1,721,034 research outputs found
Do family history of coronary heart disease and social status improve 20-year risk prediction of first major cardiovascular event?
No full textIntroduction. Family history of CHD and low socio-economic status are well-established independent risk factors with the same level of evidence as biomarkers like high-sensitivity CRP or fibrinogen [1]. In addition, they are relatively easy to assess in clinical practice at a lower cost than biomarkers. However, their contribution to risk prediction beyond traditional risk factors has been examined to a lesser degree and with controversial findings; they are included in only a few risk equations, mainly from the UK.
Aims. To assess whether family history of CHD and social status might improve long-term risk prediction in a Northern Italy population.
Methods. N=3956 35-69 years old men and women free of cardiovascular disease were enrolled in three independent population-based cohorts conducted between 1986 and 1990 in Brianza (Northern Italy). Self-reported positive family history of CHD (prevalence: 27% in men, 34% in women) was ascertained at baseline. Three educational classes (high, intermediate and low education) were defined from age- and sex-specific tertiles of years of schooling. Absolute 20-year risk of first fatal or non-fatal coronary or ischemic stroke event during follow-up (MONICA validated) was estimated from gender-specific Cox models including age, total- and HDL-cholesterol, systolic blood pressure, anti-hypertensive treatment, diabetes and smoking (reference model). Model calibration (Grønnesby-Bogan goodness-of-fit test) and discrimination (Area Under the ROC-Curve, AUC) were estimated taking censoring into account. Changes in discrimination (Δ-AUC) and reclassification (Net Reclassification Improvement, NRI) defined the improvement from the reference model due to the addition of education and family history of CHD. Bootstrapped confidence intervals (CI) for Δ-AUC and NRI are also provided.
Results. The estimated Kaplan-Meier 20-year risk was 16.8% in men (254 events) and 6.4% in women (102 events). All the models were well calibrated (goodness-of-fit p-value >0.20 in both genders). Education (2 df test p-value 0.03) and family history of CHD (hazard ratio: 1.55; 95%CI 1.19-2.03) were associated with the endpoint in men, but not in women. In men, the addition of both education and family history improved discrimination (Δ-AUC=0.01; 95% CI 0.002-0.02) and risk stratification (NRI=6%; 95%CI: 0.2%-15.2%). Considering men at intermediate risk (10%-20%) according to the reference model, NRI among cases was 12%, and the overall NRI was 20.1% (95%CI: 0.5%-44%).
Conclusions. In this northern Italian population, two indicators of genetic risk and social status improve long-term risk prediction in men beyond traditional risk factors. Due to the low cost of assessment, they should be implemented in standard algorithms for risk prediction
Long-term prediction of first major cardiovascular event: model development and assessment of clinical utility
No full textIntroduction. Primary prevention of cardiovascular disease is based on subjects’ stratification into risk categories according to their predicted risk of event over a given time period, generally 10 years. The risk category triggers the treatment [1]; however, risk stratification is based on arbitrarily-chosen thresholds, showing sometimes no clinical utility [2]. Current research is moving forward the concept of “long-term” risk prediction, to better discriminate risk in young subjects and women. Therefore, long–term risk could be specially beneficial in the Italian population, considered at low incidence of event.
Aims. To develop a long-term prediction model of first major cardiovascular event and to assess its clinical utility in the Italian population. Methods. N=5247 35-69 years old men and women free of cardiovascular disease were enrolled in four independent population-based cohorts conducted between 1986 and 1993 in Brianza (Northern Italy). Absolute 20-year risk of first fatal or non-fatal coronary or ischemic stroke event during follow-up (MONICA validated) was estimated from gender-specific Cox models including age, total- and HDL-cholesterol, systolic blood pressure, anti-hypertensive treatment, diabetes and smoking. The Area Under the ROC-Curve (AUC), computed taking censoring into account and adjusted for over-optimisms, was a measure of model discrimination. “High-risk” subjects were identified based on several threshold values for the 20-year predicted risk. Clinical utility was defined in terms of fraction of missed events (events among those considered at low-risk) and unnecessary treatment (false:true positives ratio). A Net Benefit curve analysis, which plots a weighted difference between true and false positives along all the possible threshold values, was also provided. Results. Kaplan-Meier 20-year risk was 16.1% in men (315 events) and 6.1% in women (123 events). Model discrimination (AUC=0.737 in men, 0.801 in women) did not change significantly as compared to 10-year prediction time interval. In men, with respect to risk stratification based on the number of risk factors, a 20% predicted risk cut-off would miss less events (36% vs. 50%) and reduce unnecessary treatment (false:true positive ratio: 2.2 vs. 3.0). Similarly in women the 8% risk threshold would miss 23% of events with a false:true positive ratio of 4.5, compared to 42.3% and 5.8, respectively, of the strategy based on the number of risk factors. In both genders, the Net Benefit for predicted risk was higher than for the count of risk factors along all the possible risk thresholds. Conclusions. Long-term prediction has good discrimination ability and is clinically useful for risk stratification in primary prevention. Together with model development, a clinical utility analysis is crucial to identify the optimal stratification according to different public health goals
Prevalence of metabolic syndrome in a low CHD incidence population and its association with incidence of major CHD and stroke events: 11-year follow-up of the MONICA Brianza and PAMELA cohorts
No full textPredicting the 20-year risk of first coronary or ischemic stroke event in Northern Italy: the CAMUNI absolute risk equation
No full textAims. Recent US guidelines advocate the introduction of lifetime or long-term absolute risk prediction for primary prevention of cardiovascular events, especially for young people and women. Therefore, long-term prediction models might be specially beneficial in population considered at low incidence. We aim to develop a 20-year absolute risk prediction equation in a Northern Italy population.
