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De la Rosa A, Arrington K, Desai R, Acharya PC. Polypill Strategy in Secondary Cardiovascular Prevention. Curr Cardiol Rep 2024; 26:443-450. [PMID: 38557814 DOI: 10.1007/s11886-024-02046-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW The polypill strategy, originally developed to improve medication adherence, has demonstrated efficacy in improving baseline systolic blood pressures and cholesterol levels in multiple clinical trials. However, the long-term clinical impact of improved major cardiovascular events (MACE) outcomes by the polypill remains uncertain. RECENT FINDINGS Recent trials with long-term follow-up, which included minority groups and people with low socioeconomic status, have shown non-inferiority with no difference in adverse effects rates for the secondary prevention of MACE. Although the polypill strategy was initially introduced to improve adherence to guideline-directed medical therapy (GDMT) for cardiovascular complications, the strategy has surpassed standard medical treatment for secondary prevention of MACE outcomes. Studies also showed improved medication compliance in underserved populations.
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Affiliation(s)
- Alan De la Rosa
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Kedzie Arrington
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA
| | - Rohan Desai
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Prakrati C Acharya
- Division of Nephrology Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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2
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Disparities in Cardiovascular Care and Outcomes for Women From Racial/Ethnic Minority Backgrounds. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:75. [PMID: 33223802 PMCID: PMC7669491 DOI: 10.1007/s11936-020-00869-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/14/2022]
Abstract
Purpose of review Racial, ethnic, and gender disparities in cardiovascular care are well-documented. This review aims to highlight the disparities and impact on a group particularly vulnerable to disparities, women from racial/ethnic minority backgrounds. Recent findings Women from racial/ethnic minority backgrounds remain underrepresented in major cardiovascular trials, limiting the generalizability of cardiovascular research to this population. Certain cardiovascular risk factors are more prevalent in women from racial/ethnic minority backgrounds, including traditional risk factors such as hypertension, obesity, and diabetes. Female-specific risk factors including gestational diabetes and preeclampsia as well as non-traditional psychosocial risk factors like depressive and anxiety disorders, increased child care, and familial and home care responsibility have been shown to increase risk for cardiovascular disease events in women more so than in men, and disproportionately affect women from racial/ethnic minority backgrounds. Despite this, minimal interventions to address differential risk have been proposed. Furthermore, disparities in treatment and outcomes that disadvantage minority women persist. The limited improvement in outcomes over time, especially among non-Hispanic Black women, is an area that requires further research and active interventions. Summary Understanding the lack of representation in cardiovascular trials, differential cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds highlights opportunities for improving cardiovascular care among this particularly vulnerable population.
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Orimoloye OA, Budoff MJ, Dardari ZA, Mirbolouk M, Uddin SMI, Berman DS, Rozanski A, Shaw LJ, Rumberger JA, Nasir K, Miedema MD, Blumenthal RS, Blaha MJ. Race/Ethnicity and the Prognostic Implications of Coronary Artery Calcium for All-Cause and Cardiovascular Disease Mortality: The Coronary Artery Calcium Consortium. J Am Heart Assoc 2019; 7:e010471. [PMID: 30371271 PMCID: PMC6474975 DOI: 10.1161/jaha.118.010471] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Coronary artery calcium (CAC) predicts cardiovascular disease (CVD) events; however, less is known about how its prognostic implications vary by race/ethnicity. Methods and Results A total of 38 277 whites, 1621 Asians, 977 blacks, and 1349 Hispanics from the CAC Consortium (mean age 55 years, 35% women) were followed over a median of 11.7 years. Modeling CAC in continuous and categorical (CAC=0; CAC 1–99; CAC 100–399; CAC ≥400) forms, we assessed its predictive value for all‐cause and CVD mortality by race/ethnicity using Cox proportional hazards and Fine and Gray competing‐risk regression, respectively. We also assessed the impact of race/ethnicity on risk within individual CAC strata, using whites as the reference. Models were adjusted for traditional cardiovascular risk factors. Increased CAC was associated with higher total and CVD mortality risk in all race/ethnicity groups, including Asians. However, the risk gradient with increasing CAC was more pronounced in blacks and Hispanics. In Fine and Gray subdistribution hazards models adjusted for traditional cardiovascular risk factors and CAC (continuous), blacks (subdistribution hazard ratio 3.4, 95% confidence interval, 2.5–4.8) and Hispanics (subdistribution hazard ratio 2.3, 95% confidence interval, 1.6–3.2) showed greater risk of CVD mortality when compared with whites, while Asians had risk similar to whites. These race/ethnic differences persisted when CAC=0. Conclusions CAC predicts all‐cause and CVD mortality in all studied race/ethnicity groups, including Asians and Hispanics, who may be poorly represented by the Pooled Cohort Equations. Blacks and Hispanics may have greater mortality risk compared with whites and Asians after adjusting for atherosclerosis burden, with potential implications for US race/ethnic healthcare disparities research.
