Polyvascular Disease

Atherosclerosis within 2 or more arterial beds has been termed polyvascular disease. Although polyvascular disease has long been associated with heightened cardiovascular risk, much is still unknown regarding its pathophysiology and management. In this past decade, the field of cardiovascular disease has experienced exponential growth in terms of antithrombotic and lipid-lowering therapies aimed at mitigating ischemic events. This review describes the inherent risk associated with polyvascular disease in contemporary observational and clinical trial populations and summarizes novel therapies in this high-risk population.

Download Full-text

Effect of coexisting vascular disease on long-term risk of recurrent events after TIA or stroke

Neurology ◽

10.1212/wnl.0000000000007935 ◽

2019 ◽

Vol 93 (7) ◽

pp. e695-e707 ◽

Cited By ~ 5

Author(s):

Marion Boulanger ◽

Linxin Li ◽

Shane Lyons ◽

Nicola G. Lovett ◽

Magdalena M. Kubiak ◽

...

Keyword(s):

Cardiovascular Disease ◽

Ischemic Stroke ◽

High Risk ◽

Secondary Prevention ◽

Recurrent Events ◽

Lipid Lowering ◽

Prevention Guidelines ◽

Coronary Events ◽

Ischemic Events ◽

Age And Sex

ObjectiveTo determine whether patients with TIA or ischemic stroke with coexisting cardiovascular disease (i.e., history of coronary or peripheral artery disease) are still at high risk of recurrent ischemic events despite current secondary prevention guidelines.MethodsIn a population-based study in Oxfordshire, UK (Oxford Vascular Study), we studied consecutive patients with TIA or ischemic stroke for 2002–2014. Patients were treated according to current secondary prevention guidelines and we determined risks of coronary events, recurrent ischemic stroke, and major bleeding stratified by the presence of coexisting cardiovascular disease.ResultsAmong 2,555 patients (9,148 patient-years of follow-up), those (n = 640; 25.0%) with coexisting cardiovascular disease (449 coronary only; 103 peripheral only; 88 both) were at higher 10-year risk of coronary events than those without (22.8%, 95% confidence interval 17.4–27.9; vs 7.1%, 5.3–8.8; p < 0.001; age- and sex-adjusted hazard ratio [HR] 3.07, 2.24–4.21) and of recurrent ischemic stroke (31.5%, 25.1–37.4; vs 23.4%, 20.5–26.2; p = 0.0049; age- and sex-adjusted HR 1.23, 0.99–1.53), despite similar rates of use of antithrombotic and lipid-lowering medication. However, in patients with noncardioembolic TIA/stroke, risk of extracranial bleeds was also higher in those with coexisting cardiovascular disease, particularly in patients aged <75 years (8.1%, 2.8–13.0; vs 3.4%, 1.6–5.3; p = 0.0050; age- and sex-adjusted HR 2.71, 1.16–6.30), although risk of intracerebral hemorrhage was not increased (age- and sex-adjusted HR 0.36, 0.04–2.99).ConclusionsAs in older studies, patients with TIA/stroke with coexisting cardiovascular disease remain at high risk of recurrent ischemic events despite current management. More intensive lipid-lowering might therefore be justified, but benefit from increased antithrombotic treatment might be offset by the higher risk of extracranial bleeding.

Download Full-text

961Absolute cardiovascular disease risk scores and medication use in rural India

International Journal of Epidemiology ◽

10.1093/ije/dyab168.082 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

Author(s):

Mulugeta Molla Birhanu ◽

Roger G Evans ◽

Ayse Zengin ◽

Michaela A Riddell ◽

Kartik Kalyanram ◽

...

Keyword(s):

