Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies.

AIMS: There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after 'recalibration', a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied. METHODS AND RESULTS: Using individual-participant data on 360 737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham risk score (FRS), Systematic COronary Risk Evaluation (SCORE), pooled cohort equations (PCE), and Reynolds risk score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at 'high' 10 year CVD risk. Original risk algorithms were recalibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before recalibration, FRS, SCORE, and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, whereas RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high risk. By contrast, recalibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms. CONCLUSION: Before recalibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple recalibration nearly equalized their performance and improved modelled targeting of preventive action to clinical need.

Evaluación de la validez de las funciones SCORE de bajo riesgo y calibrada para población española en las cohortes FRESCO / Validity assessment of low-risk SCORE function and SCORE function calibrated to the Spanish population in the FRESCO cohorts

Introducción y objetivos. Estudiar la validez de la función SCORE original de bajo riesgo sin y con colesterol unido a lipoproteínas de alta densidad y SCORE calibrada en población española. Métodos. Análisis agrupado con datos individuales de 12 estudios de cohorte de base poblacional. Se incluyó a 30.919 participantes de 40-64 años sin enfermedades cardiovasculares en el momento del reclutamiento, que se siguieron durante 10 años para la mortalidad cardiovascular contemplada en el proyecto SCORE. La validez de las funciones se analizó mediante el área bajo la curva ROC (discriminación) y el test de Hosmer-Lemeshow (calibración), respectivamente. Resultados. Se dispuso de 286.105 personas/año. La mortalidad a 10 años por causas cardiovasculares fue del 0,6%. La razón de casos esperados/observados fue de 9,1, 6,5 y 9,1 en varones y de 3,3, 1,3 y 1,9 en mujeres con las funciones SCORE original de bajo riesgo sin y con colesterol unido a lipoproteínas de alta densidad y SCORE calibrada, respectivamente; diferencias estadísticamente significativas con el test de calibración de Hosmer-Lemeshow entre la mortalidad predicha con SCORE y la observada (p < 0,001 en ambos sexos y en todas las funciones). Las áreas bajo la curva ROC con SCORE original fueron 0,68 en varones y 0,69 en mujeres. Conclusiones. Todas las versiones de las funciones SCORE disponibles en España sobreestiman significativamente la mortalidad cardiovascular observada en la población española. A pesar de la aceptable capacidad de discriminación, la predicción del número de acontecimientos cardiovasculares mortales (calibración) fue significativamente imprecisa (AU)

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 (AU)

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.

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.

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.

Glycated hemoglobin measurement and prediction of cardiovascular disease.

IMPORTANCE: The value of measuring levels of glycated hemoglobin (HbA1c) for the prediction of first cardiovascular events is uncertain. OBJECTIVE: To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease (CVD) risk. DESIGN, SETTING, AND PARTICIPANTS: Analysis of individual-participant data available from 73 prospective studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment. MAIN OUTCOMES AND MEASURES: Measures of risk discrimination for CVD outcomes (eg, C-index) and reclassification (eg, net reclassification improvement) of participants across predicted 10-year risk categories of low (<5%), intermediate (5% to <7.5%), and high (≥ 7.5%) risk. RESULTS: During a median follow-up of 9.9 (interquartile range, 7.6-13.2) years, 20,840 incident fatal and nonfatal CVD outcomes (13,237 coronary heart disease and 7603 stroke outcomes) were recorded. In analyses adjusted for several conventional cardiovascular risk factors, there was an approximately J-shaped association between HbA1c values and CVD risk. The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate, but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein. The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 (95% CI, 0.7350 to 0.7517). The addition of information on HbA1c was associated with a C-index change of 0.0018 (0.0003 to 0.0033) and a net reclassification improvement of 0.42 (-0.63 to 1.48) for the categories of predicted 10-year CVD risk. The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting, random, or postload plasma glucose levels. CONCLUSIONS AND RELEVANCE: In a study of individuals without known CVD or diabetes, additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk.

