Predictive improvement of adding coronary calcium score and a genetic risk score to a traditional risk model for cardiovascular event prediction

AIMS

Coronary artery calcium score (CACS) and polygenic risk score have been used as novel markers to predict cardiovascular (CV) events of asymptomatic individuals compared with traditional scores. No previous studies have directly compared the additive capacity of these two markers relative to conventional scores. The aim of the study was to evaluate the change in CV risk prediction ability when CACS, genetic risk score (GRS), or both are added to Systematic Coronary Risk Evaluation 2 (SCORE2).

METHODS AND RESULTS

In a prospective, observational population-based study, 1002 asymptomatic subjects (mean age 53.1 ± 6.8 years, 73.8% male), free of clinical coronary disease and diabetes, were selected from GENEMACOR-study controls. SCORE2, CACS, and GRS were estimated to evaluate CV events' predictive and discriminative ability through Harrell's C-statistics. Net reclassification improvement (NRI) and integrated discrimination index were used to reclassify the population. Multivariable Cox proportional hazard ratio (HR) analysis assessed the variables independently associated with CV events. C-statistic demonstrated that the discriminative value for CV event occurrence was 0.608 for SCORE2, increasing to 0.749 (P = 0.001) when CACS was added, and improved to 0.802 (P = 0.0008) with GRS, showing a better discriminative capacity for CV events. Continuous NRI reclassified >70% of the population. Cox proportional analysis showed that the highest categories of SCORE2, CACS, and GRS remained in the equation with an HR of 2.9 (P = 0.003), 5.0 (P < 0.0001), and 3.2 (P = 0.003), respectively, when compared with the lowest categories.

CONCLUSION

In our population, CACS added to SCORE2 had better ability than GRS in CV event risk prediction, discrimination, and reclassification. However, adding the three scores can become clinically relevant, especially in intermediate-risk persons.

Validation of the SCORE2 risk prediction algorithm in a Portuguese population: A new model to estimate 10-year cardiovascular disease incidence in Europe

INTRODUCTION AND OBJECTIVES

Subjects without cardiovascular (CV) disease (CVD) may suffer from subclinical atherosclerosis, and are at increased risk for atherosclerotic CV events (ASCVE). The ESC/EAS risk SCORE was updated by SCORE2, which estimates 10-year risk of fatal and non-fatal CVD in European populations aged 40-69 years without established CVD or diabetes. Our aim was to compare the two ESC/EAS risk scores and to validate SCORE2 in our population.

METHODS

A total of 1071 individuals (age 57.2±6.1 years; 75.2% male) without CVD or diabetes, from GENEMACOR study controls, were analyzed over 5.4±3.9 years. The population was stratified into risk categories according to the two scores, and the area under the ROC curve (AUC) and Harrell's C-index assessed the scores' performance. Calibration was performed using the goodness-of-fit test, and occurrence of the first event assessed by Cox regression. Kaplan-Meier analysis estimated SCORE2 survival.

RESULTS

SCORE stratified subjects into four risk categories: low (7.4%), moderate (46.5%), high (25.3%) and very high (20.8%), and SCORE2 into three: low-to-moderate (24.7%), high (59.0%) and very high (16.2%). SCORE presented good discrimination for CV mortality (AUC=0.838; C-index=0.834, 95% CI: 0.728-0.940), as did SCORE2 for total CV events (AUC=0.744; C-index=0.728, 95% CI: 0.648-0.808). Calibration did not show a disparity between observed and expected ASCVE. The probability of ASCVE was eight times higher in very-high-risk SCORE2 (p=0.001), and three times in the high-risk group (p=0.049). Event-free survival was 99%, 90% and 72% in the low-to-moderate, high and very-high-risk categories, respectively (p<0.0001).

CONCLUSIONS

SCORE2 improved population stratification by identifying higher-risk patients, enabling early preventive measures. It showed good discriminative ability for all ASCVE.

Transcription factor 21 gene and prognosis in a coronary population

INTRODUCTION AND OBJECTIVES

Transcription factor 21 (TCF21) is a member of the basic helix-loop-helix (bHLH) transcription factor family, and is critical for embryogenesis of the heart. It regulates differentiation of epicardium-derived cells into smooth muscle cell (SMC) and fibroblast lineages. The biological role of TCF21 in the progression of atherosclerosis is the subject of debate. The aim of this study was to investigate the impact of the TCF21 rs12190287 gene variant on the prognosis of coronary artery disease (CAD) in a Portuguese population from Madeira island.

METHODS

We analyzed major adverse cardiovascular events (MACE) in 1713 CAD patients, mean age 53.3±7.8, 78.7% male, for 5.0±4.3 years. Genotype and allele distribution between groups with and without MACE was determined. The dominant genetic model (heterozygous GC plus homozygous CC) was used and compared with the wild GG to assess survival probability. Cox regression with risk factors and genetic models assessed variables associated with MACE. Kaplan-Meier analysis was used to estimate survival.

