Riskard 2005. New tools for prediction of cardiovascular disease risk derived from Italian population studies

The Role of Visualization in Estimating Cardiovascular Disease Risk: Scoping Review

BACKGROUND

Supporting and understanding the health of patients with chronic diseases and cardiovascular disease (CVD) risk is often a major challenge. Health data are often used in providing feedback to patients, and visualization plays an important role in facilitating the interpretation and understanding of data and, thus, influencing patients' behavior. Visual analytics enable efficient analysis and understanding of large datasets in real time. Digital health technologies can promote healthy lifestyle choices and assist in estimating CVD risk.

OBJECTIVE

This review aims to present the most-used visualization techniques to estimate CVD risk.

METHODS

In this scoping review, we followed the Joanna Briggs Institute PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The search strategy involved searching databases, including PubMed, CINAHL Ultimate, MEDLINE, and Web of Science, and gray literature from Google Scholar. This review included English-language articles on digital health, mobile health, mobile apps, images, charts, and decision support systems for estimating CVD risk, as well as empirical studies, excluding irrelevant studies and commentaries, editorials, and systematic reviews.

RESULTS

We found 774 articles and screened them against the inclusion and exclusion criteria. The final scoping review included 17 studies that used different methodologies, including descriptive, quantitative, and population-based studies. Some prognostic models, such as the Framingham Risk Profile, World Health Organization and International Society of Hypertension risk prediction charts, Cardiovascular Risk Score, and a simplified Persian atherosclerotic CVD risk stratification, were simpler and did not require laboratory tests, whereas others, including the Joint British Societies recommendations on the prevention of CVD, Systematic Coronary Risk Evaluation, and Framingham-Registre Gironí del COR, were more complex and required laboratory testing-related results. The most frequently used prognostic risk factors were age, sex, and blood pressure (16/17, 94% of the studies); smoking status (14/17, 82%); diabetes status (11/17, 65%); family history (10/17, 59%); high-density lipoprotein and total cholesterol (9/17, 53%); and triglycerides and low-density lipoprotein cholesterol (6/17, 35%). The most frequently used visualization techniques in the studies were visual cues (10/17, 59%), followed by bar charts (5/17, 29%) and graphs (4/17, 24%).

CONCLUSIONS

On the basis of the scoping review, we found that visualization is very rarely included in the prognostic models themselves even though technology-based interventions improve health care worker performance, knowledge, motivation, and compliance by integrating machine learning and visual analytics into applications to identify and respond to estimation of CVD risk. Visualization aids in understanding risk factors and disease outcomes, improving bioinformatics and biomedicine. However, evidence on mobile health's effectiveness in improving CVD outcomes is limited.

Risk Models and Scores of Cardiovascular Disease in Patients with Diabetes Mellitus

Diabetes mellitus (DM) is an established risk factor for atherosclerotic cardiovascular disease (CVD), and patients with DM are at a two to four-fold higher cardiovascular risk, including myocardial infraction, unstable angina, stroke, and heart failure. All of the above have arisen interest in CVD preventive strategies by the use of non-invasive methods, such as risk scores. The most common approach is to consider DM as a CVD equivalent and, therefore, to treat patients with DM in a similar way to those who required secondary CVD prevention. However, this approach has been disputed as all patients with DM do not have the same risk for CVD, and since other potentially important factors within the context of DM, such as DM duration, presence of albuminuria, and comorbidities, should be taken into consideration. Thus, the second and third approach is the application of risk models that were either developed initially for the general population or designed specifically for patients with DM, respectively. This review summarizes the evidence and implications for clinical practice regarding these scores. Up to date, several models that can be applied to the diabetic population have been proposed. However, only a few meet the minimum requirement of adequate external validation. In addition, moderate discrimination and poor calibration, which might lead to inaccurate risk estimations in populations with different characteristics, have been reported. Therefore, future research is needed before recommending a specific risk model for universal clinical practice in the management of diabetes.

From classical to innovative clinical epidemiology: the 50 years' experience of the Brisighella Heart Study

INTRODUCTION

The Brisighella Heart Study (BHS) is a long-term, prospective, population-based longitudinal study on 2939 randomly selected residents of the town of Brisighella, Emilia-Romagna, Italy.

EVIDENCE ACQUISITION

At the enrollment time in 1972 no participant had any cardiovascular disease, 1491 participants were men and 1448 women, and the age span was 14 to 84 years.

EVIDENCE SYNTHESIS

The observational phase of the study contributed to the evidence of a strong pathophysiological association between hypercholesterolemia and hypertension. The interventional phase was one of the first examples of successful cardiovascular risk reduction obtained through a population-based educational intervention. Currently, the BHS staff is planning its 11th four-yearly population survey in 2022. Today, the study is moving from an epidemiological perspective to a translational approach, involving advanced biomolecular analyses, genetic tests, and functional vascular investigations.

CONCLUSIONS

This review aims to summarize the main findings of the first 50 years of BHS research and spot the latest developments and future perspectives of this remarkable Italian cardiovascular study.

