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Hoes LLF, Geleijnse JM, Bonekamp NE, Dorresteijn JAN, van der Meer MG, van der Schouw YT, Visseren FLJ, Koopal C. Prevalence and determinants of self-reported low-fat-, low-salt-, and vegetarian diets in patients with cardiovascular disease between 1996 and 2019. Nutr Metab Cardiovasc Dis 2024; 34:935-943. [PMID: 38403481 DOI: 10.1016/j.numecd.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/01/2023] [Accepted: 01/10/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND AIMS Guidelines no longer recommend low-fat diets and currently recommend more plant-based diets to reduce atherosclerotic cardiovascular disease (ASCVD) risk. Furthermore, these guidelines have consistently recommended salt-reduced diets. This article describes current self-reported use and time-trends in the self-reported use of low-fat, low-salt and vegetarian diets in ASCVD patients and examines patient characteristics associated with each diet. METHODS AND RESULTS 9005 patients with ASCVD included between 1996 and 2019 in the UCC-SMART cohort were studied. The prevalence of self-reported diets was assessed and multi-variable logistic regression was used to identify the determinants of each diet. Between 1996-1997 and 2018-2019, low-fat diets declined from 22.4 % to 3.8 %, and low-salt diets from 14.7 % to 4.6 %. The prevalence of vegetarian diets increased from 1.1 % in 1996-1997 to 2.3 % in 2018-2019. Patients with cerebrovascular disease (CeVD) and peripheral artery disease or an abdominal aortic aneurysm (PAD/AAA) were less likely to report a low-salt diet than coronary artery disease (CAD) patients (OR 0.62 [95%CI 0.49-0.77] and 0.55 [95%CI 0.41-0.72]). CONCLUSION In the period 1996 to 2019 amongst patients with ASCVD, the prevalence of self-reported low-fat diets was low and decreased in line with changes in recommendations in major guidelines. The prevalence of self-reported vegetarian diets was low but increased in line with societal and guideline changes. The prevalence of self-reported low-salt diets was low, especially in CeVD and PAD/AAA patients compared to CAD patients, and decreased over time. Renewed action is needed to promote low-salt diets in ASCVD patients.
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Affiliation(s)
- L L F Hoes
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J M Geleijnse
- Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherlands
| | - N E Bonekamp
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Charlotte Koopal
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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2
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Van Trier T, Jorstad HT, Snaterse M, Scholte Op Reimer WJM, Visseren FLJ, Dorresteijn JAN, Wareham NJ, Lindeboom R, Peters RJG, Boekholdt SM. Cardiovascular mortality risk beyond 10 years in men and women; long-term follow-up from the EPIC-Norfolk prospective population study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Current primary prevention strategies in cardiovascular (CV) disease focus on initiating preventive interventions in people at high 10-year risk of CV mortality. However, initiating such strategies should be beneficial not only in the first 10 years, but throughout life. Established risk algorithms estimate the risk of 10-year CV mortality, but limited evidence is available about the relationship between 10-year and longer-term CV mortality.
Purpose
To compare cumulative incidence of CV mortality in a population cohort at 10- and 20-years follow-up, stratified by sex.
Methods
We analysed CV mortality at 10-years and 20-years follow-up using Kaplan-Meier estimates among men and women aged 39–70 years without baseline CV disease or diabetes mellitus in the large, prospective population-based EPIC-Norfolk cohort. CV mortality included death with as underlying or contributing cause ischaemic heart disease, heart failure, cerebrovascular disease or peripheral artery disease.
Results
We analysed data from 20,453 participants (56% women), with a mean age of 56±8 years, and median (IQR) follow-up of 22 (21–23) years. At baseline, there were no clinically relevant differences in CV risk factors between men and women. Overall cumulative CV mortality rate was 1.9% (384 deaths) in the first 10 years, and 7.3% (995 deaths) at 20 years follow-up (ratio 3.8). Among men, 10-year CV mortality was 2.9% (249 deaths), and 9.6% (785 deaths) at 20 years follow-up (ratio 3.3). Among women, CV mortality was 1.2% (135 deaths) at 10 year and 5.5% (594 deaths) at 20 years follow-up (ratio 4.6).
Conclusion
We observed an incremental increase in CV mortality beyond the 10-year scope of current established CV risk algorithms. At 20 years follow-up, CV mortality rates were 3–5 times higher compared with the first decade, indicating that 20-year CV mortality risk for both men and women cannot simply be estimated based on extrapolation of 10-year risk.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): EPIC-Norfolk is supported by programme grants from the Medical Research Council UK (MRC G0401527, MRC G0701863, MRC G1000143) and Cancer Research UK (CRUK 8257).
