Artificial intelligence-based classification of cardiac autonomic neuropathy from retinal fundus images in patients with diabetes: The Silesia Diabetes Heart Study.

BACKGROUND: Cardiac autonomic neuropathy (CAN) in diabetes mellitus (DM) is independently associated with cardiovascular (CV) events and CV death. Diagnosis of this complication of DM is time-consuming and not routinely performed in the clinical practice, in contrast to fundus retinal imaging which is accessible and routinely performed. Whether artificial intelligence (AI) utilizing retinal images collected through diabetic eye screening can provide an efficient diagnostic method for CAN is unknown. METHODS: This was a single center, observational study in a cohort of patients with DM as a part of the Cardiovascular Disease in Patients with Diabetes: The Silesia Diabetes-Heart Project (NCT05626413). To diagnose CAN, we used standard CV autonomic reflex tests. In this analysis we implemented AI-based deep learning techniques with non-mydriatic 5-field color fundus imaging to identify patients with CAN. Two experiments have been developed utilizing Multiple Instance Learning and primarily ResNet 18 as the backbone network. Models underwent training and validation prior to testing on an unseen image set. RESULTS: In an analysis of 2275 retinal images from 229 patients, the ResNet 18 backbone model demonstrated robust diagnostic capabilities in the binary classification of CAN, correctly identifying 93% of CAN cases and 89% of non-CAN cases within the test set. The model achieved an area under the receiver operating characteristic curve (AUCROC) of 0.87 (95% CI 0.74-0.97). For distinguishing between definite or severe stages of CAN (dsCAN), the ResNet 18 model accurately classified 78% of dsCAN cases and 93% of cases without dsCAN, with an AUCROC of 0.94 (95% CI 0.86-1.00). An alternate backbone model, ResWide 50, showed enhanced sensitivity at 89% for dsCAN, but with a marginally lower AUCROC of 0.91 (95% CI 0.73-1.00). CONCLUSIONS: AI-based algorithms utilising retinal images can differentiate with high accuracy patients with CAN. AI analysis of fundus images to detect CAN may be implemented in routine clinical practice to identify patients at the highest CV risk. TRIAL REGISTRATION: This is a part of the Silesia Diabetes-Heart Project (Clinical-Trials.gov Identifier: NCT05626413).

Erythrocyte membrane fluidity: A novel biomarker of residual cardiovascular risk in type 2 diabetes.

AIMS: Improving the composition of circulating fatty acids (FA) leads to a reduction in cardiovascular diseases (CVD) in high-risk individuals. The membrane fluidity of red blood cells (RBC), which reflects circulating FA status, may be a valid biomarker of cardiovascular (CV) risk in type 2 diabetes (T2D). METHODS: Red blood cell membrane fluidity, quantified as general polarization (GP), was assessed in 234 subjects with T2D, 86 with prior major CVD. Based on GP distribution, a cut-off of .445 was used to divide the study cohort into two groups: the first with higher GP, called GEL, and the second, defined as lower GP (LGP). Lipidomic analysis was performed to evaluate FA composition of RBC membranes. RESULTS: Although with comparable CV risk factors, the LGP group had a greater percentage of patients with major CVD than the GEL group (40% vs 24%, respectively, p < .05). Moreover, in a logistic regression analysis, a lower GP value was independently associated with the presence of macrovascular complications. Lipidomic analysis showed a clear shift of LGP membranes towards a pro-inflammatory condition due to higher content of arachidonic acid and increased omega 6/omega 3 index. CONCLUSIONS: Increased membrane fluidity is associated with a higher CV risk in subjects with T2D. If confirmed in prospective studies, membrane fluidity could be a new biomarker for residual CV risk assessment in T2D.

Performance of the non-laboratory based 2019 WHO cardiovascular disease risk prediction chart in Eastern Sub-Saharan Africa.