A systematic review of the status and methodological considerations for estimating risk of first ever stroke in the general population

AIMS

The methodological quality of development, validation, and modification of those models have not been evaluated via a thoroughly literature review. This study aims to describe the overall status and evaluate the methodological quality of risk prediction models for stroke incidence in the general population.

METHODS

We searched the database of EMBASE and MEDLINE by the combination of subject words and key words to collect the research on stroke risk prediction model in the general population. The retrieval time was from the establishment of the database to September 2019. It should be mentioned that risk of bias for each model was assessed, and data on population characteristics and model performance was also extracted.

RESULTS

The search screened 11,386 peer-reviewed publications and 57 citation searching, of which 48 were included in the review, describing the development of 51 prediction models, 47 external validation models, and 12 modification models. Among 51 development models, the predicted outcome concentrated on fatal or non-fatal stroke (n = 37, 73%). Thirty-nine development models (76%) were without internal validation. C-statistic or AUC was adopted for discrimination in 80% models, and Hosmer-Lemeshow test (n = 25, 49%) was also performed for calibration. Twenty-six development models (53%) were externally validated, among which only 2 (8%) were validated by independent researchers. Risk prediction performance was improved when models were modified by adding novel risk factors, such as the internal carotid artery plaque and intima-media thickness.

CONCLUSION

Models for predicting stroke occurrence need further external validation, recalibration, or modification in different populations, to help interpret those models in the practice of stroke prevention.

Cardiometabolic risk prediction algorithms for young people with psychosis: a systematic review and exploratory analysis

OBJECTIVE

Cardiometabolic risk prediction algorithms are common in clinical practice. Young people with psychosis are at high risk for developing cardiometabolic disorders. We aimed to examine whether existing cardiometabolic risk prediction algorithms are suitable for young people with psychosis.

METHODS

We conducted a systematic review and narrative synthesis of studies reporting the development and validation of cardiometabolic risk prediction algorithms for general or psychiatric populations. Furthermore, we used data from 505 participants with or at risk of psychosis at age 18 years in the ALSPAC birth cohort, to explore the performance of three algorithms (QDiabetes, QRISK3 and PRIMROSE) highlighted as potentially suitable. We repeated analyses after artificially increasing participant age to the mean age of the original algorithm studies to examine the impact of age on predictive performance.

RESULTS

We screened 7820 results, including 110 studies. All algorithms were developed in relatively older participants, and most were at high risk of bias. Three studies (QDiabetes, QRISK3 and PRIMROSE) featured psychiatric predictors. Age was more strongly weighted than other risk factors in each algorithm. In our exploratory analysis, calibration plots for all three algorithms implied a consistent systematic underprediction of cardiometabolic risk in the younger sample. After increasing participant age, calibration plots were markedly improved.

CONCLUSION

Existing cardiometabolic risk prediction algorithms cannot be recommended for young people with or at risk of psychosis. Existing algorithms may underpredict risk in young people, even in the face of other high-risk features. Recalibration of existing algorithms or a new tailored algorithm for the population is required.

How the Seven Countries Study contributed to the launch and development of cardiovascular epidemiology in Italy. A historical perspective

The Italian research group of the Seven Countries Study of Cardiovascular Diseases (SCS), through the independent use of the national cohorts and data, had the lucky opportunity, starting in the early 1960, to launch the Italian research in epidemiology of cardiovascular diseases (CVD). In this way, the Italian Section of that international study became the first investigation with baseline measurements in various cohorts, subsequent re-examinations, systematic search for morbid events, and follow-up for mortality up to 50 years. A large number of scientific aspects has been tackled including estimates of morbidity and mortality rates, the association of risk factors with cardiovascular events and total mortality, the role of risk factor changes, the use of multivariable models, the role of lifestyle behavior, the determinants of all-cause mortality including risk factors rarely measured in other studies, the identification of characteristics of a condition called Heart Disease of Uncertain Etiology (HDUE), the production of predictive tools for practical use and several other issues. All this has been enhanced by the availability of extremely long follow-up data rarely found in other studies. Field work organization, measurement techniques, diagnostic criteria, data handling and computing had the limitations and difficulties typical of those times, the mid of last century, when CVD epidemiology was at its beginning. All this represented anyhow the start of CVD epidemiology research in the country and was the stimulus to the start of other studies and a valuable collaboration with some of them.

Management of the hypertensive patient with elevated heart rate: Statement of the Second Consensus Conference endorsed by the European Society of Hypertension

In June 2015, a panel of experts gathered in a consensus conference to plan updating recommendations on the management of the hypertensive patient with elevated heart rate (HR), previously released in 2006. The issues examined during that meeting and further discussed by the participants during the following months involved the assessment of HR, the relevance of HR as a cardiovascular risk factor, the definition of tachycardia and the treatment of the hypertensive patient with high HR. For the measurement of resting HR the panel experts recommended that scientific investigations focusing on HR should report information on length of resting period before measurement, information about temperature and environment, method of measurement, duration of measurement, number of readings, time interval between measurements, body position and type of observer. According to the panellists there is convincing evidence that HR is an important risk factor for cardiovascular disease and they suggest to routinely include HR measurement in the assessment of the hypertensive patient. Regarding the definition of tachycardia, the panellists acknowledged that in the absence of convincing data any threshold used to define tachycardia is arbitrary. Similarly, as there are no outcome studies of HR lowering in tachycardia hypertension, the panellists could not make practical therapeutic suggestions for the management of such patients. However, the experts remarked that absence of evidence does not mean evidence against the importance of tachycardia as a risk factor for cardiovascular disease and that long-term exposure to a potentially important risk factor may impair the patient's prognosis. The main aims of the present document are to alert researchers and physicians about the importance of measuring HR in hypertensive patients, and to stimulate research to clarify unresolved issues.

