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

Cardiovascular risk of the general population assessed through SCORE and CUORE charts: an extensive survey by the General Practitioners from Abruzzo, Italy

BACKGROUND

Current European guidelines for coronary heart diseases (CHD) prevention recommend to base any intervention on individual's global risk evaluation. An extensive survey was conducted to evaluate the ten-year CHD risk of the general population of Abruzzo, Italy.

METHODS

In 2007, all regional general practitioners (GPs) received educational intervention; software allowing immediate risk calculation and data transmission to the Region; economic incentives for participation.

RESULTS

Overall, 78.6% of all GPs (n=873) assessed and reported the CHD risk of 155,900 individuals (31.6% of the population aged 40-69 years with no history of CHD). Ninety seven GPs sent data on >90% of their patients (n=47,120), and analyses were based upon this restricted sample with lower potential for selection bias. According to Italian CUORE risk-scoring chart, the estimated prevalence of high-risk (≥20%) subjects for CHD was 5.0% (males=8.5%; females=1.6%). According to European SCORE chart, the estimated prevalence of subjects at high risk (≥5%) for fatal CHD was 8.6% (males=15.0%; females=2.3%). The agreement between SCORE and CUORE methods was moderate (kappa=0.51).

CONCLUSIONS

Beyond epidemiological significance, the composite approach of the survey represents a promising intervention of CHD prevention, as almost one third of the target population was evaluated by GPs with subsequent implications for clinical practice. Among the key reasons for the high participation rate, educational interventions and economic incentives played a role, but software characteristics may have been crucial. Because no individual aged 40-49 years was considered at high risk using both CUORE and SCORE charts, their widespread use in such age class deserves discussion.

A novel programme to evaluate and communicate 10-year risk of CHD reduces predicted risk and improves patients' modifiable risk factor profile

AIMS

We assessed whether a novel programme to evaluate/communicate predicted coronary heart disease (CHD) risk could lower patients' predicted Framingham CHD risk vs. usual care.

METHODS

The Risk Evaluation and Communication Health Outcomes and Utilization Trial was a prospective, controlled, cluster-randomised trial in nine European countries, among patients at moderate cardiovascular risk. Following baseline assessments, physicians in the intervention group calculated patients' predicted CHD risk and were instructed to advise patients according to a risk evaluation/communication programme. Usual care physicians did not calculate patients' risk and provided usual care only. The primary end-point was Framingham 10-year CHD risk at 6 months with intervention vs. usual care.

RESULTS

Of 1103 patients across 100 sites, 524 patients receiving intervention, and 461 receiving usual care, were analysed for efficacy. After 6 months, mean predicted risks were 12.5% with intervention, and 13.7% with usual care [odds ratio = 0.896; p = 0.001, adjusted for risk at baseline (17.2% intervention; 16.9% usual care) and other covariates]. The proportion of patients achieving both blood pressure and low-density lipoprotein cholesterol targets was significantly higher with intervention (25.4%) than usual care (14.1%; p < 0.001), and 29.3% of smokers in the intervention group quit smoking vs. 21.4% of those receiving usual care (p = 0.04).

CONCLUSIONS

A physician-implemented CHD risk evaluation/communication programme improved patients' modifiable risk factor profile, and lowered predicted CHD risk compared with usual care. By combining this strategy with more intensive treatment to reduce residual modifiable risk, we believe that substantial improvements in cardiovascular disease prevention could be achieved in clinical practice.

Reducing coronary risk by raising HDL-cholesterol: risk modelling the addition of nicotinic acid to existing therapy

BACKGROUND AND OBJECTIVES

Reduction in total cholesterol (TC) and LDL-cholesterol (LDL-C) forms one of the principal objectives of most cardiovascular secondary prevention strategies. Many patients being treated with statins, however, have significant residual dyslipidaemia, with many having suboptimal HDL-cholesterol (HDL-C) levels. The addition of nicotinic acid to a statin has been shown to improve this profile, although clinical outcome evidence is currently lacking. This study set out to model the impact of nicotinic acid therapy on cardiovascular risk in these patients, based on Framingham risk assessments on a cohort of patients drawn from UK general practitioner records.

METHODS

Cardiovascular risk profiles were extracted from a research database of 602,222 patients from 98 UK general practices. 23 262 statin-treated patients with established cardiovascular disease or diabetes were identified and their 4-year Framingham risk was estimated. Patients who had either TC or HDL-C outside the desirable range then had their lipid profile adjusted in accordance with the likely performance of nicotinic acid, and the Framingham risk was then re-assessed.

RESULTS

Baseline 4-year coronary risk in the group as a whole was 11.5% (95%CI: 11.4-11.6). After adjustment of the lipid profile, this was reduced to 9.7% (95%CI: 9.6-9.8), a reduction in risk of 15.9% (95%CI: 15.1-16.6). When modelling was limited to those with diabetes or an abnormal treated lipid profile, the magnitude of change was increased to 23-29% depending on sex and subgroup.

CONCLUSIONS

Risk factor modelling suggests that raising HDL-C levels using nicotinic acid in statin-treated patients is likely to yield significant incremental clinical benefits. The results of clinical trials currently under way are awaited with interest.

Cardiovascular risk score change in HIV-1-infected patients switched to an atazanavir-based combination antiretroviral regimen

BACKGROUND

We aimed to establish whether the limited impact of atazanavir on the plasma lipid profile could translate into a reduction in the predicted cardiovascular risk in antiretroviral (ARV)-experienced patients switching to an atazanavir-containing regimen.

METHODS

HIV-1-infected treatment-experienced patients, switched to atazanavir for whatever reason and without prior major cardiovascular events, were selected and followed for at least 1 month. An individual cardiovascular risk score (10-year risk of major cardiovascular events) based on validated events and measurable risk factors in Italian cardiovascular cohorts was calculated using software available online.

RESULTS

A total of 197 patients were selected for inclusion in the study. After switching to atazanavir, the mean changes from pre-switch to last available measurement were -6.5% (P<0.001) for total cholesterol, -1.7% (P=0.029) for high-density lipoprotein (HDL) cholesterol, -11.3% (P<0.001) for non-HDL cholesterol and -8.6% (P<0.001) for triglycerides. The crude cardiovascular risk score was reduced from 3.43 to 3.38% (P=0.51); the analysis normalized by age showed a reduction from 3.43 to 3.14% (P<0.001). Subsets of patients with high baseline total cholesterol or triglycerides showed more marked reductions.

CONCLUSIONS

A treatment switch to atazanavir caused significant reductions in plasma lipids and a modest but significant reduction in the normalized-for-age cardiovascular risk score. Efforts should be made to concomitantly reduce the other preventable cardiovascular risk factors.