BACKGROUND AND AIMS: The World Health Organization (WHO) updated its cardiovascular disease (CVD) risk prediction charts in 2019 to cover 21 global regions. We aimed to assess the performance of an updated non-lab-based risk chart for people with normoglycaemia, impaired fasting glucose (IFG), and diabetes in Eastern Sub-Saharan Africa. METHODS AND RESULTS: We used data from six WHO STEPS surveys conducted in Eastern Sub-Saharan Africa between 2012 and 2017. We included 9857 participants aged 40-69 years with no CVD history. The agreement between lab- and non-lab-based charts was assessed using Bland-Altman plots and Cohen's kappa. The median age of the participants was 50 years (25-75th percentile: 44-57). The pooled median 10-year CVD risk was 3 % (25-75th percentile: 2-5) using either chart. According to the estimation, 7.5 % and 8.4 % of the participants showed an estimated CVD risk ≥10 % using the non-lab-based chart or the lab-based chart, respectively. The concordance between the two charts was 91.3 %. The non-lab-based chart underestimated the CVD risk in 57.6 % of people with diabetes. In the Bland-Altman plots, the limits of agreement between the two charts were widest among people with diabetes (-0.57-7.54) compared to IFG (-1.75-1.22) and normoglycaemia (-1.74-1.06). Kappa values of 0.79 (substantial agreement), 0.78 (substantial agreement), and 0.43 (moderate agreement) were obtained among people with normoglycaemia, IFG, and diabetes, respectively. CONCLUSIONS: Given limited healthcare resources, the updated non-lab-based chart is suitable for CVD risk estimation in the general population without diabetes. Lab-based risk estimation is suitable for individuals with diabetes to avoid risk underestimation.

Prevalence of interarm blood pressure difference is notably higher in women; the Viborg population-based screening program (VISP).

BACKGROUND: Bilateral blood pressure (BP) measurement is important in cardiovascular prevention for identifying systolic interarm BP difference (IAD) and hypertension. We investigated sex-stratified IAD prevalence and its associations and coexistence with screen-detected peripheral atherosclerosis and hypertension. Furthermore, we determined the proportion misclassified as non-hypertensive when using the lower versus the higher reading arm. METHODS: This sub-study formed part of the Viborg Screening Program (VISP), a cross-sectorial population-based cardiovascular screening programme targeting 67-year-old Danes. VISP includes screening for peripheral atherosclerosis (lower extremity arterial disease and carotid plaque), abdominal aortic aneurysm, hypertension, diabetes mellitus, and cardiac disease. Self-reported comorbidities, risk factors, and medication use were also collected. Among 4,602 attendees, 4,517 (82.1%) had eligible bilateral and repeated BP measurements. IAD was defined as a systolic BP difference ≥ 10 mmHg. IAD-associated factors (screening results and risk factors) were estimated by logistic regression; proportional coexistence was displayed by Venn diagrams (screening results). RESULTS: We included 2,220 women (49.2%) and 2,297 men (50.8%). IAD was more predominant in women (26.8%) than men (21.0%) (p < 0.001). This disparity persisted after adjustment [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.32-1.77]. No other association was recorded with the conditions screened for, barring potential hypertension: BP 140-159/90-99 mmHg (OR 1.68, 95% CI 1.44-1.97) and BP ≥ 160/100 mmHg (OR 1.82, 95% CI 1.49-2.23). Overall, IAD and BP ≥ 160/100 mmHg coexistence was 4% in women and 5% in men; for BP ≥ 140/90 mmHg, 13% and 14%, respectively. Among those recording a mean BP ≥ 140/90 mmHg in the higher reading arm, 14.5% of women and 15.3% of men would be misclassified as non-hypertensive compared with the lowest reading arm. CONCLUSION: Female sex was an independent factor of IAD prevalence but not associated with other arterial lesions. Approximately 15% needed reclassification according to BP ≥ 140/90 mmHg when the lower rather than the higher reading arm was used; verifying bilateral BP measurements improved detection of potential hypertension. In future, the predictive value of sex-stratified IAD should be assessed for cardiovascular events and death to verify its potential as a screening tool in population-based cardiovascular screening. TRIAL REGISTRATION FOR VISP: NCT03395509:10/12/2018.

Cardiovascular risk assessment methods yield unequal risk predictions: a large cross-sectional study in psychiatric secondary care outpatients.

