaneously assess 92 inflammation markers. Differences in inflammation patterns between HIV-positive and HIV-negative participants were explored using a principal component analysis (PCA) and ANCOVA. The impact of differentiating immune markers, as identified by ANCOVA, on CIMT was assessed using linear regression while adjusting for classic CVD risk factors.ResultsIn total, 185 HIV-positive and 104 HIV negative participants, 63% females, median age 40.7 years (IQR 35.4 – 47.7) were included. HIV-positive individuals were older (+6 years, p <0.01) and had a higher CIMT (p <0.01). No clear patterns of inflammation were identified by use of PCA. Following ANCOVA, nine immune markers differed significantly between HIV-positive and HIV-negative participants, including PDL1. PDL1 was independently associated with CIMT, but upon stratification this effect remained for HIV-negative individuals only.ConclusionHIV positive patients on stable ART and HIV negative controls had similar immune activation patterns. CVD risk in HIV-positive participants was mediated by inflammation markers included in this study.

Download Full-text

Differences in estimates for ten-year risk of cardiovascular disease in Black versus white persons with identical risk factor profiles using pooled cohort equations

10.1101/2021.04.18.21255704 ◽

2021 ◽

Author(s):

Ramachandran S. Vasan ◽

Edwin van den Heuvel

Keyword(s):

Cardiovascular Disease ◽

Black Women ◽

White Women ◽

Absolute Risk ◽

Density Lipoprotein ◽

Clinical Decision ◽

Population Based ◽

Decision Threshold ◽

Cvd Risk ◽

Risk Profiles

AbstractBackgroundSex- and race-specific pooled cohort equations (PCE) are recommended for estimating the 10-year risk of cardiovascular disease (CVD), with an absolute risk >7.5% indicating a clinical decision threshold.MethodsWe generated in silico 30,565 risk profiles in men and 29,515 in women by combining numerical (age, total and high-density lipoprotein cholesterol, systolic blood pressure) and binary risk factors (smoking, diabetes, antihypertensive treatment). We compared PCE-estimated 10-year CVD risk in Black versus white individuals with identical risk profiles. We performed similar comparisons in participants in the Framingham Third Generation cohort and the National Health and Nutrition Examination Survey 2017-2018.ResultsThere were 6357 risk profiles associated with 10-year CVD risk >7.5% for Black but not for white men (median risk difference [RD] 6.25%, range 0.15-22.8%; median relative risk [RR] 2.40, range 1.02-12.6). There were 391 profiles with 10-year CVD risk >7.5% for white but not for Black men (median RD 2.68%, range 0.07-16.9%; median RR 1.42, range 1.01-3.57). There were 6543 risk profiles associated with 10-year estimated CVD risk >7.5% for Black but not for white women (median RD 6.14%, range 0.35-26.8%; median RR 2.29, range 1.05-12.6). There were 318 profiles with 10-year CVD risk >7.5% for white but not for Black women (median RD 3.71%, range 0.22-20.1%; median RR 1.66, range 1.03-5.46). The population-based samples demonstrated similar risk differences.ConclusionsThe PCE may generate substantially divergent CVD risk estimates for Black versus white individuals with identical risk profiles, which could introduce race-related variations in clinical recommendations for CVD prevention.

Download Full-text

Nutrients in Fish and Possible Associations with Cardiovascular Disease Risk Factors in Metabolic Syndrome

Nutrients ◽

10.3390/nu10070952 ◽

2018 ◽

Vol 10 (7) ◽

pp. 952 ◽

Cited By ~ 25

Author(s):

Christine Tørris ◽

Milada Cvancarova Småstuen ◽

Marianne Molin

Keyword(s):

Risk Factors ◽

Cardiovascular Disease ◽

Metabolic Syndrome ◽

Fatty Acids ◽

Fish Consumption ◽

Disease Risk ◽

Cardiovascular Disease Risk ◽

Protective Role ◽

Cvd Risk ◽

The Impact

Non-communicable diseases (NSDs) are responsible for two-thirds of all deaths globally, whereas cardiovascular disease (CVD) alone counts for nearly half of them. To reduce the impact of CVD, targeting modifiable risk factors comprised in metabolic syndrome (e.g., waist circumference, lipid profile, blood pressure, and blood glucose) is of great importance. Beneficial effects of fish consumption on CVD has been revealed over the past decades, and some studies suggest that fish consumption may have a protective role in preventing metabolic syndrome. Fish contains a variety of nutrients that may contribute to health benefits. This review examines current recommendations for fish intake as a source of various nutrients (proteins, n-3 fatty acids, vitamin D, iodine, selenium, and taurine), and their effects on metabolic syndrome and the CVD risk factors. Fatty fish is recommended due to its high levels of n-3 fatty acids, however lean fish also contains nutrients that may be beneficial in the prevention of CVD.