Cardiovascular Disease Risk Score: Results from the Filipino-American Women Cardiovascular Study

INTRODUCTION

Although cardiovascular disease (CVD) is a leading cause of morbidity and mortality of Filipino-Americans, conventional CVD risk calculators may not be accurate for this population. CVD risk scores of a group of Filipino-American women (FAW) were measured using the major risk calculators. Secondly, the sensitivity of the various calculators to obesity was determined.

METHODS

This is a cross-sectional descriptive study that enrolled 40-65-year-old FAW (n = 236), during a community-based health screening study. Ten-year CVD risk was calculated using the Framingham Risk Score (FRS), Reynolds Risk Score (RRS), and Atherosclerotic Cardiovascular Disease (ASCVD) calculators. The 30-year risk FRS and the lifetime ASCVD calculators were also determined.

RESULTS

Levels of predicted CVD risk varied as a function of the calculator. The 10-year ASCVD calculator classified 12 % of participants with ≥10 % risk, but the 10-year FRS and RRS calculators classified all participants with ≤10 % risk. The 30-year "Hard" Lipid and BMI FRS calculators classified 32 and 43 % of participants with high (≥20 %) risk, respectively, while 95 % of participants were classified with ≥20 % risk by the lifetime ASCVD calculator. The percent of participants with elevated CVD risk increased as a function of waist circumference for most risk score calculators.

CONCLUSIONS

Differences in risk score as a function of the risk score calculator indicate the need for outcome studies in this population. Increased waist circumference was associated with increased CVD risk scores underscoring the need for obesity control as a primary prevention of CVD in FAW.

The clinical performance of an office-based risk scoring system for fatal cardiovascular diseases in North-East of Iran

BACKGROUND

Cardiovascular diseases (CVD) are becoming major causes of death in developing countries. Risk scoring systems for CVD are needed to prioritize allocation of limited resources. Most of these risk score algorithms have been based on a long array of risk factors including blood markers of lipids. However, risk scoring systems that solely use office-based data, not including laboratory markers, may be advantageous. In the current analysis, we validated the office-based Framingham risk scoring system in Iran.

METHODS

The study used data from the Golestan Cohort in North-East of Iran. The following risk factors were used in the development of the risk scoring method: sex, age, body mass index, systolic blood pressure, hypertension treatment, current smoking, and diabetes. Cardiovascular risk functions for prediction of 10-year risk of fatal CVDs were developed.

RESULTS

A total of 46,674 participants free of CVD at baseline were included. Predictive value of estimated risks was examined. The resulting Area Under the ROC Curve (AUC) was 0.774 (95% CI: 0.762-0.787) in all participants, 0.772 (95% CI: 0.753-0.791) in women, and 0.763 (95% CI: 0.747-0.779) in men. AUC was higher in urban areas (0.790, 95% CI: 0.766-0.815). The predicted and observed risks of fatal CVD were similar in women. However, in men, predicted probabilities were higher than observed.

CONCLUSION

The AUC in the current study is comparable to results of previous studies while lipid profile was replaced by body mass index to develop an office-based scoring system. This scoring algorithm is capable of discriminating individuals at high risk versus low risk of fatal CVD.

Population health needs assessment and healthcare services use in a 3 years follow-up on administrative and clinical data: results from the Brisighella Heart Study

INTRODUCTION

A large number of epidemiological trials clearly show the impact of the main cardiovascular disease risk factors in term of hospitalization and related cost, but relatively less frequently if this reflect the health needs of a given population.

AIM

To develop a model for the health needs-assessment that will be applied to verify if and how the prevalence of some classical risk factors for cardiovascular disease predicts mortality and hospitalisation episodes at 3 years, and if it could express the health need of that population. The long-life clinical record of 1,704 subjects, recruited during the 2004 Brisighella Heart Study survey, has been monitored. We defined the health profile of these subjects at 2004 (based on clinical history, smoking and dietary habits, physical activity, drug use, anthropometric data, blood pressure, and hematological data) and then sampled data relative to their hospitalisations, mortality, and general medical assistance.

RESULTS

Our results shows that age over 65 years (OR 4.08; 95 % CI 2.74-6.08), hypertension (OR 3.44; 95 % CI 2.36-5.01) and hypercholesterolemia (OR 1.33; 95 % CI 0.92-1.94) increase the probability to get hospitalised. Furthermore, the burden of care was defined and computed for our sample. Vascular and respiratory diseases [Burden of health care (Bc) = 24.5 and 36.5, respectively] are the most costly DRGs which means that the biggest part of our resources directed to cardiovascular patients were provided for these diagnoses.

