Real-life evaluation of European and American high-risk strategies for primary prevention of cardiovascular disease in patients with first myocardial infarction

Cardiovascular prevention: Frontiers in lipid guidelines

Cardiovascular disease (CVD) remains one of the principal causes of morbidity and mortality in the world. International guidelines are being updated to take into account new evidence and improved health economics as drug patents expire. Recent studies have investigated the best lipid fractions to predict CVD, suggested additional CVD risk factors and a potential role for novel biomarkers while big data approaches have allowed improvements to be made to CVD risk calculators. The increasing availability of next generation sequencing is allowing systematic efforts to be made to detect monogenic familial hypercholesterolaemia.Previous trials have validated the low-density lipoprotein cholesterol (LDL-C) hypothesis of atherosclerosis. Statins now form part of universal treatment advice for CVD and trial data on ezetimibe also suggests it has a place in the treatment pathway. New data has been published on novel lipid-lowering therapies such as proprotein convertase subtilisin kexin 9 inhibitors but the role of these expensive drugs has yet to be fully settled and a diversity of approaches exists between guidelines.The role of lipid fractions outside LDL-C is unclear. There will be challenges in incorporating new non-linear data on omega-3 fatty acids that not only affect triglycerides but more directly CVD.

Negative Risk Markers for Cardiovascular Events in the Elderly

BACKGROUND

Cardiovascular risk increases dramatically with age, leading to nearly universal risk-based statin eligibility in the elderly population. To limit overtreatment, elderly individuals at truly low risk need to be identified.

OBJECTIVES

Discovering "negative" risk markers able to identify elderly individuals at low short-term risk for coronary heart disease and cardiovascular disease.

METHODS

In 5,805 BioImage participants (mean age 69 years; median follow-up 2.7 years), the authors evaluated 13 candidate markers: coronary artery calcium (CAC) = 0, CAC ≤10, no carotid plaque, no family history, normal ankle-brachial index, test result <25th percentile (carotid intima-media thickness, apolipoprotein B, galectin-3, high-sensitivity C-reactive protein, lipoprotein(a), N-terminal pro-B-type natriuretic peptide, and transferrin), and apolipoprotein A1 >75th percentile. Negative risk marker performance was compared using patient-specific diagnostic likelihood ratio (DLR) and binary net reclassification index (NRI).

RESULTS

CAC = 0 and CAC ≤10 were the strongest negative risk markers with mean DLRs of 0.20 and 0.20 for coronary heart disease (i.e., ≈80% lower risk than expected from traditional risk factor assessment) and 0.41 and 0.48 for cardiovascular disease, respectively, followed by galectin-3 <25th percentile (DLR 0.44 and 0.43, respectively) and absence of carotid plaque (DLR 0.39 and 0.65, respectively). Results obtained by other candidate markers were less impressive. Accurate downward risk reclassification across the Class I statin-eligibility threshold defined by the American College of Cardiology/American Heart Association was largest for CAC = 0 (NRI 0.23) and CAC ≤10 (NRI 0.28), followed by galectin-3 <25th percentile (NRI 0.14) and absence of carotid plaque (NRI 0.08).

CONCLUSIONS

Elderly individuals with CAC = 0, CAC ≤10, low galectin-3, or no carotid plaque had remarkable low cardiovascular risk, calling into question the appropriateness of a treat-all approach in the elderly population.

Lifetime cardiovascular risk is associated with a multimarker score of systemic oxidative status in young adults independently of traditional risk factors

Cardiovascular risk (CVR) tends to be estimated in the short-term, which underestimates lifetime (LT)-CVR of young subjects. We determined whether LT-CVR is associated with a multimarker score of oxidative status in young adults and whether this association is independent of traditional CVR factors. Seventy-two young adults were stratified into: (1) low or (2) high LT-CVR, and (3) stable coronary artery disease (SCAD). CVR was estimated with QRisk and atherosclerotic CV disease (ASCVD) risk estimators, or second manifestations of arterial disease (SMART). Risk score. oxidative damage was determined by measuring carbonyls, oxidized LDL (oxLDL), 8-hydroxy-2'-deoxyguanosine (8-OHdG), and xanthine oxidase activity. Antioxidant defence was determined by total antioxidant capacity (TAC), catalase (CAT) activity and superoxide dismutase (SOD) activity. Multimarker scores of systemic oxidative damage (OxyScore) and antioxidant defence (AntioxyScore) were computed as standardized variables. Subjects with high LT-CVR had significantly higher levels of oxLDL, 8-OHdG, TAC, and CAT activity than subjects with low LT-CVR or with SCAD. QRisk and ASCVD estimators correlated positively with oxLDL, TAC, and CAT activity, while SMART Risk Score correlated with carbonyls and SOD activity. OxyScore and AntioxyScore were significantly higher in subjects with high LT-CVR than with low LT-CVR or with SCAD. OxyScore, but not AntioxyScore, was associated with LT-CVR independently of each traditional CVR factor. This study for the first time demonstrates a positive association between oxidative stress and the risk of first and recurrent CV events in young adults.

