Interaction between cardiovascular risk factors and body mass index and 10-year incidence of cardiovascular disease, cancer death, and overall mortality.

The effect of above-normal body mass index (BMI) on health outcomes is controversial because it is difficult to distinguish from the effect due to BMI-associated cardiovascular risk factors. The objective was to analyze the impact on 10-year incidence of cardiovascular disease, cancer deaths and overall mortality of the interaction between cardiovascular risk factors and BMI. We conducted a pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79years old at basal examination. Body mass index was measured at baseline being the outcome measures ten-year cardiovascular disease, cancer and overall mortality. Multivariable analyses were adjusted for potential confounders, considering the significant interactions with cardiovascular risk factors. We included 54,446 individuals (46.5% with overweight and 27.8% with obesity). After considering the significant interactions, the 10-year risk of cardiovascular disease was significantly increased in women with overweight and obesity [Hazard Ratio=2.34 (95% confidence interval: 1.19-4.61) and 5.65 (1.54-20.73), respectively]. Overweight and obesity significantly increased the risk of cancer death in women [3.98 (1.53-10.37) and 11.61 (1.93-69.72)]. Finally, obese men had an increased risk of cancer death and overall mortality [1.62 (1.03-2.54) and 1.34 (1.01-1.76), respectively]. In conclusion, overweight and obesity significantly increased the risk of cancer death and of fatal and non-fatal cardiovascular disease in women; whereas obese men had a significantly higher risk of death for all causes and for cancer. Cardiovascular risk factors may act as effect modifiers in these associations.

Derivation and validation of a set of 10-year cardiovascular risk predictive functions in Spain: the FRESCO Study.

OBJECTIVE: To derive and validate a set of functions to predict coronary heart disease (CHD) and stroke, and validate the Framingham-REGICOR function. METHOD: Pooled analysis of 11 population-based Spanish cohorts (1992-2005) with 50,408 eligible participants. Baseline smoking, diabetes, systolic blood pressure (SBP), lipid profile, and body mass index were recorded. A ten-year follow-up included re-examinations/telephone contact and cross-linkage with mortality registries. For each sex, two models were fitted for CHD, stroke, and both end-points combined: model A was adjusted for age, smoking, and body mass index and model B for age, smoking, diabetes, SBP, total and HDL cholesterol, and for hypertension treatment by SBP, and age by smoking and by SBP interactions. RESULTS: The 9.3-year median follow-up accumulated 2973 cardiovascular events. The C-statistic improved from model A to model B for CHD (0.66 to 0.71 for men; 0.70 to 0.74 for women) and the combined CHD-stroke end-points (0.68 to 0.71; 0.72 to 0.75, respectively), but not for stroke alone. Framingham-REGICOR had similar C-statistics but overestimated CHD risk. CONCLUSIONS: The new functions accurately estimate 10-year stroke and CHD risk in the adult population of a typical southern European country. The Framingham-REGICOR function provided similar CHD prediction but overestimated risk.

Prevalence of obesity and associated cardiovascular risk: the DARIOS study.