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Affiliation(s)
- Olusola A Orimoloye
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD
| | - Matthew J Budoff
- 2 Department of Medicine Harbor-UCLA Medical Center Los Angeles CA
| | - Zeina A Dardari
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD
| | - Mohammadhassan Mirbolouk
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD
| | - S M Iftekhar Uddin
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD
| | - Daniel S Berman
- 3 Department of Imaging Cedars-Sinai Medical Center Los Angeles CA
| | - Alan Rozanski
- 4 Division of Cardiology Mount Sinai St. Luke's Hospital New York NY
| | - Leslee J Shaw
- 5 Department of Radiology, Weill Cornell Medicine New York NY
| | | | - Khurram Nasir
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD.,7 Center for Outcomes Research and Evaluation (CORE) Section of Cardiovascular Medicine, Yale University School of Medicine New Haven CT
| | - Michael D Miedema
- 8 Minneapolis Heart Institute Abbott Northwestern Hospital Minneapolis MN
| | - Roger S Blumenthal
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD
| | - Michael J Blaha
- 1 Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Johns Hopkins School of Medicine Baltimore MD
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4
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The Evolving View of Coronary Artery Calcium: A Personalized Shared Decision-Making Tool in Primary Prevention. Cardiol Res Pract 2019; 2019:7059806. [PMID: 31511792 PMCID: PMC6714321 DOI: 10.1155/2019/7059806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/16/2019] [Indexed: 12/22/2022] Open
Abstract
The 2018 American Heart Association and American College of Cardiology (AHA/ACC) cholesterol management guideline considers current evidence on coronary artery calcium (CAC) testing while incorporating learnings from previous guidelines. More than any previous guideline update, this set encourages CAC testing to facilitate shared decision making and to individualize treatment plans. An important novelty is further separation of risk groups. Specifically, the current prevention guideline recommends CAC testing for primary atherosclerotic cardiovascular disease (ASCVD) prevention among asymptomatic patients in borderline and intermediate risk groups (5–7.5% and 7.5–20% 10-year ASCVD risk). This additional sub-classification reflects the uncertainty of treatment strategies for patients broadly considered to be “intermediate risk,” as treatment recommendations for high and low risk groups are well established. The 2018 guidelines, for the first time, clearly recognize the significance of a CAC score of zero, where intensive statin therapy is likely not beneficial and not routinely recommended in selected patients. Lifestyle modification should be the focus in patients with CAC = 0. In this article, we review the recent AHA/ACC cholesterol management guideline and contextualize the transition of CAC testing to a guideline-endorsed decision aid for borderline-to-intermediate risk patients who seek more definitive risk assessment as part of a clinician-patient discussion. CAC testing can reduce low-value treatment and focus primary prevention therapy on those most likely to benefit.
