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Kong N, Sakhuja S, Colantonio LD, Levitan EB, Lloyd-Jones DM, Cushman M, Muntner P, Polonsky TS. Atherosclerotic cardiovascular disease events among adults with high predicted risk without established risk factors. Am J Prev Cardiol 2024; 17:100612. [PMID: 38125204 PMCID: PMC10730342 DOI: 10.1016/j.ajpc.2023.100612] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 10/27/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Objective Age is the strongest contributor to 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk. Some older adults have a predicted ASCVD risk ≥7.5 %, without established risk factors. We sought to compare ASCVD incidence among adults with predicted ASCVD risk ≥7.5 %, with and without established ASCVD risk factors, to adults with predicted risk <7.5 %. Methods We analyzed data from REasons for Geographic and Racial Differences in Stroke study participants, 45-79 years old, without ASCVD or diabetes, not taking statins and with low-density lipoprotein cholesterol 70-189 mg/dL. Participants were categorized into 3 groups based on their 10-year predicted ASCVD risk and presence of established risk factors: <7.5 %, ≥7.5 % with established risk factors and ≥7.5 % without established risk factors. Established risk factors included smoking, systolic blood pressure ≥130 mmHg or antihypertensive medication use, total cholesterol ≥200 mg/dL, or high-density lipoprotein cholesterol <50 mg/dL for women (<40 mg/dL for men). Participants were followed for ASCVD events. Results Among 11,115 participants, 911 incident ASCVD events occurred over a median of 11.1 years. ASCVD incidence rates were 3.6, 12.8, and 9.8 per 1,000 person-years for participants with predicted risk <7.5 %, predicted risk ≥7.5 % with established risk factors and predicted risk ≥7.5 % without established risk factors, respectively. Compared to adults with predicted risk <7.5 %, hazard ratios for incident ASCVD in participants with risk ≥7.5 % with and without established risk factors were 3.58 (95 %CI 3.03 - 4.21) and 2.72 (95 %CI 1.91-3.88), respectively. Conclusions Adults with a 10-year predicted ASCVD risk ≥7.5 % but without established risk factors had a high ASCVD incidence.
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Affiliation(s)
- Nathan Kong
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Swati Sakhuja
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Lisandro D. Colantonio
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Emily B. Levitan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Donald M. Lloyd-Jones
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Paul Muntner
- Office of Science, Center for Disease Control and Prevention, Atlanta, GA, United States
| | - Tamar S. Polonsky
- Department of Medicine, University of Chicago, Chicago, IL, United States
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Wetscherek MTA, McNaughton E, Majcher V, Wetscherek A, Sadler TJ, Alsinbili A, Teh WH, Moore SD, Patel N, Smith WPW, Krishnan U. Incidental coronary artery calcification on non-gated CT thorax correlates with risk of cardiovascular events and death. Eur Radiol 2023:10.1007/s00330-023-09428-z. [PMID: 36705681 PMCID: PMC9881510 DOI: 10.1007/s00330-023-09428-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To assess coronary artery calcification (CAC) on non-contrast non-ECG-gated CT thorax (NC-NECG-CTT) and to evaluate its correlation with short-term risk of cardiovascular disease (CVD) events and death. METHODS Single-institution retrospective study including all patients 40-70 years old who underwent NC-NECG-CTT over a period of 6 months. Individuals with known CVD were excluded. The presence of CAC was assessed and quantified by the Agatston score (CACS). CAC severity was defined as mild (< 100), moderate (100-400), or severe (> 400). CVD events (including CVD death, myocardial infarction, revascularisation procedures, ischaemic stroke, acute peripheral atherosclerotic ischaemia), and all-cause mortality over a median of 3.5 years were recorded. Cox proportional-hazards regression modelling was performed including CACS, age, gender and CVD risk factors (smoking, hypertension, diabetes mellitus, dyslipidaemia, and family history of CVD). RESULTS Of the total 717 eligible cases, 325 (45%) had CAC. In patients without CAC, there was only one CVD event, compared to 26 CVD events including 5 deaths in patients with CAC. The presence and severity of CAC correlated with CVD events (p < 0.001). A CACS > 100 was significantly associated with both CVD events, hazard ratio (HR) 5.74, 95% confidence interval: 2.19-15.02; p < 0.001, and all-cause mortality, HR 1.7, 95% CI: 1.08-2.66; p = 0.02. Ever-smokers with CAC had a significantly higher risk for all-cause mortality compared to never-smokers (p = 0.03), but smoking status was not an independent predictor for CVD events in any subgroup category of CAC severity. CONCLUSIONS The presence and severity of CAC assessed on NC-NECG-CTT correlates with short-term cardiovascular events and death. KEY POINTS • Patients aged 40-70 years old without known CVD but with CAC on NC-NECG-CTT have a higher risk of CVD events compared to those without CAC. • CAC (Agatston) score above 100 confers a 5.7-fold increase in the risk of short-term CVD events in these patients. • The presence and severity of CAC on NC-NECG-CTT may have prognostic and therapeutic implications.