BACKGROUND: To estimate the prevalence of overweight and obesity in the Spanish population as measured with body mass index (BMI), waist circumference (WC) and waist to height ratio (WHtR) and to determine the associated cardiovascular risk factors. METHODS: Pooled analysis with individual data from 11 studies conducted in the first decade of the 21st century. Participants aged 35-74 years were asked about the history of cardiovascular diseases, hypertension, diabetes and hypercholesterolemia. Height, weight, WC, blood pressure, glycaemia, total cholesterol, low-density and high-density lipoprotein cholesterol and coronary risk were measured. The prevalence of overweight (BMI 25-29.9 kg/m(2)), general obesity (BMI ≥ 30 kg/m(2)), suboptimal WC (≥ 80 cm and < 88 in women, ≥ 94 and < 102 in men), abdominal obesity (WC ≥88 cm ≥102 cm in women and men, respectively) and WHtR ≥0.5 was estimated, standardized for the European population. RESULTS: We included 28,743 individuals. The prevalence of overweight and suboptimal WC was 51% and 30% in men and 36% and 22% in women, respectively; general obesity was 28% in both sexes and abdominal obesity 36% in men and 55% in women. The prevalence of WHtR ≥0.5 was 89% and 77% in men and women, respectively. All cardiovascular risk factors were significantly associated with abnormal increased values of BMI, WC and WHtR. Hypertension showed the strongest association with overweight [OR = 1.99 (95% confidence interval 1.81-2.21) and OR = 2.10 (1.91-2.31)]; suboptimal WC [OR = 1.78 (1.60-1.97) and OR = 1.45 (1.26-1.66)], with general obesity [OR = 4.50 (4.02-5.04), and OR = 5.20 (4.70-5.75)] and with WHtR ≥0.5 [OR = 2.94 (2.52-3.43), and OR = 3.02 (2.66-3.42)] in men and women respectively, besides abdominal obesity in men only [OR = 3.51 (3.18-3.88)]. Diabetes showed the strongest association with abdominal obesity in women [OR = 3,86 (3,09-4,89). CONCLUSIONS: The prevalence of obesity in Spain was high. Overweight, suboptimal WC, general, abdominal obesity and WHtR ≥0.5 was significantly associated with diabetes, hypertension, hypercholesterolemia and coronary risk. The use of lower cut-off points for both BMI and particularly WC and could help to better identify the population at risk and therefore achieve more effective preventive measures.

The Association of Dietary Intake with Arterial Stiffness and Vascular Ageing in a Population with Intermediate Cardiovascular Risk-A MARK Study.

The aim of this study was to analyse the association of diet with arterial stiffness and vascular ageing in a Caucasian population with intermediate cardiovascular risk. We recruited 2475 individuals aged 35-75 years with intermediate cardiovascular risk. Brachial-ankle pulse wave velocity (baPWV) was measured using a VaSera VS-1500® device. Vascular ageing was defined in two steps. Step 1: The 20 individuals who presented kidney disease, peripheral arterial disease, or heart failure were classified as early vascular ageing (EVA). Step 2: The individuals with percentiles by age and sex above the 90th percentile of baPWV among the participants of this study were classified as EVA, and the rest of the individuals were classified as non-EVA. The diet of the participants was analysed with two questionnaires: (1) the diet quality index (DQI) questionnaire and (2) the Mediterranean diet (MD) adherence questionnaire. The mean age of the sample was 61.34 ± 7.70 years, and 61.60% were men. Adherence to the MD was 53.30%. The DQI was 54.90%. Of the entire sample, 10.70% (11.15% of the men and 9.95% of the women) were EVA. In the multiple linear regression analysis, for each additional point in the DQI questionnaire, there was a decrease of -0.081 (95%CI (confidence intervals) -0.105--0.028) in baPWV; in the MD adherence questionnaire, there was a decrease of -0.052 (95%CI -0141--0.008). When performing the analysis, separated by sex, the association remained significant in men but not in women. In the logistic regression analysis, there was an increase in MD adherence and a decrease in the probability of presenting EVA, both with the DQI questionnaire (OR (odds ratio) = 0.65; 95%CI 0.50-0.84) and with the MD adherence questionnaire (OR = 0.75; 95%CI 0.58-0.97). In the analysis by sex, the association was only maintained in men (with DQI, OR = 0.54; 95%CI 0.37-0.56) (with MD, OR = 0.72; 95%CI 0.52-0.99). The results of this study suggest that a greater score in the DQI and MD adherence questionnaires is associated with lower arterial stiffness and a lower probability of presenting EVA. In the analysis by sex, this association is only observed in men.

Association of physical activity with vascular aging in a population with intermediate cardiovascular risk, analysis by sex: MARK study.