CONCLUSION

The application of the proposed model could help policy makers and researchers in directing resources and workforce in the treatment of cardiovascular diseases.

Assessment of cardiovascular disease risk in South asian populations

Although South Asian populations have high cardiovascular disease (CVD) burden in the world, their patterns of individual CVD risk factors have not been fully studied. None of the available algorithms/scores to assess CVD risk have originated from these populations. To explore the relevance of CVD risk scores for these populations, literature search and qualitative synthesis of available evidence were performed. South Asians usually have higher levels of both “classical” and nontraditional CVD risk factors and experience these at a younger age. There are marked variations in risk profiles between South Asian populations. More than 100 risk algorithms are currently available, with varying risk factors. However, no available algorithm has included all important risk factors that underlie CVD in these populations. The future challenge is either to appropriately calibrate current risk algorithms or ideally to develop new risk algorithms that include variables that provide an accurate estimate of CVD risk.

Gender difference in hepatic steatosis index and lipid accumulation product ability to predict incident metabolic syndrome in the historical cohort of the Brisighella Heart Study

Abstract Background: Nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome are strongly related from both an epidemiological and a pathological point of view. The main aim of our study was to evaluate if two validated indexes of NAFLD are able to predict the 4-year metabolic syndrome incidence in a large population sample of pharmacologically untreated subjects without metabolic syndrome, type 2 diabetes, history of alcohol abuse, or known liver diseases at the baseline.

METHODS

From the database of the Brisighella Heart Study, we selected a subsample of 824 pharmacologically untreated subjects (male, 401; female, 423) without metabolic syndrome, type 2 diabetes, alcohol abuse, or known liver diseases at the 2004 survey and revisited in 2008. The Hepatic Steatosis Index (HSI) and Lipid Accumulation Product (LAP) values were calculated for everyone to evaluate their predictive role for metabolic syndrome through a Cox-regression analysis adjusted by metabolic syndrome components.

RESULTS

We observed 46 new cases of metabolic syndrome (male, 25; female, 21) with a cumulative incidence of 5.6% (1.4% per year): 6.2% in men (1.5% per year), 4.9% in women (1.2% per year). In women, the 4-year metabolic syndrome predictors (R(2)=0.680) were age [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.12-1.15], HSI (OR 1.20, 95% CI 1.15-1.26), and lnLAP (OR 1.16, 95% CI 1.14-1.17), whereas in men they were (R(2)=0.554) age (OR 1.13, 95% CI 1.11-1.14) and lnLAP (OR 1.17, 95% CI 1.15-1.18).

CONCLUSION

HSI and LAP differently predict the 4-year incidence of metabolic syndrome. In women, both indexes can be considered significant predictors, whereas in men only LAP can be considered predictive.

Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Current US guideline statements regarding primary and secondary cardiovascular risk prediction and prevention use absolute risk estimates to identify patients who are at high risk for vascular disease events and who may benefit from specific preventive interventions. These guidelines do not explicitly include patients with stroke, however. This statement provides an overview of evidence and arguments supporting (1) the inclusion of patients with stroke, and atherosclerotic stroke in particular, among those considered to be at high absolute risk of cardiovascular disease and (2) the inclusion of stroke as part of the outcome cluster in risk prediction instruments for vascular disease.

METHODS AND RESULTS

Writing group members were nominated by the committee co-chairs on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee and the AHA Manuscript Oversight Committee. The writers used systematic literature reviews (covering the period from January 1980 to March 2010), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and, when appropriate, formulate recommendations using standard AHA criteria. All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive AHA internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. There are several reasons to consider stroke patients, and particularly patients with atherosclerotic stroke, among the groups of patients at high absolute risk of coronary and cardiovascular disease. First, evidence suggests that patients with ischemic stroke are at high absolute risk of fatal or nonfatal myocardial infarction or sudden death, approximating the ≥20% absolute risk over 10 years that has been used in some guidelines to define coronary risk equivalents. Second, inclusion of atherosclerotic stroke would be consistent with the reasons for inclusion of diabetes mellitus, peripheral vascular disease, chronic kidney disease, and other atherosclerotic disorders despite an absence of uniformity of evidence of elevated risks across all populations or patients. Third, the large-vessel atherosclerotic subtype of ischemic stroke shares pathophysiological mechanisms with these other disorders. Inclusion of stroke as a high-risk condition could result in an expansion of ≈10% in the number of patients considered to be at high risk. However, because of the heterogeneity of stroke, it is uncertain whether other stroke subtypes, including hemorrhagic and nonatherosclerotic ischemic stroke subtypes, should be considered to be at the same high levels of risk, and further research is needed. Inclusion of stroke with myocardial infarction and sudden death among the outcome cluster of cardiovascular events in risk prediction instruments, moreover, is appropriate because of the impact of stroke on morbidity and mortality, the similarity of many approaches to prevention of stroke and these other forms of vascular disease, and the importance of stroke relative to coronary disease in some subpopulations. Non-US guidelines often include stroke patients among others at high cardiovascular risk and include stroke as a relevant outcome along with cardiac end points.

