This website is intended for healthcare professionals only.
Take a look at a selection of our recent media coverage:
6th May 2022
Adding coronary artery calcium scores (CACS) to further assess an individual’s cardiovascular risk assessment does not appear to be associated with any clinical benefit. This was the main finding of a systematic review and meta-analysis by a team from the School of Public Health, University of Sydney, Sydney, Australia.
Cardiovascular risk assessment is a critical step in the current approach to primary prevention of heart disease and is calculated using tools such as QRISK. Cardiac computed tomography (CT) imaging is an important tool for cardiovascular risk assessment in observational prospective studies and which provides a measure of subclinical disease such as coronary artery calcium. Moreover, the use of CACS has been shown to be an independent predictor of incident coronary heart disease among those deemed to be at intermediate-risk based on their Framingham risk score. The use of CACS screening has been found to improve medication adherence and provide superior coronary artery disease risk factor control without increasing downstream medical testing. By contrast, however, a study in post-menopausal women concluded that there was no independent benefit of coronary CT imaging in a low-to-moderate risk group.
With some uncertainty over whether addition of CACS derived from CT imaging provides an incremental benefit beyond that obtained from traditional risk assessment methods, in the current study, the Australian team undertook a systematic review and meta-analysis of available studies. They included studies in patients without existing cardiovascular disease, where at least one recognised risk calculator and a CACS had been used. The primary outcome as the change in C statistic for a model which contained the CACS compared to the base model without the CACS.
Coronary artery calcium scores and improvement in CVD risk prediction
A total of 6 studies with 17,961 individuals and 1043 cardiovascular events were included in the analysis. The studies varied in sample size from 470 to 5185 and mean ages ranged from 50 to 75.1 years (38.4 to 59.4% female).
The C statistic for cardiovascular disease (CVD) risk models but without CACS ranged from 0.693 to 0.80. Inclusion of CACS improved the pooled C statistic by 0.036.
When CACS was added, among participants whose risk was reclassified from low to intermediate or high risk, 85.5% to 96.4% did not experience an event during follow-up (ranging from 5.1 to 10 years). Among those who were reclassified from high risk to low risk by CACS, a similarly high proportion, 91.4% to 99.2% did not have a CVD event during follow-up.
The authors suggested that while CACS did appear to provide modest further discriminatory power to traditional risk factor assessments, this additional gain needed to be balanced against the higher costs and radiation risks. They concluded that while there were gains from inclusion of CACS, which patients might benefit remains to be determined and that there is no evidence to suggest that use of CACS offers a clinical benefit.
Bell KJL et al. Evaluation of the Incremental Value of a Coronary Artery Calcium Score Beyond Traditional Cardiovascular Risk Assessment: A Systematic Review and Meta-analysis JAMA Intern Med 2022
24th March 2022
Two cardiac biomarkers, cardiac troponin I and N-terminal pro-brain-type natriuretic peptide (NT-proBNP), although independently associated with an increased risk of incident cardiovascular events (CV) in patients with psoriasis disease, offer no additional benefit when added to cardiovascular risk stratification tools. This was the finding of a longitudinal study by researchers from the Women’s College Hospital, Toronto, Canada.
Patients with both psoriasis and psoriatic arthritis, collectively referred to as psoriasis disease, have an increased risk of cardiovascular disease. For instance, one meta-analysis found that patients with psoriatic arthritis had a 43% increased risk of cardiovascular diseases compared with the general population. Furthermore, among those with psoriasis, but without the inflammatory arthritis, there is also an apparent higher risk of both cardiovascular disease and cardiovascular risk factors, although only among those with more severe disease. While part of the reason behind this increased risk of cardiovascular disease can be explained due to the presence of traditional risk factors such as smoking, physical inactivity etc, patients with psoriasis have been shown to have increased vascular, subcutaneous and hepatic inflammation.
