Cardiovascular risk assessment and management in rheumatoid arthritis : are guidelines being followed?

Aim: The aim of the audit was to determine whether the cardiovascular risk assessment and management in rheumatoid arthritis patients at Mater Dei Hospital is in concordance with the recommendations by the European League Against Rheumatism (EULAR). Background: Patients who suffer from rheumatoid arthritis have an increased risk of morbidity and mortality from cardiovascular disease. This is due to both the high prevalence of traditional risk factors, and systemic inflammation. Method: This audit was carried out retrospectively on 91 patients by using the medical notes to collect data on demographics, co-morbidities, drug history and cardiovascular risk assessment and management over a two year period (August 2010 to July 2012). The data was then analysed in order to assess whether the management of cardiovascular risk in rheumatoid arthritis patients was in concordance with EULAR recommendations. Results: Cardiovascular risk factors were documented as follows over the two year period audited: weight in 27.5%, BMI in 0%, smoking status in 72.5%, blood pressure in 72.5%, blood glucose in 72.5% and lipid profile in 54.9%. Smoking cessation advice was given in 15.8% and advice on other lifestyle changes in 14.3%. 81.1% of hypertensive patients were on treatment recommended as first-line by the guidelines and HbA1c was adequately controlled in 85.7% of diabetic patients in whom it was monitored. Conclusion: Cardiovascular risk factors are highly prevalent in rheumatoid arthritis patients. This audit identified aspects of cardiovascular risk assessment that require improvement. This would enable a better identification of cardiovascular risk factors that could be treated in order to reduce the patients’ cardiovascular morbidity and mortality.peer-reviewe

Special Article: Physical Activity, Physical Fitness, and Cardiovascular Risk Factors in Childhood

In adults, physical activity and exercise training are associated with reduced cardiovascular morbidity and mortality, a reduced likelihood of developing adverse cardiovascular risk factors, and improved insulin sensitivity. In childhood, participation in appropriate physical activity may prevent the development of cardiovascular risk factors in the future and complement treatment of existing cardiovascular risk factors, including hypertension, dyslipidemia, and overweight. Exercise in children can also significantly improve insulin sensitivity independent of weight loss. These e fects are mediated in overweight children by increases in lean body mass relative to fat mass and associated improvements in inflammatory mediators, endothelial function, and the associated adverse hormonal milieu

Evidence on the prevalence and geographic distribution of major cardiovascular risk factors in Italy

Objective: To assess the prevalence and geographic distribution of major cardiovascular risk factors in a large community-wide sample of the Italian population. Design: A cross-sectional survey. Standardized methods were used to collect and measure cardiovascular risk factors. Data were adjusted for survey weightings. Qualitative and quantitative variables were compared with parametric and non-parametric tests, as appropriate. Setting: Towns (n 193) across different Italian regions. Subjects: Unselected adults (n 24 213; 12 626 men; 11 587 women) aged 18–98 years (mean age 56·9 (sd 15·3) years), who volunteered to participate in a community-wide screening programme over a 2 d period in 2007. Results: Overall, the prevalence of major cardiovascular risk factors was: obesity, 22·7 % (women 18·9 %, men 26·1 %); overweight, 44·7 % (women 31·6 %, men 56·7 %); hypertension, 59·6 % (women 48·3 %, men 70·0 %); dyslipidaemia, 59·1 % (women 57·7 %, men 60·3 %); diabetes, 15·3 % (women 11·2 %, men 19·0 %) and smoking, 19·8 % (women 14·0 %, men 25·2 %). We found a high prevalence of unhealthy eating habits; fruit and vegetable consumption was below the recommended range in 60 % of the study population. Ninety per cent of the study population had more than one cardiovascular risk factor and 84 % had between two and five cardiovascular risk factors. There were differences among Italian macro-areas mainly for obesity, hypertension, dyslipidaemia and diabetes. Conclusions: The study provides alarming evidence on current prevalence data for major cardiovascular risk factors in a large sample of the Italian population. Particularly, obesity and hypertension represent a relevant public health problem. There is a pressing need for effective preventive health measures which must also take into account the differences among Italian macro-areas