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5
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Superko HR, Williams PT, Dansinger M, Schaefer E. Trends in low-density lipoprotein-cholesterol blood values between 2012 and 2017 suggest sluggish adoption of the recent 2013 treatment guidelines. Clin Cardiol 2018; 42:101-110. [PMID: 30444024 DOI: 10.1002/clc.23115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Over a 14-year period, age-adjusted high total cholesterol (≥240 mg/dL) in the United States declined from 18.3% in 1999 to 2000 to 11.0% in 2013 to 2014, coinciding with the 2001 National Cholesterol Education Program Adult Treatment Panel (ATP)-III guidelines that endorsed low-density lipoprotein (LDL)-cholesterol blood value goals. Statin treatment recommendations were revised by the American College of Cardiology and the American Heart Association (ACC/AHA) in November 2013 to a "risk-based prescription" approach that did not utilize blood cholesterol values. This increased dosage and expanded the statin-eligible population by an estimated 12.8 million US adults. These changes should further lower total and LDL cholesterol concentrations nationally. METHODS We examined data from 507 752 patients nationally aged ≥16 years whose fasting bloods were sent to Boston Heart Diagnostics for direct LDL-cholesterol measurements. Between 2012 and 2017, age-adjusted concentrations were examined by analysis of covariance and LDL-cholesterol ≥160 mg/dL by logistic regression. RESULTS Contrary to expectations, age-adjusted mean LDL-cholesterol concentrations (±SE, mg/dL) increased significantly (P < 10-16 ) in men (2012:113.8 ± 0.3; 2013:115.3 ± 0.2; 2014:114.7 ± 0.2; 2015:116.0 ± 0.2; 2016:117.6 ± 0.2; and 2017:117.1 ± 0.2 mg/dL) and women (2012:119.5 ± 0.3; 2013:120.7 ± 0.2; 2014:119.8 ± 0.02; 2015:120.8 ± 0.2; 2016:122.7 ± 0.1; and 2017:123.8 ± 0.2 mg/dL). The percentage with LDL-cholesterol ≥160 mg/dL also increased significantly (P < 10-9 ) in men and women. Similar results were obtained for ages 40 to 75 years olds (corresponding to ACC/AHA guidelines). CONCLUSION These results provide additional evidence that declining blood LDL-cholesterol levels observed following the ATP-III recommendations, did not further decline (actually increased) following the 2013 ACC/AHA recommendations.
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Affiliation(s)
- H Robert Superko
- Cholesterol, Genetics, and Heart Disease Institute, Carmel, California
| | | | - Michael Dansinger
- Boston Heart Diagnostics, Framingham, Massachusetts.,Department of Internal Medicine, Tuft's University, Medford, Massachusetts
| | - Ernst Schaefer
- Boston Heart Diagnostics, Framingham, Massachusetts.,Department of Internal Medicine, Tuft's University, Medford, Massachusetts
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6
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Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:89. [DOI: 10.1007/s11936-018-0685-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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7
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Buch V, Ralph H, Salas J, Hauptman PJ, Davis D, Scherrer JF. Chest Pain, Atherosclerotic Cardiovascular Disease Risk, and Cardiology Referral in Primary Care. J Prim Care Community Health 2018; 9:2150132718773259. [PMID: 29756524 PMCID: PMC5954572 DOI: 10.1177/2150132718773259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: The atherosclerotic cardiovascular disease (ASCVD) 10-year risk estimate is recommended by cardiologists for determining risk of a cardiac event. However, the majority of patients presenting to primary care with chest pain have noncardiac etiologies. Therefore, we determined if high versus low ASCVD risk was associated with primary care physicians’ referral to cardiology in patients with and without chest pain. Methods: Deidentified electronic health record (EHR) data was obtained from 5795 patients treated in academic primary care clinics from 2008 to 2015. Referral to cardiology was defined by an EHR code, chest pain was defined by ICD-9-CM code (786.5) and ASCVD was modeled as high versus low risk. Separate logistic regression models were computed to estimate the association between chest pain and referral to cardiology, ASCVD risk and referral, and both chest pain and ASCVD risk and referral with adjustment for potential confounding factors. Results: More patients with (n = 95, 7.8%) versus without (n = 75, 2.0%) chest pain were referred to cardiology (P < .0001). Separate unadjusted models revealed chest pain and high versus low ASCVD risk were significantly associated with referral (odds ratio [OR] = 4.20; 95% confidence interval [CI] 3.07-5.73 and OR = 1.41; 95% CI 1.04-1.91, respectively). After adjusting for ASCVD risk and confounders, chest pain but not high ASCVD risk remained significantly associated with referral (OR = 1.75; 95% CI 1.24-2.47 and OR = 1.15; 95% CI 0.72-1.82, respectively). Conclusions: In primary care patients presenting with chest pain, ASCVD risk scores are not associated with referral to cardiology. Overall, less than 8% of patients with chest pain were referred. While there is no evidence to indicate excessive referral to cardiology, we posit that implementing ASCVD risk tools in decision aids could contribute to referring those most in need of cardiology care.