BACKGROUND: Patients with a mental illness are more likely to develop, and die from, cardiovascular diseases (CVD), necessitating optimal CVD-risk (CVR)-assessment to enable early detection and treatment. Whereas psychiatrists use the metabolic syndrome (MetS)-concept to estimate CVR, GPs use absolute risk-models. Additionally, two PRIMROSE-models have been specifically designed for patients with severe mental illness. We aimed to assess the agreement in risk-outcomes between these CVR-methods. METHODS: To compare risk-outcomes across the various CVR-methods, we used somatic information of psychiatric outpatients from the PHAMOUS-, and MOPHAR-database, aged 40-70 years, free of past or current CVD and diabetes. We investigated: (1) the degree-of-agreement between categorical assessments (i.e. MetS-status vs. binary risk-categories); (2) non-parametric correlations between the number of MetS-criteria and absolute risks; and (3) strength-of-agreement between absolute risks. RESULTS: Seven thousand twenty-nine measurements of 3509 PHAMOUS-patients, and 748 measurements of 748 MOPHAR-patients, were included. There was systematic disagreement between the categorical CVR-assessments (all p < 0.036). Only MetS-status versus binary Framingham-assessment had a fair strength-of-agreement (κ = 0.23-0.28). The number of MetS-criteria and Framingham-scores, as well as MetS-criteria and PRIMROSE lipid-scores, showed a moderate-strong correlation (τ = 0.25-0.34). Finally, only the continuous PRIMROSE desk and lipid-outcomes showed moderate strength-of-agreement (ρ = 0.91). CONCLUSIONS: The varying methods for CVR-assessment yield unequal risk predictions, and, consequently, carry the risk of significant disparities regarding treatment initiation in psychiatric patients. Considering the significantly increased health-risks in psychiatric patients, CVR-models should be recalibrated to the psychiatric population from adolescence onwards, and uniformly implemented by health care providers. TRIAL REGISTRATION: The MOPHAR research has been prospectively registered with the Netherlands Trial Register on 19th of November 2014 (NL4779).

NT-proBNP level as a substitute for myocardial perfusion scan in preoperative cardiovascular risk assessment in noncardiac surgery.

BACKGROUND: Preoperative cardiovascular risk assessment is one of the main principles before noncardiac surgeries. Cardiac stress imaging, such as myocardial perfusion scan (MPS), is a proposed cardiovascular risk evaluation method according to the latest guidelines. Yet, its efficacy, along with the cost-effectiveness of the method, has been questioned in previous studies. Our study aims to evaluate the utility of N-terminal pro-b-type natriuretic peptide (NT-proBNP) level measurement in predicting postoperative cardiovascular complications in candidates who have undergone an MPS before surgery and compare the results. METHODS: A cohort of 80 patients with a revised cardiac risk index score of one or more who were scheduled for moderate to high-risk noncardiac surgeries and met the criteria to undergo an MPS for risk assessment were included in the study. All of them underwent an MPS one week before surgery. Their preoperative NT-proBNP, troponin levels, and electrocardiograms were obtained one day before surgery and again on day three postoperative. The predictive efficacy of NT-proBNP levels and MPS were compared. RESULTS: Seventy-eight patients underwent surgery, three of which exhibited a rise in troponin level, six showed changes on electrocardiogram, and pulmonary edema was detected in one, three days after surgery. There was no mortality in our patients. The sensitivity and specificity of the MPS for predicting postoperative cardiovascular complications were 100% and 66%, respectively. MPS also had a positive predictive value of 20% and a negative predictive value of 100% in our study. A 332.5 pg/ml cut-off value for NT-proBNP level yielded a sensitivity of 100%, specificity of 79.2%, positive predictive value of 40%, and negative predictive value of 100%. CONCLUSIONS: Our study reveals the incremental specificity and positive predictive value of NT-proBNP level measurement in preoperative cardiovascular risk evaluation compared to MPS. Given the low feasibility, high costs, and disappointing predictive value of MPS, preoperative NT-proBNP level assessment can be substituted. This method can assist anesthesiologists and surgeons with precisely detecting at-risk patients resulting in taking proper measures to reduce the morbidity and mortality of the proposed patients before and during surgeries.

Arterial Stiffness and its Impact on Cardiovascular Health.

PURPOSE OF REVIEW: Cardiovascular diseases are the leading cause of mortality globally. Identifying patients at risk is important to initiate preventive strategies. Over the last few decades, the role of the endothelium and its impact on arterial stiffness have been recognised as playing a pivotal role in cardiovascular disease. This review will focus on the effect of arterial stiffness in different patient cohorts with regard to cardiovascular morbidity and mortality, as well as its use in clinical practice. RECENT FINDINGS: Arterial stiffness is associated with a range of cardiovascular risk factors and is an independent predictor of cardiovascular mortality. The gold standard for evaluating arterial stiffness is pulse wave velocity. Recently, cardio-ankle vascular index has been implemented as an easy and highly reproducible measure of arterial stiffness. Moreover, certain pharmacologic agents may modify arterial stiffness and alter progression of cardiovascular disease. The endothelium plays an important role in cardiovascular disease. Implementing assessment of arterial stiffness in clinical practice will improve stratification of patients at risk of cardiovascular disease and help modify disease progression.