Cardiovascular Disease ◽

High Risk ◽

Absolute Risk ◽

Risk Groups ◽

Assessment Tools ◽

Lipid Lowering ◽

Risk Scores ◽

High Risk Population ◽

Cvd Risk ◽

Risk Scoring

Abstract Background Low-to-middle-income countries (LMICs) have limited resources to tackle the burden of cardiovascular disease (CVD). Most screening guidelines recommend the use of absolute risk scoring to determine treatment, but there is uncertainty among policy makers and clinicians about which risk algorithm to choose. We aimed to compare laboratory-based absolute CVD risk algorithms in a LMIC setting. Methods The study was conducted in the Rishi Valley, Andhra Pradesh, India. Over 8,000 participants were surveyed between 2012-2015. The 10-year absolute risk was computed and compared using the Framingham, WHO, and Australian absolute risk CVD algorithms. Results In participants aged 35-74 years, 151 (3%) had prior CVD. In all algorithms, absolute CVD risk increased with age and was greater in men than women. Using the WHO algorithm 4% were characterized as high-risk while >29% were at high-risk using the Australian risk tool. Agreement of risk classification among men ranged from a high of 84% (Spearman’s rho (rs) =0.92) between Australian and Framingham algorithms to 43% (rs=0.6) between the Australian and WHO risk scores. Among the high-risk population, only 15% were on lipid-lowering or antihypertensive therapy. Conclusions The Framingham and Australian risk scores enable some discrimination between high- and low-risk groups. However, the WHO algorithm underestimates these high-risk groups. Even though one third of the participants were at high-risk, most of them were not receiving recommended treatment. Key messages Lab-based CVD risk assessment tools have the potential in identifying high-risk populations in LMICs but the WHO risk scoring tool should be used with caution.

Download Full-text

Very similar cardiometabolic profile in the moderate and high cardiovascular risk classes: a population-based study

European Journal of Preventive Cardiology ◽

10.1093/eurjpc/zwab061.227 ◽

2021 ◽

Vol 28 (Supplement_1) ◽

Author(s):

M Chlabicz ◽

J Jamolkowski ◽

W Laguna ◽

P Sowa ◽

M Paniczko ◽

...

Keyword(s):

Insulin Resistance ◽

Cardiovascular Disease ◽

Cardiovascular Risk ◽

High Risk ◽

Population Based ◽

Low Risk ◽

Public Institution ◽

Population Based Study ◽

The Metabolic Syndrome ◽

Cardiometabolic Profile

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Bialystok, Poland Background Cardiovascular disease (CVD) is a major, worldwide problem and remain the dominant cause of premature mortality in the word. Simultaneously the metabolic syndrome is a growing problem. The aim of this study was to investigate the cardiometabolic profile among cardiovascular risk classes, and to estimate CV risk using various calculators. Methods The longitudinal, population-based study, was conducted in 2017-2020. A total of 931 individuals aged 20-79 were included. Anthropometric and biochemical profiles were measured according to a standardized protocols. The study population was divided into CV risk classes according to the latest recommendation. Comparisons variables between subgroups were conducted using Dwass-Steele-Critchlow-Fligner test. To estimate CV risk were used: the Systematic Coronary Risk Estimation system, Framingham Risk Score and LIFEtime-perspective model for individualizing CardioVascular Disease prevention strategies in apparently healthy people (LIFE-CVD). Results The mean age was 49.1± 15.5 years, 43.2% were male. Percentages of low-risk, moderate-risk, high-risk and very-high CV risk were 46.1%, 22.8%, 13.5%, 17.6%, respectively. Most of the analyzed anthropometric, body composition and laboratory parameters did not differ between the moderate and high CV risk participants, whereas the low risk group differed significantly. In the moderate and high-risk groups, abdominal distribution of adipose tissue dominated with significantly elevated parameters of insulin resistance. Interestingly, estimating lifetime risk of myocardial infarction, stroke or CV death using LIFE-CVD calculator yielded similar results in moderate and high CV risk classes. Conclusion The participants belonging to moderate and high CV risk classes have a very similar unfavorable cardiometabolic profile which may result in the similar lifetime CV risk. This may imply the need for more aggressive pharmacological and non-pharmacological management of CV risk factors in the moderate CV risk population. It would be advisable to consider combining the moderate and high risk classes into one high CV risk class, or it may be worth adding one of the parameters of abdominal fat distribution to the CV risk calculators as an expression of increased insulin resistance. Abstract Figure 1.

Download Full-text

Lipid-lowering treatment in hypercholesterolaemic patients: the CEPHEUS Pan-Asian survey

European Journal of Preventive Cardiology ◽

10.1177/1741826710397100 ◽

2011 ◽

Vol 19 (4) ◽

pp. 781-794 ◽

Cited By ~ 49

Author(s):

Jeong Euy Park ◽

Chern-En Chiang ◽

Muhammad Munawar ◽

Gia Khai Pham ◽

Apichard Sukonthasarn ◽

...