Comparing Strategies for Lipid Lowering in Argentina: An Analysis from the CVD Policy Model-Argentina

INTRODUCTION

In Argentina, the national guidelines for lipid control emphasize the use of relatively inexpensive low- or moderate-potency statins by patients at high risk (>20 %) of a cardiovascular event. The objective of this study was to compare the impact and costs of the current national CVD prevention guidelines with regard to morbidity and mortality in Argentina with the impact and costs of three strategies that incorporate high-potency statins.

METHODS

We used the CVD Policy Model-Argentina to model the proposed interventions. This model is a national-scale, state-transition (Markov) computer simulation model of the CVD incidence, prevalence, mortality, and costs in adults 35-84 years of age. We modeled three scenarios: scenario 1 lowers the risk threshold for treatment to >10 % according the Framingham Risk Score (FRS); scenario 2 intensifies statin potency under current treatment thresholds; and scenario 3 combines both scenarios by lowering the treatment threshold to ≥10 % FRS and intensifying statin potency.

RESULTS

Scenario 1 would translate into 1400 fewer MIs and 500 fewer CHD deaths every year, a 3 % and 2 % reduction, respectively. Scenario 2 would lead to 2000 fewer MIs and 1000 fewer CHD deaths every year. Scenario 3 would result in the greatest reduction in MIs and CHD deaths, with 3400 fewer MIs and 1400 fewer CHD deaths every year, which translates to a 7 % and 6 % reduction, respectively. All scenarios were cost-effective if the cost of a high-potency statin pill was under US$0.25.

CONCLUSION

Incorporating those individuals with greater than 10 % cardiovascular risk and the use of high-potency statins into Argentina's national lipid guidelines could result in fewer CHD deaths and events at a reasonable cost.

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Estimating Longitudinal Risks and Benefits From Cardiovascular Preventive Therapies Among Medicare Patients: The Million Hearts Longitudinal ASCVD Risk Assessment Tool: A Special Report From the American Heart Association and American College of Cardiology

The Million Hearts Initiative has a goal of preventing 1 million heart attacks and strokes-the leading causes of mortality-through several public health and healthcare strategies by 2017. The American Heart Association and American College of Cardiology support the program. The Cardiovascular Risk Reduction Model was developed by Million Hearts and the Center for Medicare & Medicaid Services as a strategy to assess a value-based payment approach toward reduction in 10-year predicted risk of atherosclerotic cardiovascular disease (ASCVD) by implementing cardiovascular preventive strategies to manage the "ABCS" (aspirin therapy in appropriate patients, blood pressure control, cholesterol management, and smoking cessation). The purpose of this special report is to describe the development and intended use of the Million Hearts Longitudinal ASCVD Risk Assessment Tool. The Million Hearts Tool reinforces and builds on the "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" by allowing clinicians to estimate baseline and updated 10-year ASCVD risk estimates for primary prevention patients adhering to the appropriate ABCS over time, alone or in combination. The tool provides updated risk estimates based on evidence from high-quality systematic reviews and meta-analyses of the ABCS therapies. This novel approach to personalized estimation of benefits from risk-reducing therapies in primary prevention may help target therapies to those in whom they will provide the greatest benefit, and serves as the basis for a Center for Medicare & Medicaid Services program designed to evaluate the Million Hearts Cardiovascular Risk Reduction Model.