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Affiliation(s)
- Vishaal Buch
- 1 Saint Louis University School of Medicine, St Louis, MO, USA
| | - Hayley Ralph
- 1 Saint Louis University School of Medicine, St Louis, MO, USA
| | - Joanne Salas
- 1 Saint Louis University School of Medicine, St Louis, MO, USA
| | - Paul J Hauptman
- 1 Saint Louis University School of Medicine, St Louis, MO, USA
| | - Dawn Davis
- 1 Saint Louis University School of Medicine, St Louis, MO, USA
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8
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Blaha MJ, Yeboah J, Al Rifai M, Liu K, Kronmal R, Greenland P. Providing Evidence for Subclinical CVD in Risk Assessment. Glob Heart 2018; 11:275-285. [PMID: 27741975 DOI: 10.1016/j.gheart.2016.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/27/2016] [Accepted: 08/01/2016] [Indexed: 10/20/2022] Open
Abstract
When the MESA (Multi-Ethnic Study of Atherosclerosis) began, the Framingham risk score was the preferred tool for 10-year global coronary heart disease risk assessment; however, the Framingham risk score had limitations including derivation in a homogenous population lacking racial and ethnic diversity and exclusive reliance on traditional risk factors without consideration of most subclinical disease measures. MESA was designed to study the prognostic value of subclinical atherosclerosis and other risk markers in a multiethnic population. In a series of landmark publications, MESA demonstrated that measures of subclinical cardiovascular disease add significant prognostic value to the traditional Framingham risk variables. In head-to-head studies comparing these markers, MESA established that the coronary artery calcium score may be the single best predictor of coronary heart disease risk. Results from MESA have directly influenced recent prevention guidelines including the recommendations on risk assessment and cholesterol-lowering therapy. The MESA study has published its own risk score, which allows for the calculation of 10-year risk of coronary heart disease before and after knowledge of a coronary artery calcium score.
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Affiliation(s)
- Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Baltimore, MD, USA.
| | - Joseph Yeboah
- Department of Internal Medicine/Cardiology, Wake Forest University Health Sciences, Winston Salem, NC, USA
| | - Mahmoud Al Rifai
- Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kiang Liu
- Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard Kronmal
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Philip Greenland
- Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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9
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Kianoush S, Mirbolouk M, Makam RC, Nasir K, Blaha MJ. Coronary Artery Calcium Scoring in Current Clinical Practice: How to Define Its Value? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:85. [PMID: 28948466 DOI: 10.1007/s11936-017-0582-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OPINION STATEMENT Detecting subclinical atherosclerosis with coronary artery calcium (CAC) is promising for identifying individuals at risk for cardiovascular events and appears to be a robust tool for guiding initiation of appropriate and timely primary prevention strategies. However, how do we best determine its clinical value? It is clear that traditional risk prediction models based primarily on age, gender, and risk factors are insufficient for ideal personalization of risk estimation. It is now well established from epidemiologic studies that CAC adds to traditional risk scores for a more accurate risk prediction. However, such traditional epidemiology studies have limitations in establishing "clinical value," and they must be supplemented by additional data before being translated into strong recommendations in clinical practice guidelines. Fortunately, over the last few years, the research around CAC has matured to include data supporting enhanced clinician-patient risk discussions, shared decision-making, flexible risk factor treatment goals, specific clinical decision algorithms, as well as favorable cost-effectiveness analyses. We had moved from a time when we asked "if CAC adds to the risk score" to a time when we are asking "does CAC facilitate a shared decision-making model matching risk, treatment, and patient preferences?" A new risk calculator incorporating CAC into global risk scoring, and 2017 guidelines on the use of CAC published by the Society of Cardiovascular Computed Tomography (SCCT), reflect this new approach. In this article, we review the recent transition to this more clinically relevant CAC research that may support a stronger recommendation for its use in future prevention guidelines.