Oxidative stress and adverse cardiovascular effects among professional divers in Egypt.

Professional divers are exposed to unique multifactorial hazards in their working environment and adverse cardiovascular effects such as ischemia, arrhythmia, stroke, and death are associated with professional diving. Cardiovascular events are aggravated by diving-induced oxidative stress and account for one-fourth of diving fatalities. This study aimed to measure oxidative and cardiovascular stress in a group of professional divers in Alexandria, Egypt using a panel of biomarkers. A comparative cross-sectional study was conducted between June 2017 and May 2018 at the General Naval Hospital in Alexandria. A total of 50 professional divers and a comparison group of 50 marine seafarers sharing similar maritime environments were enrolled in the study. Participants were clinically evaluated by electrocardiography (ECG) and plasma measurement of trace metals (Fe+, Cu+, and Zn+), electrolytes (Na+, K+, Ca+), and oxidative stress biomarkers (OSBMs; MDA, TAS, GST, GSH, GR, GPx, SOD, and CAT). Significant ECG abnormalities including short corrected QT interval, sinus bradycardia, left ventricular hypertrophy, early repolarization, first-degree heart block, and intraventricular conduction defect were identified among divers. Biochemical analyses revealed high mean levels of FBG [89.0 ± 12.46 vs. 100.5 ± 29.03 mg/dl], LDH-C [41.46 ± 4.01 vs. 39.34 ± 4.34 mg/dl], electrolyte imbalance [higher Na+ (9.44 ± 0.52 vs. 9.19 ± 0.60 mmol/L), and lower Ca+ (141.72 ± 3.53 and 143.26 ± 3.99 mmol/L)], disturbed trace metals [Fe+ and Zn+ (101.1 ± 38.17 vs. 147.6 ± 38.08 and 85.52 ± 27.37 vs. 116.6 ± 21.95 µm/dl, respectively), higher Cu+ (271.3 ± 75.01 vs. 100.8 ± 30.20 µm/dl)], and higher OSBMs (high MDA and reduced CAT, GPx, GSH, GR, and GST enzyme levels) among professional divers compared to the marine seafarers (t-test p < 0.05). Oxidative stress and trace metal imbalance are associated with the pathophysiology of cardiovascular disease; this association, together with electrophysiological changes of ECG may serve as biomarkers for cardiovascular risk assessment in diver periodic medical examinations.

Performance of WHO updated cardiovascular disease risk prediction charts in a low-resource setting - Findings from a community-based survey in Puducherry, India.

BACKGROUND AND AIM: The World Health Organization has revised the cardiovascular disease (CVD) risk prediction charts in 2019 for each of the 21 Global Burden of Disease regions. These charts (non-lab and lab versions) estimate the total CVD risk in an individual, of which the non-lab is for low-resource settings. We aimed to estimate the burden of ten-year risk of fatal or non-fatal CVD event in the district of Puducherry in India using 'non-lab' and 'lab' versions of WHO CVD risk prediction charts, and to evaluate the agreement between them. METHODS AND RESULTS: We included 710 individuals aged 40-69 years who participated in a district wide non-communicable diseases survey conducted in Puducherry, India, during 2019-20. Both charts use information on age, gender, systolic blood pressure and smoking status. Additionally, lab-chart requires individual's status on diabetes mellitus and total cholesterol while non-lab requires body mass index. Population in different CVD risk levels was presented using proportions (95% confidence intervals). Agreement between lab and non-lab charts was evaluated using Cohen's Kappa (k). The lab and non-lab charts estimated 3% (95% CI: 1.7-4.2) and none of the population respectively, to have high risk (≥20%) for fatal or non-fatal CVD event over the next ten years. Both the charts showed 89.4% (95% CI:87.2%-91.7%) concordance in CVD risk prediction indicating a good level of agreement (k = 0.653). CONCLUSION: WHO updated CVD risk prediction charts are feasible to apply when data is available and there is good agreement between non-lab and lab based charts.

Relevance of Cardiovascular Risk Factors Screening in People Aged over 65 Years: Results from a Large French Urban Population (The CARVAR92 Study).