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Affiliation(s)
- Maria T A Wetscherek
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - Edwina McNaughton
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
| | - Veronika Majcher
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Andreas Wetscherek
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Rd, London, SM2 5NG, UK
| | - Timothy J Sadler
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Ahmed Alsinbili
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
| | - Wen Hui Teh
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
| | - Samuel D Moore
- School of Clinical Medicine, University of Cambridge, Hills Rd, Cambridge, CB2 0SP, UK
| | - Nirav Patel
- School of Clinical Medicine, University of Cambridge, Hills Rd, Cambridge, CB2 0SP, UK
| | - William P W Smith
- School of Clinical Medicine, University of Cambridge, Hills Rd, Cambridge, CB2 0SP, UK
| | - Unni Krishnan
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Trumpington, Cambridge, CB2 0AY, UK
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Denby KJ, Cho L, Toljan K, Patil M, Ferrando CA. Assessment of Cardiovascular Risk in Transgender Patients Presenting for Gender-Affirming Care. Am J Med 2021; 134:1002-8. [PMID: 33895118 DOI: 10.1016/j.amjmed.2021.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND The transgender population is rapidly growing in the United States and abroad. Transgender men and women are marginalized as a result of their transgender status, with resultant health repercussions. This and other factors such as increased substance use, mental health disorders, violence, and chronic stress may place transgender individuals at higher risk for cardiovascular disease. Additionally, many transgender patients pursue gender-affirming hormone therapy, which has been linked to increased rates of some cardiovascular events such as metabolic syndrome, venous thromboembolism, and stroke. Despite the likelihood of elevated cardiovascular risk in this population, there is a paucity of published data about the cardiovascular risk of this population. METHODS We present baseline cardiovascular data from a transgender population at a large tertiary care center prior to the initiation of hormone therapy. RESULTS The described transgender population had much higher rates of mental health disorders and substance use than the general population. Furthermore, there were high rates of undiagnosed and untreated comorbidities, such as hypertension and dyslipidemia, that increase risk for cardiovascular disease. Baseline risk assessment using the ASCVD (Atherosclerotic Cardiovascular Disease) and QRISK3 calculators showed higher-than-expected cardiovascular risk, particularly given the young age of our patient population. CONCLUSIONS Transgender individuals are at high baseline cardiovascular risk. These data help fill some important knowledge gaps in this patient subgroup, and provide us with much-needed data to help guide our management and counseling of individuals seeking this type of care.
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Samuel R, Birdsey G, Amerena J. Prevalence of Familial Hypercholesterolaemia in Acute Coronary Syndrome Patients in a Large Regional Coronary Care Unit. Heart Lung Circ 2020; 30:730-733. [PMID: 33132051 DOI: 10.1016/j.hlc.2020.09.929] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 08/26/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Familial hypercholesterolaemia (FH) is an under recognised cause of coronary artery disease, despite the proven reductions in risk with early detection and treatment. METHODS Data from 180 consecutive patients presenting to a large regional hospital with acute coronary syndrome were collected. Potential FH was assessed using the Dutch Lipid Clinic Network Criteria (DLCNC), and if patients were on statins, pre-treatment cholesterol was estimated according to a validated algorithm. RESULTS Ninety per cent (90%) of patients presented with non-ST elevation myocardial infarction (NSTEMI) or ST elevation myocardial infarction (STEMI). A total of 11 patients (6%) were classified as having phenotypic FH. The phenotypic FH cohort was younger (mean age 53.1 vs 62.0, p=0.011); and more likely to have documented ischaemic heart disease (63.6% vs 20.7%, p=0.001). PHENOTYPIC FH PATIENTS Familial hypercholesterolaemia patients had a higher rate of ezetimibe use (18.2% vs 2.4%, p=0.005), but fibrate use was not significantly different. Phenotypic FH patients also had higher levels of total cholesterol, corrected LDL and triglycerides, but no statistically significant difference in HDL levels compared with non-FH counterparts. CONCLUSIONS The prevalence of FH is relatively high among patients presenting with acute coronary syndromes. This has now been established in a regional Australian population, with similar prevalence to large European registries. This highlights the need for improved access to specialised services in regional and rural areas to reduce adverse cardiovascular (CV) outcomes.
