Assessment of cardiovascular risk in low resource settings "So much to do - So little done"

Cardiovascular Risk Calculators and their Applicability to South Asians

BACKGROUND

Estimation of absolute cardiovascular disease (CVD) risk and tailoring therapies according to the estimated risk is a fundamental concept in the primary prevention of CVD is assessed in this study. Numerous CVD risk scores are currently available for use in various populations but unfortunately, none exist for South Asians who have much higher CVD risk as compared to their western counterparts.

METHODS

A literature search was done using PubMed and Google search engines to prepare a narrative review on this topic.

RESULTS

Various currently available CVD risk scores and their pros and cons are summarized. The studies performed in native as well as migrant South Asians evaluating the accuracy of these risk scores for estimation of CVD risk are also summarized. The findings of these studies have generally been inconsistent, but it appears that the British risk scores (e.g. QRISK versions) may be more accurate because of inclusion of migrant South Asians in the derivation of these risk scores. However, the lack of any prospective study precludes our ability to draw any firm conclusions. Finally, the potential solution to these challenges, including the role of recalibration and subclinical atherosclerosis imaging, is also discussed.

CONCLUSION

This review highlights the need to develop large, representative, prospectively followed databases of South Asians providing information on various CVD risk factors and their contribution to incident CVD. Such databases will not only allow the development of validated CVD risk scores for South Asians but will also enable application of machine-learning approaches to provide personalized solutions to CVD risk assessment and management in these populations.

Cardiovascular Programming During and After Diabetic Pregnancy: Role of Placental Dysfunction and IUGR

Intrauterine growth restriction (IUGR) is a condition whereby a fetus is unable to achieve its genetically determined potential size. IUGR is a global health challenge due to high mortality and morbidity amongst affected neonates. It is a multifactorial condition caused by maternal, fetal, placental, and genetic confounders. Babies born of diabetic pregnancies are usually large for gestational age but under certain conditions whereby prolonged uncontrolled hyperglycemia leads to placental dysfunction, the outcome of the pregnancy is an intrauterine growth restricted fetus with clinical features of malnutrition. Placental dysfunction leads to undernutrition and hypoxia, which triggers gene modification in the developing fetus due to fetal adaptation to adverse utero environmental conditions. Thus, in utero gene modification results in future cardiovascular programming in postnatal and adult life. Ongoing research aims to broaden our understanding of the molecular mechanisms and pathological pathways involved in fetal programming due to IUGR. There is a need for the development of effective preventive and therapeutic strategies for the management of growth-restricted infants. Information on the mechanisms involved with in utero epigenetic modification leading to development of cardiovascular disease in adult life will increase our understanding and allow the identification of susceptible individuals as well as the design of targeted prevention strategies. This article aims to systematically review the latest molecular mechanisms involved in the pathogenesis of IUGR in cardiovascular programming. Animal models of IUGR that used nutrient restriction and hypoxia to mimic the clinical conditions in humans of reduced flow of nutrients and oxygen to the fetus will be discussed in terms of cardiac remodeling and epigenetic programming of cardiovascular disease. Experimental evidence of long-term fetal programming due to IUGR will also be included.