Estimation of 10-year risk of fatal cardiovascular disease and coronary heart disease in Iceland with results comparable with those of the Systematic Coronary Risk Evaluation project.

BACKGROUND: No data are available on the comparison between an absolute 10-year risk of fatal cardiovascular disease (CVD) and coronary heart disease (CHD) morbidity using the risk assessments of the Systematic Coronary Risk Evaluation (SCORE) project. DESIGN: Data from the prospective Reykjavik Study of 15,782 patients were used to estimate the 10-year risk of fatal CVD and CHD morbidity in Iceland. METHODS: Survival to fatal CVD event was defined as in the SCORE project. Survival to CHD morbidity was defined as having a myocardial infarction, coronary artery bypass graft, or angioplasty. The statistical methodology of SCORE was used. RESULTS: Relative risk in Iceland was comparable with SCORE results but baseline risk was similar to the low-risk version of SCORE, which contradicted previous suggestions for the countries of northern Europe. Correlation between absolute risk of CHD morbidity and risk for fatal CVD was high (r=0.96), resulting in similar ranking of individuals by risk and discriminatory capacity. This is the first published comparison between total fatal CVD risk and CHD morbidity in a population-based cohort using the current risk assessment guidelines of the European Societies on Coronary Prevention. CONCLUSIONS: Risk for fatal CVD in Iceland has the same characteristics as those in a European nation with results varying in accordance with the SCORE project. The risk estimate to be used, CHD morbidity or fatal CVD, is a choice of clinical preference. The data, however, suggest that 5% high-risk threshold of fatal CVD corresponds to a 12% CHD-morbidity risk, which is a significant change from the conventional reference value of 20%.     

Systematic COronary Risk Evaluation (SCORE) and 20-year risk of cardiovascular mortality and cancer

BackgroundCardiovascular disease (CVD) followed by cancer are the two leading causes of death worldwide. SCORE charts have been recommended in Europe to identify individuals at increased CVD risk. However, the SCORE ability to identify individuals at increased risk of cancer has not yet been evaluated. The aim of this study was to determine the SCORE chart calibration in a country with changing CVD epidemiology, and its discrimination ability to identify individuals at increased risk of cancer over 20-years.MethodsThe present analysis includes data from two cross-sectional independent surveys within the Czech post-MONICA study (randomly selected representative population samples of the Czech Republic, aged 25–64 years); 3209 individuals in 1997/98 and 3612 in 2006–2009.ResultsThe SCORE had reasonable discrimination to predict 10-year CVD mortality, but significantly overestimated the risk across all risk categories. During the 20-year follow up, high and very high-risk categories were associated with an increased risk of cancer morbidity (in particular colorectal, other gastrointestinal, lung and malignant skin) and cancer mortality, as compared to low risk category.ConclusionsThe present study shows that periodical calibration testing of SCORE charts is needed in countries with changing CVD epidemiology. Furthermore, we show that in middle-aged individuals, identified by SCORE charts as being at high or very high risk for CVD, cancer morbidity and cancer mortality is increased. Rigorous cancer screening may be appropriate in this group, especially in countries with falling CVD mortality, where relative proportion of cancer mortality is increasing.     

Systematic Coronary Risk Evaluation (SCORE): JACC Focus Seminar 4/8

Clinical estimation of the combined effect of several risk factors is unreliable and this resulted in the development of a number of risk estimation systems to guide clinical practice. Here, after defining general principles of risk estimation, the authors describe the evolution of the European Society of Cardiology’s (ESC) Systematic COronary Risk Evaluation (SCORE) risk estimation system and some learnings from the data. They move on to describe the establishment of the ESC’s Cardiovascular Risk Collaboration and outline its proposed research directions. First among these is the evolution of SCORE 2, which provides updated, calibrated risk estimates for total cardiovascular events for low, moderate, high, and very high-risk regions of Europe. The authors conclude by considering that the future of risk estimation may be to express risk as years of exposure to a cardiovascular risk factor profile rather than risk over a fixed time period, such as 10 years, and how advances in genetics may permit individualized lifetime risk estimation from childhood on.     