CONCLUSIONS

Patients with atherosclerotic stroke should be included among those deemed to be at high risk (≥20% over 10 years) of further atherosclerotic coronary events. Inclusion of nonatherosclerotic stroke subtypes remains less certain. For the purposes of primary prevention, ischemic stroke should be included among cardiovascular disease outcomes in absolute risk assessment algorithms. The inclusion of atherosclerotic ischemic stroke as a high-risk condition and the inclusion of ischemic stroke more broadly as an outcome will likely have important implications for prevention of cardiovascular disease, because the number of patients considered to be at high risk would grow substantially.

Framingham risk prediction equations for incidence of cardiovascular disease using detailed measures for smoking

Current prediction models for risk of cardiovascular disease (CVD) incidence incorporate smoking as a dichotomous yes/no measure. However, the risk of CVD associated with smoking also varies with the intensity and duration of smoking and there is a strong association between time since quitting and the risk of disease onset. This study aims to develop improved risk prediction equations for CVD incidence incorporating intensity and duration of smoking and time since quitting.

The risk of developing a first CVD event was evaluated using a Cox’s model for participants in the Framingham offspring cohort who attended the fourth examination (1988–92) between the ages of 30 and 74 years and were free of CVD (n=3751). The full models based on the smoking variables and other risk factors, and reduced models based on the smoking variables and non-laboratory risk factors demonstrated good discrimination, calibration and global fit. The incorporation of both time since quitting among past smokers and pack-years among current smokers resulted in better predictive performance as compared to a dichotomous current/non-smoker measure and a current/quitter/never smoker measure. Compared to never smokers, the risk of CVD incidence increased with pack-years. Risk among those quitting more than five years prior to the baseline exam and within five years prior to the baseline exam were similar and twice as high as that of never smokers. A CVD risk equation incorporating the effects of pack-years and time since quitting provides an improved tool to quantify risk and guide preventive care.

The role of HDL cholesterol in metabolic syndrome predicting cardiovascular events. The Gubbio population study

BACKGROUND AND AIMS

Metabolic syndrome (MS) has recently been claimed to be an important new risk factor for the occurrence of coronary heart disease (CHD) and cardiovascular disease (CVD) events, although it is simply a combination of known risk factors used in a dichotomized fashion. The aims of this analysis were to explore the predictive role of MS for CHD and CVD events in a population study, in comparison with using the same factors in a continuous fashion, with special emphasis on HDL cholesterol.

METHODS AND RESULTS

In the second examination of the Gubbio population study from central Italy, 2650 cardiovascular disease-free men and women, aged 35-74 years around 1990, were examined and followed-up for 12 years. The classic risk factors (sex, age, systolic blood pressure, serum cholesterol and smoking habits) were studied as predictors of CHD and CVD events, alone and with the contribution of other factors (HDL cholesterol, blood glucose, serum triglycerides and waist circumference) included in the so-called MS, based on several multivariate models. MS was also tested after adjustment for other risk factors. MS produced a predictive significant relative risk of 1.67 for CHD events and 1.82 for CVD events, but considering its single risk factors, the only ones contributing to prediction were HDL cholesterol and systolic blood pressure. Dedicated analyses showed that MS does not add anything to the power of prediction beyond the role of the single risk factors treated in a continuous fashion, while the best predictive power is obtained using classic risk factors (sex, age, smoking habits, total cholesterol, systolic blood pressure) with the addition of HDL cholesterol.

CONCLUSIONS

The predictive power of MS is bound only to the presence of HDL cholesterol and blood pressure and does not add anything to using the same risk factor treated in a continuous fashion.

Psychosocial factors and metabolic parameters: is there any association in elderly people? The Massa Lombarda Project

OBJECTIVE

Several studies claim that psychophysical stress and depression contribute significantly to cardiovascular disease (CVD) development. The aim of our research is to discover and analyse a possible relationship between two psychosocial disorders (depression and perceived mental stress) and traditional cardiovascular risk markers.

METHODS

We selected 106 subjects (58 males and 48 females), mean age 79.5 +/- 3.8-years old, from the Massa Lombarda Project, an epidemiological study, including 7000 north Italian adult subjects. We carried out anamnesis, clinical and blood tests. Then, we administered the Perceived Stress Questionnaire (PSQ range score 0-1) and the Self-Rating Depression Scale (SRDS range score 50-70 Z), as validated instruments for depression and stress evaluation, which focus on the individual's subjective perception and emotional response. Statistical descriptive and inferential analyses of data collected were performed.

RESULTS

The multiple linear regression analysis showed a negative correlation between PSQ index score and uric acid, low-density lipoprotein cholesterol (LDL-c), body mass index (BMI), systolic and diastolic blood pressure values, a positive and statistically significant correlation between PSQ index score and triglycerides (p < 0.05). We found an inverse relationship between Zung SRDS score and LDL-c, uric acid, glucose waist circumference values, this correlation was significant only for uric acid (p < 0.01). Besides, a positive and significant correlation between Zung SRDS and triglycerides (p < 0.05) was observed.