Keyword(s):

Cardiovascular Risk ◽

High Risk ◽

Large Scale ◽

Goal Attainment ◽

Density Lipoprotein ◽

Final Analysis ◽

Relevant Information ◽

Lipid Lowering ◽

Lipid Lowering Therapy ◽

Lipid Lowering Drugs

Background: Treatment of hypercholesterolaemia in Asia is rarely evaluated on a large scale, and data on treatment outcome are scarce. The Pan-Asian CEPHEUS study aimed to assess low-density lipoprotein cholesterol (LDL-C) goal attainment among patients on lipid-lowering therapy. Methods: This survey was conducted in eight Asian countries. Hypercholesterolaemic patients aged ≥18 years who had been on lipid-lowering treatment for ≥3 months (stable medication for ≥6 weeks) were recruited, and lipid concentrations were measured. Demographic and other clinically relevant information were collected, and the cardiovascular risk of each patient was determined. Definitions and criteria set by the updated 2004 National Cholesterol Education Program guidelines were applied. Results: In this survey, 501 physicians enrolled 8064 patients, of whom 7281 were included in the final analysis. The mean age was 61.0 years, 44.4% were female, and 85.1% were on statin monotherapy. LDL-C goal attainment was reported in 49.1% of patients overall, including 51.2% of primary and 48.7% of secondary prevention patients, and 36.6% of patients with familial hypercholesterolaemia. The LDL-C goal was attained in 75.4% of moderate risk, 55.4% of high risk, and only 34.9% of very high-risk patients. Goal attainment was directly related to age and inversely related to cardiovascular risk and baseline LDL-C. Conclusion: A large proportion of Asian hypercholesterolaemic patients on lipid-lowering drugs are not at recommended LDL-C levels and remain at risk for cardiovascular disease. Given the proven efficacy of lipid-lowering drugs in the reduction of LDL-C, there is room for further optimization of treatments to maximize benefits and improve outcomes.

Download Full-text

Lipoprotein Particle Predictors of Arterial Stiffness after 17 Years of Follow Up: The Malmö Diet and Cancer Study

International Journal of Vascular Medicine ◽

10.1155/2020/4219180 ◽

2020 ◽

Vol 2020 ◽

pp. 1-9

Author(s):

Jacob Hartz ◽

Ronald M. Krauss ◽

Mikael Göttsater ◽

Olle Melander ◽

Peter Nilsson ◽

...

Keyword(s):

Cardiovascular Risk ◽

High Risk ◽

Arterial Stiffness ◽

Density Lipoprotein ◽

Lipoprotein Cholesterol ◽

Lipid Lowering ◽

Cancer Study ◽

Lipoprotein Particle ◽

Ldl Particles ◽

Diet And Cancer

Background. Central arterial stiffness is a surrogate of cardiovascular risk and predicts cardiovascular mortality. Apolipoprotein B lipoproteins are also established cardiovascular risk factors. It is not known whether specific lipoprotein subclasses measured in the Malmö Diet and Cancer Study and previously shown to be associated with coronary heart disease also predict arterial stiffening after a mean period of 17 years. Methods. Lipoprotein particle analysis was performed on 2,505 men and women from Malmö, Sweden, from 1991 to 1994, and arterial stiffness was assessed by carotid-femoral pulse wave velocity (c-fPWV) on this same cohort from 2007 to 2012. Associations between c-fPWV and lipoprotein particles were determined with multiple linear regression, controlling for sex, presence of diabetes, waist-to-hip circumference, and smoking status at baseline, as well as heart rate (measured at the carotid artery), mean arterial pressure, antihypertensive and lipid-lowering medications, C-reactive protein (CRP), and age at the time of c-fPWV measurement. Results. The results confirm that triglycerides (TG) and high-density lipoprotein cholesterol (HDL-c) but not low-density lipoprotein cholesterol (LDL-c) predict c-fPWV. We identify a positive predictive association for very small, small, and medium (high risk), but not large LDL particles. There was a negative association for large HDL particles. The relationships between c-fPWV and high-risk LDL particles were unaffected by adjusting for LDL-c or CRP and were only mildly attenuated by adjusting for the homeostatic model for insulin resistance (HOMA-IR). Due to the collinearity of very small, small, and medium LDL particles and dyslipidemia (elevated TG and decreased HDL-c), the observed relationship between c-fPWV and high-risk LDL particles became insignificant after controlling for the concentration of HDL-c, large cholesterol-rich HDL particles, and TG. Conclusions. The development of central arterial stiffness previously associated with combined dyslipidemia may be mediated in part by LDL particles, particularly the very small-, small-, and medium-sized LDL particles.