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Affiliation(s)
- T Van Trier
- Amsterdam University Medical Center, Department of Cardiology , Amsterdam , The Netherlands
| | - H T Jorstad
- Amsterdam University Medical Center, Department of Cardiology , Amsterdam , The Netherlands
| | - M Snaterse
- Amsterdam University Medical Center, Department of Cardiology , Amsterdam , The Netherlands
| | | | - F L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine , Utrecht , The Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of Vascular Medicine , Utrecht , The Netherlands
| | - N J Wareham
- University of Cambridge, MRC Epidemiology Unit, School of Clinical Medicine, Institute of Metabolic Science , Cambridge , United Kingdom
| | - R Lindeboom
- Amsterdam University Medical Center, Department of Clinical Epidemiology, Biostatistics and Bioinformatics , Amsterdam , The Netherlands
| | - R J G Peters
- Amsterdam University Medical Center, Department of Cardiology , Amsterdam , The Netherlands
| | - S M Boekholdt
- Amsterdam University Medical Center, Department of Cardiology , Amsterdam , The Netherlands
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3
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Hageman SHJ, Lu W, Kaptoge S, Lall K, Bobak M, Pikhart H, Kubinova R, Pajak A, Tamosiunas A, Stang A, Schmidt B, Schramm S, Di Angelantonio E, Visseren FLJ, Dorresteijn JAN. Prediction of lifetime cardiovascular risk and individual lifetime treatment benefit in four European risk regions: geographic recalibration of the LIFE-CVD model. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The life expectancy free of cardiovascular disease (CVD) in individuals without previous CVD can be estimated with the LIFEtime-perspective CardioVascular Disease (LIFE-CVD) model, as recommended by the 2021 ESC CVD prevention guidelines. Our aim was to systematically recalibrate the LIFE-CVD model to four European risk regions using contemporary and representative registry data.
Methods and results
The LIFE-CVD model was systematically recalibrated to four distinct risk regions within Europe, using representative aggregate data on age- and sex-specific expected CVD and non-CVD mortality incidences and risk factor distributions. For external validation, 1,451,077 individuals without previous CVD were included from seven European cohorts, with 53,721 CVD events and 62,902 non-CVD deaths during follow up. After applying the recalibrated risk prediction models to external validation cohorts, C-indices (figure 1) ranged from 0.670 (95% CI 0.650–0.690) to 0.787 (95% CI 0.785–0.789). Predicted risks matched the observed risks in the CPRD data. With the recalibrated LIFE-CVD model, the estimated gain in CVD-free life expectancy from preventive therapy differed per region, for example a 50-year-old smoking women with a systolic blood pressure of 140mm Hg was estimated to gain 0.4 years of CVD-free life from 10 mm Hg SBP reduction in the low risk region, whereas this would be 1.5 years in the very high risk region (figure 2).
Interpretation
By taking into account geographical differences in CVD incidence, the recalibrated LIFE-CVD model provides a more accurate tool for the prediction of lifetime risk and CVD-free life expectancy for individuals without previous CVD, facilitating shared decision-making in cardiovascular prevention options as recommended by the 2021 European Prevention Guidelines.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S H J Hageman
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - W Lu
- University College London, Department of Epidemiology and Public Health , London , United Kingdom
| | - S Kaptoge
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - K Lall
- University of Tartu, Estonian Genome Centre , Tartu , Estonia
| | - M Bobak
- University College London, Department of Epidemiology and Public Health , London , United Kingdom
| | - H Pikhart
- University College London, Department of Epidemiology and Public Health , London , United Kingdom
| | - R Kubinova
- National Institute of Public Health , Prague , Czechia
| | - A Pajak
- Institute of Public Health, Department of Epidemiology and Population Studies , Krakow , Poland
| | - A Tamosiunas
- Lithuanian University of Health Sciences, Institute of Cardiology , Kaunas , Lithuania
| | - A Stang
- Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - B Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - S Schramm
- Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - E Di Angelantonio
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - F L J Visseren
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
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4
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Hageman SHJ, Pennells L, Pajouheshnia R, Tillmann T, Blaha MJ, McClelland RL, Matsushita K, Nambi V, Van Der Schouw YT, Verschuren WMM, Lehmann N, Jockel KH, Di Angelantonio E, Visseren FLJ, Dorresteijn JAN. The value of additional risk factors for improving 10-year cardiovascular risk prediction in apparently healthy people. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
In clinical practice, factors known to be associated with cardiovascular disease (CVD) like albuminuria, education level, or coronary calcium score are not directly incorporated in cardiovascular risk prediction models. The aim of the current study was to quantify the added value of potential risk modifying characteristics when added to the SCORE2 algorithm for individuals without diabetes mellitus (DM) or prior CVD.