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.

Opinión de los universitarios sobre los cuidados al final de la vida / University students' opinions regarding end-of-life care

Introducción. El progresivo envejecimiento de la población por el aumento de la esperanza de vida, unido a los avances tecnológicos y científicos, hace que la población demande cuidados específicos al final de la vida, con especial cuidado al respeto a sus voluntades y cuidados finales que lleven a lo que se considera una muerte digna y sin sufrimiento. Materiales y métodos. A través de este estudio descriptivo mediante encuesta conocemos la información que manejan los universitarios y cuáles son sus deseos y opiniones con respecto a la enfermedad terminal y los cuidados al final de la vida, el testamento vital y la declaración de últimas voluntades. Se han encuestado 300 alumnos del Campus Universitario de Zaragoza, estudiantes de facultades de sociales y ciencias. Resultados. Los universitarios, mayoritariamente mujeres, de religión cristiana y con una edad media de 22 años, desearían ser informadas de su enfermedad por su médico, que tuviera disposición para hablar de su enfermedad y de sus sentimientos. Valoran en su médico especialmente su implicación y comprensión. Desean hablar de su etapa final, de sus deseos, de la donación de órganos y de los cuidados paliativos necesarios aplicados en su domicilio. En caso de fallecimiento preferirían la incineración. Conclusión. Los jóvenes universitarios no están suficientemente informados sobre los documentos de últimas voluntades (voluntades anticipadas o testamento vital), tienen interés por este tema y esperan de sus médicos y familiares implicación y comprensión ante la enfermedad y la muerte. Desean ser escuchados y tienen opinión sobre lo que se debería hacer cuando llegase el final de su vida (AU)

Introduction. The progressive aging of the population, increased life expectancy, coupled with technological and scientific advances mean that the population demands specific care at the end of life, with special care to respect their wishes and care leading to end what has been called a dignified death without suffering. Materials and methods. Through this study descriptive survey know the information handled by university and what their wishes and opinions regarding terminal illness and care at the end of life, living will and declaration of wills (advance directives). Respondents were 300 students of the University of Zaragoza Campus, students and faculties of social and sciences. Results. University students, mostly women, of Christian religion with a mean age of 22 years, would like to be informed of your condition by your doctor, you have available to discuss their illness and their feelings. Your doctor especially valued their involvement and understanding. They want to talk about the final stage, their desires, of organ donation. Wish, also, applied necessary palliative care at home. In case of death wish to be cremated. Conclusion. The university students are not sufficiently informed about the documents of wills (advance directives or living will), have an interest in this issue and expect from their doctors and family involvement and understanding of the disease and death. They want to be heard and have an opinion on what should be done when it came to the end of their lives (AU)

[Abdominal girth utility as a method of metabolic syndrome screening in people with hypertension]. / Utilidad del perímetro abdominal como método de cribaje del síndrome metabólico en las personas con hipertensión arterial.

BACKGROUND: The most useful criteria for diagnosis of the Metabolic Syndrome (MS) are those proposed by the ATP-III from NCEP 2001, reviewed in 2005. Waist circumference is one of the criteria included in the ATP-III estimate. Given the high incidence of coronary disease attributable to this risk factor, it seems interesting to evaluate its performance as an isolated parameter for the screening of MS among people with a variety of other prevalent cardiovascular risk factors, such as high blood pressure. DESIGN: case-control study. Cases were defined as patients with hypertension and MS. Controls were those patients with hypertension and without MS. SAMPLE: the entire population attended in a Primary Care area that had, unless one blood analysis performed between July first 2007 and December 31st 2007. SAMPLE size: 137 individuals were included (60 cases and 77 controls). STATISTICAL ANALYSIS: test of logistical regression was used to estimate of the probability of suffering from MS according to values of waist circumference. RESULTS: Probability of MS among hypertensive patients = 1/ (1+2,718281828-(-10+ (perimeter x 0,097))). Probability of MS among female hypertensive patients = 1/(1+2,718281828-(-10+ (perimeter x 0,099))). Probability of MS among male hypertensive patients = 1/(1 +2,718281828-(-10+ (perimeter x 0,105))). CONCLUSIONS: Among hypertensive patients, MS can be predicted by means of a formula (calculator), which takes waist circumference as unique variable. This method can be used to better stratify patients according to their cardiovascular risk and to identify those who need an early preventive intervention. We propose a table with the calculations already made.

