Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report from the American Heart Association and American College of Cardiology

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current US prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general US clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (eg, family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice

Antihypertensive adherence and outcomes among community-dwelling Medicare beneficiaries: the Atherosclerosis Risk in Communities Study

Rationale, aims, and objectives: Despite proven benefits for reducing incidence of major cardiac events, antihypertensive drug therapy remains underutilized in the United States. This analysis assesses antihypertensive drug adherence, utilization predictors, and associations between adherence and outcomes (a composite of cardiovascular events, Medicare inpatient payments, and inpatient days). Methods: The sample consisted of Atherosclerosis Risk in Communities Study cohort participants reporting hypertension without prevalent cardiovascular disease during 2006 to 2007 annual follow-up calls. Atherosclerosis Risk in Communities records were linked to Medicare claims through 2012. Antihypertensive medication adherence was measured as more than 80% proportion days covered by using Medicare Part D claims. Standard and hierarchical regression models were used to evaluate adjusted associations between person characteristics and adherence and between adherence and outcomes. Results: Among 1826 hypertensive participants with Part D coverage, 31.5% had no antihypertensive class with more than 80% proportion days covered in the 3 months preceding the report of hypertension in 2006 to 2007. After adjustment for confounders, positive predictors of use included female gender and diabetes; negative predictors were African-American race and current smoking. Adjusted association between receiving no therapy and a composite endpoint of cardiovascular outcomes through 2012 was not statistically significant (hazard ratio: 0.93; 95% confidence interval: 0.72, 1.22) nor was the adjusted association with Medicare inpatient days or payments (incremental difference at 48 months in payments: $1217; 95$2030, $4463). Conclusions: Despite having medical and prescription coverage, nearly a third of hypertensive participants were not adherent to antihypertensive drug therapy. Differences in clinical outcomes associated with nonadherence, though not statistically significant, were consistent with results from randomized trials. The approach provides a model framework for rigorous assessment of detailed data that are increasingly available through emerging sources

Isolated right ventricular failure in hyperthyroidism: a clinical dilemma

We present a unique case of a 42-year-old gentleman with newly diagnosed Graves’ disease and isolated right ventricular failure. Extensive evaluation to include echocardiogram and cardiac catheterization were negative for significant pulmonary hypertension or coronary artery disease as potential etiologies. Hyperthyroid induced vasospasm is a rare but reported clinical entity that serves to be a clinical and diagnostic dilemma

BNP and obesity in acute decompensated heart failure with preserved vs. reduced ejection fraction: The Atherosclerosis Risk in Communities Surveillance Study

Background Levels of B-type natriuretic peptide (BNP), a prognostic marker in patients with heart failure (HF), are lower among HF patients with obesity or preserved Left Ventricular Ejection Fraction (LVEF). We examined the distribution and prognostic value of BNP across BMI categories in acute decompensated heart failure (ADHF) patients with preserved vs. reduced LVEF. Methods We analyzed data from the Atherosclerosis Risk in Communities (ARIC) HF surveillance study which sampled and adjudicated ADHF hospitalizations in patients aged ≥ 55 years from 4 US communities (2005–2009). We examined 5 BMI categories: underweight (< 18.5 kg/m2), normal weight (18.5–<25), overweight (25–<30), obese (30–<40) and morbidly obese (≥ 40) in HF with preserved LVEF (HFpEF) and reduced LVEF (HFrEF). The outcome was 1-year mortality from admission. We used ANCOVA to model log BNP and logistic regression for 1-year mortality, both adjusted for demographics and clinical characteristics. Results The cohort included 9820 weighted ADHF hospitalizations (58% HFrEF; 42% HFpEF). BNP levels were lower in HFpEF compared to HFrEF (p < 0.001) and decreased as BMI increased within the LVEF groups (p < 0.001). After adjustment for covariates, log10 BNP independently predicted 1-year mortality (adjusted OR 1.62 (95% CI 1.17–2.24)) with no significant interaction by BMI or LVEF groups. Conclusions BNP levels correlated inversely with BMI, and were higher in HFrEF compared to HFpEF. Obese patients with HFpEF and ADHF had a significant proportion with BNP levels below clinically accepted thresholds. Nevertheless, BNP was a predictor of mortality in ADHF across groups of BMI in HFpEF and HFrEF

Applicability and Cost Implications for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Based on the ODYSSEY Outcomes Trial: Insights From the Department of Veterans Affairs