CONCLUSION

We suppose that psycho-emotional stress and depression disorder, often diagnosed in elderly people, may influence different metabolic parameters (triglycerides, uric acid and BMI) that are involved in the complex process of metabolic syndrome.

Prevention and treatment of nonalcoholic fatty liver disease

A better knowledge of the biochemical mechanisms implicated in the development and progression of nonalcoholic fatty liver disease, linking fatty liver to insulin resistance and the metabolic syndrome, has shifted the goal of treatment from a mere clearing of fat from the liver to a systematic treatment of metabolic risk factors for fatty liver. Any attempt to modify the "unhealthy" habits responsible for fatty liver requires an integrated approach, based on the cognitive theory of behaviour by a multidisciplinary team including physicians, psychologists, dieticians and physical exercise experts, and recent data demonstrate that this is feasible and effective. Whenever this goal is not attained, a treatment based on insulin-sensitizers remains the best option, to simultaneously tackle all metabolic alterations of the metabolic syndrome. However, in individual patients, both raised blood pressure and dyslipidemia need to be controlled, in order to reduce cardiovascular risk. In these areas, any attempt should be made to use of drugs less likely to induce a deterioration of glucose control. It remains to be determined whether these treatments are able to modify the natural history of nonalcoholic fatty liver disease in the long term.

Common genetic variants on chromosome 9p21 are associated with myocardial infarction and type 2 diabetes in an Italian population

Background

A genomic region on chromosome 9p21 has been identified as closely associated with increased susceptibility to coronary artery disease (CAD) and to type 2 diabetes (T2D) although the evidence suggests that the genetic variants within chromosome 9p21 that contribute to CAD are different from those that contribute to T2D.

We carried out an association case-control study in an Italian population to test the association between two single nucleotide polymorphisms (SNPs) on the 9p21 locus, rs2891168 and rs10811661, previously reported by the PROCARDIS study, and respectively myocardial infarction (MI) and T2D. Our aim was to confirm the previous findings on a larger sample and to verify the independence of their susceptibility effects: rs2891168 associated with MI but not with T2D and rs10811661 associated with T2D but not with MI.

Methods

Genomic DNA samples of 2407 Italians with T2D (602 patients), who had had a recent MI (600), or had both diseases (600) and healthy controls (605) were genotyped for the two SNPs. The genotypes were determined by allelic discrimination using a fluorescent-based TaqMan assay.

Results

SNP rs2891168 was associated with MI, but not with T2D and the G-allele odds ratio (OR) was 1.20 (95% CI 1.02-1.41); SNP rs10811661 was associated with T2D, but not with MI, and the T-allele OR was 1.27 (95% CI 1.04-1.55). ORs estimates from the present study and the PROCARDIS study were pooled and confirmed the previous findings, with greater precision.

Conclusions

Our replication study showed that rs2891168 and rs10811661 are independently associated respectively with MI and T2D in an Italian population. Pooling our results with those reported by the PROCARDIS group, we also obtained a significant result of association with diabetes for rs10811661 in the European population.

Different Effect of Psyllium and Guar Dietary Supplementation on Blood Pressure Control in Hypertensive Overweight Patients: A Six-Month, Randomized Clinical Trial

In the setting of a six-month, open-label clinical trial, 141 consecutively enrolled, hypertensive, overweight patients were randomized to the oral ingestion of psyllium powder or guar gum 3.5 gr t.i.d., to be taken 20 min before the main two meals, or to standard diet. Both fibers improved significantly BMI, FPG, FPI, HOMA Index, HbA1c, LDL-C, and ApoB. Psyllium supplementation only exerted a significant improvement in plasma TG concentration, in SBP and DBP. In our study, six-month supplementation with psyllium fiber, but not with guar fiber nor standard diet, appears to significantly reduce both SBP and DBP in hypertensive overweight subjects.

Predicting the 30-year risk of cardiovascular disease: the framingham heart study

BACKGROUND

Present cardiovascular disease (CVD) risk prediction algorithms were developed for a < or =10-year follow up period. Clustering of risk factors at younger ages and increasing life expectancy suggest the need for longer-term risk prediction tools.

METHODS AND RESULTS

We prospectively followed 4506 participants (2333 women) of the Framingham Offspring cohort aged 20 to 59 years and free of CVD and cancer at baseline examination in 1971-1974 for the development of "hard" CVD events (coronary death, myocardial infarction, stroke). We used a modified Cox model that allows adjustment for competing risk of noncardiovascular death to construct a prediction algorithm for 30-year risk of hard CVD. Cross-validated survival C statistic and calibration chi2 were used to assess model performance. The 30-year hard CVD event rates adjusted for the competing risk of death were 7.6% for women and 18.3% for men. Standard risk factors (male sex, systolic blood pressure, antihypertensive treatment, total and high-density lipoprotein cholesterol, smoking, and diabetes mellitus), measured at baseline, were significantly related to the incidence of hard CVD and remained significant when updated regularly on follow-up. Body mass index was associated positively with 30-year risk of hard CVD only in models that did not update risk factors. Model performance was excellent as indicated by cross-validated discrimination C=0.803 and calibration chi2=4.25 (P=0.894). In contrast, 30-year risk predictions based on different applications of 10-year functions proved inadequate.