The use of population-based risk algorithms like the Framingham Risk Score (FRS) are widely used in risk stratification for the development of CV events, such algorithms may underestimate long term risk of major adverse cardiac events in psoriasis patients.
Elevated levels in the general population of the cardiac biomarker high cardiac troponin is associated with increased CVD risk. In addition, among older people with type 2 diabetes, NT-proBNP was strongly associated with subsequent risk of all cardiovascular disease events. Moreover, elevated NT-proBNP levels have a mortality predictive value in patients with rheumatoid arthritis. While both cardiac troponin I and NT-proBNP are useful cardiac biomarkers in the general population, whether the two markers add value for the risk stratification of patients with psoriasis disease is uncertain.
For the present study, the researchers evaluated the association between cardiac troponin I and NT-proBNP and a marker of CV risk, the presence and progression of carotid atherosclerosis, assessed by the carotid total plaque area (TPA). They recruited patients with psoriasis disease and a cohort who had undertaken a baseline and subsequent carotid ultrasound assessment of atherosclerosis. For all participants, Framingham risk scores, which includes several factors such as age, gender, smoking status, systolic blood pressure, diabetes etc were calculated, to estimate their 10-year risk of CV. The researchers set the primary end point as the occurrence of the first CV event which was a composite outcome including angina, myocardial infarction, ischaemic cerebrovascular accident and cardiovascular death.
Cardiac biomarkers and CV events
A carotid ultrasound was performed on 358 individuals and the mean duration of follow-up was 3.69 years. After adjustment for CV risk factors, the association between baseline TPA and cardiac troponin I remained significant but not for NT-proBNP. However, this association was no longer significant for atherosclerosis progression.
During a follow-up of 7.1 years there were 64 incident CV events, giving a rate of 0.90 events per 100 person-years. Both cardiac troponin I (hazard ratio, HR = 3.02, 95% CI 1.12 – 8.16) and NT-proBNP (HR = 2.02, 95% CI 1.28 – 3.18) were significantly associated with CV events per one standard deviation increase.
However, inclusion of both biomarkers into the FRS this did not improve the diagnostic accuracy of the score. In other words, while cardiac troponin I was associated with atherosclerotic burden, it had no subsequent predictive value as the level of atherosclerosis increased. Furthermore, while it was clear that the two biomarkers were associated with a higher risk of a CV event, adding these into the FRS did not improve the overall diagnostic accuracy for predicting CV events.
They concluded that the use of both biomarkers while predictive of CV events in the general population, did not aid CV risk stratification in patients with psoriasis disease.
Colaco K et al. Association of Cardiac Biomarkers with Cardiovascular Outcomes in Patients with Psoriatic Arthritis and Psoriasis: A Longitudinal Cohort Study Arthritis Rheumatol 2022
10th March 2022
A higher sodium intake from the use of soluble paracetamol tablets has been found to increase the risk of both cardiovascular disease (CVD) and mortality in patients, irrespective of their hypertensive status. This was the conclusion of a study by researchers from the Department of Orthopaedics, Xiangya Hospital, Changsha, China.
It has been known for some time that a higher sodium intake increases blood pressure and is therefore a risk factor for cardiovascular disease. Furthermore, an increased intake of the mineral has also been linked to an additional 1.65 million deaths from cardiovascular causes above a reference level intake of 2.0 g per day. In addition, studies suggest that in comparison to a moderate intake of sodium, higher intakes are associated with an increased risk of cardiovascular events and death among those with hypertensive but not form normotensive patients.
While lowering intake of sodium is known to be associated with a reduced risk of stroke and fatal coronary heart disease in adults, it would be unethical to examine the impact of a greater intake on CVD and mortality risk, given the benefits of reducing intake. While dietary sodium is a major source of intake, sodium is also contained within several medicines, in particular, soluble paracetamol. For the present study, the Chinese team compared the risks of incident CVD and all-cause mortality associated with the intake of sodium-containing soluble paracetamol (acetaminophen) compared to intake of non-sodium containing formulations according to patient’s hypertension status.