BACKGROUND: Cardiovascular disease is the leading cause of death and disability in older people. Traditional cardiovascular risk factors (CVRFs) still have an impact on cardiovascular risk among older people. Nevertheless, screening campaigns rarely target subjects aged over 65 years. This study aimed to assess the distribution and relevance of conventional CVRF screening in people aged over 65 years. METHODS: Between 2007 and 2018, among a screening CVRF campaign in the western suburbs of Paris (32,692 subjects), we individualized 6,577 subjects aged 65 years and over. All conventional CVRFs have been systematically assessed. RESULTS: The screening allowed to suspect hypertension in a larger proportion of subjects over 65 years compared to subjects under 65 years (27% vs. 18%, p < 0.0001). Hypertension control was higher in women compared to men but not significantly different in the age-groups (p = 0.91). Screening for diabetes mellitus was positive in 3% of older subjects and 2.4% in younger (p = 0.005). Risk assessment with dedicated score (SCORE O.P.) allowed to move toward a low-risk estimation, resulting in the diminution of intermediate risk group in women over 65 years (from 68 to 61%, p < 0.001). CONCLUSIONS: Screening CVRFs especially hypertension remains relevant in people aged over 65 years as it enables to detect unknown CVRFs in numerous subjects. Increasing awareness of CVRFs may be the first step to CVRF control, which is known to be efficient on cardiovascular mortality and functional autonomy in later life.

Association of glycated hemoglobin A1c levels with cardiovascular outcomes in the general population: results from the BiomarCaRE (Biomarker for Cardiovascular Risk Assessment in Europe) consortium.

BACKGROUND: Biomarkers may contribute to improved cardiovascular risk estimation. Glycated hemoglobin A1c (HbA1c) is used to monitor the quality of diabetes treatment. Its strength of association with cardiovascular outcomes in the general population remains uncertain. This study aims to assess the association of HbA1c with cardiovascular outcomes in the general population. METHODS: Data from six prospective population-based cohort studies across Europe comprising 36,180 participants were analyzed. HbA1c was evaluated in conjunction with classical cardiovascular risk factors (CVRFs) for association with cardiovascular mortality, cardiovascular disease (CVD) incidence, and overall mortality in subjects without diabetes (N = 32,496) and with diabetes (N = 3684). RESULTS: Kaplan-Meier curves showed higher event rates with increasing HbA1c levels (log-rank-test: p < 0.001). Cox regression analysis revealed significant associations between HbA1c (in mmol/mol) in the total study population and the examined outcomes. Thus, a hazard ratio (HR) of 1.16 (95% confidence interval (CI) 1.02-1.31, p = 0.02) for cardiovascular mortality, 1.13 (95% CI 1.03-1.24, p = 0.01) for CVD incidence, and 1.09 (95% CI 1.02-1.17, p = 0.01) for overall mortality was observed per 10 mmol/mol increase in HbA1c. The association with CVD incidence and overall mortality was also observed in study participants without diabetes with increased HbA1c levels (HR 1.12; 95% CI 1.01-1.25, p = 0.04) and HR 1.10; 95% CI 1.01-1.20, p = 0.02) respectively. HbA1c cut-off values of 39.9 mmol/mol (5.8%), 36.6 mmol/mol (5.5%), and 38.8 mmol/mol (5.7%) for cardiovascular mortality, CVD incidence, and overall mortality, showed also an increased risk. CONCLUSIONS: HbA1c is independently associated with cardiovascular mortality, overall mortality and cardiovascular disease in the general European population. A mostly monotonically increasing relationship was observed between HbA1c levels and outcomes. Elevated HbA1c levels were associated with cardiovascular disease incidence and overall mortality in participants without diabetes underlining the importance of HbA1c levels in the overall population.

Epicardial fat tissue can predict subclinical left ventricular dysfunction in patients with erectile dysfunction.

BACKGROUND: Erectile dysfunction (ED) is an early form of atherosclerosis and subclinical myocardial dysfunction. Epicardial fat tissue (EFT) is associated with impaired left ventricular (LV) function, even in the absence of cardiovascular disease. The aim of this study was to investigate the association between EFT and LV systolic function in patients with erectile ED by speckle tracking echocardiography (2D-STE) method. METHODS: A total of 129 consecutive patients with ED were compared with 145 age- and sex-matched control subjects. ED was evaluated using the International Index of Erectile Function questionnaire. Thickness of EFT was measured by TTE. Global LV longitudinal strain (LV-GLS) and global LV circumferential strain (LV-GCS) were measured by 2D-STE method. RESULTS: The EFT thickness was significantly higher in the patients with ED (p <.01). LV-GLS and LV-GCS were revealed to be more deterioration in the ED group compared to controls (-18.2 ± 2.7 vs. (-21.1 ± 3.9, p<.001; -19.5 ± 4.1 vs. -21.9 ± 3.9, p<.001, respectively). It has been shown that EFT thickness is an independent predictor of LV dysfunction. CONCLUSIONS: These results indicate that EFT thickness is associated with subclinical LV systolic dysfunction in patients with ED.

