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.

Agreement between ten-years cardiovascular disease risk assessment tools: An application to Iranian population in Shahedieh Cohort Study.

Background and aim: Cardiovascular risk-prediction models are efficient primary prevention tools to detect high-risk individuals. The study aims to use three tools to estimate the 10-year risk of developing cardiovascular disease (CVD) and investigate their agreement in an Iranian adult population. Methods: The current cross-sectional study was carried out on 8569 adults between 35 and 70 who participated in the first phase of the Shahedieh cohort study in Yazd, Iran, and were free of CVDs (cardiac ischemia or myocardial infarction or stroke). World Health Organization/International Society of Hypertension (WHO/ISH) chart, Laboratory-Based (LB) and Non-Laboratory-Based (NLB) Framingham Risk Score (FRS) were used to predict the 10-year risk of developing CVD. The agreement across tools was determined by Kappa. Results: WHO/ISH chart indicated the highest prevalence of low CVD risk for males (96.10%) and females (96.50%), while NLB Framingham had the highest prevalence of high CVD risk for males (19.40%) and females (5.30%). In total, there was substantial agreement between both FRS models (Kappa = o.70), while there was a slight agreement between WHO/ISH and both FRS tools. For under 60 years males and females, substantial agreements were observed between FRS methods (kappa = 0.73 and kappa = 0.68). For males and females over 60 years, this agreement was moderate and substantial, respectively (kappa = 0.54 and kappa = 0.64). WHO/ISH and LB Framingham model had substantial agreement for over 60 years females (kappa = 0.61). Conclusions: Framingham models classified more participants in the high-risk category than WHO/ISH. Due to the lethality of CVDs, categorizing individuals based on FRS can ensure that most of the real high-risk people are detected. Remarkable agreement between FRS methods in all sex-age groups suggested using the NLB Framingham model as a primary screening tool, especially in a shortage of resources condition.

Basic Surveillance Parameters Improve the Prediction of Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage.

Background: To establish a practical risk chart for prediction of delayed cerebral infarction (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) by using information that is available until day 5 after ictus. Methods: We assessed all consecutive patients with aSAH admitted to our service between September 2008 and September 2015 (n = 417). The data set was randomly split into thirds. Two-thirds were used for model development and one-third was used for validation. Characteristics that were present between the bleeding event and day 5 (i.e., prior to >95% of DCI diagnoses) were assessed to predict DCI by using logistic regression models. A simple risk chart was established and validated. Results: The amount of cisternal and ventricular blood on admission CT (Hijdra sum score), early sonographic vasospasm (i.e., mean flow velocity of either intracranial artery >160 cm/s until day 5), and a simplified binary level of consciousness score until day 5 were the strongest predictors of DCI. A model combining these predictors delivered a high predictive accuracy [the area under the receiver operating characteristic (AUC) curve of 0.82, Nagelkerke's R 2 0.34 in the development cohort]. Validation of the model demonstrated a high discriminative capacity with the AUC of 0.82, Nagelkerke's R 2 0.30 in the validation cohort. Conclusion: Adding level of consciousness and sonographic vasospasm between admission and postbleed day 5 to the initial blood amount allows for simple and precise prediction of DCI. The suggested risk chart may prove useful for selection of appropriate candidates for interventions to prevent DCI.

Comparison of laboratory-based and non-laboratory-based WHO cardiovascular disease risk charts: a population-based study.