Independent components of chronic kidney disease as a cardiovascular risk state: results from the Kidney Early Evaluation Program (KEEP)

BACKGROUND: The relationships of anemia, microalbuminuria, and estimated glomerular filtration rate (eGFR) with cardiovascular disease (CVD) and subsequent death are not fully understood. We hypothesized that each of these chronic kidney disease-related measures would have an independent relationship with CVD. METHODS: A cohort of 37 153 persons screened in the National Kidney Foundation's Kidney Early Evaluation Program were followed up for a median of 16.0 months (range, 0.2-47.5 months). Participants were volunteers who completed surveys regarding past medical events and who underwent blood pressure and laboratory testing. Estimated glomerular filtration rate was computed using a 4-variable equation. Mortality was ascertained by linkage to national data systems. RESULTS: Of 37 153 persons, the mean +/- SD age was 52.9 +/- 15.9 years, and 68.7% were female. A total of 1835 (4.9%) had a self-reported history of myocardial infarction, 1336 (3.6%) had a history of stroke, and 2897 (7.8%) had a history of myocardial infarction or stroke. Multivariate analysis controlling for age demonstrated that the following were independently associated with CVD: male sex (odds ratio [OR], 1.64; P<.001), smoking (OR, 1.73; P<.001), body mass index (OR, 1.01; P = .03), diabetes mellitus (OR, 1.66; P<.001), hypertension (OR, 1.77; P<.001), eGFR of 30 to 59 mL/min per 173 m(3) (OR, 1.37; P = .001), hemoglobin level of 12.8 g/dL or less (OR, 1.45; P<.001), and microalbuminuria of greater than 30 mg/L (OR, 1.28; P = .01). Survival analysis found CVD (OR, 3.02; P = .003), chronic kidney disease (OR, 1.98; P = .05), and the combination (OR, 3.80; P<.001) to be independent predictors of mortality. Persons with a combination of all 3 chronic kidney disease measures (anemia, microalbuminuria, and eGFR of <60 mL/min per 1.73 m(2)) had the lowest survival of about 93% by the end of 30 months. CONCLUSION: Anemia, eGFR, and microalbuminuria were independently associated with CVD, and when all 3 were present, CVD was common and survival was reduced.     

Distribution of the global cardiovascular risk in the Italian population: results from the cardiovascular epidemiologic observatory]

BACKGROUND: The aim of this study was to assess the 10-year cardiovascular risk categories using risk chart, recently set up by the National Institute of Health in the population examined by the Cardiovascular Epidemiologic Observatory. METHODS: 3745 men and 3664 women aged 40-69 years were classified into five risk categories (< 5 %; 5-10%; 10-15%; 15-20%; > or = 20%) taking into account age, smoking habit, history of diabetes, systolic blood pressure, serum cholesterol and excluding those already under treatment for hypertension and hypercholesterolaemia or experienced a previous major cardiovascular event (1937 persons: 955 men, 982 women). RESULTS: Proportion of people estimated at risk in 10 years > or = 20% is minimal in the youngest age range, increases in adulthood, duplicates in smokers and is higher in diabetics. In non-diabetic men that proportion varies between 3.4% in non-smokers and 5.6% in smokers. All women at risk are already under specific treatment. CONCLUSIONS: Cardiovascular Epidemiologic Observatory data allowed to assess the expected proportion of individuals at risk in 10 years > or = 20%. Besides attention to high-risk individuals, preventive measures supporting a healthier lifestyle in the general population must be adopted, considering that it will produce the greatest number of events.     

Diabetes in treated hypertension is common and carries a high cardiovascular risk: results from a 28-year follow-up