Identifying Early Vascular Ageing in Patients With Metabolic Syndrome: Unresolved Issues and a Proposed Novel VAmets Score.

PURPOSE: To identify the features of early vascular ageing (EVA) in patients with metabolic syndrome (MetS), to assess the accuracy of existing methods for determining vascular age in MetS, and to derive a new score (VAmets) for the calculation of vascular age and predicting EVA in patients with MetS. METHODS: Prospective open cohort study using routinely collected data from general practice. A total of 750 patients (age, 35-80 yrs old) with MetS were examined. EVA syndrome was detected in 484 patients with MetS and carotid-femoral pulse wave velocity (cfPWV) values exceeding average expected for age values by 2 or more standard deviations (SD). RESULTS: The presence of type 2 diabetes and insulin resistance (IR) were associated with greater risk of EVA in MetS patients; the odds ratios were 2.75 (95% confidence interval [CI]: 2.34, 3.35) and 1.57 (95% CI: 1.16, 2.00), respectively. In addition, the risk of EVA increased by 76% with an increase in homeostatic model assessment ofinsulin resistance (HOMA-IR) by 1 unit, by 17% with an increase in high-sensitivity C-reactive protein (hs-CRP) by 1 mg/L, by 4% with an increase in diastolic blood pressure (DBP) by 1 mmHg, and by 1% with each (1) µmol/L increase in the level of uric acid (UA). The area under the curve (AUC) for predicting EVA in patients with MetS was 0.949 (95% CI: 0.936-0.963), 0.630 (95% CI: 0.589-0.671), 0.697 (95% CI: 0.659-0.736) and 0.686 (95% CI: 0.647-0.726), for vascular age calculated from carotid-femoral pulse wave velocity (cfPWV), Systematic COronary Risk Evaluation (SCORE) scale, QRESEARCH cardiovascular risk algorithm (QRISK-3) scale, and Framingham scale, respectively. Diabetes mellitus and clinical markers of IR (yes/no), HOMA-IR and UA level were used to develop a new VAmets score for EVA prediction providing a total accuracy of 0.830 (95% CI: 0.799-0.860). Based on the results of the study, a VAmets calculator was developed for diagnosing EVA in patients with MetS. (The calculator is available online at https://apps.medhub.pro/evams/) CONCLUSION: Carotid-femoral pulse wave velocity is at present the most widely studied index of arterial stiffness and fulfils most of the stringent criteria for a clinically useful biomarker of EVA in patients with MetS. There are parallel efforts for the effective identification and integration of a simple clinical score into clinical practice. Our score (VAmets) may accurately identify patients with MetS and EVA on the basis of widely available clinical variables and classic cardiovascular risk factors, and may assist in prioritising the calculation and use of vascular age in routine care.

Task shifting of cardiovascular risk assessment and communication by nurses for primary and secondary prevention of cardiovascular diseases in a tertiary health care setting of Northern India.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality in India. CVDs are to a large extent preventable with the availability of wide range of interventions focusing on primary and secondary prevention. However human resource deficit is the biggest challenge for implementing these prevention programs. Task shifting of the cardiovascular risk assessment and communication to nurses can be one of the most viable and sustainable option to run prevention programs. METHODS: The study was quasi experimental in nature with 1 year follow up to determine the effect of CVD risk assessment and communication by nurses with the help of risk communication package on primary and secondary prevention of CVDs. The study was done in the outpatient departments of a tertiary health care center of Northern India. All the nurses (n = 16) working in selected OPDs were trained in CVD risk assessment and communication of risk to the patients. A total of 402 patients aged 40 years and above with hypertension (HTN) were recruited for primary prevention of CVDs from medicine and allied OPDs, whereas 500 patients who had undergone CABG/PTCA were recruited from cardiology OPDs for secondary prevention of CVDs and were randomized to intervention (n = 250) and comparison group (n = 250) by using block randomization. CVD risk modification and medication adherence were the outcomes of interest for primary and secondary prevention of CVDs respectively. RESULTS: The results revealed high level of agreement (k = 0.84) between the risk scores generated by nurses with that of investigator. In the primary prevention group, there were significantly higher proportion of participants in the low risk category (70%) as compared to baseline assessment (60.6%) at 1 year follow up. Whereas in secondary prevention group the mean medication adherence score among intervention group participants (7.60) was significantly higher than that of the comparison group (5.96) with a large effect size of 1.1.(p < 0.01). CONCLUSION: Nurse led intervention was effective in risk modification and improving medication adherence among subjects for primary and secondary prevention of CVDs respectively. TRIAL REGISTRATION: Trial registration no CTRI/2018/01/011372 [Registered on: 16/01/2018] Trial Registered Retrospectively.