CONCLUSIONS

Standard risk factors remain strong predictors of hard CVD over extended follow-up. Thirty-year risk prediction functions offer additional risk burden information that complements that of 10-year functions.

Survey of cardiovascular risk factors in overweight and obese patients (SCOOP study) six-month changes in risk factor levels and cardiovascular risk

BACKGROUND

Obesity is considered a major threat to health worldwide, and its treatment is difficult. The SCOOP project is aimed at describing the effects of treating obesity in everyday clinical practice, following a standard protocol of weight reduction.

METHODS

A total of 2472 obese or overweight men and women (with a body mass index of 27 units or more), aged between 35 and 74, were enrolled in different clinical facilities. Treatment included a 25% average reduction in caloric intake and a recommendation to take a brisk walk for at least 150 min per week. After 6 months, a second survey was then carried out.

RESULTS

At the entry examination, patients exhibited high levels of most cardiovascular risk factors and estimated cardiovascular risks, and a high prevalence of cardiovascular diseases (14.1% in men; 6.3% in women), diabetes (30.5% in men; 25.2% in women) and metabolic syndrome (25.6% in men; 22.8% in women). After 6 months, 69% of all enrolled patients reported for a final examination. Levels of all cardiovascular risk factors were significantly reduced, including estimated cardiovascular risks (-20.4% in men and -12.6% in women). A targeted 10% reduction in body weight was achieved by 19% of patients. Changes in weight and cardiovascular risk factors were highly correlated with the self-reported compliance to prescriptions, and graded with the observed weight reduction. Benefits should be lowered by 30% if it is assumed that the patients who did not show up at the follow-up did not change their characteristics.

CONCLUSION

Short term positive effects of treatment of obesity can be obtained in everyday clinical practice using a simple protocol.

Risk charts illustrating the 10-year risk of stroke among residents of Japanese rural communities: the JMS Cohort Study

Background

Risk charts are used to estimate the risk of cardiovascular diseases; however, most have been developed in Western countries. In Japan, currently available risk charts are based on mortality data. Using data on cardiovascular disease incidence from the JMS Cohort Study, we developed charts that illustrated the risk of stroke.

Methods and Results

The JMS Cohort Study is a community-based cohort study of cardiovascular disease. Baseline data were obtained between 1992 and 1995. In the present analysis, the participants were 12 276 subjects without a history of stroke; the follow-up period was 10.7 years. Color-coded risk charts were created by using Cox’s proportional hazards models to calculate 10-year absolute risks associated with sex, age, smoking status, diabetes status, and systolic blood pressure. The risks of stroke and cerebral infarction rose as age and systolic blood pressure increased. Although the risk of cerebral hemorrhage were generally lower than that of cerebral infarction, the patterns of association with risk factors were similar.

Conclusion

These risk charts should prove useful for clinicians and other health professionals who are required to estimate an individual’s risk for stroke.

General cardiovascular risk profile for use in primary care: the Framingham Heart Study

BACKGROUND

Separate multivariable risk algorithms are commonly used to assess risk of specific atherosclerotic cardiovascular disease (CVD) events, ie, coronary heart disease, cerebrovascular disease, peripheral vascular disease, and heart failure. The present report presents a single multivariable risk function that predicts risk of developing all CVD and of its constituents.

METHODS AND RESULTS

We used Cox proportional-hazards regression to evaluate the risk of developing a first CVD event in 8491 Framingham study participants (mean age, 49 years; 4522 women) who attended a routine examination between 30 and 74 years of age and were free of CVD. Sex-specific multivariable risk functions ("general CVD" algorithms) were derived that incorporated age, total and high-density lipoprotein cholesterol, systolic blood pressure, treatment for hypertension, smoking, and diabetes status. We assessed the performance of the general CVD algorithms for predicting individual CVD events (coronary heart disease, stroke, peripheral artery disease, or heart failure). Over 12 years of follow-up, 1174 participants (456 women) developed a first CVD event. All traditional risk factors evaluated predicted CVD risk (multivariable-adjusted P<0.0001). The general CVD algorithm demonstrated good discrimination (C statistic, 0.763 [men] and 0.793 [women]) and calibration. Simple adjustments to the general CVD risk algorithms allowed estimation of the risks of each CVD component. Two simple risk scores are presented, 1 based on all traditional risk factors and the other based on non-laboratory-based predictors.

CONCLUSIONS

A sex-specific multivariable risk factor algorithm can be conveniently used to assess general CVD risk and risk of individual CVD events (coronary, cerebrovascular, and peripheral arterial disease and heart failure). The estimated absolute CVD event rates can be used to quantify risk and to guide preventive care.

Can non-physician health-care workers assess and manage cardiovascular risk in primary care?

OBJECTIVE

To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs) in typical primary health-care settings.