Methods and results
Individuals without previous CVD or DM were included from the ARIC, MESA, EPIC-NL and HNR studies (n=46,285) in whom 2,177 CVD events and 2,062 non-cardiovascular deaths were observed over exactly 10.0 years of follow-up. The effect of each possible risk modifying characteristic was derived using Fine and Gray models that included an offset term for the SCORE2 linear predictor. The risk modifying characteristics were applied to individual predictions using the “naïve approach”, which modifies predicted risks based on the population prevalence and the SHR of the relevant predictor. Subdistribution hazard ratios are presented in the table. External validation was performed in the CPRD cohort (UK, n=518,015, 12,675 CVD events). In the external validation, adjustment of SCORE2 predicted risks with both single and with all available risk modifiers did not negatively affect calibration (see figure) and led to a modest increase in discrimination (C-index 0.742 [95% CI 0.737–0.746] versus unimproved SCORE2 risk C-index 0.737 [95% CI 0.732–0.741]). The net reclassification index or adding all these predictors was +0.032 (95% CI 0.025; 0.028) for future events and −0.008 (95% CI −0.009; −0.007) for future non-events. The coronary calcium score was found to the single strongest added predictor.
Interpretation
The current analysis presents a method on how to integrate possible risk modifying characteristics that are not included in existing CVD risk models for the prediction of CVD event risk in apparently healthy people. This flexible methodology improves the accuracy of predicted risks and increases applicability of prediction models for individuals with additional risk known modifiers
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S H J Hageman
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - L Pennells
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - R Pajouheshnia
- Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Clinical Pharmacology , Utrecht , The Netherlands
| | - T Tillmann
- University of Tartu, Institute of Family Medicine and Public Health , Tartu , Estonia
| | - M J Blaha
- The Johns Hopkins Hospital, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease , Baltimore , United States of America
| | - R L McClelland
- University of Washington, Department of Biostatistics , Seattle , United States of America
| | - K Matsushita
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology , Baltimore , United States of America
| | - V Nambi
- Baylor College of Medicine, Department of Medicine , Houston , United States of America
| | - Y T Van Der Schouw
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , The Netherlands
| | - W M M Verschuren
- National Institute for Public Health and the Environment (RIVM), Centre for Nutrition, Prevention and Health Services , Bilthoven , The Netherlands
| | - N Lehmann
- University hospital Essen, Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - K H Jockel
- University hospital Essen, Institute for Medical Informatics, Biometry and Epidemiology , Essen , Germany
| | - E Di Angelantonio
- University of Cambridge, Department of Public Health and Primary Care , Cambridge , United Kingdom
| | - F L J Visseren
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of vascular medicine , Utrecht , The Netherlands
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5
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Klooster CCV', Bhatt DL, Steg PG, Massaro JM, Dorresteijn JAN, Westerink J, Ruigrok YM, de Borst GJ, Asselbergs FW, van der Graaf Y, Visseren FLJ. Predicting 10-year risk of recurrent cardiovascular events andcardiovascular interventions in patients with established cardiovascular disease: results from UCC-SMART and REACH. Int J Cardiol 2020; 325:140-148. [PMID: 32987048 DOI: 10.1016/j.ijcard.2020.09.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/11/2020] [Accepted: 09/20/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Existing cardiovascular risk scores for patients with established cardiovascular disease (CVD) estimate residual risk of recurrent major cardiovascular events (MACE). The aim of the current study is to develop and externally validate a prediction model to estimate the 10-year combined risk of recurrent MACE and cardiovascular interventions (MACE+) in patients with established CVD. METHODS Data of patients with established CVD from the UCC-SMART cohort (N = 8421) were used for model development, and patient data from REACH Western Europe (N = 14,528) and REACH North America (N = 19,495) for model validation. Predictors were selected based on the existing SMART risk score. A Fine and Gray competing risk-adjusted 10-year risk model was developed for the combined outcome MACE+. The model was validated in all patients and in strata of coronary heart disease (CHD), cerebrovascular disease (CeVD), peripheral artery disease (PAD). RESULTS External calibration for 2-year risk in REACH Western Europe and REACH North America was good, c-statistics were moderate: 0.60 and 0.58, respectively. In strata of CVD at baseline good external calibration was observed in patients with CHD and CeVD, however, poor calibration was seen in patients with PAD. C-statistics for patients with CHD were 0.60 and 0.57, for patients with CeVD 0.62 and 0.61, and for patients with PAD 0.53 and 0.54 in REACH Western Europe and REACH North America, respectively. CONCLUSIONS The 10-year combined risk of recurrent MACE and cardiovascular interventions can be estimated in patients with established CHD or CeVD. However, cardiovascular interventions in patients with PAD could not be predicted reliably.
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Affiliation(s)
- C C van 't Klooster
- Department of Vascular Medicine, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - D L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - P G Steg
- French Alliance for Cardiovascular Trials, Hôpital Bichat, Paris, France; Assistance Publique-Hôpitaux de Paris, Université de Paris, INSERM Unité, 1148 Paris, France
| | - J M Massaro
- Department of Biostatistics Boston University School of Public Health, Boston, MA, USA
| | - J A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - J Westerink
- Department of Vascular Medicine, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - Y M Ruigrok
- Department of Neurology and Neurosurgery, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - F W Asselbergs
- Department of Cardiology, Division Heart & Lungs, UMCU, Utrecht University, Utrecht, the Netherlands; Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom; Health Data Research UK and Institute of Health Informatics, University College London, London, United Kingdom
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands
| | - F L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht (UMCU), University Utrecht, Utrecht, the Netherlands.