In the recently presented ODYSSEY Outcomes: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab trial, alirocumab use in patients with acute coronary syndrome (ACS) and low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dL (or non–high-density lipoprotein cholesterol ≥100 mg/dL or apolipoprotein B ≥80 mg/dL) resulted in a 15% relative (1.6% absolute) reduction in the risk of major adverse cardiovascular events. We evaluated what proportion of patients in the VA Health Care System would qualify for alirocumab on the basis of ODYSSEY Outcomes criteria, how they are currently treated with LDL-C–lowering medications, and the cost implications if other evidence-based medications were used first before a proprotein convertase subtilisin/kexin type 9 inhibitor was considered

Very High-Risk ASCVD and Eligibility for Nonstatin Therapies Based on the 2018 AHA/ACC Cholesterol Guidelines

The 2018 American Heart Association/American College of Cardiology Multisociety Cholesterol Guidelines recommend risk stratification among patients with atherosclerotic cardiovascular disease (ASCVD) to identify “very high-risk ASCVD patients.” These patients have characteristics associated with a higher risk of recurrent ASCVD events; consequently, they derive a higher net absolute benefit from addition of ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) to statin therapy. From a clinical and payer’s perspective, we assessed the proportion of patients with ASCVD who will qualify as very high-risk based on the guideline criteria, their current lipid management, and how this will change with maximizing statin therapy and stepwise use of ezetimibe before consideration for a PCSK9i, as recommended by the 2018 cholesterol guideline

High-Intensity Statins Benefit High-Risk Patients: Why and How to Do Better

Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option; if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well

Clinical significance, angiographic characteristics, and short-term outcomes in 30 patients with early coronary artery graft failure

Background: Despite technical advances in coronary artery bypass grafting (CABG), early postoperative myocardial ischaemia still remains a challenging problem. The aim of this study was to determine the incidence, clinical features, angiographic characteristics, and management of early graft failure in the present CABG era.Methods: Between January 1997 and December 2002, 1731 patients underwent CABG at our institution. Coronary angiography was performed in patients with clinical evidence of early postoperative ischaemia (≤=3 months). Thirty of these patients with graft failure constituted the population of this study.Results: Off-pump and on-pump CABG were almost evenly performed in these patients [n=16 (53%) and n=14 (47%) respectively]. Acute myocardial infarction and unstable angina were the leading indications for coronary angiography in the majority of patients [n=28 (93%)]. The most common cause of graft failure was occlusion / thrombosis [n=20 (67%)]. Percutaneous coronary intervention (PCI) was offered to the majority of patients [n=22 (73%)]. Of these patients, 14 underwent PCI to native coronary arteries, whereas eight underwent PCI to the culprit vessel. Three patients underwent reoperation, and five received medical management. Four patients (13%) died in hospital (two after redo CABG, one after unsuccessful PCI, and one patient managed medically). Two patients (7%) had nonfatal major complications (one non-ST-elevation myocardial infarction and one stroke).Conclusion: Early graft failure generally presents as acute coronary syndrome. Graft occlusion/ thrombosis is the leading cause of ischaemia. Patients with graft failure can undergo PCI with a relatively low risk, but the need for redo CABG in associated with a high mortality. (Neth Heart J 2009;17:13-7.)

Tuberculosis: do we know enough? a study of patients and their families in an out-patient hospital setting in Karachi, Pakistan

SETTING: In Pakistan approximately 5.7 million people suffer from tuberculosis, with 260000 new cases occurring every year. This study was conducted in an out-patient hospital setting in Karachi. OBJECTIVE: To explore the level of awareness about tuberculosis amongst patients and their families, and recommend strategies for increasing understanding of the disease. DESIGN: Descriptive cross-sectional survey based on a structured questionnaire using convenience sampling. RESULTS: Of the 203 patients interviewed, 131 were males. Nearly 82% knew that tuberculosis is contagious and 78% were aware that lungs are commonly affected. Almost half knew that it spreads by droplets and causes cough and that treatment is long and costly. With regard to commonly affected age and sex, however, respectively only 43% and 23% had the correct knowledge. Less than one third could identify appropriate risk factors and ways to cure and limit spread. Almost half considered tuberculosis to be a social stigma. Media emerged as the main source of information. Respondents with more than 12 years of formal education were more likely to have better knowledge. CONCLUSIONS: Further population-based studies are recommended. Misconceptions about tuberculosis need to be removed through focused health education messages. The importance of complete and appropriate treatment needs to be emphasised