Impact of Aging on Cardiovascular Diseases: From Chronological Observation to Biological Insights: JACC Family Series

Cardiovascular disease (CVD) has increasing challenges for human health with an increasingly aging population worldwide, imposing a significant obstacle to the goal of healthy aging. Rapid advancements in our understanding of biological aging process have shed new light on some important insights to aging-related diseases. Although numerous reviews delved into the mechanisms through which biological aging affects CVD and age-related diseases, most of these reviews relied heavily on research related to cellular and molecular processes often observed from animal experiments. Few reviews have provided insights that connect hypotheses regarding the biological aging process with the observed patterns of chronological aging-related impacts on CVD in human populations. The purpose of this review is to highlight some of the major questions in studies of aging-related CVD and provide our perspectives in the context of real-world patterns of CVD with multidimensional information and potential biological insights.

Relationship between combat-related traumatic injury and its severity to predicted cardiovascular disease risk: ADVANCE cohort study

BACKGROUND

This study investigated the relationship between combat-related traumatic injury (CRTI) and its severity and predicted cardiovascular disease (CVD) risk.

MATERIAL AND METHODS

This was an analysis of comparative 10-year predicted CVD risk (myocardial infarction, stroke or CVD-death) using the QRISK®3 scoring-system among adults recruited into the Armed Services Trauma Rehabilitation Outcome (ADVANCE) cohort study. Participants with CRTI were compared to uninjured servicemen frequency-matched by age, sex, rank, deployment (Afghanistan 2003-2014) and role. Injury severity was quantified using the New Injury Severity Score (NISS).

RESULTS

One thousand one hundred forty four adult combat veterans were recruited, consisting of 579 injured (161 amputees) and 565 uninjured men of similar age ethnicity and time from deployment/injury. Significant mental illness (8.5% vs 4.4%; p = 0.006) and erectile dysfunction (11.6% vs 5.8%; p < 0.001) was more common, body mass index (28.1 ± 3.9 vs 27.4 ± 3.4 kg/m2; p = 0.001) higher and systolic blood pressure variability (median [IQR]) (1.7 [1.2-3.0] vs 2.1 [1.2-3.5] mmHg; p = 0.008) lower among the injured versus uninjured respectively. The relative risk (RR) of predicted CVD (versus the population expected risk) was higher (RR:1.67 [IQR 1.16-2.48]) among the injured amputees versus the injured non-amputees (RR:1.60 [1.13-2.43]) and uninjured groups (RR:1.52 [1.12-2.34]; overall p = 0.015). After adjustment for confounders CRTI, worsening injury severity (higher NISS, blast and traumatic amputation) were independently associated with QRISK®3 scores.

CONCLUSION

CRTI and its worsening severity were independently associated with increased predicted 10-year CVD risk.

Psychometric evaluation of the 'Attitudes and Beliefs about Cardiovascular Disease (ABCD) Risk Questionnaire' with validation of a previously untested 'Intentions and Beliefs around Smoking' subscale

OBJECTIVES

To provide evidence of validity, reliability and generalisability of results obtained using the Attitudes and Beliefs about Cardiovascular Disease (ABCD) Risk Questionnaire with a sample of the English population surveyed within the 'SPICES' Horizon 2020 Project (Nottingham study site), and to specifically evaluate the psychometric and factor properties of an as-yet untested five-item subscale relating to smoking behaviours.

DESIGN AND SETTING

Community and workplace-based cross-sectional study in Nottingham, UK.

PARTICIPANTS

466 English adults fitting inclusion criteria (aged 18+ years, without known history of cardiovascular disease, not pregnant, able to provide informed consent) participated in the study.

INTERVENTION

We revalidated the ABCD Questionnaire on a sample of the general population in Nottingham to confirm the psychometric properties. Furthermore, we introduced five items related to smoking, which were dropped in the original study due to inadequate valid samples.

PRIMARY AND SECONDARY OUTCOME MEASURES

Psychometric and factor performance of untested five-item 'smoking behaviours' subscale.Psychometric and factorial properties in combination with the remaining 18 items across 3 subscales.

RESULTS

Analyses of the data largely confirmed the validity, reliability and factor structure of the original ABCD Risk Questionnaire. Sufficient participants in our study provided data against additional five smoking-related items to confirm their validity as a subscale and to advocate for their inclusion in future applications of the scale. Exploratory factor analysis and confirmatory factor analysis calculations support some minor changes to the remaining subscales, which may further improve psychometric performance and therefore generalisability of the instrument.

CONCLUSIONS

An amended version of the ABCD Risk Questionnaire would provide public health researchers and practitioners with a brief, easy-to-use, reliable and valid survey tool. The amended tool may assist public health practitioners and researchers to survey patient or public intentions and beliefs around three key areas of individually modifiable risk (physical activity, diet, smoking).

TRIAL REGISTRATION NUMBER

ISRCTN Registry (ISRCTN68334579).