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6
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De Vries TI, Eikelboom JW, Bosch J, Westerink J, Dorresteijn JAN, Alings M, Dyal L, Berkowitz SD, Van Der Graaf Y, Fox KAA, Visseren FLJ. 2180Estimating individual lifetime benefit and bleeding risk of adding rivaroxaban to aspirin for patients with stable cardiovascular disease: results from the COMPASS trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial has demonstrated that adding low-dose rivaroxaban to aspirin in patients with stable atherosclerotic disease on average reduces recurrence of cardiovascular disease (CVD) events, but increases the risk of major bleeding. For clinical practice, it is important to be able to weigh the absolute benefit from the intervention in terms of lower cardiovascular risk against the absolute increase in risk for major bleeding.
Purpose
The aim of this study was to estimate the individual lifetime benefit and harm of adding low-dose rivaroxaban to aspirin in patients with stable cardiovascular disease by predicting individual months free from CVD events gained and individual months free from major bleeding lost.
Methods
Analyses were based on data of patients with established CVD in the COMPASS trial (n=27,390) and SMART prospective cohort study (n=8,139). The externally validated lifetime SMART-REACH model for recurrent CVD was used to predict life expectancy free of stroke and myocardial infarction, based on the following predictors: sex, current smoking, diabetes mellitus, systolic blood pressure, total cholesterol, creatinine, number of locations of CVD, history of atrial fibrillation, and history of congestive heart failure. A new Fine & Gray competing-risk adjusted Cox proportional hazard model was derived in the COMPASS study population for prediction of life expectancy free from major bleeding, including the same predictors as the SMART-REACH model and additionally ethnicity, geographical region, and history of bleeding requiring transfusion. These lifetime estimates were then combined with hazard ratios from the COMPASS trial to estimate lifetime treatment effects from adding low-dose rivaroxaban to aspirin, expressed in terms of 1) months free from stroke or myocardial infarction gained, and 2) months free from major bleeding lost.
Results
External goodness-of-fit of the SMART-REACH model in the COMPASS study was sufficient. The newly developed major bleeding risk model also showed sufficient external goodness-of-fit in the SMART cohort. The median predicted individual gain in life-expectancy free of stroke or MI from added low-dose rivaroxaban was 16 months (range 1–48 months), while the median predicted individualized lifetime lost in terms of major bleeding was 2 months (range 0–20 months) (Figure 1A). Predicted benefit was higher than predicted harm in more than 90% of the study population. An interactive calculator for use in clinical practice will be made available (example in figure 1B).
Figure 1
Conclusions
There is a wide distribution in lifetime gain and harm from adding low-dose rivaroxaban to aspirin in individual patients with stable CVD. Using these lifetime models, benefits and bleeding risk can be weighed for and with each individual patient, to support treatment decision making in clinical practice.
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Affiliation(s)
- T I De Vries
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - J W Eikelboom
- McMaster University, Population Health Research Institute, Hamilton, Canada
| | - J Bosch
- McMaster University, Population Health Research Institute, Hamilton, Canada
| | - J Westerink
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - J A N Dorresteijn
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - M Alings
- Amphia Hospital, Department of Cardiology, Breda, Netherlands (The)
| | - L Dyal
- McMaster University, Population Health Research Institute, Hamilton, Canada
| | - S D Berkowitz
- Bayer Healthcare Pharmaceuticals, Whippany, United States of America
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands (The)
| | - K A A Fox
- University of Edinburgh, Center for Cardiovascular Science, Edinburgh, United Kingdom
| | - F L J Visseren
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
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7
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Hageman SHJ, Dorresteijn JAN, Bots ML, Westerink J, Asselbergs FW, De Borst GJ, Visseren FLJ. P1540Major adverse limb events (MALE) and the relation with classical risk factors in patients with symptomatic cardiovascular disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with symptomatic cardiovascular disease are at high risk for recurrent major adverse cardiovascular events (MACE). Major adverse limb events (MALE) are only rarely reported as a (primary) outcome in trials and cohorts although MALE often lead to significant morbidity and disability.
Purpose
The aim of this study was to determine the incidence of MALE in patients with coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD) or abdominal aortic aneurysm (AAA) and to assess to what extent the classical modifiable risk factors systolic blood pressure (SBP), smoking and non-high density lipoprotein cholesterol (non-HDL-c) affect the risk of MALE.
Methods
Patients with symptomatic vascular disease were included from the ongoing UCC-SMART cohort (1996–2017, n=8139). MALE was defined as a major amputation, peripheral revascularization or thrombolysis of the lower limb. A major amputation included all amputations at the level of the forefoot or higher due to a vascular cause. For non-HDL-c, smoking (per category: non-smoking, former smoking and current smoking) and SBP, the risk for MALE was analyzed with Cox proportional hazard models adjusted for potential confounders. All results were stratified for the presence of PAD/AAA or CAD/CVD at baseline. To calculate the population attributable fraction, non-HDL-c was dichotomized at 1.8 mmol/L and SBP at 140 mmHg.