OBJECTIVE: The objective of this study was to analyse predictive factors for development of type 2 diabetes during life-long therapy for hypertension and the alleged additional cardiovascular risk this constitutes. METHODS: The study group (n = 754) comprised the hypertensive subgroup of a randomized population sample of 7500 men, aged 47-54 years, screened for cardiovascular risk factors and followed for 25-28 years. The patients were treated with thiazide diuretics and beta-adrenergic blocking drugs with the addition of hydralazin during the first decade. Calcium antagonists were substituted for hydralazin and, if needed, angiotensin-converting enzyme inhibitors were added when these drugs became available. RESULTS: A total of 148 (20.4%) treated hypertensive patients developed diabetes during 25 years, and in multivariate Cox regression analysis body mass index, serum triglycerides and treatment with beta-blockers were positively related with this complication. New-onset diabetes implied a significantly increased risk for stroke [hazard ratio (HR): 1.67; 95% confidence interval (95% CI): 1.1-2.6; P < 0.05], myocardial infarction (OR: 1.66; 95% CI: 1.1-2.5; P < 0.05) and mortality (OR: 1.42; 95% CI: 1.1-1.9; P < 0.05). The greatest risk for stroke was new-onset diabetes, followed by smoking (OR: 1.46; 95% CI: 1-2.2; P = 0.07) and the greatest risk for myocardial infarction was new-onset diabetes, followed by smoking (HR: 1.64; 95% CI: 1.1-2.4; P < 0.01). The greatest risk for mortality was smoking (HR: 1.73; 95% CI: 1.3-2.2; P < 0.005). Achieved systolic and diastolic blood pressure were not predictive of cardiovascular complications or death. The mean observation time from onset of diabetes mellitus to a first stroke was 9.1 years and to a first myocardial infarction 9.3 years. CONCLUSION: Diabetes in treated hypertensive patients is alarmingly common and carries a high risk for cardiovascular complications and mortality.     

Use of snus and risk for cardiovascular disease: results from the Swedish Twin Registry

Objective.  To study the association between snus use and the risk for cardiovascular disease, i.e. ischemic heart disease and stroke. Design.  Cohort study. Setting.  Sweden. Subjects.  Sixteen thousand six hundred and forty‐two male Swedish twins participating in the Screening Across the Lifespan Twin Study, conducted in 1998–2002, were followed for incident cardiovascular disease. Participants were without a history of cardiovascular disease at baseline and incident cases were identified via the Swedish Cause of Death Register and Hospital Discharge Register. Results.  Overall, there was no association between use of snus and risk for cardiovascular disease. Current snus users, without a smoking history, had a relative risk of 1.00 (95% confidence interval 0.69–1.46) for cardiovascular disease as compared to non users. Corresponding relative risks for ischemic heart disease and stroke were 0.85 (95% confidence interval 0.51–1.41) and 1.18 (95% confidence interval 0.67–2.08), respectively. In smoking adjusted models, risk estimates for ischemic heart disease in relation to snus use were all close to unity regardless of timing or intensity of snus use. However, current heavy snus users (consuming more than four cans week^?1) had a relative risk for stroke of 1.75 (95% confidence interval 0.95–3.21). Conclusion.  These data do not support any strong association between snus use and risk for cardiovascular disease.     

Evaluation of cardiovascular risk in blood donors: results of the CARDIORISK study in the Parma Transfusion Service

Background

Cardiovascular disease, which is one of the main causes of mortality in industrialised countries, is ever increasingly the focus of prevention. In this study, called “Cardiorisk”, we evaluated cardiovascular risk in the population of blood donors at the Service of Immunohaematology and Transfusion Medicine in Parma.

Patients and methods

Between January 2007 and December 2008, 6,172 consecutive blood donors (aged 35–65 years) were enrolled in this project which entailed calculating each subject’s cardiovascular risk score, based on an evaluation of both unalterable risk factors (age and gender) and modifiable risk factors (total cholesterol, HDL, LDL, triglycerides, glycaemia, smoking, hypertension) as well as anti-hypertensive and/or cholesterol-lowering therapy.

Results

Of the 6,172 donors enrolled in the study, 5,039 (81.7%) had a low cardiovascular risk (score from 0–10), 774 (12.5%) had a moderate cardiovascular risk (score from 11–19) and 359 (5.8%) donors had a high cardiovascular risk (score from 20–28).

Conclusions

In our opinion, the calculation of cardiovascular risk is an important instrument for preventive medicine in blood donors.     