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Affiliation(s)
- Sina Kianoush
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Mohammadhassan Mirbolouk
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Raghavendra Charan Makam
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA.,Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, 1500 San Remo Ave, Suite 340, Coral Gables, FL, 33139, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Blalock building Suit 501, 600 N Wolfe Street, Baltimore, MD, 21287, USA. .,Division of Cardiology, Johns Hopkins Ciccarone Center Preventive Cardiology Center, Blalock 524C, 600 North Wolfe St, Baltimore, MD, 21287, USA.
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10
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Thacher TD, Rajkumar SV, Lanier WL. Call for Papers on Clinical Practice Guidelines. Mayo Clin Proc 2017; 92:327-328. [PMID: 28259225 DOI: 10.1016/j.mayocp.2017.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 11/17/2022]
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11
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Hecht H, Blaha MJ, Berman DS, Nasir K, Budoff M, Leipsic J, Blankstein R, Narula J, Rumberger J, Shaw LJ. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:157-168. [PMID: 28283309 DOI: 10.1016/j.jcct.2017.02.010] [Citation(s) in RCA: 217] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/20/2017] [Indexed: 12/21/2022]
Abstract
This expert consensus statement summarizes the available data regarding the prognostic value of CAC in the asymptomatic population and its ability to refine individual risk prediction, addresses the limitations identified in the current traditional risk factor-based treatment strategies recommended by the 2013 ACC/AHA Prevention guidelines including use of the Pooled Cohort Equations (PCE), and the US Preventive Services Task Force (USPSTF) Recommendation Statement for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. It provides CAC based treatment recommendations both within the context of the shared decision making model espoused by the 2013 ACC/AHA Prevention guidelines and independent of these guidelines.
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Affiliation(s)
- Harvey Hecht
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Medical Center, New York, NY, USA.
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Daniel S Berman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Khurram Nasir
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
| | - Matthew Budoff
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Medical Center, New York, NY, USA
| | | | - Leslee J Shaw
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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12
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Yadav R, Yadav RK, Sarvottam K, Netam R. Framingham Risk Score and Estimated 10-Year Cardiovascular Disease Risk Reduction by a Short-Term Yoga-Based LifeStyle Intervention. J Altern Complement Med 2017; 23:730-737. [PMID: 28437144 DOI: 10.1089/acm.2016.0309] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of a short-term yoga-based lifestyle intervention program in lowering Framingham Risk Score (FRS) and estimated 10-year cardiovascular risk. METHODS This was a single-arm, pre-post interventional study including data from a historical cohort with low to moderate risk for cardiovascular disease (CVD). It was conducted in a tertiary-care hospital. Participants with low (0 or 1 CVD risk factors) to moderately high risk (10-year risk between 10% and 20% and two or more CVD risk factors) were included. Participants with previously diagnosed CVD, defined as a history of myocardial infarction, congestive heart failure, or cerebrovascular accident, were excluded from the analysis. However, those with controlled hypertension were included. Intervention included a pretested short-term yoga-based lifestyle intervention, which included asanas (physical postures), pranayama (breathing exercises), meditation, relaxation techniques, stress management, group support, nutrition awareness program, and individualized advice. The intervention was for 10 days, spread over 2 weeks. However, participants were encouraged to include it in their day-to-day life. Outcomes included changes in FRS, and estimated 10-year CVD risk from baseline to week 2. A gender-based subgroup analysis was also done, and correlation between changes in FRS and cardiovascular risk factors was evaluated. RESULTS Data for 554 subjects were screened, and 386 subjects (252 females) were included in the analysis. There was a significant reduction in FRS (p < 0.001) and estimated 10-year cardiovascular risk (p < 0.001) following the short-term yoga-based intervention. There was a strong positive correlation between reduction in FRS and serum total cholesterol (r = 0.60; p < 0.001). There was a moderate positive correlation between reduction in FRS and low-density lipoprotein cholesterol (r = 0.58; p < 0.001), and a weak but positive correlation between reduction in FRS and triglycerides (r = 0.26; p ≤ 0.001), serum very-low-density lipoprotein cholesterol (r = 0.29; p < 0.001), and systolic blood pressure (r = 0.20; p ≤ 0.001). CONCLUSIONS This yoga-based lifestyle intervention program significantly reduced the CVD risk, as shown by lowered FRS and estimated 10-year CVD risk. Further testing of this promising intervention is warranted in the long term.