BACKGROUND: The aim of this study was to analyze the association of physical activity and its intensity with arterial stiffness and vascular aging and differences by sex in a Spanish population with intermediate cardiovascular risk. METHODS: Cross-sectional study. A total of 2475 individuals aged 35-75 years participated in the study. Brachial-ankle pulse wave velocity (baPWV) was measured using a VaSera VS-1500® device. Based on the age and sex percentile presented by the participants, the latter were classified as follows: those with a percentile above 90 and presenting established cardiovascular disease were classified as early vascular aging (EVA); those with a percentile between 10 and 90 were classified as normal vascular aging (NVA) and those with a percentile below 10 were classified as healthy vascular aging (HVA). Physical activity was analyzed through the short version of the Minnesota Leisure Time Physical Activity Questionnaire (MLTPAQ). RESULTS: The mean age of the participants was 61.34 ± 7.70 years, with 61.60% men. Of the total sample, 86% were sedentary (83% men vs 90% women). The total physical activity showed a negative association with baPWV (ß = - 0.045; 95% CI - 0.080 to - 0.009). Intense physical activity showed a negative relationship with baPWV (ß = - 0.084; 95% CI - 0.136 to - 0.032). The OR of the total physical activity and the intense physical activity carried out by the subjects classified as NVA with respect to those classified as HVA was OR = 0.946; (95% CI 0.898 to 0.997) and OR = 0.903; (95% CI 0.840 to 0.971), and of those classified as EVA it was OR = 0.916; (95% CI 0.852 to 0.986) and OR = 0.905; (95% CI 0.818 to 1.000). No association was found with moderate- or low-intensity physical activity. CONCLUSIONS: The results of this study suggest that, when intense physical activity is performed, the probability of presenting vascular aging is lower. In the analysis by sex, this association is only observed in men.

Improving interMediAte risk management. MARK study.

BACKGROUND: Cardiovascular risk functions fail to identify more than 50% of patients who develop cardiovascular disease. This is especially evident in the intermediate-risk patients in which clinical management becomes difficult. Our purpose is to analyze if ankle-brachial index (ABI), measures of arterial stiffness, postprandial glucose, glycosylated hemoglobin, self-measured blood pressure and presence of comorbidity are independently associated to incidence of vascular events and whether they can improve the predictive capacity of current risk equations in the intermediate-risk population. METHODS/DESIGN: This project involves 3 groups belonging to REDIAPP (RETICS RD06/0018) from 3 Spanish regions. We will recruit a multicenter cohort of 2688 patients at intermediate risk (coronary risk between 5 and 15% or vascular death risk between 3-5% over 10 years) and no history of atherosclerotic disease, selected at random. We will record socio-demographic data, information on diet, physical activity, comorbidity and intermittent claudication. We will measure ABI, pulse wave velocity and cardio ankle vascular index at rest and after a light intensity exercise. Blood pressure and anthropometric data will be also recorded. We will also quantify lipids, glucose and glycosylated hemoglobin in a fasting blood sample and postprandial capillary glucose. Eighteen months after the recruitment, patients will be followed up to determine the incidence of vascular events (later follow-ups are planned at 5 and 10 years). We will analyze whether the new proposed risk factors contribute to improve the risk functions based on classic risk factors. DISCUSSION: Primary prevention of cardiovascular diseases is a priority in public health policy of developed and developing countries. The fundamental strategy consists in identifying people in a high risk situation in which preventive measures are effective and efficient. Improvement of these predictions in our country will have an immediate, clinical and welfare impact and a short term public health effect. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT01428934.

Capacity adiposity indices to identify metabolic syndrome in subjects with intermediate cardiovascular risk (MARK study).

