CVD risk estimation in populations with high prevalence of MetS. Dilek Ural, 12 March 2017 Koç University, Istanbul

Transcription

1 CVD risk estimation in populations with high prevalence of MetS Dilek Ural, 12 March 2017 Koç University, Istanbul

2 Understanding CV risk Likelihood of a person developing an atherosclerotic CV event over a defined time period. 2 of 13 Palling J, et al. BMJ 2003;327:745

3 Whom to tell the risk? ESC 2012/6: The ideal scenario is for all adults to have their risk of CVD assessed, this is not practical in many societies Goff DC, Jr et al. Circulation 2014;129:S49-S73 3 of 13

4 How to tell the risk? - Current Models FINRISK Joint British Societies Coronary Risk Prediction ASSIGN Cambridge DM RS QRISK Dundee RS PRECARD (Kopenhagen) ACCF/AHA 2013 Risk Score Framingham RS Reynolds Risk S. SCORE HeartScore PROCAM 4 of 13

5 Which CV events? When? With which variables? SCORE FRS ACCF/AHA Fatal MI x X x Fatal stroke x X X Nonfatal MI X X Nonfatal stroke X X SCORE FRS ACCF/AHA Gender X X X Age X X X Tot. Cholest X X X HDL C (X) X X Revascularization X Systolic BP X X X Peripheral artery disease X Smoking X X X Heart failure x Diabetes X X Time 10 years 10 years 30 years, life time HT treatment Race X X X 5 of 13

6 Problems in Current Global Risk Assessment - Dynamic nature of risk factors within individuals and populations - Impossibility of the evaluation of temporal changes in risk factors in an individuals life - Differences between various populations, ethnicities - Lack of studies with a risk category based treatment methodology - Fatal/nonfatal risk - Special populations (Young, elderly, women, diabetics) - Ten years/life long risk - Lack of genetic features or family history - Lack of lifestyle risk factors - Addition of new markers - Addition of imaging modalities Ural D. Anatolian J Cardiol of 13

7 Countries and CV mortality In populations other than the Framingham, FRS overestimates risk of initial CAD events in Native Americans, Japanese-American, Hispanic, European, and Chinese populations. FRS was recalibrated using local CAD rates and cohort average levels of risk factors in China. 7 of 13

8 SCORE Risk Charts 8 of 13

9 Countries who recalibrated SCORE Low risk charts: Andorra, Austria, Belgium*, Cyprus, Denmark, Finland, France, Germany, Greece*, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, The Netherlands*, Norway, Portugal, San Marino, Slovenia, Spain*, Sweden*, Switzerland and the UK *Updated, re-calibrated charts are available for these at-low risk countries and for Poland. Jdanov DA, et al.. Eur J Epidemiol 2014 ;29: of 13

10 Factors scoring systems can t score Life style (Nutrition and physical activity) Cognitive function / Education Depression / Stress / Socioeconoical status 10 of 13

11 INTERHEART ve INTERSTROKE RISK FACTOR MI* Stroke Apolipoprotein B/A1 ratio 1 4 Active smoking 2 3 Diabetes mellitus 3 7 Hypertension 4 1 Waist-to-hip ratio 5 5 Psychosocial stress and depression 6 9 Diet risk score 7 8 Regular physical activity 8 10 Alcohol consumption of 13 O'Donnell MJ, et al. Lancet 2010;376:

12 INTERHEART ve INTERSTROKE RISK FACTOR MI* Stroke Apolipoprotein B/A1 ratio 1 4 Active smoking 2 3 Diabetes mellitus ( ) 3 7 Hypertension 4 1 Waist-to-hip ratio 5 5 Psychosocial stress and depression 6 9 Diet risk score 7 8 Regular physical activity 8 10 Alcohol consumption of 13 O'Donnell MJ, et al. Lancet 2010;376:

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14 Metabolic syndrome/dm 14 of 13 O'Donnell MJ, et al. Lancet 2010;376:

15 Atherogenic dyslipidemia 15 of 13 Cartier A, CMR Journal 2010;3.

16 Emerging Risk Factors Collaboration Hazard ratios for coronary heart disease and ischaemic stroke across quantiles of usual concentrations of triglycerides, HDL, and non-hdl cholesterol levels 16 of 13 Chapman MJ, et al. Eur Heart J 2011;32:

17 Non-HDL vs. LDL-C and Outcome 17 of 13 Harari G, et al Am J Cardiol 2017

18 Accuracy of multiple cardiovascular risk scores in a modern multiethnic cohort and hs-crp The new AHA-ACC-ASCVD and 3 older Framingham-based risk scores overestimated CV events by 37% to 154% in men and 8% to 67% in women throughout the continuum of risk. The Reynolds Risk Score overestimated risk by 9% in men but underestimated risk by 21% in women. JDeFilippis AP, et al. MESA study. Ann Intern Med 2015;162: of 13

