Ten-Year Risk Equations for Incident Heart Failure in Established Atherosclerotic Cardiovascular Disease Populations.

BACKGROUND: Ten-year risk equations for incident heart failure (HF) are available for the general population, but not for patients with established atherosclerotic cardiovascular disease (ASCVD), which is highly prevalent in HF cohorts. This study aimed to develop and validate 10-year risk equations for incident HF in patients with known ASCVD. METHODS AND RESULTS: Ten-year risk equations for incident HF were developed using the United Kingdom Biobank cohort (recruitment 2006-2010) including participants with established ASCVD but free from HF at baseline. Model performance was validated using the Australian Baker Heart and Diabetes Institute Biobank cohort (recruitment 2000-2011) and compared with the performance of general population risk models. Incident HF occurred in 13.7% of the development cohort (n=31 446, median 63 years, 35% women, follow-up 10.7±2.7 years) and in 21.3% of the validation cohort (n=1659, median age 65 years, 25% women, follow-up 9.4±3.7 years). Predictors of HF included in the sex-specific models were age, body mass index, systolic blood pressure (treated or untreated), glucose (treated or untreated), cholesterol, smoking status, QRS duration, kidney disease, myocardial infarction, and atrial fibrillation. ASCVD-HF equations had good discrimination and calibration in development and validation cohorts, with superior performance to general population risk equations. CONCLUSIONS: ASCVD-specific 10-year risk equations for HF outperform general population risk models in individuals with established ASCVD. The ASCVD-HF equations can be calculated from readily available clinical data and could facilitate screening and preventative treatment decisions in this high-risk group.

Differences in predictors of incident heart failure according to atherosclerotic cardiovascular disease status.

AIMS: Heart failure (HF) is a common cause of morbidity and mortality, related to a broad range of sociodemographic, lifestyle, cardiometabolic, and comorbidity risk factors, which may differ according to the presence of atherosclerotic cardiovascular disease (ASCVD). We assessed the association between incident HF with baseline status across these domains, overall and separated according to ASCVD status. METHODS AND RESULTS: We included 5758 participants from the Baker Biobank cohort without HF at baseline enrolled between January 2000 and December 2011. The primary endpoint was incident HF, defined as hospital admission or HF-related death, determined through linkage with state-wide administrative databases (median follow-up 12.2 years). Regression models were fitted adjusted for sociodemographic variables, alcohol intake, smoking status, measures of adiposity, cardiometabolic profile measures, and individual comorbidities. During 65 987 person-years (median age 59 years, 38% women), incident HF occurred among 784 participants (13.6%) overall. Rates of incident HF were higher among patients with ASCVD (624/1929, 32.4%) compared with those without ASCVD (160/3829, 4.2%). Incident HF was associated with age, socio-economic status, alcohol intake, smoking status, body mass index (BMI), waist circumference, waist-hip ratio, systolic blood pressure (SBP), and low- and high-density lipoprotein cholesterol (LDL-C and HDL-C), with non-linear relationships observed for age, alcohol intake, BMI, waist circumference, waist-hip ratio, SBP, LDL-C, and HDL-C. Risk factors for incident HF were largely consistent regardless of ASCVD status, although diabetes status had a greater association with incident HF among patients without ASCVD. CONCLUSIONS: Incident HF is associated with a broad range of baseline sociodemographic, lifestyle, cardiometabolic, and comorbidity factors, which are mostly consistent regardless of ASCVD status. These data could be useful in efforts towards developing risk prediction models that can be used in patients with ASCVD.

Association of traditional risk factors with carotid intima-media thickness and carotid plaque in asymptomatic individuals with a family history of premature cardiovascular disease.

The use of imaging to detect subclinical atherosclerosis helps to inform decision-making in people classified as having intermediate risk for cardiovascular disease (CVD). This study sought to use carotid plaque as an alternative to carotid intima media thickness (cIMT). Carotid ultrasound for assessment of cIMT and plaque was obtained in 1031 people (53 years, 61% female) with a family history of atherosclerotic CVD. The association of baseline characteristics and standard atherosclerotic risk factors (RFs) were sought with abnormal cIMT and plaque. The strongest association of plaque was a history of hypertension (odds ratio [OR] 1.87 (1.02-3.42), followed by age (OR 1.08 [95% CI 1.02-1.13]). For cIMT, the strongest association was smoking history (OR 1.57 [1.13-2.19]). The area under the receiver operator curve for the presence of plaque was 0.74 (95% CI 0.68-0.81, p < 0.001) and 0.65 (95% CI 0.61-0.70, p < 0.001) for cIMT elevation. Isolated elevation of cIMT (n = 178) was associated with increased total cholesterol, body mass index (BMI) and systolic blood pressure (SBP). Plaque only (n = 29) was associated with hypertension, male sex and older age. The presence of both markers abnormal (n = 22) was associated with a history of smoking. The absence of either abnormal cIMT or plaque (n = 773), was inversely associated with current or past smoking, SBP and BMI. Abnormalities in carotid vessels are present in a minority of intermediate risk patients with familial premature disease. The associations with RFs differ and are more closely associated with plaque.