BACKGROUND: Obesity increases mortality, and is linked to cardiovascular diseases and metabolic syndrome (MetS). Therefore, the purpose of this study was to analyze the ability of different adiposity indices to identify subjects with MetS among people with intermediate cariovascular risk. MATERIALS AND METHODS: The cross-sectional study involved 2478 subjects, recruited by the MARK study. Adiposity measures: general adiposity by body mass index (BMI), central adiposity by waist-to-height ratio (WHtR), fat mass percent by the Clínica Universidad de Navarra-body adiposity estimator (CUN-BAE), percentage of body fat and of visceral adipose tissue by body roundness index (BRI) and visceral obesity and general adiposity with body shape index (ABSI). The diagnosis of MetS was made in accordance with the criteria established in the international consensus of the Joint Scientific Statement National Cholesterol Education Program III. RESULTS: The highest correlation coefficients were obtained by the glycemic components (HbA1c and FPG) of the MetS and ranged from 0.155 to 0.320. The exception was ABSI, which showed lower values in the global analysis and in the males. Values of the area under the ROC curve with the adiposity indices ranged from 0.773 with the BMI in males to 0.567 with ABSI in males. In the logistic regression analysis, all adiposity factors, except ABSI, showed similar OR values of MetS after adjusting for possible confounding factors. In the global analysis, the adiposity index that showed a highest OR of MetS was CUN-BAE (OR 5.50; 95% CI 4.27-7.09). In the analysis by gender, the highest ORs were BMI in males (OR 5.98; 95% CI 4.70-7.60) and both WHtR and BRI in females (OR 4.15; 95% CI 3.09-5.58). CONCLUSION: All adiposity indices, except for ABSI, show an association with MetS and similar ability to detect subjects with MetS among people with intermediate cariovascular risk.

A body shape index and vascular structure and function in Spanish adults (MARK study): A cross-sectional study.

A body shape index (ABSI) has been introduced as a marker of the relationship between body composition and all-cause mortality. However, until now, the relationships between ABSI and vascular structure and function have not been evaluated. The aim of this study was to investigate the association of ABSI with vascular structure and function in Spanish adults with intermediate cardiovascular risk. This cross-sectional study analyzed the data of 2354 subjects [age, 35-74 years (median, 62.0 years [range, 56.0-67.0 years]), 61.9% men] enrolled into the MediAte Risk management (MARK) study. ABSI was calculated by using the following formula: ABSI = waist circumference (m)/[body mass index × height (m))]. Vascular function was assessed by measuring cardio-ankle vascular index (CAVI) with the VaSera device and brachial ankle pulse wave velocity (baPWV) by using a validated equation. Vascular structure was assessed by measuring carotid intima-media thickness (IMT) by ultrasonography. Median value of ABSI was 0.083 (range, 0.081-0.090), mean CAVI was (8.5 ±â€Š1.2), and median IMT was 0.727 (range, 0.672-0.799). The values of ABSI and CAVI were higher in men. After adjusting for confounders, ABSI was positively associated with CAVI, baPWV, and average mean IMT. Thus, for each unit increase in ABSI, CAVI increased by 0.16 units, baPWV by 0.25 m/s, and IMT by 0.033 mm. In the logistic regression analysis, the odds ratio of ABSI was > 1 for high CAVI ≥ 9, baPWV ≥ 15 m/s, and IMT ≥ 0.90 mm in the overall subject group, and in the sex- and age-specific (> 62 years, ≤ 62 years) subgroups, after adjusting for confounders. The area under the receiver-operating characteristic curve of the ABSI was 0.631 (95% confidence interval [CI], 0.608-0.654) for CAVI ≥ 9, and 0.617 (95% CI, 0.593-0.641) for high baPWV ≥ 15 m/s. ABSI showed a positive association with vascular structure and function, independent of other confounders that might influence weight and fat mass distribution in Spanish subjects at intermediate cardiovascular risk.Trial Registration: ClinicalTrials.gov Identifier: NCT01428934 (registered: September 2, 2011; last updated: September 8, 2016).

Validity Assessment of Low-risk SCORE Function and SCORE Function Calibrated to the Spanish Population in the FRESCO Cohorts.

INTRODUCTION AND OBJECTIVES: To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population. METHODS: Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively. RESULTS: Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women. CONCLUSIONS: All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate.

Adiposity measures and arterial stiffness in primary care: the MARK prospective observational study.