Results
A total of 577 MALE were observed in 65,402 person-years (median follow up 7.6 years, IQR 3.9–11.7 years) (figure 1A), of which 32 major amputations. In PAD/AAA patients 413 MALE were observed (incidence rate 24.9/1000 person-years). In the CAD/CVD patients 164 MALE were observed (incidence rate 3.4/1000 person-years). The MALE risk per 1 mmol/L higher non-HDL-c was not elevated: HR 1.01 (95% CI 0.94–1.09) for patients with PAD/AAA and HR 1.03 (95% CI 0.91–1.18) for patients with CAD/CVD (figure 1B). The MALE risk per 10mmHg higher SBP was HR 1.10 (95% CI 1.05–1.15) for PAD/AAA patients and HR 1.14 (95% CI 1.06–1.22) for CAD/CVD patients. In patients with PAD/AAA the risk for MALE by former smoking was HR 1.34 (95% CI 0.92–1.97) and for current smoking HR 1.66 (95% CI 1.14–2.44). In CAD/CVD patients, this was for former smoking HR 2.98 (95% CI 1.65–5.39) and for current smoking HR 6.81 (95% CI 3.72–12.45). The population attributable fraction was 0.13 (95% CI −0.07–0.32) for non-HDL-c, 0.21 (95% CI 0.13–0.28) for SBP and 0.28 (95% CI 0.22–0.33) for current smoking.
Figure 1
Conclusions
The incidence of MALE is high in patients with PAD/AAA, and much lower in patients with CAD or CVD. Systolic blood pressure and smoking increase the risk of MALE in PAD/AAA and CAD/CVD patients, Non-HDL-c was not related to the risk of MALE. These findings confirm the importance of MALE as an outcome in patients with clinical manifest vascular disease and underline the importance of the management of classical risk factors to prevent these disabling clinical events.
Acknowledgement/Funding
None
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Affiliation(s)
- S H J Hageman
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| | - M L Bots
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands (The)
| | - J Westerink
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
| | - F W Asselbergs
- University Medical Center Utrecht, Department of cardiology, Utrecht, Netherlands (The)
| | - G J De Borst
- University Medical Center Utrecht, Department of Vascular Surgery, Utrecht, Netherlands (The)
| | - F L J Visseren
- University Medical Center Utrecht, Department of vascular medicine, Utrecht, Netherlands (The)
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8
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De Vries TI, Dorresteijn JAN, Van Der Graaf Y, Visseren FLJ, Westerink J. P4990Heterogeneity of treatment effects from an intensive lifestyle weight loss intervention on cardiovascular events in patients with type 2 diabetes: data from the Look AHEAD trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The Action for Health in Diabetes trial (Look AHEAD) randomized overweight and obese patients with type 2 diabetes to either an intensive lifestyle intervention (ILI) or diabetes support and education (DSE). The trial was stopped early for futility after a median follow-up of 9.6 years due to a lack of effect on cardiovascular disease outcomes, despite beneficial effects on metabolic control and cardiovascular risk factors. Subgroup analyses identified no subgroups based on baseline characteristics with a significant treatment effect. However, traditional simple subgroup analyses have several disadvantages compared to a multivariable risk-based approach to identify heterogeneity of treatment effects (HTE).
Purpose
To explore the possible presence of HTE of an ILI on the occurrence of major cardiovascular events (4-point MACE: nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, and death from cardiovascular causes) in overweight or obese patients with type 2 diabetes mellitus, and to identify patient characteristics associated with treatment.
Methods
In 4,901 patients from Look AHEAD, a ridge penalized Cox regression model to predict treatment effect of ILI versus DSE on the risk of MACE was derived including all possible treatment-by-covariate interaction terms. Next, the ability of the model to predict HTE was confirmed by calculating hazard ratios (HR) and absolute risk change in quartiles of predicted treatment effect, thereby leaving randomization intact. Finally, baseline patient characteristics were compared between quartiles of predicted treatment effect.
Results
During a median follow-up of 9.4 years, 799 events occurred (Fig. 1A). The derived risk model showed good internal calibration, with a C-statistic for discrimination of 0.73 (95% confidence interval [95% CI] 0.71–0.73). The median estimated absolute treatment effect on 10 year risk for MACE with ILI was −1.3% and varied substantially, ranging from −39% to +43% (Fig. 1B). In quartile 1, the quartile with the highest benefit, there was a significant treatment benefit of ILI versus DSE (HR 0.64; 95% CI 0.49–0.83), while there was no effect from treatment in quartiles 2 and 3 (HR 0.81, 95% CI 0.58–1.14, and 1.13, 95% CI 0.80–1.60, respectively), and a detrimental effect in quartile 4 (HR 1.37, 95% CI 1.09–1.73) (Fig. 1C). Patient characteristics most notably associated with higher benefit of ILI were higher age, male sex, higher socio-economic status, no history of cardiovascular disease, no use of insulin, higher blood pressure, lower HbA1c, and the presence of micro-albuminuria but absence of macro-albuminuria.