Utilidad del perímetro abdominal como método de cribaje del síndrome metabólico en las personas con hipertensión arterial / Abdominal girth utility as a method of metabolic syndrome screening in people with hypertension

Fundamento: Para el diagnóstico de Síndrome Metabólico (SM)los criterios mas utilizados son los propuestos, por el ATP-III del NCEPde 2001, actualizados posteriormente en 2005. El perímetro de cinturaes uno de los cinco criterios utilizados para su diagnóstico. Dada la elevadaincidencia ajustada de enfermedad coronaria atribuible a este factorde riesgo, el objetivo de este trabajo es valorar la utilidad del perímetrode cintura como método de cribaje único de SM en la poblacióncon otros factores de riesgo muy prevalentes, como la HTA.Método: Estudio de casos (pacientes hipertensos con SM) y controles(pacientes hipertensos sin SM). Mediante muestreo sistemáticode la totalidad de individuos hipertensos de un cupo de Atención Primariacon resultados de al menos una analítica sanguínea desde el1/07/2007 hasta 31/12/2007. El tamaño muestral fue de 137 individuos(casos = pacientes hipertensos con SM = 60 y controles = pacienteshipertensos sin SM=77). Se utilizó el test de regresión logística para elcálculo de la probabilidad de SM disponiendo únicamente del perímetroabdominal.Resultados: Los resultados para el objetivo principal fueron: Probabilidadde SM en población hipertensa=1/(1+2,718281828-(-10+ (perímetrox 0,097))), Probabilidad de SM en mujeres hipertensas=1/(1+2,718281828-(-10+ (perímetro x 0,099))), Probabilidad de SM en varoneshipertensos=1/(1+2,718281828-(-10+ (perímetro x 0,105))).Conclusiones: Utilizando una calculadora podría predecirse laprobabilidad de SM en personas hipertensas con el perímetro de cinturacomo única variable, priorizando mejor a los pacientes con más necesidadpreventiva y mayor riesgo cardiovascular. Se propone una tablacon los cálculos ya realizados(AU)

Background: The most useful criteria for diagnosis of theMetabolic Syndrome (MS) are those proposed by the ATP-III fromNCEP 2001, reviewed in 2005. Waist circumference is one of the criteriaincluded in the ATP-III estimate. Given the high incidence ofcoronary disease attributable to this risk factor, it seems interesting toevaluate its performance as an isolated parameter for the screening ofMS among people with a variety of other prevalent cardiovascularrisk factors, such as high blood pressure.Methods: Design: case-control study. Cases were defined aspatients with hypertension and MS. Controls were those patientswith hypertension and without MS. Sample: the entire populationattended in a Primary Care area that had, unless one blood analysisperformed between July first 2007 and December 31st 2007. Samplesize: 137 individuals were included (60 cases and 77 controls). Statisticalanalysis: test of logistical regression was used to estimate ofthe probability of suffering from MS according to values of waist circumference.Results: Probability of MS among hypertensive patients = 1/(1+2,718281828-(-10+ (perimeter x 0,097))). Probability of MS among femalehypertensive patients = 1/(1+2,718281828-(-10+ (perimeter x 0,099))).Probability of MS among male hypertensive patients = 1/(1+2,718281828-(-10+ (perimeter x 0,105)))Conclusions: Among hypertensive patients, MS can be predictedby means of a formula (calculator), which takes waist circumferenceas unique variable. This method can be used to better stratifypatients according to their cardiovascular risk and to identify thosewho need an early preventive intervention. We propose a table withthe calculations already made(AU)