Rheumatoid Arthritis: Atherosclerosis Imaging and Cardiovascular Risk Assessment Using Machine and Deep Learning-Based Tissue Characterization.

PURPOSE OF THE REVIEW: Rheumatoid arthritis (RA) is a chronic, autoimmune disease which may result in a higher risk of cardiovascular (CV) events and stroke. Tissue characterization and risk stratification of patients with rheumatoid arthritis are a challenging problem. Risk stratification of RA patients using traditional risk factor-based calculators either underestimates or overestimates the CV risk. Advancements in medical imaging have facilitated early and accurate CV risk stratification compared to conventional cardiovascular risk calculators. RECENT FINDING: In recent years, a link between carotid atherosclerosis and rheumatoid arthritis has been widely discussed by multiple studies. Imaging the carotid artery using 2-D ultrasound is a noninvasive, economic, and efficient imaging approach that provides an atherosclerotic plaque tissue-specific image. Such images can help to morphologically characterize the plaque type and accurately measure vital phenotypes such as media wall thickness and wall variability. Intelligence-based paradigms such as machine learning- and deep learning-based techniques not only automate the risk characterization process but also provide an accurate CV risk stratification for better management of RA patients. This review provides a brief understanding of the pathogenesis of RA and its association with carotid atherosclerosis imaged using the B-mode ultrasound technique. Lacunas in traditional risk scores and the role of machine learning-based tissue characterization algorithms are discussed and could facilitate cardiovascular risk assessment in RA patients. The key takeaway points from this review are the following: (i) inflammation is a common link between RA and atherosclerotic plaque buildup, (ii) carotid ultrasound is a better choice to characterize the atherosclerotic plaque tissues in RA patients, and (iii) intelligence-based paradigms are useful for accurate tissue characterization and risk stratification of RA patients.

Cardiovascular risk assessment tools: A scoping review.

OBJECTIVES: The objective of this review was to describe cardiovascular risk (CVR) assessment methods and to identify evidence-based practice recommendations when dealing with population at risk of developing cardiovascular diseases. REVIEW METHODS AND DATA SOURCES: A literature review following the Arksey and O'Malley scoping review methodology was conducted. By using appropriate key terms, literature searches were conducted in PubMed, SciELO, Cochrane Library, Dialnet, ENFISPO, Medigraphic, ScienceDirect, Cuiden, and Lilacs databases. A complementary search on websites related to the area of interest was conducted. Articles published in English or Spanish in peer-review journals between 2010 and 2017. Critical appraisal for methodological quality was conducted. Data was extracted using ad-hoc tables and qualitatively synthesized. RESULTS: After eliminating duplicates, 55325 records remained, and 1432 records were selected for screening. Out of these, 88 full-text articles were selected for eligibility criteria, and finally, 67 studies were selected for this review, and 25 studies were selected for evidence synthesis. In total, 23 CVR assessment tools have been identified, pioneered by the Framingham study. Qualitative findings were grouped into four thematic areas: assessment tools and scores, CVR indicators, comparative models, and evidence-based recommendations. CONCLUSIONS: It is necessary to adapt the instruments to the epidemiological reality of the population. The most appropriate way to estimate CVR is to choose the assessment tool that best suits individual conditions, accompanied by a comprehensive assessment of the patient. More research is required to determine a single, adequate, and reliable tool.

Concordance between two versions of world health organization/international society of hypertension risk prediction chart and framingham risk score among postmenopausal women in a rural area of Bangladesh.