BACKGROUND: The cardiovascular risk of obesity is potentially increased by arterial stiffness. OBJECTIVE: To assess the relationship of adiposity measures with arterial stiffness in Caucasian adults with intermediate cardiovascular risk. SETTING: Six Spanish health centres. PARTICIPANTS: We enrolled 2354 adults (age range, 35-74 years; mean age, 61.4±7.7 years, 61.9% male). METHODS: This is a cross-sectional study that analyses data from the baseline visit of the improving interMediAte RisK management (MARK) study. The main outcome variables were body mass index (BMI), waist-to-height ratio (WHtR), Clínica Universidad de Navarra-body adiposity estimation (CUN-BAE) body fat percentage and body roundness index (BRI). Vascular function was assessed by the cardio-ankle vascular index (CAVI) with the VaSera device; brachial-ankle pulse wave velocity (baPWV) was determined using a validated equation. RESULTS: The mean adiposity measures were a BMI of 29.2±4.4, WHtR of 0.61±0.07, CUN-BAE of 35.7±1.7 and BRI of 5.8±1.7. The mean stiffness measures were a CAVI of 8.8±1.2 and baPWV of 14.9±2.5. In multiple linear regression analyses, all adiposity measures were negatively associated with CAVI and baPWV (p<0.01 for all) after adjustment for possible factors of confusion. The proportion of CAVI variability via the adiposity measures were 5.5% for BMI, 5.8% for CUN-BAE, 3.8% for WHtR and 3.7% for BRI. These were higher among diabetic, obese, younger (≤62 years) and non-hypertensive subjects who had similar activity and sedentary profiles. CONCLUSIONS: Adiposity measures are negatively associated with arterial stiffness measures. The percentage of variation in CAVI explained by its relation to the different measures of adiposity ranges from 5.8% (CUN-BAE) to 3.7% (BRI). In the case of baPWV, it oscillates between 0.7% (CUN-BAE and BMI) and 0.1% (WHtR). TRIAL REGISTRATION NUMBER: NCT01428934.

On the problem of type 2 diabetes-related mortality in the Canary Islands, Spain. The DARIOS Study.

AIMS: To compare diabetes-related mortality rates and factors associated with this disease in the Canary Islands compared with other 10 Spanish regions. METHODS: In a cross-sectional study of 28,887 participants aged 35-74 years in Spain, data were obtained for diabetes, hypertension, dyslipidemia, obesity, insulin resistance (IR), and metabolic syndrome. Healthcare was measured as awareness, treatment and control of diabetes, dyslipidemia, and hypertension. Standardized mortality rate ratios (SRR) were calculated for the years 1981 to 2011 in the same regions. RESULTS: Diabetes, obesity, and hypertension were more prevalent in people under the age of 64 in the Canary Islands than in Spain. For all ages, metabolic syndrome and insulin resistance (IR) were also more prevalent in those from the Canary Islands. Healthcare parameters were similar in those from the Canary Islands and the rest of Spain. Diabetes-related mortality in the Canary Islands was the highest in Spain since 1981; the maximum SRR was reached in 2011 in men (6.3 versus the region of Madrid; p<0.001) and women (9.5 versus Madrid; p<0.001). Excess mortality was prevalent from the age of 45 years and above. CONCLUSIONS: Diabetes-related mortality is higher in the Canary Islands population than in any other Spanish region. The high mortality and prevalence of IR warrants investigation of the genetic background associated with a higher incidence and poor prognosis for diabetes in this population. The rise in SRR calls for a rapid public health policy response.

Risk of Cause-Specific Death in Individuals With Diabetes: A Competing Risks Analysis.