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Affiliation(s)
- Rohit Samuel
- Department of Cardiology, Barwon Heath, Geelong, Vic, Australia.
| | - Garth Birdsey
- Department of Cardiology, Barwon Heath, Geelong, Vic, Australia; Faculty of Health, Deakin University, Melbourne, Vic, Australia
| | - John Amerena
- Department of Cardiology, Barwon Heath, Geelong, Vic, Australia; Faculty of Health, Deakin University, Melbourne, Vic, Australia
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Alder M, Bavishi A, Zumpf K, Peterson J, Stone NJ. A Meta-Analysis Assessing Additional LDL-C Reduction from Addition of a Bile Acid Sequestrant to Statin Therapy. Am J Med 2020; 133:1322-1327. [PMID: 32416177 DOI: 10.1016/j.amjmed.2020.03.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Statins are the first-line therapy for reducing low-density lipoprotein cholesterol (LDL-C). However, there are secondary prevention patients who are either intolerant to maximal statin therapy or do not get adequate effects from a high-intensity statin. While data exist for the additional LDL-C-lowering effects of ezetimibe, there are no data on additional LDL-C lowering of bile acid sequestrants when combined with statin therapy. The purpose of this study was to quantify the LDL-C-lowering effects of bile acid sequestrants when added to statin therapy. METHODS Databases (Medline via PubMed, Embase, and the Cochrane Library) were searched for randomized controlled trials comparing statin therapy to statin therapy with the addition of bile acid sequestrants. Nine studies were included in the meta-analysis. A meta-regression was performed to estimate the mean difference in LDL-C between the 2 groups. RESULTS Without controlling for other variables, data suggest that combining statin with bile acid sequestrant increases the percentage change in LDL-C by 16.2 points, on average, compared with statin use alone. CONCLUSION In patients unable to tolerate an adequate statin dosage, bile acid sequestrants offer a viable alternative with additional LDL-C-lowering benefit.
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Ambrose JA, Najafi A. Strategies for the Prevention of Coronary Artery Disease Complications: Can We Do Better? Am J Med 2018; 131:1003-1009. [PMID: 29729244 DOI: 10.1016/j.amjmed.2018.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
Billions of dollars have been spent over the past 25 years on developing new therapies for the prevention/treatment of adverse cardiac events related to atherosclerotic cardiovascular disease. Although some therapies have been lifesaving, several mega-randomized studies have shown only a <2% absolute reduction in adverse events with a large residual event rate. Is all this money well spent? Atherosclerosis develops decades before an adverse event, and the trials previously alluded to have nearly always been applied to secondary prevention, decades after disease initiation. Will earlier intervention result in a lower incidence of events? Individuals with an absence of the usual cardiac risk factors have a lifelong low incidence of events. Early initiation of strategies against the common cardiovascular risk factors in primary or primordial prevention will lower the incidence of adverse events, although many groups have not been well studied, including individuals younger than 40 years of age. New strategies are required to realize a radical reduction in events, and this article proposes new methods of prevention/treatment for coronary artery disease complications.