Extensive carotid atherosclerosis and the diagnostic accuracy of coronary risk calculators

Preventive therapy in primary care is guided by risk thresholds for future cardiovascular events. We aimed to assess whether the sensitivity of various risk calculators for the detection of subclinical carotid atherosclerosis (TPA80) could be improved by lowering risk thresholds in younger age groups. We compared sensitivity, specificity, and discriminatory performance of SCORE, SCORE-HDL, PROCAM, AGLA, FRAM and PCE coronary risk calculators to detect total plaque area > 80 mm2 (TPA80), a coronary risk equivalent, in age groups 40–55, 56–65, 66–75 from Germany (DE, N = 2942) and Switzerland (CH, N = 2202) during the years 2002 to 2016. All calculators showed good to moderate discriminatory performance to detect TPA80 with AUC ranging from 0.74 (CH-AGLA) to 0.87 (DE- SCORE), but the sensitivity of high risk risk thresholds varied widely from 39% for DE-FRAM-CVD to 5% for CH-AGLA. Lowering of the risk threshold increased sensitivity substantially at the expense of minor losses in specificity, but the sensitivity generally remained < 45% at the 90% specificity threshold.

Current risk thresholds of American and European coronary risk calculators have a low sensitivity to detect TPA80 in younger individuals.

•

Low sensitivity of European and American risk calculators in two independent populations

•

Relatively high prevalence of advanced carotid atherosclerosis in people aged 40–65

•

New thresholds for intermediate or high risk in younger subjects

Comparison of different cardiovascular risk score calculators for cardiovascular risk prediction and guideline recommended statin uses

Objective

The accuracy of various 10-year cardiovascular disease (CVD) risk calculators in Indians may not be the same as in other populations. Present study was conducted to compare the various calculators for CVD risk assessment and statin eligibility according to different guidelines.

Methods

Consecutive 1110 patients who presented after their first myocardial infarction were included. Their CVD risk was calculated using Framingham Risk score- Coronary heart disease (FRS-CHD), Framingham Risk Score- Cardiovascular Disease (FRS-CVD), QRISK2, Joint British Society risk calculator 3 (JBS3), American College of Cardiology/American Heart Association (ACC/AHA), atherosclerotic cardiovascular disease (ASCVD) and WHO risk charts, assuming that they had presented one day before cardiac event for risk assessment. Eligibility for statin uses was also looked into using ACC/AHA, NICE and Canadian guidelines.

Results

FRS-CVD risk assessment model has performed the best as it could identify the highest number of patients (51.9%) to be at high CVD risk while WHO and ASCVD calculators have performed the worst (only 16.2% and 28.3% patients respectively were stratified into high CVD risk) considering 20% as cut off for high risk definition. QRISK2, JBS3 and FRS-CHD have performed intermediately. Using NICE, ACC/AHA and Canadian guidelines; 76%, 69% and 44.6% patients respectively were found to be eligible for statin use.

Conclusion

FRS-CVD appears to be the most useful for CVD risk assessment in Indians, but the difference may be because FRS-CVD estimates risk for several additional outcomes as compared with other risk scores. For statin eligibility, however, NICE guideline use is the most appropriate.

Survival Benefits of Statins for Primary Prevention: A Cohort Study

OBJECTIVES

Estimate the effect of statin prescription on mortality in the population of England and Wales with no previous history of cardiovascular disease.

METHODS

Primary care records from The Health Improvement Network 1987-2011 were used. Four cohorts of participants aged 60, 65, 70, or 75 years at baseline included 118,700, 199,574, 247,149, and 194,085 participants; and 1.4, 1.9, 1.8, and 1.1 million person-years of data, respectively. The exposure was any statin prescription at any time before the participant reached the baseline age (60, 65, 70 or 75) and the outcome was all-cause mortality at any age above the baseline age. The hazard of mortality associated with statin prescription was calculated by Cox's proportional hazard regressions, adjusted for sex, year of birth, socioeconomic status, diabetes, antihypertensive medication, hypercholesterolaemia, body mass index, smoking status, and general practice. Participants were grouped by QRISK2 baseline risk of a first cardiovascular event in the next ten years of <10%, 10-19%, or ≥20%.

RESULTS

There was no reduction in all-cause mortality for statin prescription initiated in participants with a QRISK2 score <10% at any baseline age, or in participants aged 60 at baseline in any risk group. Mortality was lower in participants with a QRISK2 score ≥20% if statin prescription had been initiated by age 65 (adjusted hazard ratio (HR) 0.86 (0.79-0.94)), 70 (HR 0.83 (0.79-0.88)), or 75 (HR 0.82 (0.79-0.86)). Mortality reduction was uncertain with a QRISK2 score of 10-19%: the HR was 1.00 (0.91-1.11) for statin prescription by age 65, 0.89 (0.81-0.99) by age 70, or 0.79 (0.52-1.19) by age 75.