Validation of Cardiovascular Risk Prediction by the Arriba Instrument

BACKGROUND

It is recommended in cardiovascular prevention guidelines that treatment should be based on overall cardiovascular risk. The arriba instrument has been widely used for this purpose in Germany. The aim of this study is to validate risk prediction by arriba with the aid of morbidity and mortality data from the population- based Study of Health in Pomerania.

METHODS

In a longitudinal analysis, the arriba instrument was used to calculate the 10-year overall cardiovascular risk at baseline for subjects who had not sustained any prior cardiovascular event. Cardiovascular event rates were determined from follow-up data, and discrimination and calibration measures for the risk determination algorithm were calculated.

RESULTS

Data from 1973 subjects (mean age 51 ± 13 years, 48% men) were included in the analysis. After a median follow-up of 10.9 years, cardiovascular events had occurred in 196 subjects, or 9.8%. The ratio of predicted to observed event rate was 0.8 (95% confidence interval: [0.5; 1.1]), 1.3 [1.0; 1.8], and 1.1 [0.8; 1.4] for subjects at low, intermediate, and high cardiovascular risk, respectively. Arriba underestimated cardiovascular event rates in women and overestimated them in persons aged 30-44 and 45-59. The area under curve was 0.84 [95% CI 0.81; 0.86].

CONCLUSION

The discrimination scores of the arriba instrument resemble those of SCORE-Germany and PROCAM, but a better adjustment to the target population would be desirable. The results support the recommendation of the German Guideline for Cardiovascular Risk Counseling in General Practice for the use of the arriba instrument. An unresolved problem is the failure to consider intervention effects, resulting in an overall mild overestimation of risk.

Hypertension and high ankle brachial index: the overlooked combination

OBJECTIVE

Assessment of asymptomatic organ damage in the management of hypertension includes low (<0.9) ankle brachial index (ABI) values. No recommendations are given for patients with high ABI (≥1.3), despite evidence of an association with increased risk. We aimed to study the association of high ABI with all-cause mortality and cardiovascular outcomes in a hypertensive population.

METHODS

In anonymized clinical records from the Catalan Primary Care (SIDIAP) database, we designed a large cohort of hypertensive patients aged 35-85 years at the start date. Participants were excluded if they had previous heart failure, coronary heart disease, stroke, diabetes mellitus, or chronic kidney disease. The study population was categorized according to ABI values. Cox proportional hazards models were used to assess all-cause mortality, heart failure, acute myocardial infarction, and stroke.

RESULTS

From 2006 through 2015, SIDIAP records included 44 657 hypertensive patients with an ABI measurement 9126 of whom met inclusion criteria. The median follow-up (first to third quartiles) was 6.0 years (4.7-7.6). High ABI (≥ 1.3) was associated with an increase in mortality risk, hazard ratio, and 95% confidence interval: 1.44 (1.10-1.88), similar to the group with ABI at least 0.9 and less than 1.1, hazard ratio 1.36 (1.12-1.65), and lower than all groups with ABI less than 0.9. High ABI values tended to associate with heart failure, hazard ratio 1.34 (0.95-1.91), but the relation of high ABI with acute myocardial infarction and stroke was nonsignificant, hazard ratios 1.30 (0.72-2.35) and 0.97 (0.65-1.42), respectively.

CONCLUSION

Patients with high ABI values and hypertension presented an increased all-cause mortality risk that could be considered when advising such patients.

Determinants of healthy ageing and its relation to 10-year cardiovascular disease incidence: the ATTICA study

OBJECTIVES

The aim of the study was to understand determinants of ageing in relation to future cardiovascular disease (CVD) events at population level, and to explore determinants of healthy ageing and its relation to 10-year CVD incidence among apparently healthy individuals.

METHODS

In the context of the ATTICA study 453 apparently healthy men (45±13 years) and 400 women (44±18 years) with complete psychological evaluation were studied and followed during 2002-2012. Healthy Ageing Index (HAI) (range 0-7) was calculated based on socio-economical, bio-clinical, psychological, and lifestyle characteristics (i.e. dietary habits and physical activity) of the participants during the baseline examination. CVD incidence during the follow-up period was defined according to ICD-10 criteria.

RESULTS

Healthy Ageing Index was inversely associated with higher 10-year CVD risk (OR per 1/7 (95% CI): 0.47 (0.28, 0.80). Age and sex-adjusted determinants of healthy ageing were abnormal waist to hip ratio (p<0.001), increased coffee consumption (p=0.04), reduced basic metabolic rhythm (p<0.001), increased triglycerides (p=0.003), and C-reactive protein levels (p=0.02), as aggravating factors, while moderate alcohol consumption (p=0.002) was identified as a positive influential parameter.

CONCLUSIONS

Understanding healthy ageing, as a dominant factor of CVD development, provides a new direction for better prevention efforts focused on healthy ageing at both population and individual level.