OBJECTIVE: Diabetes is a common cause of shortened life expectancy. We aimed to assess the association between diabetes and cause-specific death. RESEARCH DESIGN AND METHODS: We used the pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79 years old. Diabetes status was self-reported or defined as glycemia >125 mg/dL at baseline. Vital status and causes of death were ascertained by medical records review and linkage with the official death registry. The hazard ratios and cumulative mortality function were assessed with two approaches, with and without competing risks: proportional subdistribution hazard (PSH) and cause-specific hazard (CSH), respectively. Multivariate analyses were fitted for cardiovascular, cancer, and noncardiovascular noncancer deaths. RESULTS: We included 55,292 individuals (15.6% with diabetes and overall mortality of 9.1%). The adjusted hazard ratios showed that diabetes increased mortality risk: 1) cardiovascular death, CSH = 2.03 (95% CI 1.63-2.52) and PSH = 1.99 (1.60-2.49) in men; and CSH = 2.28 (1.75-2.97) and PSH = 2.23 (1.70-2.91) in women; 2) cancer death, CSH = 1.37 (1.13-1.67) and PSH = 1.35 (1.10-1.65) in men; and CSH = 1.68 (1.29-2.20) and PSH = 1.66 (1.25-2.19) in women; and 3) noncardiovascular noncancer death, CSH = 1.53 (1.23-1.91) and PSH = 1.50 (1.20-1.89) in men; and CSH = 1.89 (1.43-2.48) and PSH = 1.84 (1.39-2.45) in women. In all instances, the cumulative mortality function was significantly higher in individuals with diabetes. CONCLUSIONS: Diabetes is associated with premature death from cardiovascular disease, cancer, and noncardiovascular noncancer causes. The use of CSH and PSH provides a comprehensive view of mortality dynamics in a population with diabetes.

The ERICE-score: the new native cardiovascular score for the low-risk and aged Mediterranean population of Spain.

INTRODUCTION AND OBJECTIVES: In Spain, data based on large population-based cohorts adequate to provide an accurate prediction of cardiovascular risk have been scarce. Thus, calibration of the EuroSCORE and Framingham scores has been proposed and done for our population. The aim was to develop a native risk prediction score to accurately estimate the individual cardiovascular risk in the Spanish population. METHODS: Seven Spanish population-based cohorts including middle-aged and elderly participants were assembled. There were 11800 people (6387 women) representing 107915 person-years of follow-up. A total of 1214 cardiovascular events were identified, of which 633 were fatal. Cox regression analyses were conducted to examine the contributions of the different variables to the 10-year total cardiovascular risk. RESULTS: Age was the strongest cardiovascular risk factor. High systolic blood pressure, diabetes mellitus and smoking were strong predictive factors. The contribution of serum total cholesterol was small. Antihypertensive treatment also had a significant impact on cardiovascular risk, greater in men than in women. The model showed a good discriminative power (C-statistic=0.789 in men and C=0.816 in women). Ten-year risk estimations are displayed graphically in risk charts separately for men and women. CONCLUSIONS: The ERICE is a new native cardiovascular risk score for the Spanish population derived from the background and contemporaneous risk of several Spanish cohorts. The ERICE score offers the direct and reliable estimation of total cardiovascular risk, taking in consideration the effect of diabetes mellitus and cardiovascular risk factor management. The ERICE score is a practical and useful tool for clinicians to estimate the total individual cardiovascular risk in Spain.

Leukocyte subtype counts and its association with vascular structure and function in adults with intermediate cardiovascular risk. MARK study.

OBJECTIVES: We investigated the relationship between leukocyte subtype counts and vascular structure and function based on carotid intima-media thickness, pulse wave velocity, central augmentation index and cardio-ankle vascular index by gender in intermediate cardiovascular risk patients. METHODS: This study analyzed 500 subjects who were included in the MARK study, aged 35 to 74 years (mean: 60.3±8.4), 45.6% women. MEASUREMENT: Brachial ankle Pulse Wave Velocity (ba-PWV) estimate by equation, Cardio-AnkleVascular Index (CAVI) using the VaSera device and Carotid ultrasound was used to measure carotid Intima Media Thickness (IMT). The Mobil-O-Graph was used to measure the Central Augmentation Index (CAIx). RESULTS: Total leukocyte, neutrophil and monocyte counts were positively correlated with IMT (p < 0.01) in men. Monocyte count was positively correlated with CAIx in women (p < 0.01). In a multiple linear regression analysis, the IMT mean maintained a positive association with the neutrophil count (ß = 1.500, p = 0.007) in men. CAIx maintained a positive association with the monocyte count (ß = 2.445, p = 0.022) in women. CONCLUSION: The results of this study suggest that the relationship between subtype circulating leukocyte counts and vascular structure and function, although small, may be different by gender. In men, the neutrophil count was positively correlated with IMT and in women, the monocyte count with CAIx, in a large sample of intermediate-risk patients. These association were maintained after adjusting for age and other confounders. TRIAL REGISTRATION: ClinicalTrials.gov NCT01428934.