Download Full-text

Hyperuricemia, gout and high cardiovascular risk - how to manage them in clinical practice

Terapevticheskii arkhiv ◽

10.26442/00403660.2019.12.000173 ◽

2019 ◽

Vol 91 (12) ◽

pp. 75-83

Author(s):

V V Fomin ◽

T E Morosova ◽

V V Tsurko

Keyword(s):

Cardiovascular Disease ◽

Clinical Practice ◽

Cardiovascular Risk ◽

High Risk ◽

High Cardiovascular Risk ◽

Relationship Of ◽

The Relationship

In recent years, the relationship of hyperuricemia and gout with a high risk of cardiovascular disease has been widely discussed. Therefore, it is important to systematically examine patients in order to diagnose comorbidities, among which cardiovascular disease and its complications occupy a leading place and consider mandatory treatment of patients with hyperuricemia and gout with high cardiovascular risk with lowering drugs, which fully reflects the provisions of the latest European recommendations for the management and treatment of patients with gout.

Download Full-text

Cardiovascular risk estimation at the individual level

ESC CardioMed ◽

10.1093/med/9780198784906.003.0208_update_001 ◽

2018 ◽

pp. 846-863

Author(s):

Yvo M. Smulders ◽

Marie-Therese Cooney ◽

Ian Graham

Keyword(s):

Cardiovascular Disease ◽

Cardiovascular Risk ◽

High Risk ◽

Risk Estimation ◽

Pharmacological Therapy ◽

Cardiovascular Risks ◽

Individual Level ◽

The Individual ◽

Very High ◽

Cardiovascular Risk Estimation

The absolute benefit of any measure to prevent cardiovascular disease, be it lifestyle improvement or pharmacological therapy, depends on the baseline cardiovascular risk. This risk cannot be assessed exactly, but only be estimated because many known risk determinants cannot be accounted for in existing risk scoring systems, and because the application to an individual of risk estimates derived from populations is imprecise. Several cardiovascular risk estimation methods are available, and the European Society of Cardiology has favoured the European-based Systematic COronary Risk Evaluation (SCORE) system as a basis for their cardiovascular disease prevention guidelines. SCORE estimates absolute 10-year cardiovascular mortality risk. In specific circumstances, estimation of relative risk, risk age, or lifetime risk may be considered. High- and very-high-risk population are defined by SCORE risks greater than 5% and greater than 10%, respectively, or by clinical conditions conferring (very) high risk, such as existing cardiovascular disease or chronic kidney disease. The role of additional risk information on top of the information entered in SCORE is generally limited. In particular, markers of early cardiovascular damage should be collected and interpreted with caution. Absolute cardiovascular risks in young and elderly individuals are almost always low or very high, respectively, and the options for appropriate interpretation and management of these risks are discussed.

Download Full-text

P938Extensive formation of atherosclerotic cardiovascular disease in subjects with severe familial hypercholesterolemia defined by the international atherosclerosis society criteria

European Heart Journal ◽

10.1093/eurheartj/ehz747.0532 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Funabashi ◽

Y Kataoka ◽

M Harada-Shiba ◽

M Hori ◽

T Doi ◽

...

Keyword(s):