A metabolic syndrome severity score: A tool to quantify cardio-metabolic risk factors.

Metabolic syndrome is a cluster of cardio-metabolic risk factors and is associated with increased mortality. There is no standard, validated way to assess the severity of aggregated metabolic syndrome risk factors. Cardiovascular and diabetes risk factor data came from two studies conducted in Australia from 2006 to 2010 in adults aged 18 or above. In medication free adults, sex-specific clinical thresholds and Principal Component Analysis were used to develop a formula to calculate a metabolic syndrome severity score (MetSSS). These scores were compared to scores derived using the same process in subgroups by sex, age, medication status, and time. We also examined the MetSSS in relation to other known risk factors. In 2125 adults (57.6±14.7years of age), the MetSSS ranged from 0 to 8.7 with a mean of 2.6. There were strong correlations (.95-.99) between the MetSSS in medication free adults and the MetSSS calculated from subgroups. MetSSS predicted medication initiation for hypertension, hyperlipidemia and hyperglycemia over six months (OR=1.31, 95% CI [1.00-1.70], per MetSSS unit, p=.043). Lower education, medication prescription, history of smoking and age were associated with higher MetSSS (all p<.05). Higher physical but not mental health quality of life was associated with lower MetSSS (p<.001). A standardized formula to measure cardio-metabolic risk factor severity was constructed and demonstrated expected relations with known risk factors. The use of the MetSSS is recommended as a measure of change within individuals in cardio-metabolic risk factors and to guide treatment and management.

Is There an Association between Sleeping Patterns and Other Environmental Factors with Obesity and Blood Pressure in an Urban African Population?

Beyond changing dietary patterns, there is a paucity of data to fully explain the high prevalence of obesity and hypertension in urban African populations. The aim of this study was to determine whether other environmental factors (including sleep duration, smoking and physical activity) are related to body anthropometry and blood pressure (BP). Data were collected on 1311 subjects, attending two primary health care clinics in Soweto, South Africa. Questionnaires were used to obtain data on education, employment, exercise, smoking and sleep duration. Anthropometric and BP measurements were taken. Subjects comprised 862 women (mean age 41 ± 16 years and mean BMI 29.9 ± 9.2 kg/m²) and 449 men (38 ± 14 years and 24.8 ± 8.3 kg/m²). In females, ANOVA showed that former smokers had a higher BMI (p<0.001) than current smokers, while exposure to second hand smoking was associated with a lower BMI (p<0.001) in both genders. Regression analyses demonstrated that longer sleep duration was associated with a lower BMI (p<0.05) in older females only, and not in males, whilst in males napping during the day for > 30 minutes was related to a lower BMI (ß = -0.04, p<0.01) and waist circumference (ß = -0.03, p<0.001). Within males, napping for >30 minutes/day was related to lower systolic (ß = -0.02, p<0.05) and lower diastolic BP (ß = -0.02, p = 0.05). Longer night time sleep duration was associated with higher diastolic (ß = 0.005, p<0.01) and systolic BP (ß = 0.003, p<0.05) in females. No health benefits were noted for physical activity. These data suggest that environmental factors rarely collected in African populations are related, in gender-specific ways, to body anthropometry and blood pressure. Further research is required to fully elucidate these associations and how they might be translated into public health programs to combat high levels of obesity and hypertension.

Assessing cardiovascular risk in regional areas: the Healthy Hearts Beyond City Limits program.

BACKGROUND: Cardiovascular disease (CVD) is more prevalent in regional and remote Australia compared to metropolitan areas. The aim of Healthy Hearts was to determine age and sex specific CVD risk factor levels and the potential value of national risk clinics. METHODS: Healthy Hearts was an observational research study conducted in four purposefully selected higher risk communities in regional Victoria, Australia. The main outcome measures were the proportion of participants with CVD risk factors with group comparisons to determine the adjusted likelihood of elevated risk factor levels. Trained personnel used a standardized protocol over four weeks per community to measure CVD risk factor levels, estimate absolute CVD risk and provide feedback and advice. RESULTS: A total of 2125 self-selected participants were assessed (mean age 58 ± 15 years, 57% women). Overall, CVD risk factors were highly prevalent. More men than women had ≥ 2 modifiable CVD risk factors (76% vs. 68%, p < .001), pre-existing CVD (20 vs. 15%, p < .01) and a major ECG abnormality requiring follow-up (15% vs. 7%, p < .001) . Less men reported depressive symptoms compared to women (28% vs. 22%, p < .01). A higher proportion of women were obese (adjusted OR 1.36, 95% CI 1.13 to 1.63), and physically inactive (adjusted OR 1.32, 95% CI 1.07 to 1.63). CONCLUSIONS: High CVD risk factor levels were confirmed for regional Victoria. Close engagement with individuals and communities provides scope for the application of regional risk management clinics to reduce the burden of CVD risk in regional Australia.

Heart failure, ventricular dysfunction and risk factor prevalence in Australian Aboriginal peoples: the Heart of the Heart Study.