Metabolic syndrome in Spain: prevalence and coronary risk associated with harmonized definition and WHO proposal. DARIOS study.

INTRODUCTION AND OBJECTIVES: To update the prevalence of metabolic syndrome and associated coronary risk in Spain, using the harmonized definition and the new World Health Organization proposal (metabolic premorbid syndrome), which excludes diabetes mellitus and cardiovascular disease. METHODS: Individual data pooled analysis study of 24,670 individuals from 10 autonomous communities aged 35 to 74 years. Coronary risk was estimated using the REGICOR function. RESULTS: Prevalence of metabolic syndrome was 31% (women 29% [95% confidence interval, 25%-33%], men 32% [95% confidence interval, 29%-35%]). High blood glucose (P=.019) and triglycerides (P<.001) were more frequent in men with metabolic syndrome, but abdominal obesity (P<.001) and low high-density lipoprotein cholesterol (P=.001) predominated in women. Individuals with metabolic syndrome showed moderate coronary risk (8% men, 5% women), although values were higher (P<.001) than in the population without the syndrome (4% men, 2% women). Women and men with metabolic syndrome had 2.5 and 2 times higher levels of coronary risk, respectively (P<.001). Prevalence of metabolic premorbid syndrome was 24% and the increase in coronary risk was also proportionately larger in women than in men (2 vs 1.5, respectively; P<.001). CONCLUSIONS: Prevalence of metabolic syndrome is 31%; metabolic premorbid syndrome lowers this prevalence to 24% and delimits the population for primary prevention. The increase in coronary risk is proportionally larger in women, in both metabolic syndrome and metabolic premorbid syndrome.

[Cardiovascular risk factors in Spain in the first decade of the 21st Century, a pooled analysis with individual data from 11 population-based studies: the DARIOS study]. / Factores de riesgo cardiovascular en España en la primera década del siglo xxi: análisis agrupado con datos individuales de 11 estudios de base poblacional, estudio DARIOS.

INTRODUCTION AND OBJECTIVES: To estimate the prevalence of cardiovascular risk factors in individuals aged 35-74 years in 10 of Spain's autonomous communities and determine the geographic variation of cardiovascular risk factors distribution. METHODS: Pooled analysis with individual data from 11 studies conducted in the first decade of the 21st century. The average response rate was 73%. Lipid profile (with laboratory cross-validation), glucose level, blood pressure, waist circumference, height, and weight were measured and standard questionnaires administered. Age-standardized prevalence of smoking, diabetes, hypertension, dyslipidemia, and obesity in the European population were calculated. Furthermore, the coefficient of variation between component studies was determined for the prevalence of each risk factor. RESULTS: In total, 28,887 participants were included. The most prevalent cardiovascular risk factors were high blood pressure (47% in men, 39% in women), total cholesterol ≥ 250 mg/dL (43% and 40%, respectively), obesity (29% and 29%, respectively), tobacco use (33% and 21%, respectively), and diabetes (16% and 11%, respectively). Total cholesterol ≥ 190 and ≥ 250 mg/dL were the respective minimum and maximum coefficients of variation (7%-24% in men, 7%-26% in women). Average concordance in lipid measurements between laboratories was excellent. CONCLUSIONS: Prevalence of high blood pressure, dyslipidemia, obesity, tobacco use and diabetes is high. Little variation was observed between autonomous communities in the population aged 35-74 years. However, presence of the most prevalent cardiovascular risk factors in the Canary Islands, Extremadura and Andalusia was greater than the mean of the 11 studies.

Derivation and validation of REASON: a risk score identifying candidates to screen for peripheral arterial disease using ankle brachial index.