CONCLUSIONS

The current internationally recommended thresholds for statin therapy for primary prevention of cardiovascular disease in routine practice may be too low and may lead to overtreatment of younger people and those at low risk.

Statin use and cardiovascular risk factors in diabetic patients developing a first myocardial infarction

BACKGROUND

The risk for a first myocardial infarction (MI) in people with diabetes has been shown to be as high as the risk for a new MI in non-diabetic patients with a prior MI. Consequently, risk-reducing statin therapy is recommended for nearly all patients with diabetes 40 years of age or older, regardless of cholesterol level. The purpose of this study was to assess the recommended and real-life use of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in diabetic patients who develop ASCVD.

METHODS

In a cross-sectional multicenter study of consecutive patients without previous ASCVD hospitalized with a first MI in 2010-2012, we obtained information on diabetic status, statin use, and cardiovascular risk factors prior to MI.

RESULTS

The study population consisted of 1622 patients with first MI (63 % men), 228 of whom had known diabetes before MI. All but three of the diabetic patients were ≥40 years of age. Diabetic patients were older (70 vs 68, p = 0.006), were more often women (43 vs 36 %, p = 0.05) and had a higher prevalence of statin use (47 vs 11 %, p < 0.001) compared with non-diabetic patients. Despite a high risk factor burden, the majority (53 %) of patients with known diabetes was not treated with statins before MI, and there was no relationship between the number of high-risk markers and statin use. Nearly all diabetic patients not treated with statins before first MI had at least one marker of very high cardiovascular risk, including hypertension (71 %), current smoking (37 %), and nephropathy (33 %).

CONCLUSIONS

Primary prevention with statins had been initiated in less than half of diabetic patients destined for a first MI, despite the presence of one or more markers of very high cardiovascular risk in nearly all. These results highlight an urgent need for optimizing statin therapy and global risk factor control in diabetic patients.

Statin use prior to first myocardial infarction in contemporary patients: Inefficient and not gender equitable

OBJECTIVES

Guidelines recommend initiating primary prevention with statins to those at highest cardiovascular risk. We assessed the gender-specific implementation and effectiveness of this risk-guided approach.

METHODS

We identified 1399 consecutive patients without known cardiovascular disease or diabetes hospitalized with a first myocardial infarction (MI) in Denmark. Statin use before MI was assessed, and cardiovascular risk was calculated using SCORE (Systematic COronary Risk Evaluation).

RESULTS

Among patients with first MI, 36% were women. Compared with men, they were older (mean 72 vs. 65years) but had a lower estimated risk (median 3.4% vs. 6.7%, SCORE high-risk model in the statin-naïve patients). Statin therapy had been initiated in 12% of women and 10% of men prior to MI. After adding 1.5mmol/L to the total cholesterol concentration of those already on statins, the estimated pre-treatment risk was much lower in women than men (median 3.8% vs. 9.2%, SCORE high-risk model), and only 29% of women would have passed the risk-based treatment threshold defined by the European guidelines (SCORE ≥5%). Estimated risk and statin use correlated directly in men but not in women. Only ~5% of first MI are prevented by the current use of statins in people without diabetes.

CONCLUSION

In people destined for a first MI, statin therapy is uncommon and prevents few events. Lower-risk women receive as much statins as higher risk men. This gender disparity and inefficient targeting of statins to those at highest risk indicate that risk scoring is not widely used in routine clinical practice in Denmark.

Applicability of the 2013 ACC/AHA Risk Assessment and Cholesterol Treatment Guidelines in the real world: results from a multiethnic case-control study

BACKGROUND

The 2013 ACC/AHA cholesterol treatment guidelines have introduced a new cardiovascular risk assessment approach (PCE) and have revisited the threshold for prescribing statins. This study aims to compare the ex ante application of the ACC/AHA and the ATP-III guideline models by using a multiethnic case-control study.

METHODS

ATP-III-FRS and PCE were assessed in 739 patients with first STEMI and 739 age- and gender-matched controls; the proportion of cases and controls that would have been eligible for statin as primary prevention therapy and the discriminatory ability of both models were evaluated.