METHODS

Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate logit regression.

FINDINGS

Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant.

CONCLUSION

Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care.

Knowledge of cardiovascular risk factors and awareness of non-pharmacological approach for risk prevention in young survivors of acute myocardial infarction. The cardiovascular risk prevention project "Help Your Heart Stay Young"

BACKGROUND AND AIMS

Knowledge of cardiovascular disease (CVD) risk factors in young patients who experienced myocardial infarction (MI) is poorly described.

METHODS AND RESULTS

Knowledge of traditional CVD risk factors, non-fatal cardiovascular events and of non-pharmacological factors able to reduce CVD risk and education level were evaluated by questionnaires in subjects who visited their family doctors. Sixty-one participants with history of MI in age <50 years (MI+) were compared with 3749 subjects with age <50 years, from the same population source, but without history of MI (MI-). MI+ were more frequently men (p<0.01), did not have significantly higher prevalences of family history of CVD, diabetes and hypertension. MI+ individuals reported previous non-fatal stroke (13% vs. 0.5%, p<0.001), overweight, diabetes, and hypercholesterolemia (all p<0.001) more frequently than controls, whereas prevalence of arterial hypertension, smoking habit and physical inactivity did not differ between the two groups; MI+ and MI- individuals did not differ in terms of the proportion of those who were unaware of being hypertensive, diabetic or hypercholesterolemic. MI+ participants reported more frequently lower education level than controls (p<0.05). Knowledge of non-pharmacological approach for CVD risk reduction was similar in MI+ and MI-. In a logistic multivariate analysis, male gender (adjusted odds ratio=5.8) and high cholesterol level (adjusted odds ratio 2.8, both p<0.01) were independent correlates of MI+. CVD risk factors distribution was similar between participants with juvenile MI+ and MI in age >or=50 years (n=167) extracted from the same population source; however, stroke was reported more frequently in juvenile MI+ than in those who had MI at age >or=50 years/old (13% vs. 4%, p<0.01).

CONCLUSIONS

Juvenile non-fatal MI was associated with metabolic CVD risk factors, with higher cerebrovascular co-morbidity and lower education level.

Comparison of methods to identify individuals at increased risk of cardiovascular disease in Italian cohorts

BACKGROUND AND AIMS

Guidelines for the primary prevention of cardiovascular disease recommend the use of risk-assessment methods to identify high risk patients who can benefit from lifestyle changes and/or drug treatment. Although all these risk-prediction methods are based on the same principle, they produce different risk estimates. The aim of this study was to compare the most recent and widely used cardiovascular risk-prediction methods and the respective guidelines when applied to Italian cohorts.

METHODS AND RESULTS

Seven different risk-assessment methods were applied to two groups of subjects, 536 healthy individuals and 426 diabetic patients. Sensitivity and specificity of Framingham-based risk-assessment methods were calculated using the Framingham full equation as the reference standard. The extent of concordance among the different risk-assessment methods was determined by kappa test. By using NCEP-ATPIII risk calculator, modified Sheffield tables, Joint European Societies charts, Joint British Societies charts, Italian CUORE Project charts, European SCORE charts and New Zealand National Heart Foundation charts in the group of 536 healthy subjects, lipid-lowering treatment would be recommended in 17.5%, 12.7%, 12.1%, 8.6%, 5.0%, 4.7%, and 1.1% subjects, respectively. By using the same risk-assessment methods in the group of 426 diabetic patients, treatment would be recommended for 100%, 82.9%, 66.9%, 77.7%, 43.0%, 74.9%, and 47.4% patients, respectively. The Joint British charts and the modified Sheffield tables showed the closest agreement with the reference standard.

CONCLUSIONS

Our study confirms that the use of different risk-assessment methods in clinical practice can substantially change risk estimation and consequently statin prescription rate. The Framingham-based risk-assessment methods and particularly the NCEP-ATPIII guidelines select for lipid-lowering treatment a higher number of subjects than those identified according to European and Italian recommendations.

Risk scoring in the assessment of cardiovascular risk

PURPOSE OF REVIEW

Cardiovascular risk scoring is incorporated in guidelines and recommended for targeting preventive treatment. Evidence is required on the most appropriate method, its accuracy in a given population, and its effectiveness in favourably influencing clinical behaviour and health outcomes.

RECENT FINDINGS

Recent risk scores address inaccuracies that arise when methods are transferred between populations, and specific methods and recalibrations are described for use in low-risk populations. Ethnic and social differences in risk are also recognized in the context of cardiovascular risk scoring. More sensitive measures of known risk factors and numerous emerging risk factors are reported and new statistical methods and sources of data suggested. Little emphasis has been placed on evaluation of the clinical effectiveness of cardiovascular risk scores. Education in cardiovascular risk assessment may help improve uptake of methods by healthcare professionals.

SUMMARY

Numerous risk scoring methods are available to the healthcare professional but use is patchy. Accuracy varies between populations and methods have been developed to compensate for some of this variability. If risk scoring methods are to be widely used in general practice, evidence is required on both the accuracy of methods in appropriate populations and their effectiveness in improving health outcomes.