NSTEMI in the context of cardiovascular risk factors and co-morbidities

Mr A.N., a 59-year-old male, was referred to casualty by a health centre physician, following the complaint of two episodes of worsening exertional chest pain. He is a known case of hypertension, non-insulin-dependent diabetes mellitus and smokes 1 pack of cigarettes daily. Following appropriate investigations such as electrocardiogram (ECG), cardiac biomarkers and echocardiography, the patient was diagnosed with non-ST elevation myocardial infarction (NSTEMI). The patient is now stable on treatment; however, his overall cardiovascular risk remains high due to factors such as smoking, uncontrolled type 2 diabetes, hypertension and hypercholesterolaemia. This case highlights the importance of measuring global cardiovascular risk since this has important treatment and follow-up implications; importantly, ischaemic heart disease can be primarily or secondarily prevented through non- pharmacological or pharmacological alteration of the cardiovascular risk factors.peer-reviewe

Association of high-sensitive C-reactive protein with advanced stage beta-cell dysfunction and insulin resistance in patients with type 2 diabetes mellitus

Background: Type 2 diabetes mellitus is associated with increased cardiovascular risk. One laboratory marker for cardiovascular risk assessment is high-sensitivity C-reactive protein (hsCRP). Methods: This cross-sectional study attempted to analyze the association of hsCRP levels with insulin resistance, beta-cell dysfunction and macrovascular disease in 4270 non-insulin-treated patients with type 2 diabetes {[}2146 male, 2124 female; mean age +/- SD, 63.9 +/- 11.1 years; body mass index (BMI) 30.1 +/- 5.5 kg/m(2); disease duration 5.4 +/- 5.6 years; hemoglobin A(1c) (HbA(1c)) 6.8 +/- 1.3% ]. It consisted of a single morning visit with collection of a fasting blood sample. Observational parameters included several clinical scores and laboratory biomarkers. Results: Stratification into cardiovascular risk groups according to hsCRP levels revealed that 934 patients had low risk (hsCRP < 1 mg/L), 1369 patients had intermediate risk (hsCRP 1-3 mg/L), 1352 patients had high risk (hsCRP > 3-10 mg/ L), and 610 patients had unspecific hsCRP elevation ( > 10 mg/ L). Increased hsCRP levels were associated with other indicators of diabetes-related cardiovascular risk (homeostatic model assessment, intact proinsulin, insulin, BMI, beta-cell dysfunction, all p < 0.001), but showed no correlation with disease duration or glucose control. The majority of the patients were treated with diet (34.1%; hsCRP levels 2.85 +/- 2.39 mg/L) or metformin monotherapy (21.1%; 2.95 +/- 2.50 mg/L hsCRP). The highest hsCRP levels were observed in patients treated with sulfonylurea (17.0%; 3.00 +/- 2.43 mg/ L). Conclusions: Our results indicate that hsCRP may be used as a cardiovascular risk marker in patients with type 2 diabetes mellitus and should be evaluated in further prospective studies

Exercise, cognition and Alzheimer’s disease: More is not necessarily better

Regional hypoperfusion, associated with a reduction in cerebral metabolism, is a hallmark of Alzheimer’s disease (AD) and contributes to cognitive decline. Cerebral perfusion and hence cognition can be enhanced by exercise. The present review describes first how the effects of exercise on cerebral perfusion in AD are mediated by nitric oxide (NO) and tissue-type plasminogen activator, the release of which is regulated by NO. A conclusion of clinical relevance is that exercise may not be beneficial for the cognitive functioning of all people with dementia if cardiovascular risk factors are present. The extent to which cardiovascular risk factors play a role in the selection of older people with dementia in clinical studies will be addressed in the second part of the review in which the effects of exercise on cognition are presented. Only eight relevant studies were found in the literature, emphasizing the paucity of studies in this field. Positive effects of exercise on cognition were reported in seven studies, including two that excluded and two that included patients with cardiovascular risk factors. These findings suggest that cardiovascular risk factors do not necessarily undo the beneficial effects of exercise on cognition in cognitively impaired people. Further research is called for, in view of the limitations of the clinical studies reviewed here.

Application of non-HDL cholesterol for population-based cardiovascular risk stratification: results from the Multinational Cardiovascular Risk Consortium.