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Affiliation(s)
- Rashmi Yadav
- Department of Physiology, All India Institute of Medical Sciences , New Delhi, India
| | - Raj Kumar Yadav
- Department of Physiology, All India Institute of Medical Sciences , New Delhi, India
| | - Kumar Sarvottam
- Department of Physiology, All India Institute of Medical Sciences , New Delhi, India
| | - Ritesh Netam
- Department of Physiology, All India Institute of Medical Sciences , New Delhi, India
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13
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Abstract
Current American College of Cardiology/American Heart Association guidelines for the management of patients with elevated blood cholesterol increasingly emphasize assessment of atherosclerotic cardiovascular disease (ASCVD) risk in deciding when to initiate pharmacotherapy. The decision to treat is based primarily on mathematical integration of traditional risk factors, including age, sex, race, lipid values, systolic blood pressure, hypertension therapy, diabetes mellitus, and smoking. Advanced risk testing is selectively endorsed for patients when the decision to treat is otherwise uncertain, or more broadly interpreted as those patients who are at so-called "intermediate risk" of ASCVD events using traditional risk factors alone. These new guidelines also place new emphasis on a clinician-patient risk discussion, a process of shared decision making in which patient and physician consider the potential benefits of treatment, risk of adverse events, and patient preferences before making a final decision to initiate treatment. Advanced risk testing is likely to play an increasingly important role in this process as weaknesses in exclusive reliance on traditional risk factors are recognized, new non-statin therapies become available, and guidelines are iteratively updated. Comparative efficacy studies of the various advanced risk testing options suggest that coronary artery calcium scoring is most strongly predictive of ASCVD events. Most importantly, coronary artery calcium scoring appears to identify an important subgroup of patients with advanced subclinical atherosclerosis-who are "between" primary and secondary prevention-that might benefit from the most aggressive lipid-lowering pharmacotherapy.
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Affiliation(s)
- Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease and Department of Epidemiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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14
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Thompson-Paul AM, Lichtenstein KA, Armon C, Palella FJ, Skarbinski J, Chmiel JS, Hart R, Wei SC, Loustalot F, Brooks JT, Buchacz K. Cardiovascular Disease Risk Prediction in the HIV Outpatient Study. Clin Infect Dis 2016; 63:1508-1516. [PMID: 27613562 DOI: 10.1093/cid/ciw615] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 09/01/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) risk prediction tools are often applied to populations beyond those in which they were designed when validated tools for specific subpopulations are unavailable. METHODS Using data from 2283 human immunodeficiency virus (HIV)-infected adults aged ≥18 years, who were active in the HIV Outpatient Study (HOPS), we assessed performance of 3 commonly used CVD prediction models developed for general populations: Framingham general cardiovascular Risk Score (FRS), American College of Cardiology/American Heart Association Pooled Cohort equations (PCEs), and Systematic COronary Risk Evaluation (SCORE) high-risk equation, and 1 model developed in HIV-infected persons: the Data Collection on Adverse Effects of Anti-HIV Drugs (D:A:D) study equation. C-statistics assessed model discrimination and the ratio of expected to observed events (E/O) and Hosmer-Lemeshow χ2 P value assessed calibration. RESULTS From January 2002 through September 2013, 195 (8.5%) HOPS participants experienced an incident CVD event in 15 056 person-years. The FRS demonstrated moderate discrimination and was well calibrated (C-statistic: 0.66, E/O: 1.01, P = .89). The PCE and D:A:D risk equations demonstrated good discrimination but were less well calibrated (C-statistics: 0.71 and 0.72 and E/O: 0.88 and 0.80, respectively; P < .001 for both), whereas SCORE performed poorly (C-statistic: 0.59, E/O: 1.72; P = .48). CONCLUSIONS Only the FRS accurately estimated risk of CVD events, while PCE and D:A:D underestimated risk. Although these models could potentially be used to rank US HIV-infected individuals at higher or lower risk for CVD, the models may fail to identify substantial numbers of HIV-infected persons with elevated CVD risk who could potentially benefit from additional medical treatment.