Figure 1
Conclusion
This post-hoc analysis of the Look AHEAD trial shows evidence of considerable HTE of an intensive lifestyle intervention aimed at weight loss for reducing MACE. Future research into ILI for MACE risk reduction should be specifically aimed at subgroups of patients with a high likelihood of treatment benefit.
Acknowledgement/Funding
None
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Affiliation(s)
- T I De Vries
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - J A N Dorresteijn
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands (The)
| | - F L J Visseren
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - J Westerink
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
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9
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Jaspers NEM, Visseren FLJ, Van Der Graaf Y, Damman OC, Smulders YM, Dorresteijn JAN. P646Effects of personalized therapy-effect predictions on statin treatment decisions by patients and physicians: a three-armed, blinded, randomized controlled trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Several online tools express an individual's therapy-benefit for various cardiovascular disease (CVD) prevention strategies. The benefit can be expressed in multiple formats, such as absolute 10-year CVD risk reduction or gain in CVD-free life-years. It is increasingly suggested that these estimates can be used in doctor-patient communication to support shared decision-making. However, the actual therapy-benefit to be expected from preventive therapy might be small from the perspective of patients, and it remains unclear how the estimates affect patient and physician decision-making.
Purpose
The primary objective was to determine whether communicating personalized predictions of prognosis and treatment-effects (compared to non-personalized standard practice) leads to lower decisional conflict among patients with stable CVD and prescribed statin medication.
Methods
A hypothesis-blinded, three-armed randomized controlled trial was performed in which 303 patients were randomized in a 1:1:1 ratio to either standard practice (control-group) or to one of two intervention arms. Intervention arms received personalized estimates of prognostic changes associated with both discontinuation of current statin and intensification to the most potent statin type and dose (atorvastatin 80 mg). Intervention arms differed only in the format of the treatment effect estimates: change in personal 10-year absolute CVD risk (iAR-group) or CVD-free life-expectancy (iLE-group). Primary outcome was patient decisional conflict score (DCS) after one-month, which varies from 0 (no conflict) to 100 (high conflict). Secondary outcomes were collected at one or six months: DCS, quality of life, illness perception, patient activation, patient perception of statin efficacy and shared decision-making, self-reported statin adherence, understanding of statin-therapy, post-randomization low-density lipoprotein cholesterol levels, and physician opinion of statin therapy decisions and the intervention. Outcomes are reported as median (25th–75th percentile).
Results
In the iAR group, the change in 10-year absolute CVD-risk was −2.4 (−1.2 to −3.9%) from intensification and +10.2% (+7.7 to +13.5) from discontinuation. In the iLE group, the change in CVD-free life-expectancy was +0.5 years (+0.3 to +0.8) from intensification and −2.0 years (−1.3 to −2.8) from discontinuation. Decisional conflict differed between the intervention arms: median control 27 (20–43), iAR-group 22 (11–30; p-value versus control 0.002), and iLE-group 25 (10–31; p-value versus control 0.02). No differences in secondary outcomes were observed.
Figure 1. Part of the personalized information received by iAR-group (left) and iLE-group (right).
Conclusion
In patients with clinically manifest CVD, providing personalized estimations of treatment-effects lowers decisional conflict associated with statin use. The results support the use of personalized predictions for patient decision making.
Acknowledgement/Funding
Partially funded by a Netherlands Heart Foundation grant (2016T026)
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Affiliation(s)
- N E M Jaspers
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - F L J Visseren
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands (The)
| | - O C Damman
- VU University Amsterdam, Amsterdam, Netherlands (The)
| | - Y M Smulders
- VU University Medical Center, Amsterdam, Netherlands (The)
| | - J A N Dorresteijn
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands (The)
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10
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Saratzis A, Jaspers NEM, Gwilym B, Thomas O, Tsui A, Lefroy R, Parks M, Htun V, Mera Z, Thatcher A, Bosanquet D, Forsythe R, Benson R, Dattani N, Dovell G, Lane T, Shalhoub J, Sidloff D, Visseren FLJ, Dorresteijn JAN, Richards T. Observational study of the medical management of patients with peripheral artery disease. Br J Surg 2019; 106:1168-1177. [PMID: 31259387 DOI: 10.1002/bjs.11214] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/21/2019] [Accepted: 03/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. METHODS The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. RESULTS Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. CONCLUSION The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.