Download Full-text

Aspirin and statin therapy for primary prevention of cardiovascular disease in older adults

Heart ◽

10.1136/heartjnl-2021-320154 ◽

2021 ◽

pp. heartjnl-2021-320154

Author(s):

Sophie Montgomery ◽

Michael D Miedema ◽

John Dodson

Keyword(s):

Cardiovascular Disease ◽

Older Adults ◽

Decision Making ◽

Cognitive Impairment ◽

Primary Prevention ◽

Absolute Risk ◽

Functional Decline ◽

Calcium Score ◽

Risk Of Death ◽

Therapeutic Decisions

The value of primary preventative therapies for cardiovascular disease (CVD) in older adults (age ≥75 years) is less certain than in younger patients. There is a lack of quality evidence in older adults due to underenrolment in pivotal trials. While aspirin is no longer recommended for routine use in primary prevention of CVD in older adults, statins may be efficacious. However, it is unclear which patient subgroups may benefit most, and guidelines differ between expert panels. Three relevant geriatric conditions (cognitive impairment, functional impairment and polypharmacy) may influence therapeutic decision making; for example, baseline frailty may affect statin efficacy, and some have advocated for deprescription in this scenario. Evidence regarding statins and incident functional decline are mixed, and vigilance for adverse effects is important, especially in the setting of polypharmacy. However, aspirin has not been shown to affect incident cognitive or functional decline, and its lack of efficacy extends to patients with baseline cognitive impairment or frailty. Ultimately, the utility of primary preventative therapies for CVD in older adults depends on potential lifetime benefit. Rather than basing treatment decisions on absolute risk alone, consideration of comorbidities, polypharmacy and life expectancy should play a significant role in decision making. Coronary calcium score and new tools for risk stratification validated in older adults that account for the competing risk of death may aid in evaluating potential benefits. Given the complexity of therapeutic decisions in this context, shared decision making provides an important framework.

Download Full-text

Global variation of risk thresholds for initiating statins for primary prevention of cardiovascular disease: a benefit-harm balance modelling study

BMC Cardiovascular Disorders ◽

10.1186/s12872-020-01697-6 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Henock G. Yebyo ◽

Sofia Zappacosta ◽

Hélène E. Aschmann ◽

Sarah R. Haile ◽

Milo A. Puhan

Keyword(s):

Cardiovascular Disease ◽

Primary Prevention ◽

Assessment Method ◽

Competing Risk ◽

Net Benefit ◽

Cvd Risk ◽

Risk Threshold ◽

Risk Thresholds ◽

Statin Use ◽

Country Specific

Abstract Background We previously showed that the 10-year cardiovascular disease (CVD) risk threshold to initiate statins for primary prevention depends on the baseline CVD risk, age, sex, and the incidence of statin-related harm outcome and competing risk for non-CVD death. As these factors appear to vary across countries, we aimed in this study to determine country-specific thresholds and provide guidelines a quantitative benefit-harm assessment method for local adaptation. Methods For each of the 186 countries included, we replicated the benefit-harm balance analysis using an exponential model to determine the thresholds to initiate statin use for populations aged 40 to 75 years, with no history of CVD. The analyses took data inputs from a priori studies, including statin effect estimates (network meta-analysis), patient preferences (survey), and baseline incidence of harm outcomes and competing risk for non-CVD (global burden of disease study). We estimated the risk thresholds above which the benefits of statins were more likely to outweigh the harms using a stochastic approach to account for statistical uncertainty of the input parameters. Results The 5th and 95th percentiles of the 10-year risk thresholds above which the benefits of statins outweigh the harms across 186 countries ranged between 14 and 20% in men and 19–24% in women, depending on age (i.e., 90% of the country-specific thresholds were in the ranges stated). The median risk thresholds varied from 14 to 18.5% in men and 19 to 22% in women. The between-country variability of the thresholds was slightly attenuated when further adjusted for age resulting, for example, in a 5th and 95th percentiles of 14–16% for ages 40–44 years and 17–21% for ages 70–74 years in men. Some countries, especially the islands of the Western Pacific Region, had higher thresholds to achieve net benefit of statins at 25–36% 10-year CVD risks. Conclusions This extensive benefit-harm analysis modeling shows that a single CVD risk threshold, irrespective of age, sex and country, is not appropriate to initiate statin use globally. Instead, countries need to carefully determine thresholds, considering the national or subnational contexts, to optimize benefits of statins while minimizing related harms and economic burden.

Download Full-text