RESULTS

The wild homozygous GG, heterozygous GC and risk CC genotypes were found in 9.5%, 43.2% and 47.3% of the population, respectively. The dominant genetic model remained in the equation as an independent risk factor for MACE (HR 1.41; p=0.033), together with multivessel disease, chronic kidney disease, low physical activity and type 2 diabetes. The C allele in the dominant genetic model showed worse survival (22.5% vs. 44.3%) at 15 years of follow-up.

CONCLUSION

The TCF21 rs12190287 variant is a risk factor for CAD events. This gene may influence fundamental SMC processes in response to vascular stress, accelerating atherosclerosis progression, and may represent a target for future therapies.

Oral Presentation No. 55 Is White Blood Count a Good Marker to Coronary Disease Risk?

Background

High white blood cells (WBC) count is a well-recognized indicator of inflammation. Previous research has considered it a risk factor for coronary artery disease (CAD). Other new inflammatory risk markers are expensive to test, are not readily available, lack standardization and have not been confirmed as risk markers by multiple prospective studies. We aim to investigate whether elevated WBC count representsan independent risk factor for CAD in our Portuguese population.

Material and methods

A case-control study with 3,160 individuals (mean age 53.1 ± 7.8; 77.6% male), namely 1,723 coronary patients and 1,437 controls, was performed. Together with WBC, the following CAD risk factors were analyzed: smoking, hypertension, diabetes, dyslipidemia and obesity through bivariate analysis. Multivariate logistic regression evaluated the independent risk factors for CAD.

Results and conclusions

Comparing cases with controls, 47.2% were smokers vs. 23.8% (P &lt; 0.0001); 71.0% were hypertensive individuals vs. 52.3% (P &lt; 0.0001); 89.0% had dyslipidemiavs 70.4% (P &lt; 0.0001); 33.8% had diabetes vs. 13.2% (P &lt; 0.0001) and 34.2% were obese patients vs. 28.9% (P = 0.001). After multivariate regression, smoking (OR = 3.14, P &lt; 0.0001), diabetes (OR = 2.89, P &lt; 0.0001), dyslipidemia (OR = 2.72, P &lt; 0.0001), hypertension (OR = 1.95, P &lt; 0.0001) and WBC (OR = 1.05, P = 0.035) remained as independent risk factors for CAD. Elevated white blood counts are associated with CAD risk in our population. This marker is inexpensive, widely available and may further predict inflammation and coronaryartery disease risk.

Oral Presentation No. 56 Elevated White Blood Cells Count and C-Reactive Protein as markers for coronary heart disease prognosis

Background

White blood count (WBC) and C-reactive protein (CRP) elevation are well-recognized inflammation indicators and considered risk factors for coronary heart disease (CHD). Most of the other newly introduced inflammatory risk markers are expensive to test, are not readily available, lack standardization, and have not been confirmed by multiple prospective studies. Whether these classic inflammatory markers may predict majoradverse coronary events (MACE) in CHD patients is controversial. We aimed to evaluate whether high WBC and CRP are independent risk factors for MACE occurrence in CHD patients with an extended follow-up.

Material and methods

A cohort of 1,713 CHD patients (mean age 54.0 ± 7.5 years, 78.6% male) was prospectively followed during an extended time of 4.9 ± 3.4 years (range 1 to 17 years). Bivariate and multivariate Cox regression with WBC, CRP and traditional risk factors (age,gender, smoking, family history, dyslipidemia, diabetesand BMI) analyzed those significantlyassociated with MACE.

Results and conclusions

MACE group presented a higher percentage of non-smokers (P = 0.006); hypertension (P = 0.003); dyslipidemia (P = 0.025) and diabetes (P &lt; 0.0001). WBC (P = 0.048) and CRP (P &lt; 0.0001) were also significantly higher in patients with MACE relatively to non-MACE patients. After multivariate Cox analysis, WBC and CRP remained significant risk factors for MACE, with diabetes and hypertension presenting as strong statistical value. As a conclution, the inflammatory CRP and WBC factors are accurate to predict MACE in secondary prevention. These biomarkersare easily accessed, providing helpful information in the prognosis of cardiovascular patients.

Clinical Case 22—When the unusual appears

Clinical case

A 57 years old female, smoker, presented to emergency department with a constrictive chest and epigastric pain lasting for 30 minutes. Admission electrocardiogram showed a sinus bradycardia and ST elevation in the inferior leads. Inferior STEMI was assumed and was referred for primary coronary intervention. Coronary angiography revealed a right coronary artery (RCA) occluded at ostial level and primary angioplasty was performed with drug eluting stent implantation. After angioplasty, the chest pain didn´t relief, although the procedure had no complications. Transthoracic echocardiogram revealed a ‘flap’ on the ascending aorta (AAo), suggesting dissection of the AAo; left ventricular systolic function preserved, with hypokinesia of the inferior wall; right ventricular dysfunction; aortic regurgitation and no pericardial effusion. Emerging angio CT confirmed type A aortic dissection extending to abdominal aorta. The patient was then admitted to the operating room and a supracoronary conduit (hemiarch) and a bypass (saphenous vein/RCA) procedure was done. She had progressive clinical improvement and was discharged on the 17th day.