Cardiovascular Disease ◽

High Risk ◽

Familial Hypercholesterolemia ◽

Peripheral Artery Disease ◽

Cardiac Death ◽

Lipid Lowering ◽

Lipid Lowering Therapy ◽

Peripheral Artery ◽

Lowering Therapy ◽

Artery Disease

Abstract Introduction The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia (FH)” as a FH phenotype with the highest cardiovascular risk. Coronary artery disease (CAD) represents a major atherosclerotic change in FH patients. Given their higher LDL-C level and atherogenic clinical features, more extensive formation of atherosclerosis cardiovascular disease including not only CAD but stroke/peripheral artery disease (PAD) may more frequently occur in severe FH. Methods 481 clinically-diagnosed heterozygous FH subjects were analyzed. Severe FH was defined as untreated LDL-C>10.3 mmol/l, LDL-C>8.0 mmol/l+ 1 high-risk feature, LDL-C>4.9 mmol/l + 2 high-risk features or presence of clinical ASCVD according to IAS proposed statement. Cardiac (cardiac death and ACS) and non-cardiac (stroke and peripheral artery disease) events were compared in severe and non-severe FH subjects. Results Severe FH was identified in 50.1% of study subjects. They exhibit increased levels of LDL-C and Lipoprotein (a) with a higher frequency of LDLR mutation. Furthermore, a proportion of %LDL-C reduction>50% was greater in severe FH under more lipid-lowering therapy (Table). However, during the observational period (median=6.3 years), severe FH was associated with a 5.9-fold (95% CI, 2.05–25.2; p=0.004) and 5.8-fold (95% CI, 2.02–24.7; p=0.004) greater likelihood of experiencing cardiac-death/ACS and stroke/PAD, respectively (picture). Multivariate analysis demonstrated severe FH as an independent predictor of both cardiac-death/ACS (hazard ratio=3.39, 95% CI=1.12–14.7, p=0.02) and stroke/PAD (hazard ratio=3.38, 95% CI=1.16–14.3, p=0.02) events. Clinical characteristics of severe FH Non-severe FH Severe FH P-value Baseline LDL-C (mmol/l) 5.3±1.5 6.6±2.0 <0.0001 Lp(a) (mg/dl) 15 [8–28] 21 [10–49] <0.0001 LDLR mutation (%) 49.6% 58.9% 0.00398 On-treatment LDL-C (mmol) 133 [106–165] 135 [103–169] 0.9856 %LDL-C reduction>50% 21.3% 49.8% <0.0001 High-intensity statin (%) 13.3% 42.3% <0.0001 PCSK9 inhibitor (%) 6.3% 21.2% <0.0001 Clinical outcome Conclusions Severe FH subjects exhibit substantial atherosclerotic risks for coronary, carotid and peripheral arteries despite lipid lowering therapy. Our finding underscore the screening of systemic arteries and the adoption of further stringent lipid management in severe FH patients.

Download Full-text

Lipid profile, cardiovascular disease and mortality in a Mediterranean high-risk population: The ESCARVAL-RISK study

PLoS ONE ◽

10.1371/journal.pone.0186196 ◽

2017 ◽

Vol 12 (10) ◽

pp. e0186196 ◽

Cited By ~ 23

Author(s):

Domingo Orozco-Beltran ◽

Vicente F. Gil-Guillen ◽

Josep Redon ◽

Jose M. Martin-Moreno ◽

Vicente Pallares-Carratala ◽

...

Keyword(s):

Cardiovascular Disease ◽

High Risk ◽

Lipid Profile ◽

High Risk Population ◽

Risk Population

Download Full-text

Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme

BMJ Open ◽

10.1136/bmjopen-2017-019041 ◽

2018 ◽

Vol 8 (3) ◽

pp. e019041 ◽

Cited By ~ 4

Author(s):

Farshid Hajati ◽

Evan Atlantis ◽

Katy J L Bell ◽

Federico Girosi

Keyword(s):

Cardiovascular Disease ◽

High Risk ◽

High Density Lipoprotein ◽

High Density Lipoprotein Cholesterol ◽

Density Lipoprotein ◽

High Density ◽

Lipoprotein Cholesterol ◽

Lipid Lowering ◽

National Guidelines ◽

Pharmaceutical Benefits Scheme

ObjectivesWe examine the extent to which the adult Australian population on lipid-lowering medications receives the level of high-density lipoprotein cholesterol (HDL-C) testing recommended by national guidelines.DataWe analysed records from 7 years (2008–2014) of the 10% publicly available sample of deidentified, individual level, linked Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) electronic databases of Australia.MethodsThe PBS data were used to identify individuals on stable prescriptions of lipid-lowering treatment. The MBS data were used to estimate the annual frequency of HDL-C testing. We developed a methodology to address the issue of ‘episode coning’ in the MBS data, which causes an undercounting of pathology tests. We used a published figure on the proportion of unreported HDL-C tests to correct for the undercounting and estimate the probability that an HDL-C test was performed. We judged appropriateness of testing frequency by comparing the HDL-C testing rate to guidelines’ recommendations of annual testing for people at high risk for cardiovascular disease.ResultsWe estimated that approximately 49% of the population on stable lipid-lowering treatment did not receive any HDL-C test in a given year. We also found that approximately 19% of the same population received two or more HDL-C tests within the year. These levels of underutilisation and overutilisation have been changing at an average rate of 2% and −4% a year, respectively, since 2009. The yearly expenditure associated with test overutilisation was approximately $A4.3 million during the study period, while the cost averted because of test underutilisation was approximately $A11.3 million a year.ConclusionsWe found that approximately half of Australians on stable lipid-lowering treatment may be having fewer HDL-C testing than recommended by national guidelines, while nearly one-fifth are having more tests than recommended.

Download Full-text