BACKGROUND: Determining the risk of Cardiovascular Disease (CVD) is a necessity for timely preventive interventions in high-risk groups. However, laboratory testing may be impractical in countries with limited resources. This study aimed at comparison and assessment of the agreement between laboratory-based and non-laboratory-based WHO risk charts models. METHODS: This study was performed using the baseline data of 8138 participants in the pars cohort study who had no history of CVD and stroke. The updated 2019 WHO model was used to determine the 10-year fatal and non-fatal CVD risks. In general, there are two types of new WHO risk prediction models for CVD. The scores were determined based on age, sex, smoking status, diabetes, Systolic Blood Pressure (SBP), and total cholesterol for the laboratory-based model and age, sex, smoking status, SBP, and Body Mass Index (BMI) for the non-laboratory-based model. The agreement of these two models was determined via kappa statistics for the classified risk (low: < 10%, moderate: 10-< 20%, high: ≥ 20%). Correlation coefficients (r) and scatter plots was used for correlation between scores. RESULTS: The results revealed very strong correlation coefficients for all sex and age groups (r = 0.84 for males < 60 years old, 0.93 for males ≥ 60 years old, 0.85 for females < 60 years old, and 0.88 for females ≥ 60 years old). In the laboratory-based model, low, moderate, and high risks were 76.10%, 18.17%, and 5.73%, respectively. These measures were respectively obtained as 77.00%, 18.08%, and 4.92% in the non-laboratory-based model. Based on risk classification, the agreement was substantial for males < 60 years old and for both males and females aged ≥ 60 years (kappa values: 0.79 for males < 60 years old, 0.65 for males ≥ 60 years old, and 0.66 for females ≥ 60 years old) and moderate for females < 60 years old (kappa = 0.46). CONCLUSIONS: The non-laboratory-based risk prediction model, which is simple, inexpensive, and non-invasive, classifies individuals almost identically to the laboratory-based model. Therefore, in countries with limited resources, these two models can be used interchangeably.

[Development of a risk prediction model and a sample risk chart for long-term care certification based on the functional health of older adults].

Objectives　The first aim of this study was to develop risk prediction models based on age, sex, and functional health to estimate the absolute risk of the 3-year incidence of long-term care certification and to evaluate its performance. The second aim was to produce risk charts showing the probability of the incident long-term care certification as a tool for prompting older adults to engage in healthy behaviors.Methods　This study's data was obtained from older adults, aged ≥65 years, without any disability (i.e., they did not certify≥care level 1) and residing in Yabu, Hyogo Prefecture, Japan (n=5,964). A risk prediction model was developed using a logistic regression model that incorporated age and the Kihon Checklist (KCL) score or the Kaigo-Yobo Checklist (KYCL) score for each sex. The 3-year absolute risk of incidence of the long-term care certification (here defined as≥care level 1) was then calculated. We evaluated the model's discrimination and calibration abilities using the area under the receiver operating characteristic curves (AUC) and the Hosmer-Lemeshow goodness-of-fit test, respectively. For internal validity, the mean AUC was calculated using a 5-fold cross-validation method.Results　After excluding participants with missing KCL (n=4) or KYCL (n=1,516) data, we included 5,960 for the KCL analysis and 4,448 for the KYCL analysis. We identified incident long-term care certification for men and women during the follow-up period: 207 (8.2%) and 390 (11.3%) for KCL analysis and 128 (6.6%) and 256 (10.2%) for KYCL analysis, respectively. For calibration, the χ2 statistic for the risk prediction model using KCL and KYCL was: P=0.26 and P=0.44 in men and P=0.75 and P=0.20 in women, respectively. The AUC (mean AUC) in the KCL model was 0.86 (0.86) in men and 0.83 (0.83) in women. In the KYCL model, the AUC was 0.86 (0.85) in men and 0.85 (0.85) in women. The risk charts had six different colors, suggesting the predicted probability of incident long-term care certification.Conclusions　The risk prediction model demonstrated good discrimination, calibration, and internal validity. The risk charts proposed in our study are easy to use and may help older adults in recognizing their disability risk. These charts may also support health promotion activities by facilitating the assessment and modification of the daily behaviors of older adults in community settings. Further studies with larger sample size and external validity verification are needed to promote the widespread use of risk charts.

Absolute mortality risk assessment of COVID-19 patients: the Khorshid COVID Cohort (KCC) study.