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Affiliation(s)
| | - Amir Najafi
- University of California San Francisco, Fresno
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Kirke AB, Barbour RA, Burrows S, Bell DA, Vickery AW, Emery J, Watts GF. Systematic detection of familial hypercholesterolaemia in primary health care: a community based prospective study of three methods. Heart Lung Circ 2014; 24:250-6. [PMID: 25445428 DOI: 10.1016/j.hlc.2014.09.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 09/17/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Familial hypercholesterolaemia (FH), a co-dominantly inherited disease of cholesterol that markedly increases risk of premature coronary artery disease (CAD), is significantly under-diagnosed. Primary health care is increasingly seen as a setting in which to increase the detection rate of index cases. We report a prospective study of three methods of case detection using pre-existing primary health care services in one community. METHODS Three methods of case detection were tested: pathology laboratory database search, workplace health checks and general practice database search. People identified at risk by each of the three screening methods were offered detailed assessment for FH using the Dutch Lipid Clinic Network Criteria score (DLCNCS). RESULTS 1316 participants underwent detailed assessment for FH. The proportion of at risk people identified for further assessment was in decreasing order: GP (659 of 2494, 26.4%), workplace assessment (60 of 268, 22.4%) and pathology database (597 of 4517, 13.2%) p<0.001. Eight-six (6.5%) were identified as clinical FH (DLCNCS>5) of which 59 had genetic testing and 11 of 59, 18.6%, were confirmed to have a mutation causing FH. Pathology database detected the greatest number of clinical FH (51 of 86, 59.3%) and mutation positive participants (8 of 11, 72.7%). CONCLUSION Screening within primary health care was successful in detecting participants with FH. An integrated case detection model combining screening of pathology and GP databases is proposed.
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Affiliation(s)
- Andrew B Kirke
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia.
| | - Rita A Barbour
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Sally Burrows
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia
| | - Damon A Bell
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia; Department of Clinical Biochemistry, PathWest Royal Perth Hospital, Perth, Australia
| | - Alistair W Vickery
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Jon Emery
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia; General Practice and Primary Care Academic Centre, University of Melbourne, Melbourne, Australia
| | - Gerald F Watts
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia; Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, Perth, Australia
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Bell DA, Kirke AB, Barbour R, Southwell L, Pang J, Burrows S, Watts GF. Can patients be accurately assessed for familial hypercholesterolaemia in primary care? Heart Lung Circ 2014; 23:1153-7. [PMID: 25065543 DOI: 10.1016/j.hlc.2014.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/13/2014] [Accepted: 06/18/2014] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Familial Hypercholesterolaemia (FH) is the most prevalent monogenic condition causing premature coronary artery disease, although the majority of individuals remain undiagnosed. We sought to investigate whether individuals with FH could be accurately identified in primary care. METHODS The Dutch Lipid Clinic Network Criteria scores (DLCNCS) assessed by general practitioners (GPs) were compared with DLCNCS assessed by specialists using primary care data in 153 individuals. Thirty individuals with DLCNCS ≥4 underwent specialist review and genetic testing. Clinical FH was defined as DLCNCS ≥6, encompassing the probable and definite FH categories. RESULTS GPs correctly classified 39 (86.7%) individuals with 'clinical FH', and 32 (94%) with 'unlikely FH' relative to specialists. Lin's concordance correlation coefficient was high (0.832 (0.783 - 0.881), p< 0.001) between specialist and GPs, with an overall agreement of 83.6%, κ 0.744 (0.642 - 0.831). After specialist review, 15 individuals (50%) were diagnosed with clinical FH, four (26.7%) had FH mutations. GPs correctly classified 12 (80%) of these individuals with clinical FH. CONCLUSION GPs can accurately identify individuals at high and low risk of FH using the DLCNCS, which may augment opportunistic FH detection in the community. Increased education may enhance the diagnostic accuracy of FH in primary care.
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Affiliation(s)
- Damon A Bell
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia; Cardiometabolic Service, Department of Internal Medicine, Royal Perth Hospital, Perth, Australia; Familial Hypercholesterolaemia Western Australia (FHWA), Royal Perth Hospital, Perth, Australia; Department of Clinical Biochemistry, PathWest Royal Perth Hospital, Perth, Australia.
| | - Andrew B Kirke
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Rita Barbour
- School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Lynda Southwell
- Familial Hypercholesterolaemia Western Australia (FHWA), Royal Perth Hospital, Perth, Australia
| | - Jing Pang
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia; Familial Hypercholesterolaemia Western Australia (FHWA), Royal Perth Hospital, Perth, Australia
| | - Sally Burrows
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia
| | - Gerald F Watts
- School of Medicine & Pharmacology, University of Western Australia, Perth, Australia; Cardiometabolic Service, Department of Internal Medicine, Royal Perth Hospital, Perth, Australia; Familial Hypercholesterolaemia Western Australia (FHWA), Royal Perth Hospital, Perth, Australia
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