Methods. Four independent population-based cohorts were enrolled between 1986 and 1994 from the Brianza population (Northern Italy), adopting standardized MONICA procedures. The study sample comprises n=2574 men and 2673 women, aged 35 to 69 years and free of CVD at baseline. Participants were followed-up for incidence of first coronary and ischemic stroke events (fatal and non-fatal; all MONICA validated) for a median time of 15 years (IQ range: 12-20) and up to the end of 2008. We compared several gender-specific Cox Proportional Hazards models: the basic one includes age, total cholesterol, HDL-cholesterol, systolic blood pressure, anti-hypertensive treatment, cigarette smoking and diabetes. Candidates to model addition were diastolic blood pressure, triglycerides, BMI, family history of CHD, and education. Model calibration was tested using the Grønnesby-Bogan goodness-of-fit statistic. The Area Under the ROC-Curve (AUC) was a measure of discrimination, corrected for over-optimism via bootstrapping. Changes in discrimination (Δ-AUC) and reclassification (Net Reclassification Improvement, NRI) defined the improvement from the basic model due to an additional risk factor. Intermediate risk was defined as 20-year risk between 10% and 40%.
Results. We observed n=286 events in men (incidence rate 7.7 per 1000 person-years) and n=108 in women (2.6 per 1000 person-years). All risk factors included in the basic model were predictive of first cardiovascular event in both genders; discrimination was 0.725 and 0.802 in men and women, respectively. Average specificity in the top risk quintile (cut-off value: 23% in men and 8.5% in women) was similar in men and women (85% vs. 83%), while sensitivity was higher in women (63% vs. 46%). All the models were well-calibrated (p-values >0.05). The addition of a positive family history of CHD in men (Hazard Ratio: 1.6; 95%CI 1.2-2.1) and of diastolic blood pressure in women (HR: 1.4 for 11 mmHg increase; 1.1-1.8) significantly improved discrimination (Δ-AUC=0.01; 95%CI 0.002-0.02 [men] and Δ-AUC=0.005; 95%CI 0.0001-0.01 [women]) and reclassification of subjects at intermediate risk (NRI=8.4%;1.7%-19.1% [men]; and NRI=11.7%; -3.2%-33.5% [women]).
Conclusions. Traditional risk factors are predictive of cardiovascular events after 20 years, with good discrimination. The addition of family history of CHD may contribute to model improvement, at least among men; the role of diastolic blood pressure in women should be carefully evaluated
Validity of a long-term cardiovascular disease risk prediction equation for low-incidence populations: The CAMUNI-MATISS Cohorts Collaboration Study.
No full textBackground Before introducing long-term cardiovascular disease (CVD) risk models in clinical practice, their external validity should be investigated. We assessed the validity of the CArdiovascular Monitoring Unit in Northern Italy (CAMUNI) 20-year risk score, developed in Northern Italy, and published previously, when applied to a population with different risk factors distribution and event incidence. Methods The validation sample consisted of 5307 35-69 year-old subjects (2418 men) enrolled in Central Italy during the 1980s (Malattia ATerosclerotica Istituto Superiore di Sanità (MATISS) study). Baseline risk factor assessment and follow-up procedures, including MONICA definition of acute events, followed a shared protocol with the derivation cohorts. We estimated model calibration and discrimination (area under the ROC curve, AUC) in the validation set; as well as the net benefit of using the CAMUNI risk score as second-level screening in subjects at different levels of short-term risk. Results The 20-year risk of event was 14% in men and 7% in women. Model calibration was satisfactory, and the strength of the association between predictors and the endpoint was the same as in the derivation population. The AUC was 0.734 (men) and 0.802 (women). The net benefit of the CAMUNI score was 3.9 (95% confidence interval: 2.1-5.7) and 2.9 (1.7-4.3) in men and women at low 10-year risk, respectively. Among subjects at high short-term risk, a significant net benefit of 9.8 was observed in men only. A pooled CAMUNI-MATISS risk score is provided. Conclusions In this low-incidence European population, long-term CVD prediction through the CAMUNI risk score is accurate and it has the potential to improve current primary prevention strategies based on short-term risk scores alone. © European Society of Cardiology 2014
Time trends of myocardial infarction 28-day case-fatality in the 1990s: is there a contribution from different changes among socio-economic classes?