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Affiliation(s)
| | | | - Carl Armon
- Cerner Corporation, Kansas City, Missouri
| | - Frank J Palella
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Joan S Chmiel
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Fleetwood Loustalot
- Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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15
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Lipid Management Guidelines from the Departments of Veteran Affairs and Defense: A Critique. Am J Med 2016; 129:906-12. [PMID: 27154781 DOI: 10.1016/j.amjmed.2016.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 01/27/2023]
Abstract
In December 2014, the US Department of Veterans Affairs and Department of Defense (VA/DoD) published an independent clinical practice guideline for the management of dyslipidemia and cardiovascular disease risk, adding to the myriad of recently published guidelines on this topic. The VA/DoD guidelines differ from major US guidelines published by the American College of Cardiology/American Heart Association in 2013 in the following ways: recommending moderate-intensity statins for the majority of patients with statin indications regardless of atherosclerotic cardiovascular disease risk; advocating for limited on-treatment lipid monitoring; and deemphasizing ancillary data, such as coronary artery calcium testing, to improve atherosclerotic cardiovascular disease risk estimation. In the context of manifold treatment recommendations from numerous guideline committees, the VA/DoD recommendations may generate further confusion and mixed messages among healthcare providers about the optimal treatment of dyslipidemia. In this review, we critically appraise the VA/DoD recommendations with a focus on the evidence base for each area where the VA/DoD guidelines differ from the American College of Cardiology/American Heart Association guidelines. We also call for harmonization of lipid treatment guidelines to ensure high-quality and consistent care for patients with, and at risk for, atherosclerotic cardiovascular disease.
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16
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17
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Christensen CL, Wulff Helge J, Krasnik A, Kriegbaum M, Rasmussen LJ, Hickson ID, Liisberg KB, Oxlund B, Bruun B, Lau SR, Olsen MNA, Andersen JS, Heltberg AS, Kuhlman AB, Morville TH, Dohlmann TL, Larsen S, Dela F. LIFESTAT – Living with statins: An interdisciplinary project on the use of statins as a cholesterol-lowering treatment and for cardiovascular risk reduction. Scand J Public Health 2016; 44:534-9. [DOI: 10.1177/1403494816636304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Christa Lykke Christensen
- Section of Film, Media and Communication, Department of Media, Cognition and Communication, Faculty of the Humanities, University of Copenhagen, Denmark
| | - Jørn Wulff Helge
- Xlab, Center for Healthy Aging, Department of Biomedical Sciences, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Allan Krasnik
- Section of Health Services Research, Department of Public Health, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Margit Kriegbaum
- Section of Health Services Research, Department of Public Health, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Lene Juel Rasmussen
- Center for Healthy Aging, Department of Cellular and Molecular Medicine, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Ian D. Hickson
- Center for Healthy Aging, Department of Cellular and Molecular Medicine, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Kasper Bering Liisberg
- Section of Film, Media and Communication, Department of Media, Cognition and Communication, Faculty of the Humanities, University of Copenhagen, Denmark
| | - Bjarke Oxlund
- Department of Anthropology, Faculty of Social Sciences, University of Copenhagen, Denmark
| | - Birgitte Bruun
- Department of Anthropology, Faculty of Social Sciences, University of Copenhagen, Denmark
| | - Sofie Rosenlund Lau
- Department of Anthropology, Faculty of Social Sciences, University of Copenhagen, Denmark
| | - Maria Nathalie Angleys Olsen
- Center for Healthy Aging, Department of Cellular and Molecular Medicine, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - John Sahl Andersen
- Section of General Practice, Department of Public Health, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Andreas Søndergaard Heltberg
- Section of General Practice, Department of Public Health, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Anja Birk Kuhlman
- Xlab, Center for Healthy Aging, Department of Biomedical Sciences, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Thomas Hoffmann Morville
- Xlab, Center for Healthy Aging, Department of Biomedical Sciences, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Tine Lovsø Dohlmann
- Xlab, Center for Healthy Aging, Department of Biomedical Sciences, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Steen Larsen
- Xlab, Center for Healthy Aging, Department of Biomedical Sciences, Faculty of Health and Medicine, University of Copenhagen, Denmark
| | - Flemming Dela
- Xlab, Center for Healthy Aging, Department of Biomedical Sciences, Faculty of Health and Medicine, University of Copenhagen, Denmark
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