19 Turkey Population statistics Cardiovascular diseases Malignancies Respiratory diseases Men Women Endocrinological diseases METSAR (Population aged >20 years) TARF (Population aged >30 years) 19 of 13 Turkish Institute of Statistics 2015

20 Sensitivity FRS - SCORE Risk models in Turkish Population TARF Study Ural D, et al SD 22,2 Mean 9, SD -3, SCORE Observed CV events were in men 2 times, in women 3 times higher than calculated in FRS Specificity FRS SCORE FRS SCORE PROCAM 0,613 TEKHARF 0,809 (%95 CI (%95 CI ) ) 20 of 13 2 Onat, ve ark. Türk Kard Dern Arş 2004; 2 Ural, ve ark. UKK 2013.

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22 Accuracy in a Large Contemporary, Multiethnic Population 22 of 13 Rana JS, et al. J Am Coll Cardiol 2016;67:

23 Solution: Recalibration of scoring systems according to national data SCORE for high-risk countries 23 of 13

24 Comparison of recent scoring systems CV events AUC SE P CI FRS,628,056,027,518,739 ACCF-AHA,651,055,009,543,760 SCORE,790,047,000,697,883 SCORE-TR,625,056,032,514, of 13 Ural D, Europrevent 2016

25 TARF Study Coronary heart disease Women Men N=133/1457 N=133/ person-years RR %95 CI RR %95 CI Age ; ; ; ; ; ;31.3 Impaired FG ; ;1.63 DM ; ;3.48 SBP, mg Hg ; ; mm Hg ; ; mm Hg ; ; of 13 Onat A, in press

26 TARF Study Coronary heart disease Women Men N=133/1457 N=133/ person-years RR %95 CI RR %95 CI Non HDL, mg/dl ; ;1.57 >150 mg/dl ; ;2.33 HDL, 40-49/50-59 mg/dl ; ;1.16 >50/>60 mg/dl ; ;1.96 Low vs high phys. Activity ; ;1.71 Smokers vs never smokers ; ;3.16 Past vs never smokers ; ; of 13

27 Risk discrimination 27 of 13

28 All cause mortality Variable Age; years Diabetes 70 Yes Systolic BP, mm Hg Non-HDL-cholesterol, mg/dl Current smoking Past smoking Low physical activity Yes Yes Yes 28 of 13 Onat A, Ural D. Int J Cardiol 2016

29 A G E Genetics Gender Fate (nation, family, social and economic factors) Lifestyle Diet Physical activity Fate (family, social and economic factors, infections, accidents) Blood pressure, lipids Genomics Lifestyle Diet, physical activity, smoking, alcohol Psycological factors Blood pressure, lipids hs-crp, m.albuminuria Biomarkers Imaging (esp. 45+, intermediate risk) CLINICAL DISEASE - Troponins, BNP and other markers - Imaging - Other risk stratification methods 29 of 13

30 Assessment of vascular age Endoth. dysfunction, ABI, arterial stiffness LVH and DD, aortic valve sclerosis, carotid IMT and plaques Calcium score Tests for ischemia 30 of 13

31 Carotis Intima Media Thickness 15 articles Age yrs FU: yrs 31 of 13 van den Oord SC, et al. Atherosclerosis 2013;228:1-11.

32 Carotid plaque or coronary calcium? 5,808 asymptomatic U.S. adults (mean age: 69 years, 56.5% female) in a prospective cohort evaluating the role of vascular imaging (CAC and novel 3-dimensional carotid ultrasound) on 3 years CV risk prediction. Baber U, et al. The BioImage study. J Am Coll Cardiol 2015;65: Fudim M, et al. Int J Cardiol 2016;204: of 13

33 One size to fit all 33 of 13

34 Omics and Risk 34 of 13 Lewis GD, et al. JACC 2008; 52(2):

35 Genomics and CV risk 35 of 13 Kullo IJ, Cooper LT. Rev Cardiol 2010;7(6):

36 Biomarkers Emerging Biomarkers: Micro-RNAs Metabolites Proteomic markers 36 of 13 Ward-Caviness CK, et al. Heart 2017;0:1 8. de Ronde MW, et al. Ann Transl Med 2016;4:490. Kullo IJ, Cooper LT. Rev Cardiol 2010;7(6):

37 Presicion & Personalized and Telemedicine 37 of 13 Krittanawong C, et al. ACC 2015

38 Conclusion There is an unmet need to create accurate risk estimation systems for populations with high prevalence of metabolic syndrome/obesity/diabetes. Inclusion of variables like non-hdl cholesterol, lack of physical activity, impaired glucose tolerance/diabetes have the potential to improve risk assessment in these patients. Robust national data on rate of CVD mortality and its risk factors are essential for an accurate risk assessment. The beneficial effect of implementing novel techniques and precision medicine approach in risk assessment remains to be proven. 38 of 13

39 Thank you for your attention 39 of 13