BACKGROUND: The recommendation of screening with ankle brachial index (ABI) in asymptomatic individuals is controversial. The aims of the present study were to develop and validate a pre-screening test to select candidates for ABI measurement in the Spanish population 50-79 years old, and to compare its predictive capacity to current Inter-Society Consensus (ISC) screening criteria. METHODS AND RESULTS: Two population-based cross-sectional studies were used to develop (n = 4046) and validate (n = 3285) a regression model to predict ABI < 0.9. The validation dataset was also used to compare the model's predictive capacity to that of ISC screening criteria. The best model to predict ABI < 0.9 included age, sex, smoking, pulse pressure and diabetes. Assessment of discrimination and calibration in the validation dataset demonstrated a good fit (AUC: 0.76 [95% CI 0.73-0.79] and Hosmer-Lemeshow test: χ(2): 10.73 (df = 6), p-value = 0.097). Predictions (probability cut-off value of 4.1) presented better specificity and positive likelihood ratio than the ABI screening criteria of the ISC guidelines, and similar sensitivity. This resulted in fewer patients screened per diagnosis of ABI < 0.9 (10.6 vs. 8.75) and a lower proportion of the population aged 50-79 years candidate to ABI screening (63.3% vs. 55.0%). CONCLUSION: This model provides accurate ABI < 0.9 risk estimates for ages 50-79, with a better predictive capacity than that of ISC criteria. Its use could reduce possible harms and unnecessary work-ups of ABI screening as a risk stratification strategy in primary prevention of peripheral vascular disease.

High prevalence of undiagnosed airflow limitation in patients with cardiovascular disease.

BACKGROUND: The prevalence of airflow limitation (AL) in patients with cardiovascular disease (CVD) is unknown, and whether AL is adequately diagnosed and treated in these patients has not been investigated before, to our knowledge. METHODS: We compared clinical and spirometric data in three groups of individuals. Two of them were participants in the follow-up of an ongoing population-based study according to the presence or absence of CVD. The third group included patients with coronary artery disease (CAD) confirmed by coronariography regularly visited at a tertiary referral university hospital. AL was defined according to the Global Initiative for Obstructive Lung Disease guidelines. RESULTS: We studied 450 population participants without CVD, 52 population participants with CVD, and 119 hospital patients with CAD. The prevalence of AL in these three groups was 17.5% (95% CI, 14.0-21.0), 19.2% (95% CI, 8.1-30.7), and 33.6% (95% CI, 25.0-42.2), respectively (P < .05). Underdiagnosis of AL ranged from 60% in population participants with CVD up to 87.2% in hospital patients with CAD. Sixty percent of those with spirometrically confirmed AL (in all three groups) did not receive any respiratory treatment. CONCLUSIONS: AL is frequent in individuals with CVD, particularly in those with CAD attended in the hospital, is largely underdiagnosed and therefore is highly undertreated. TRIAL REGISTRATION: Clinicaltrials.gov; Identifier: NCT00787748.

Prevalence, geographic distribution and geographic variability of major cardiovascular risk factors in Spain. Pooled analysis of data from population-based epidemiological studies: the ERICE Study.

INTRODUCTION AND OBJECTIVES: To determine the prevalence and geographic distribution of major cardiovascular risk factors in the Spanish population. To investigate whether geographic variability exists. METHODS: Data were pooled from eight cross-sectional epidemiologic studies carried out in Spain between 1992 and 2001 whose methodological quality satisfied predefined criteria. Individual data were reassessed and analyzed by age group (20-44 years, 45-64 years, and 365 years), sex and geographic area. The study population included 19,729 individuals. Mean values and unadjusted and adjusted prevalence rates were derived for various risk factors. RESULTS: The most common cardiovascular risk factors in the Spanish population were, in descending order: hypercholesterolemia (i.e., total cholesterol >200 mg/dL) in 46.7%, hypertension in 37.6%, smoking in 32.2%, obesity in 22.8%, and diabetes mellitus in 6.2%. The mean values for blood pressure, body mass index, high-density lipoprotein cholesterol and glycemia varied considerably with age, sex and geographic area. The highest levels of cardiovascular risk factors were observed in Mediterranean and south-eastern areas of the country and the lowest, in northern and central areas. CONCLUSIONS: The prevalence of major cardiovascular risk factors in Spain was high. Their distribution varied considerably with geographic area.