BACKGROUND: Already at hospital admission, clinicians require simple tools to identify hospitalized COVID-19 patients at high risk of mortality. Such tools can significantly improve resource allocation and patient management within hospitals. From the statistical point of view, extended time-to-event models are required to account for competing risks (discharge from hospital) and censoring so that active cases can also contribute to the analysis. METHODS: We used the hospital-based open Khorshid COVID Cohort (KCC) study with 630 COVID-19 patients from Isfahan, Iran. Competing risk methods are used to develop a death risk chart based on the following variables, which can simply be measured at hospital admission: sex, age, hypertension, oxygen saturation, and Charlson Comorbidity Index. The area under the receiver operator curve was used to assess accuracy concerning discrimination between patients discharged alive and dead. RESULTS: Cause-specific hazard regression models show that these baseline variables are associated with both death, and discharge hazards. The risk chart reflects the combined results of the two cause-specific hazard regression models. The proposed risk assessment method had a very good accuracy (AUC = 0.872 [CI 95%: 0.835-0.910]). CONCLUSIONS: This study aims to improve and validate a personalized mortality risk calculator based on hospitalized COVID-19 patients. The risk assessment of patient mortality provides physicians with additional guidance for making tough decisions.

Cardiovascular risk and validation of cardiovascular risk prediction functions in a cohort of patients with type 2 diabetes followed for 10 years in Badajoz (SPAIN). AN observational study.

AIMS: To analyse whether diabetes behaves as an equivalent of coronary risk and assess the performance of the original and REGICOR Framingham functions in a cohort of patients with type 2 diabetes observed for 10 years in primary care practices in Badajoz, Spain. METHODS: Observational, longitudinal study. A total of 643 patients (mean age 64.0 years, 55.7% women), without evidence of cardiovascular disease were studied. We assessed the incidence of cardiovascular events and the patients' 10-year coronary risk predicted-values at the time of their recruitment. RESULT: The actual incidence rate of coronary events was 14.5% (15.1% in women and 13.7% in men, p = 0.616). Patients who suffered coronary events were older (66.3 vs 63.6 years, p < 0.05), had higher total cholesterol (236.3 vs 219.5 mg/dl, p < 0.01), fasting plasma glucose levels (177.6 vs 159.8 mg/dl, p < 0.01), glycated haemoglobin (7.3 vs 6.7%, p < 0.05) and also higher prevalence of high blood pressure, dyslipidemia and chronic renal disease. The original Framingham equation overpredicted risk by 88%, whereas the REGICOR Framingham function underpredicted risk by 24%. CONCLUSIONS: Diabetes in our cohort does not behave as a coronary heart disease equivalent and both the original and REGICOR Framingham coronary risk functions have little utility in a diabetic population.

Red Blood Cell Morphodynamics: A New Potential Marker in High-Risk Patients.

In the last years, a substantial contribution of red blood cells (RBCs) in cardiovascular homeostasis has been evidenced, as these cells are able to regulate cardiovascular function by the export of adenosine triphosphate and nitric oxide as well as to maintain redox balance through a well-developed antioxidant system. Recently a link between high-risk plaque (HRP) features and myocardial ischemia, in the absence of severe lumen stenosis, has been evidenced. Nonobstructive coronary artery disease (nonob CAD) has been associated in fact with a greater 1-year risk of myocardial infarction and all-cause mortality compared with no apparent CAD. This new evidence increases interest in searching new triggers to identify these high-risk patients, in the absence/or on top of traditional hazard markers. In this study, we investigated the existence of any association between RBC morphodynamics and HRP features in individuals with different grades of coronary stenosis detected by coronary computed tomography angiography (CCTA). Ninety-one consecutive individuals who underwent CCTA [33 no CAD; 26 nonobstructive (nonob), and 32 obstructive (ob) CAD] were enrolled. RBC morphodynamic features, i.e., RBC aggregability and deformability, were analyzed by means of Laser Assisted Optical Rotation Cell Analyzer (LoRRca MaxSis). The putative global RBC morphodynamic (RMD) score and the related risk chart, associating the extent of HRP (e.g., the non-calcified plaque volume) with both the RMD score and the max % stenosis were computed. In nonob CAD group only positive correlations between RBC rigidity, osmotic fragility or aggregability and HRP features (plaque necrotic core, fibro-fatty and fibro-fatty plus necrotic core plaque volumes) were highlighted. Interestingly, in this patient cohort three of these RBC morphodynamic features result to be independent predictors of the presence of non-calcified plaque volume in this patients group. The risk chart created shows that only in nonob CAD plaque vulnerability increases according to the score quartile. Findings of this work, by evidencing the association between erythrocyte morphodynamic characteristics assessed by LoRRca and plaque instability in a high-risk cohort of nonob CAD, suggest the use of these blood cell features in the identification of high-risk patients, in the absence of severe coronary stenosis.