No full textComparing short-term and long-term absolute cardiovascular risk prediction models in a low-incidence Country. Insights from the CAMUNI absolute risk equation in Northern Italy
No full textAims. The 10-year absolute risk of cardiovascular events, a current standard for treatment indication in CVD primary prevention, has been recently shown to inadequately estimate the risk in young subjects and women, even in presence of a cluster of risk factors. We aim to compare a 10- and a 20-year absolute risk of CVD prediction models in a low incidence population.
Methods. Four independent population-based cohorts were enrolled between 1986 and 1994 in Northern Italy, adopting standardized MONICA procedures. N=2574 men and n=2673 women, 35-69 years old and free of CVD at baseline, were followed-up to ascertain the first coronary or ischemic stroke event (fatal and non-fatal; all MONICA validated) for a median time of 15 years (IQ range: 12-20) and up to the end of 2008. The 10- and the 20-year absolute risk (AR) of event were estimated from gender-specific Cox models including age, total cholesterol, HDL-cholesterol, systolic blood pressure, anti-hypertensive treatment, cigarette smoking and diabetes. Model discrimination at year 10 and 20, defined as the Area Under the ROC Curve, as well as sensitivity and specificity in the top quintile, were estimated taking censoring into account; the AUC was adjusted for over-optimism via bootstrapping. We assessed the Net Reclassification Improvement (NRI) for the 20-year risk model compared to the 10-year risk model re-calibrated to the Kaplan-Meier estimate of 20-year survival. We report NRI in young men and women as well as in subjects with AR(10)240 mg/dl; HDL-cholesterol 160 mmHg; smoking; diabetes).
Results. The Kaplan-Meier estimates of AR(10) and AR(20) were 7.1% and 14.0% in men; and 2.2% and 5.3% in women. After 20 years from measurement, major risk factors were still predictive of CV events; although in comparison to the 10-year model the hazard ratio for total cholesterol in men fell from 1.40 to 1.34; and for HDL-cholesterol in women reduced from 0.64 to 0.71, both calculated for 1 SD increase. In the top risk quintile, the 20-year model had higher specificity (85% vs. 82% in men; 83% vs. 81% in women) and lower sensitivity (46% vs. 50% in men; 63% vs. 69% in women) than the 10-year model; the overall discrimination was similar (0.725 vs. 0.732 [men], and 0.802 vs. 0.813 [women]). NRI in young subjects was 10.5% in men (15.4% in cases) and 5% in women. Six per cent of men and 15% of women had 2 or more major risk factors but an AR(10)<5%. Among them, NRI was 7% in men and 13% in women (18% in cases).
Conclusions. In our low-incidence population, long-term prediction of first major ischemic cardiovascular event is more suitable to identify high CVD risk in young men and in women with a cluster of risk factors, overcoming the limits of the 10-year model. Preventive strategies based on long-term absolute risk should be evaluated
The Effects of revascularization procedures on myocardial incidence rates and time trends: the MONICA-Brianza and CAMUNI MI registries in northern Italy.
No full texturpose: Clinical guidelines recommend early reperfusion treatment in myocardial infarction (MI) patients to reduce the cardiac damage. Epidemiologic definitions of MI are often based on the evolution of the cardiac lesion. We aim to study the effect of treatment on the estimates of rates and 20-year time trends of MI. Methods: A Multinational Monitoring of trends and determinants in Cardiovascular disease (MONICA) register was active between 1985 and 2004 to survey 35- to 64-year-old residents in Brianza, Northern Italy. To the well-established MONICA definite MI, we added the MONICA possible nonfatal MI receiving either myocardial revascularization or thrombolysis within 24 hours from onset. The average annual relative changes in incidence rate and 28-day case fatality percentage were estimated from log-linear models. Results: In our population, characterized by a monotonic decrease in coronary heart disease (CHD) mortality rates, the incident rate for the standard MONICA definite MI decreased yearly by 3% in both gender groups. The addition of selected revascularizations halved the downward trends in incidence rate in men and women; conversely, the decline in 28-day case fatality became steeper. Conclusions: From an epidemiologic perspective, the increasing proportion of acute events efficaciously treated with revascularization therapy affects the estimate and the interpretation of time trends in MI incidence and CHD mortality
Treatment allocation for primary cardiovascular disease prevention based on long-term CVD risk prediction: insights from the Brianza cohort study in Northern Italy
No full textRisk of first major coronary events among occupational and educational social classes: 12-year follow-up of the MONICA Brianza and PAMELA cohorts
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