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Affiliation(s)
- A Saratzis
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
| | - N E M Jaspers
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - B Gwilym
- Vascular and Endovascular Research Network, Birmingham, UK
| | - O Thomas
- Vascular and Endovascular Research Network, Birmingham, UK
| | - A Tsui
- Vascular and Endovascular Research Network, Birmingham, UK
| | - R Lefroy
- Vascular and Endovascular Research Network, Birmingham, UK
| | - M Parks
- Vascular and Endovascular Research Network, Birmingham, UK
| | - V Htun
- Vascular and Endovascular Research Network, Birmingham, UK
| | - Z Mera
- Vascular and Endovascular Research Network, Birmingham, UK
| | - A Thatcher
- Vascular and Endovascular Research Network, Birmingham, UK
| | - D Bosanquet
- Vascular and Endovascular Research Network, Birmingham, UK
| | - R Forsythe
- Vascular and Endovascular Research Network, Birmingham, UK
| | - R Benson
- Vascular and Endovascular Research Network, Birmingham, UK
| | - N Dattani
- Vascular and Endovascular Research Network, Birmingham, UK
| | - G Dovell
- Vascular and Endovascular Research Network, Birmingham, UK
| | - T Lane
- Vascular and Endovascular Research Network, Birmingham, UK
| | - J Shalhoub
- Vascular and Endovascular Research Network, Birmingham, UK
| | - D Sidloff
- Vascular and Endovascular Research Network, Birmingham, UK
| | - F L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - T Richards
- Department of Vascular Surgery, University of Western Australia, Perth, Western Australia, Australia
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11
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Berkelmans GFN, Greving JP, Van Der Graaf Y, Visseren FLJ, Dorresteijn JAN. P4388Treatment decisions based on individual estimated lifetime benefit versus individual estimated 10-year absolute risk reduction: a cost-effectiveness analyses with PCSK9 inhibition. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p4388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- G F N Berkelmans
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | - J P Greving
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands
| | - F L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
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12
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Berkelmans GFN, Franzen S, Eliasson B, Visseren FLJ, Gudbjornsdottir S, Wild S, Van Der Graaf Y, Svensson AM, Read S, Paynter NP, Dorresteijn JAN. P1533Dealing with missing patient characteristics in clinical practice when using cardiovascular prediction models. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- G F N Berkelmans
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | - S Franzen
- National Diabetes Register Centre, Gothenburg, Sweden
| | - B Eliasson
- National Diabetes Register Centre, Gothenburg, Sweden
| | - F L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | | | - S Wild
- University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, United Kingdom
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands
| | - A M Svensson
- National Diabetes Register Centre, Gothenburg, Sweden
| | - S Read
- University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, United Kingdom
| | - N P Paynter
- Harvard Medical School, Brigham and Women's Hospital, Boston, United States of America
| | - J A N Dorresteijn
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
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13
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Jaspers NEM, Blaha MJ, Matsushita K, Joeckel KH, Erbel RA, Visseren FLJ, Van Der Graaf Y, Van Der Schouw YT, Nambi V, Boer JMA, Dorresteijn JAN. 1149Development and validation of a decision-support tool for individualizing lifelong lipid, blood-pressure, and aspirin treatment in people without cardiovascular disease. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.1149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N E M Jaspers
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - M J Blaha
- Johns Hopkins University of Baltimore, Baltimore, United States of America
| | - K Matsushita
- Johns Hopkins University of Baltimore, Baltimore, United States of America
| | - K H Joeckel
- University Hospital of Essen (Ruhr), Essen, Germany
| | - R A Erbel
- University Clinic Essen, Essen, Germany
| | - F L J Visseren
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands
| | | | - V Nambi
- Baylor College of Medicine, Houston, United States of America
| | - J M A Boer
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
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14
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Dorresteijn JAN, Kaasenbrood L, Bhatt DL, Wilson PWF, D'Agostino Sr RB, Massaro JM, Van Der Graaf Y, Cramer MJM, Kappelle J, De Borst GJ, Steg PHG, Visseren FLJ. 3141Predicting life-expectancy without recurrent vascular events in patients with cardiovascular disease: the REACH-SMART model. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.3141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J A N Dorresteijn
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | - L Kaasenbrood
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | - D L Bhatt
- Brigham and Women's Hospital, Heart & Vascular Center, Boston, United States of America
| | - P W F Wilson
- Emory University Hospital, VAMC Epidemiology and Genomic Medicine and Emory Clinical Cardiovascular Research Institute, Atlanta, United States of America
| | - R B D'Agostino Sr
- Boston University, School of Public Health, Department of Biostatistics, Boston, United States of America
| | - J M Massaro
- Boston University, School of Public Health, Department of Biostatistics, Boston, United States of America
| | - Y Van Der Graaf
- University Medical Center Utrecht, Julius Centre for Health Sciences and Primary Care, Utrecht, Netherlands
| | - M J M Cramer
- University Medical Center Utrecht, Department of Cardiology, Utrecht, Netherlands
| | - J Kappelle
- University Medical Center Utrecht, Department of Neurology, Utrecht, Netherlands
| | - G J De Borst