BACKGROUND: Prevention of cardiovascular disease (CVD) among postmenopausal women with limited resource is a great challenge for a country like Bangladesh. OBJECTIVES: This study aimed to evaluate the level of agreement among different risk prediction tools to find out the cost-effective and suitable one that can be applied in a low-resource setting. METHODS: This was a cross-sectional study conducted from February through December 2016 among 265 postmenopausal women of 40-70 years age. Data were collected from the outpatient department of a rural health-care center situated in the village Karamtola of Gazipur district, Bangladesh. The CVD risk was estimated using the World Health Organization/International Society of Hypertension (WHO/ISH) "with" and "without" cholesterol risk charts and the Framingham Risk Score (FRS). Concordance among the tools was evaluated using Cohen's kappa (κ), prevalence-adjusted bias-adjusted kappa (PABAK), and first-order agreement coefficient (AC1). RESULTS: The "without" cholesterol version showed 79% concordance against the "with" cholesterol and 75.4% concordance against the FRS. In between the WHO/ISH risk charts, slight-to-substantial levels of agreement (κ = 0.14, PABAK = 0.58, and AC1 = 0.72; P = 0.023) were observed. With FRS, the "without" cholesterol version showed higher agreement (κ = 0.38, fair; PABAK = 0.50, moderate; and AC1 = 0.60, moderate; P = 0.000) compared to "with" cholesterol version (κ = 0.13, slight; PABAK = 0.30, fair; and AC1 = 0.44, moderate; P = 0.013). Predictability of CVD risk positive (≥10%) cases was similar for both the versions of WHO/ISH risk charts. CONCLUSION: In a low-resource setting, the "without" cholesterol version of WHO/ISH risk chart is a good option to detect and target the population with high CVD risk.

Cost-effectiveness of the non-laboratory based Framingham algorithm in primary prevention of cardiovascular disease: A simulated analysis of a cohort of African American adults.

The non-lab Framingham algorithm, which substitute body mass index for lipids in the laboratory based (lab-based) Framingham algorithm, has been validated among African Americans (AAs). However, its cost-effectiveness and economic tradeoffs have not been evaluated. This study examines the incremental cost-effectiveness ratio (ICER) of two cardiovascular disease (CVD) prevention programs guided by the non-lab versus lab-based Framingham algorithm. We simulated the World Health Organization CVD prevention guidelines on a cohort of 2690 AA participants in the Atherosclerosis Risk in Communities (ARIC) cohort. Costs were estimated using Medicare fee schedules (diagnostic tests, drugs & visits), Bureau of Labor Statistics (RN wages), and estimates for managing incident CVD events. Outcomes were assumed to be true positive cases detected at a data driven treatment threshold. Both algorithms had the best balance of sensitivity/specificity at the moderate risk threshold (>10% risk). Over 12years, 82% and 77% of 401 incident CVD events were accurately predicted via the non-lab and lab-based Framingham algorithms, respectively. There were 20 fewer false negative cases in the non-lab approach translating into over $900,000 in savings over 12years. The ICER was -$57,153 for every extra CVD event prevented when using the non-lab algorithm. The approach guided by the non-lab Framingham strategy dominated the lab-based approach with respect to both costs and predictive ability. Consequently, the non-lab Framingham algorithm could potentially provide a highly effective screening tool at lower cost to address the high burden of CVD especially among AA and in resource-constrained settings where lab tests are unavailable.

Detecting familial hypercholesterolemia by serum lipid profile screening in a hospital setting: Clinical, genetic and atherosclerotic burden profile.

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is underdiagnosed and public cholesterol screening may be useful to find new subjects. In this study, we aim to investigate the prevalence of FH patients in a hospital screening program and evaluate their atherosclerotic burden using intima-media thickness (IMT). METHODS AND RESULTS: We screened 1575 lipid profiles and included for genetic analysis adults with a low-density lipoprotein (LDL) cholesterol >190 mg/dL and triglycerides <200 mg/dL and first-degree child relatives with LDL cholesterol >160 mg/dL and triglycerides <200 mg/dL. The diagnosis of FH was presumed by Dutch Lipid Clinic Network (DLCN) criteria and confirmed by the presence of the genetic variant. Mean common carotid intima-media thickness (IMT) was assessed using consensus criteria. After confirming LDL cholesterol value and excluding secondary hypercholesterolemia, 56 subjects with a DLCN ≥4 performed genetic analysis. Of these, 26 had an FH genetic variant. The proportion of patients with a mutation having a DLCN score of 6-8 was 75%; in individuals with a DLCN score >8 it was 100%. Mean IMT was higher in FH patients compared to non FH (0.73 [0.61-0.83] vs 0.71 [0.60-0.75] mm, p < 0.01). Moreover, we detected two mutations not previously described. Finally, simple regression analysis showed a correlation of IMT with LDL cholesterol >190 mg/dL and corneal arcus (p < 0.01 and p < 0.001, respectively). CONCLUSIONS: A hospital screening was useful to detect FH subjects with increased atherosclerosis. Also, next-generation sequencing was able to detect new FH mutations.