Inflammatory bowel disease is not a risk factor for cardiovascular disease mortality: results from a systematic review and meta-analysis

OBJECTIVES: Inflammation in general, and C-reactive protein (CRP) in particular, are closely associated with atherosclerosis. Similarly, the risk of cardiovascular (CV) disease is increased in several systemic inflammatory diseases. The purpose of this study was to examine whether inflammatory bowel disease (IBD) increases CV mortality, an indirect surrogate for CV disease incidence. METHODS: A systematic review of studies on CV mortality rates in patients with IBD published between 1965 and 2006 was performed. Studies were included for analysis if they reported data on CV-disease-specific standardized mortality ratios (SMRs) for Crohn's disease (CD) and/or ulcerative colitis (UC). A meta-analysis of SMRs from included studies was performed. RESULTS: The review ultimately included 11 studies. Overall there were 4,532 patients with CD and 9,533 patients with UC. SMR point estimates ranged from 0.7 to 1.5 for patients with CD and 0.6-1.1 for patients with UC. There was not a statistically significant increase in CV SMR for either CD or UC in any study. However, two studies demonstrated a statistically significant decrease in CV SMR for UC. Finally, the meta-SMR for CD was 1.0 (95% CI 0.8-1.1) and the meta-SMR for UC was 0.9 (95% CI 0.8-1.0). CONCLUSIONS: IBD is not associated with increased CV mortality. Although CV mortality is a suboptimal surrogate for CV disease incidence, this finding provides indirect evidence against an association between IBD and CV disease.     

Risk factors for delirium tremens: a retrospective chart review

A retrospective chart review was performed within an inpatient VA hospital setting in an attempt to identify risk factors for delirium tremens (DTs). Cases of delirium tremens were compared to cases where patients' alcohol withdrawal during hospitalization did not progress to DTs. Significant differences were found in regard to prior histories of DTs and laboratory values at admission. The amount and duration of benzodiazepine use during hospitalization, antipsychotic use during hospitalization, and length of hospitalization were also statistically different between the groups. While not reaching statistical significance, there were differences in reason for admission and relapse rate upon follow-up between the groups.     

Glutathione peroxidase-1 and homocysteine for cardiovascular risk prediction: results from the AtheroGene study

OBJECTIVES: This prospective study was designed to evaluate the effect of joint determination of two important contrary biomarkers--homocysteine and glutathione peroxidase (GPx)-1--on cardiovascular risk stratification. BACKGROUND: Homocysteine plasma levels have been associated with cardiovascular risk. Experimental data suggest that antioxidative GPx-1 activity modulates cardiovascular risk associated with homocysteine. METHODS: In 643 patients with coronary artery disease, we performed a prospective study to assess the risk of homocysteine plasma levels and GPx-1 activity on long-term cardiovascular risk with a median follow-up of 7.1 years. RESULTS: Both homocysteine and GPx-1 were among the strongest univariate predictors of future cardiovascular risk, even after adjustment for cardiovascular confounders. Homocysteine levels were significantly elevated in individuals with future cardiovascular events (15.4 vs. 13.4 micromol/l; p < 0.0001); GPx-1 activity was lower (45.3 +/- 13.1 vs. 50.2 +/- 11.0 U/g hemoglobin; p < 0.0001). In patients with GPx-1 activity below the median value, homocysteine plasma levels above the median were associated with a 3.2-fold (95% confidence interval 1.8 to 5.6; p < 0.0001) increase in cardiovascular risk, whereas it lost its independent risk prediction in individuals with increased antioxidative capacity, as reflected by high GPx-1 activity. In contrast to single determination, combined assessment revealed a significant increase in the area under the curve of cardiovascular risk predictive models from 0.72, including traditional risk factors to 0.75 and also including homocysteine levels and GPx-1 activity. CONCLUSIONS: Plasma homocysteine levels and GPx-1 activity are complementary in identifying individuals at high cardiovascular risk. Joint determination of both biomarkers provides substantial information on top of classic risk factors in cardiovascular risk assessment.     

Improvement of cardiovascular risk markers by pioglitazone is independent from glycemic control: results from the pioneer study