- University Medical Center Utrecht, Department of Vascular Surgery, Utrecht, Netherlands
| | - P H G Steg
- University Paris Diderot, Hôpital Bichat, Paris, France
| | - F L J Visseren
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
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15
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Jaspers NEM, Visseren FLJ, Berkelmans GFN, Van Der Graaf Y, Spiering W, Dorresteijn JAN. P5084Added predictive value of follow-up blood-pressure measurements after alteration of therapy on cardiovascular risk in patients with hypertension. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N E M Jaspers
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - F L J Visseren
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - G F N Berkelmans
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - Y Van Der Graaf
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - W Spiering
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - J A N Dorresteijn
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
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16
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De Vries TI, Peters R, Beckett NS, Dorresteijn JAN, Westerink J, Emmelot-Vonk MH, Muller M, Van Der Graaf Y, Bulpitt CJ, Visseren FLJ. 114Estimating individual cardiovascular disease risk reduction by blood pressure lowering in elderly patients: results from the HYVET study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- T I De Vries
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - R Peters
- Imperial College London, School of Public Health, London, United Kingdom
| | - N S Beckett
- Imperial College London, Imperial Clinical Trials Unit, London, United Kingdom
| | - J A N Dorresteijn
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - J Westerink
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
| | - M H Emmelot-Vonk
- University Medical Center Utrecht, Department of Geriatrics, Utrecht, Netherlands
| | - M Muller
- VU University Medical Center, Department of Internal Medicine, Amsterdam, Netherlands
| | - Y Van Der Graaf
- Julius Health Center - Julius Gezondheidscentra, Utrecht, Netherlands
| | - C J Bulpitt
- Imperial College London, Imperial Clinical Trials Unit, London, United Kingdom
| | - F L J Visseren
- University Medical Center Utrecht, Vascular Medicine, Utrecht, Netherlands
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17
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van der Sande NGC, Dorresteijn JAN, Visseren FLJ, Dwyer JP, Blankestijn PJ, van der Graaf Y, Heerspink HLJ. Individualized prediction of the effect of angiotensin receptor blockade on renal and cardiovascular outcomes in patients with diabetic nephropathy. Diabetes Obes Metab 2016; 18:1120-1127. [PMID: 27337598 DOI: 10.1111/dom.12708] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/08/2016] [Accepted: 06/15/2016] [Indexed: 11/28/2022]
Abstract
AIMS To predict individualized treatment effects of angiotensin receptor blockers (ARBs) on cardiovascular and renal complications in order to help clinicians and patients assess the benefit of treatment (or adherence) and estimate remaining disease risk. MATERIALS AND METHODS In patients with diabetic nephropathy, the 3-year treatment effect of ARBs was predicted in terms of absolute risk reduction (ARR) for end-stage renal disease (ESRD) and cardiovascular disease (CVD; i.e. myocardial infarction, stroke, hospitalization for heart failure) and all-cause mortality. Competing-risk-adjusted proportional hazard models were developed based on the Irbesartan Diabetic Nephropathy Trial (IDNT) and externally validated in the Reduction of Endpoints NIDDM with Angiotensin II Antagonist Losartan (RENAAL) trial. RESULTS Predictors included in the model were age, sex, smoking sex, systolic blood pressure, urinary albumin/creatinine ratio, estimated glomerular filtration rate, albumin and phosphorus. The median predicted 3-year risk without treatment was 6.0% for ESRD and 28.0% for CVD and mortality. The median [interquartile range (IQR)] predicted 3-year ARR was 1.2 (0.4-3.1)% for ESRD and 2.2 (1.8-2.6)% for CVD and mortality, resulting in a combined ARR of 3.4 (2.4-5.5)%. The remaining disease risk was 4.7 (IQR 1.7-12.8)% for ESRD and 25.8% (IQR 20.3-31.9)% for CVD and mortality. CONCLUSIONS The combined effects of ARBs on ESRD and CVD and mortality in patients with diabetic nephropathy vary considerably between patients. A substantial proportion of patients remain at high risk for both outcomes despite ARB treatment.
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Affiliation(s)
- N G C van der Sande
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J P Dwyer
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - P J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Y van der Graaf
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H L J Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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18
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Abstract
Obesity-related hypertension is increasingly recognized as a distinct hypertensive phenotype requiring a modified approach to diagnosis and management. In this review rapidly evolving insights into the complex and interdependent mechanisms linking obesity to hypertension are discussed. Overweight and obesity are associated with adipose tissue dysfunction, characterized by enlarged hypertrophied adipocytes, increased infiltration by macrophages and marked changes in secretion of adipokines and free fatty acids. This results in chronic vascular inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone system and sympathetic overdrive, eventually leading to hypertension. These mechanisms may provide novel targets for anti-hypertensive drug treatment. Recognition of obesity-related hypertension as a distinct diagnosis enables tailored therapy in clinical practice. This includes lifestyle modification and accommodated choice of blood pressure-lowering drugs.
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Affiliation(s)
- J A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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