BACKGROUND: The relevance of blood lipid concentrations to long-term incidence of cardiovascular disease and the relevance of lipid-lowering therapy for cardiovascular disease outcomes is unclear. We investigated the cardiovascular disease risk associated with the full spectrum of bloodstream non-HDL cholesterol concentrations. We also created an easy-to-use tool to estimate the long-term probabilities for a cardiovascular disease event associated with non-HDL cholesterol and modelled its risk reduction by lipid-lowering treatment. METHODS: In this risk-evaluation and risk-modelling study, we used Multinational Cardiovascular Risk Consortium data from 19 countries across Europe, Australia, and North America. Individuals without prevalent cardiovascular disease at baseline and with robust available data on cardiovascular disease outcomes were included. The primary composite endpoint of atherosclerotic cardiovascular disease was defined as the occurrence of the coronary heart disease event or ischaemic stroke. Sex-specific multivariable analyses were computed using non-HDL cholesterol categories according to the European guideline thresholds, adjusted for age, sex, cohort, and classical modifiable cardiovascular risk factors. In a derivation and validation design, we created a tool to estimate the probabilities of a cardiovascular disease event by the age of 75 years, dependent on age, sex, and risk factors, and the associated modelled risk reduction, assuming a 50% reduction of non-HDL cholesterol. FINDINGS: Of the 524 444 individuals in the 44 cohorts in the Consortium database, we identified 398 846 individuals belonging to 38 cohorts (184 055 [48·7%] women; median age 51·0 years [IQR 40·7-59·7]). 199 415 individuals were included in the derivation cohort (91 786 [48·4%] women) and 199 431 (92 269 [49·1%] women) in the validation cohort. During a maximum follow-up of 43·6 years (median 13·5 years, IQR 7·0-20·1), 54 542 cardiovascular endpoints occurred. Incidence curve analyses showed progressively higher 30-year cardiovascular disease event-rates for increasing non-HDL cholesterol categories (from 7·7% for non-HDL cholesterol <2·6 mmol/L to 33·7% for ≥5·7 mmol/L in women and from 12·8% to 43·6% in men; p<0·0001). Multivariable adjusted Cox models with non-HDL cholesterol lower than 2·6 mmol/L as reference showed an increase in the association between non-HDL cholesterol concentration and cardiovascular disease for both sexes (from hazard ratio 1·1, 95% CI 1·0-1·3 for non-HDL cholesterol 2·6 to <3·7 mmol/L to 1·9, 1·6-2·2 for ≥5·7 mmol/L in women and from 1·1, 1·0-1·3 to 2·3, 2·0-2·5 in men). The derived tool allowed the estimation of cardiovascular disease event probabilities specific for non-HDL cholesterol with high comparability between the derivation and validation cohorts as reflected by smooth calibration curves analyses and a root mean square error lower than 1% for the estimated probabilities of cardiovascular disease. A 50% reduction of non-HDL cholesterol concentrations was associated with reduced risk of a cardiovascular disease event by the age of 75 years, and this risk reduction was greater the earlier cholesterol concentrations were reduced. INTERPRETATION: Non-HDL cholesterol concentrations in blood are strongly associated with long-term risk of atherosclerotic cardiovascular disease. We provide a simple tool for individual long-term risk assessment and the potential benefit of early lipid-lowering intervention. These data could be useful for physician-patient communication about primary prevention strategies. FUNDING: EU Framework Programme, UK Medical Research Council, and German Centre for Cardiovascular Research

Changes in ponderal index and body mass index across childhood and their associations with fat mass and cardiovascular risk factors at age 15

Background: Little is known about whether associations between childhood adiposity and later adverse cardiovascular health outcomes are driven by tracking of overweight from childhood to adulthood and/or by vascular and metabolic changes from childhood overweight that persist into adulthood. Our objective is to characterise associations between trajectories of adiposity across childhood and a wide range of cardiovascular risk factors measured in adolescence, and explore the extent to which these are mediated by fat mass at age 15. Methods and Findings: Using data from the Avon Longitudinal Study of Parents and Children, we estimated individual trajectories of ponderal index (PI) from 0-2 years and BMI from 2-10 years using random-effects linear spline models (N = 4601). We explored associations between PI/BMI trajectories and DXA-determined total-body fat-mass and cardiovascular risk factors at 15 years (systolic and diastolic blood pressure, fasting LDL-and HDL-cholesterol, triglycerides, C-reactive protein, glucose, insulin) with and without adjustment for confounders. Changes in PI/BMI during all periods of infancy and childhood were associated with greater DXA-determined fat-mass at age 15. BMI changes in childhood, but not PI changes from 0-2 years, were associated with most cardiovascular risk factors in adolescence; associations tended to be strongest for BMI changes in later childhood (ages 8.5-10), and were largely mediated by fat mass at age 15. Conclusion: Changes in PI/BMI from 0-10 years were associated with greater fat-mass at age 15. Greater increases in BMI from age 8.5-10 years are most strongly associated with cardiovascular risk factors at age 15, with much of these associations mediated by fat-mass at this age. We found little evidence supporting previous reports that rapid PI changes in infancy are associated with future cardiovascular risk. This study suggests that associations between early overweight and subsequent adverse cardiovascular health are largely due to overweight children tending to remain overweight