Cardiovascular Risk Scores in Women Undergoing Stress Myocardial Perfusion Scan and Comparison with Scan-Predicted Risk.

BACKGROUND: Death due to cardiovascular disease is a major concern in the field of noncommunicable disease. Assessment of cardiovascular risk score using Framingham score and WHO/ISH score is a noninvasive, easier method of predicting the adverse cardiovascular event in the general population. AIMS AND OBJECTIVES: The aim of the study was to assess the cardiovascular risk using Framingham score and WHO/ISH in women undergoing stress myocardial perfusion imaging (MPI) and comparison with scan-predicted risk. MATERIALS AND METHODS: Adult females with suspected coronary artery disease referred to the department of nuclear medicine for 2 months were included in the study. Data pertaining to the risk score assessment were collected, and the risk scores were calculated. Subsequently, the patients underwent scheduled Tc-99m methoxy-isobutyl-isonitrile myocardial stress imaging, and scan-predicted risks were calculated. Then, the risk score of Framingham and WHO/ISH methods were compared with stress myocardial perfusion score using Cohen's kappa statistic. RESULTS: The mean age of the sample was 52 years (standard deviation: 11). Framingham and WHO/ISH risk scores predicted low, intermediate, and high risk in 62.2%, 28.9%, and 8.9% and 68.9%, 22.1%, and 8.89% of the population. The two scoring methods showed moderate agreement (κ =0.59). However, the scores showed only slight and fair agreement, respectively, with risk predicted by stress MPI. CONCLUSION: Although the risk scores have been shown to benefit in screening general population, they may not perform well in symptomatic patients with suspected angina. Out of the two methods, WHO/ISH fares better than Framingham score in this population.

Cardiovascular Risk Assessment Chart by Dietary Factors in Japan　- NIPPON DATA80.

BACKGROUND: Many studies show that dietary factors such as vegetables, fruit, and salt are associated with cardiovascular disease (CVD) risk. However, a risk assessment chart for CVD mortality according to combinations of dietary factors has not been established.Methods and Results:Participants were 9,115 men and women aged 30-79 years enrolled in the National Nutritional Survey of Japan in 1980 with a 29-year follow-up. Dietary intake was assessed using a 3-day weighed dietary record at baseline. Cox regression models were used to estimate the hazard ratio (HR) of CVD mortality stratified by vegetables, fruit, fish, and salt consumption. HRs of CVD mortality according to combinations of dietary factors were color coded on an assessment chart. Higher intakes of vegetables, fruit, and fish, and lower salt intake were associated with lower CVD mortality risk. HRs calculated from combinations of dietary factors were displayed using 5 colors corresponding to the magnitude of the HR. People with the lowest intake of vegetables, fruit, and fish, and higher salt intake had a HR of 2.87 compared with those with the highest intake of vegetables, fruit, and fish, and lower salt intake. CONCLUSIONS: Vegetables, fruit, fish, and salt intake were independently associated with CVD mortality risk. The assessment chart generated could be used in Japan as an educational tool for CVD prevention.