OBJECTIVES: This study was performed to assess whether the anti-inflammatory and antiatherogenic effects of pioglitazone suggested by animal experiments are reproducible in man and independent from improvements in metabolic control. BACKGROUND: Type 2 diabetes is associated with increased cardiovascular risk. METHODS: A total of 192 patients were enrolled into a six-month, prospective, open-label, controlled clinical study. They were randomized to receive either pioglitazone (45 mg) or glimepiride (1 to 6 mg, with the intent to optimize therapy). Biochemical and clinical markers to assess therapeutic effects included HbA1c, fasting glucose, insulin, adiponectin, lipids, high-sensitivity C-reactive protein (hsCRP), intracellular adhesion molecule, vascular cell adhesion molecule, vascular endothelial growth factor, fibrinogen, von Willebrand factor, matrix metalloproteinase (MMP)-9, monocyte chemoattractant protein (MCP)-1, soluble CD40 ligand, and carotid intima-media thickness (IMT). RESULTS: The study was completed by 173 patients (66 female, 107 male; age [+/- SD]: 63 +/- 8 years; disease duration: 7.2 +/- 7.2 years; HbA1c: 7.5 +/- 0.9%; pioglitazone arm: 89 patients). A comparable reduction in HbA1c was seen in both groups (p < 0.001). In the pioglitazone group, reductions were observed for glucose (p < 0.001 vs. glimepiride group at end point), insulin (p < 0.001), low-density lipoprotein/high-density lipoprotein ratio (p < 0.001), hsCRP (p < 0.05), MMP-9 (p < 0.05), MCP-1 (p < 0.05), and carotid IMT (p < 0.001), and an increase was seen in high-density lipoprotein (p < 0.001) and adiponectin (p < 0.001). Spearman ranks analysis revealed only one correlation between the reduction in cardiovascular risk parameters and the improvement in the metabolic parameters (MMP-9 and fasting blood glucose, p < 0.05) CONCLUSIONS: This prospective study gives evidence of an anti-inflammatory and antiatherogenic effect of pioglitazone versus glimepiride. This effect is independent from blood glucose control and may be attributed to peroxisome proliferator-activated receptor gamma activation.     

Coronary artery calcification and cardiovascular risk factors: impact of the analytic approach

Coronary artery calcification (CAC) may help identify novel risk factors for coronary atherosclerosis. However, analysis of CAC is challenging because of the distribution of CAC in the population. This has resulted in difficulty in interpreting and comparing results across studies. We applied several analytic approaches to CAC data in order to determine the impact of analytic methods on the association with established cardiovascular risk factors in 914 asymptomatic subjects in the Study of Inherited Risk Factors for Coronary Atherosclerosis. Multivariable analyses included: (1) linear regression of different transformations of CAC scores; (2) tobit regression of the log of (CAC + 1); (3) logistic regression using CAC zero as a cut-point; and (4) ordinal logistic regression using CAC categories. Linear regression of the log CAC scores and logistic regression of CAC zero cut-point failed to detect associations with some risk factors. In contrast, linear and tobit regression of the log (CAC + 1) and ordinal regression of CAC categories identified more associations and provided consistent results. Commonly applied methods of CAC analysis may fail to detect associations with cardiovascular risk factors. We present analytic approaches that are likely to provide consistent results and recommend the use of at least two distinct multivariable methods.     

Risk of mortality and cardiovascular disease associated with the ankle-brachial index: Systematic review

OBJECTIVE: To determine the strength and consistency with which a low ankle brachial pressure index (ABI), measured in the general population, is associated with an increased risk of subsequent death and/or cardiovascular events. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, reference lists and grey literature were searched; studies known to experts were also retrieved. MAIN OUTCOME MEASURES: All cause mortality, fatal and non-fatal coronary heart disease and stroke. REVIEW METHODS: Longitudinal studies in which participants were representative of the general population (all ages, either sex) and which used any standard method for measurement and calculation of the ABI. Studies in which participants were selected according to presence of pre-existing disease or were post intervention (e.g. angioplasty or peripheral arterial grafting) were excluded. RESULTS: 11 studies comprising 44,590 subjects from six different countries were included. Despite clinical heterogeneity between studies, the findings were remarkably consistent in demonstrating an increased risk of clinical cardiovascular disease associated with a low ABI. A low ABI (<0.9) was associated with an increased risk of subsequent all cause mortality (pooled RR 1.60, 95% CI 1.32-1.95), cardiovascular mortality (pooled RR 1.96, 95% CI 1.46-2.64), coronary heart disease (pooled RR 1.45, 95% CI 1.08-1.93) and stroke (pooled RR 1.35, 95% CI 1.10-1.65) after adjustment for age, sex, conventional cardiovascular risk factors and prevalent cardiovascular disease. CONCLUSIONS: The ABI may help to identify asymptomatic individuals in the general population who are at increased risk of subsequent cardiovascular events. Evaluation is now required of the potential of incorporating ABI measurement into cardiovascular prevention programmes.