Learning points

Acute aortic dissection is the most common acute aortic syndrome (AAoS), being more prevalent in males and in the elderly, presenting high mortality rate. Acute type A aortic dissection can be difficult to diagnose and can mimic STEMI. RCA is more often involved when myocardial infarction is present. What appeared to be a linear STEMI turned out to be an AAoS that could have a catastrophic outcome. This was a successful case of this unusual diagnosis that surprised the entire team.

Poster No. 054 Genetic variation in the TCF21 gene is associated with the severity of coronary artery disease

Introduction

In vitro studies demonstrated that targeted deletion of the transcription factor encoding gene TCF21, was associated with vascular smooth muscle cell disruption. Recent research showed that TCF21 expression contribute to fibrous cap formation, preventing heart attacks.

Purpose

Analyse the TCF21 rs12190287 gene and evaluate its association with atherosclerosis severity measured according to the coronary angiogram patients´ data. Methods: Prospective study with 1,639 coronary artery disease (CAD) patients (mean age 53.4 ± 7.8 years). Two age groups (&lt; 55 and &gt; 55 years) were stratified and analyzed. TCF21 rs12190287 G &gt; C was genotyped in all patients. The severity of CAD was graded according to the number of obstructed coronary arteries with at least 70% narrowed lumen. Chi-squared tests and multivariate logistic regression models were analysed.

Results

The CC genotype was associated with &gt; 70% obstructive lesions (vascular disease rate, 48.1%). Contrariwise, the GG wild genotype was associated with less severe obstructive disease (19.5%) (P = 0.003). When we stratified the TCF21 genotypes per age group (55 years), the CC genotype in the younger group had more obstructed disease (47.4%) when compared with GG (18.8%) (P = 0.012), but this effect was not significant in the older group. Multivariate analysis (logistic regression) showed that the CC genotype had a high risk of multivessel coronary disease (OR = 2.88; P = 0.001) than GG.

Conclusion

This work shows that the TCF21 wild genotype protects against CAD severity. In contrast, the CC genotype is associated with an increased risk of CAD severity.

[Contributions of Charcot and Marsden to the development of movement disorders in the 19th and 20th centuries]

Charcot described many neurological diseases in the 19th century, particularly in movement disorders. Charcot contributed in the clinical description of Parkinson's disease, and introduced its first pharmacological treatment. He also studied the hyperkinesias, e.g. of Tourette syndrome, differential diagnosis of tremors, dystonias, choreas and startle disease. Marsden, who died recently, was an exponent in the study of Movement Disorders, with many publications in this field in the 20th century. His most important contributions are definitions and classifications of movement disorders, such as Parkinson's disease, dystonia, myoclonus, essential tremor, the description of the syndromes "Painful Legs Moving Toes", "Gait Ignition Failure" and "Primary Writing Tremor". The contributions of Charcot in the 19th century and Marsden in the 20th century to the movement disorders allow us to conclude that both of them were the most representative icons in this field in the past two centuries.

Palatal myoclonus: report of two cases

We describe two cases of palatal myoclonus (PM), one essential and another secondary to a stroke. Case 1: a 64 years old female who developed clicking sounds in both ears after a stroke and three years later on noticed a progressive involuntary movement of the throat associated with rhythmic contractions of the soft palate, muscles of tongue and throat. MRI showed an ischemic area in brainstem. The patient had a partial response to the use of sumatriptan 6 mg subcutaneously. Case 2: a 66 years old female who began with ear clicking at left ear that worsed slowly associated with tinnitus and arrhythmic movements of soft palate and an audible click at left ear. Brain MRI was normal; audiometry showed bilateral neurosensory loss. She was prescribed clonazepan 1 mg daily with complete recovery. Primary and secondary palatal myoclonus share the same clinical features but probably have different pathophysiological underlying mechanisms.

[Clinical and therapeutical features in 135 patients with dystonia: experience of movement disorders unity of the Hospital de Clínicas of the Universidade Federal do Paraná]

This study aims to describe the clinical patterns and therapeutic responses in 135 patients with dystonia. According to the classification, 54% were focal; 17.8% were segmental; 8.1% hemidistonia; 18.6% generalized and 1.5% were multifocal. There was a positive familial history in 5.9% of the cases. The treatment of the idiopathic dystonias is divided in: specific and symptomatic, and it can be local with botulinum toxin, or systemic with oral drugs. The most common drugs used in the treatment were anticholinergics and benzodiazepines, with poor responses in the generalized forms. Botulinum toxin A was the first line treatment for focal and segmental forms of dystonia. Meanwhile, the generalized forms of dystonia show poor response to the therapies utilized.

[Professor Antonio Austregésilo. The pioneer of neurology and of the study of movement disorders in Brazil]

Professor Antonio Austregésilo was the pioneer of neurology in Brazil, creating the first neurologícal school, in Rio de Janeiro, of which he was the first professor. He was also the first to study the movement disorders in Brazil, publishing several works on this subject, primarily in "Revue Neurologique", and "L'Encephale", including a rival sign of Babinski and the first description of a posttraumatic dystonia.