BACKGROUND: Limited strategies have been developed to evaluate and address the alarming discrepancy in early mortality between Indigenous and non-Indigenous populations. OBJECTIVE: To assess heart failure (HF), HF risk factors and document cardiac characteristics in an Australian Aboriginal population. DESIGN, SETTING, PARTICIPANTS: Adults were enrolled across six Aboriginal communities in Central Australia. They undertook comprehensive cardiovascular assessments, including echocardiography, to determine HF status, asymptomatic ventricular dysfunction and underlying risk factor profile. RESULTS: Of 436 participants (mean age 44±14 years; 64% women) enrolled, 5.3% (95% CI 3.2% to 7.5%) were diagnosed with HF, only 35% of whom had a pre-existing HF diagnosis. Asymptomatic left ventricular dysfunction (ALVD) was seen in 13% (95% CI 9.4% to 15.7%) of the population. Estimates of HF risk factor prevalence were as follows: body mass index (BMI) ≥30 kg/m(2) 42%, hypertension 41%, diabetes mellitus 40%, coronary artery disease (CAD) 7% and history of acute rheumatic fever or rheumatic heart disease 7%. In logistic regression analysis (after adjustment for age and gender), HF was associated with CAD (OR=9.6, p<0.001), diabetes (OR=5.4, p=0.002), hypertension (OR=4.8, p=0.006), BMI ≥30 kg/m(2) (OR=2.9, p=0.02), acute rheumatic fever or rheumatic heart disease (OR=5.6, p=0.001) and B-type natriuretic peptide (OR=1.02, p<0.001). CONCLUSION: The burden of HF, ALVD and risk factors in this population was extremely high. This study highlights potentially modifiable targets on which to focus resources and screening strategies to prevent HF in this high-risk Indigenous population.

Exploring the potential to remain "Young @ Heart": initial findings of a multi-centre, randomised study of nurse-led, home-based intervention in a hybrid health care system.

BACKGROUND: Disease management programs have been shown to improve health outcomes in high risk individuals in many but not all health care systems. METHODS: Young @ Heart is a multi-centre, randomised controlled study of a nurse-led, home-based intervention (HBI) program vs. usual care (UC) in privately insured patients in Australia aged ≥ 45 years following an acute cardiac admission. Intensity of HBI is tailored to an individual's clinical stability, management and risk profile. The primary endpoint is the rate of all-cause stay during a mean of 2.5 years follow-up. RESULTS: A target of 602 adults (72% men) were randomised to HBI (n=306) or UC (n=296); their initial profiles being well matched. At baseline, 71% were overweight (body mass index 29.7 ± 3.9 kg/m(2)) and 66% had an elevated blood pressure (153 ± 18/89 ± 7 mm Hg). Over half had a history of smoking and 39% had a sub-optimal total cholesterol level >4 mmol/L. Overall, 62% (376 cases) were treated for coronary artery disease (27% with multi-vessel disease and 39% underwent cardiac revascularisation). A further 20% (120 cases) were treated for a cardiac arrhythmia (predominantly atrial fibrillation) and 19% type 2 diabetes mellitus. At 7-14 days post-discharge, 293 (96%) HBI patients received a home visit triggering urgent clinical review and/or enhanced clinical management in many patients. CONCLUSIONS: The Young @ Heart intervention is a well accepted and potentially effective intervention to reduce recurrent hospital stay in privately insured cardiac patients in Australia.

Pattern of blood pressure in Australian adults: results from a national blood pressure screening day of 13,825 adults.

BACKGROUND: Recent national data of cardiovascular disease (CVD) risk factors in Australia are limited. Therefore this study sought to gain a contemporary snapshot of the blood pressure (BP) profile of Australian adults. METHODS: We established 100 metropolitan and regional screening sites. Using a standardized protocol and the same automated, validated BP monitor, Registered Nurses recorded the BP and other risk factors for CVD of self-selected volunteers on a single day. RESULTS: A total of 13,825 subjects (55% female, aged 48±16 years) were assessed. Mean systolic and diastolic BP was 131±18 and 79±12 mm Hg. Overall, 34% had an elevated BP while 10% being treated for hypertension (HT) were normotensive (combined total 44%). Elevated BP was more common in older individuals, men (42% versus 27% of women), regional dwelling residents (40% versus 32% of metropolitan) and people from lower socio-economic backgrounds (39% versus 30% of higher). Overall, 50% of subjects with a history of HT had elevated BP compared to 30% without a history of HT. Adjusting for age and sex, elevated BP was independently associated with obesity (OR: 1.77, 95% CI 1.52-2.06), regional location (OR: 1.32, 95% CI 1.19-1.45) and modifiable risk factors (OR: 1.28, 95% CI 1.21-1.35); those being treated for CVD or diabetes are less likely to have high BP. CONCLUSIONS: In the largest study of its kind in Australia, the findings highlight the need for continued vigilance to detect, monitor and prevent elevated BP within an ageing population in whom metabolic disorders are becoming more frequent.