RESULTS

The application of the ACC/AHA compared to the ATP-III model, resulted in an increase in sensitivity [94% (95%CI: 91%-95%) vs. 65% (61%-68%), p< 0.0001], a reduction in specificity [19% (15%-22%) vs. 55% (51%-59%), p< 0.0001] with similar global accuracy [0.56 (0.53-0.59) vs.0.59 (0.57-0.63), p ns]. When stratifying for ethnicity, the accuracy of the ACC/AHA model was higher in Europeans than in Chinese (p = 0.003) and to identified premature STEMI patients within Europeans much better compared to the ATP-III model (p = 0.0289).

CONCLUSION

The application of the ACC/AHA model resulted in a significant reduction of first STEMI patients who would have escaped from preventive treatment. Age and ethnicity affected the accuracy of the ACC/AHA model improving the identification of premature STEMI among Europeans only. Key messages According to the ATP-III guideline model, about one-third of patients with STEMI would not be eligible for primary preventive treatment before STEMI. The application of the new ACC/AHA cholesterol treatment guideline model leads to a significant reduction of the percentage of patients with STEMI who would have been considered at lower risk before the STEMI. The global accuracy of the new ACC/AHA model is higher in the Europeans than in the Chinese and, moreover, among the Europeans, the application of the new ACC/AHA guideline model also improved identification of premature STEMI patients.

Differential gene expression analysis and network construction of recurrent cardiovascular events

Recurrent cardiovascular events are vital to the prevention and treatment strategies in patients who have experienced primary cardiovascular events. However, the susceptibility of recurrent cardiovascular events varies among patients. Personalized treatment and prognosis prediction are urged. Microarray profiling of samples from patients with acute myocardial infarction (AMI), with or without recurrent cardiovascular events, were obtained from the Gene Expression Omnibus database. Bioinformatics analysis, including Gene Oncology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG), were used to identify genes and pathways specifically associated with recurrent cardiovascular events. A protein-protein interaction (PPI) network was constructed and visualized. A total of 1,329 genes were differentially expressed in the two group samples. Among them, 1,023 differentially expressed genes (DEGs; 76.98%) were upregulated in the recurrent cardiovascular events group and 306 DEGs (23.02%) were downregulated. Significantly enriched GO terms for molecular functions were nucleotide binding and nucleic acid binding, for biological processes were signal transduction and regulation of transcription (DNA-dependent), and for cellular component were cytoplasm and nucleus. The most significant pathway in our KEGG analysis was Pathways in cancer (P=0.000336681), and regulation of actin cytoskeleton was also significantly enriched (P=0.00165229). In the PPI network, the significant hub nodes were GNG4, MAPK8, PIK3R2, EP300, CREB1 and PIK3CB. The present study demonstrated the underlying molecular differences between patients with AMI, with and without recurrent cardiovascular events, including DEGs, their biological function, signaling pathways and key genes in the PPI network. With the use of bioinformatics and genomics these findings can be used to investigate the pathological mechanism, and improve the prevention and treatment of recurrent cardiovascular events.

Prioritizing health outcomes in a limited world: writing lipid guidelines

PURPOSE OF REVIEW

Guidelines are increasing in importance as healthcare becomes standardized. This article examines the processes by which the new US American College of Cardiology-American Heart Association and UK National Institute of Health and Care Excellence lipid guidelines came to their conclusions and how the nature of the evidence base and health economics contributed to the recommendations made.

RECENT FINDINGS

The writing of guidelines is becoming a systematic formal process with increasing emphasis on maintaining integrity, minimizing conflicts of interest and using consistent systematic methods to define the evidence base, grade its quality and then make recommendations. These processes are illustrated by showing why new cardiovascular disease risk assessment tools were required, what recommendations could be made about diet and lifestyle, why a fixed-dose drug treatment protocol as opposed to a target-based approach was recommended for the management of patients in secondary prevention, diabetes and primary prevention and how these would impact clinical practice.

SUMMARY

Modern systematic evidence assessment and economic appraisal convincingly favour the use of lipid-lowering drugs especially statins at higher doses than currently prescribed in secondary prevention and at lower risk thresholds in primary care than previously imagined. As long-term adherence to treatment is required patient choice is key to realizing the benefits of these interventions.