The team turned to the Health Improvement Network which is an electronic medical record database in the UK containing anonymised data for approximately 17 million patients as their source of information. They extracted data for two separate cohorts. The first included patients aged 60 – 90 years of age and with a diagnosis of hypertension and prescribed either a sodium and non-containing paracetamol formulation. The second cohort was similar although this time included patients without a diagnosis of hypertension. Socio-demographic data including gender, age, body mass index and various lifestyle factors were recorded and used as covariates in their analysis. The primary outcomes of interest were incident CVD which included myocardial infarction, stroke and heart failure, and all-cause mortality.
Sodium intake and CVD/mortality outcomes
For the first cohort, a total of 151,398 individuals with a mean age of 78.3 years (65.8% female) and a history of hypertension were included and of whom, 4532 were given a sodium-containing paracetamol. These were matched with a total of 147,299 without hypertension and a mean age of 71.4 (63.3% female), of whom 5,351 were given a sodium-containing paracetamol formulation.
Among those with hypertension, there were 122 cases of CVD among those given the mineral and 3051 cases among the non-sodium group over a median follow-up period of 0.89 and 0,93 years respectively. This gave a 59% higher risk of incident CVD among those taking a sodium-containing paracetamol formulation (Hazard ratio, HR = 1.59, 95% CI 1.32 – 1.92). Furthermore, the risk of all-cause mortality was more than double (HR = 2.05, 95% CI 1.92 – 2.19).
Among those given a sodium-containing paracetamol formulation but without hypertension, there was a 45% increased risk of CVD (HR = 1.45, 95% CI 1.18 – 1.79) and a 87% increased mortality risk (HR = 1.87, 95% CI 1.74 – 2.00).
Commenting on these results, the authors noted that sodium-containing drugs are an important but often overlooked source of the mineral. They concluded that individuals should avoid unnecessary excessive sodium intake through sodium-containing paracetamol use.
Zeng C et al. Sodium-containing acetaminophen and cardiovascular outcomes in individuals with and without hypertension Eur Heart J 2022
28th January 2022
Breastfeeding mothers have a lower risk of subsequent cardiovascular disease in later life according to a meta-analysis by researchers from the Department of Neurology, Clinical Epidemiology Team, Medical University of Innsbruck, Innsbruck, Austria.
The World Health Organization has decreed that ‘breastfeeding is one of the most effective ways to ensure child health and survival‘ adding how breastmilk is an ideal food for infants as it is safe, clean and contains antibodies which help protect against many common childhood illnesses. Despite this perceived value, a 2019 analysis of breastfeeding in low and middle incomes countries, revealed how only 37% of children under 6 months of age are exclusively breastfed.
While there are clear benefits to children, breastfeeding also appears to benefit the health of lactating mothers, with one review identifying how breastfeeding for longer than 12 months was associated with a 26% reduced risk of breast cancer and a 32% reduced risk of ovarian cancer. In 2021, a statement from the American Heart Association, suggested that ‘lactation and breastfeeding may lower a woman’s later cardiometabolic risk‘. Furthermore, an umbrella review of the association between maternal health and cardiovascular disease in later life, also suggested an inverse association between length of lactation and morbidity or mortality from cardiovascular disease but did not provide a pooled estimate of this association.
For the present study, the Austrian team undertook a systematic literature review and meta-analysis to more precisely characterise the association between breastfeeding and the development of maternal cardiovascular events. They compared ‘ever’ versus ‘never’ breastfeeding in relation to cardiovascular disease (CVD), coronary heart disease (CHD), stroke or fatal CVD and calculated hazard ratios for each of these outcomes.
The team identified 8 relevant prospective studies which included 1,192,700 women with a mean age of 51.3 years, of whom 82% reported having ever breastfed for a mean duration of 15.6 months.
There was a significant 11% reduced risk of maternal CVD among those breastfeeding compared to who did not (Hazard ratio, HR = 0.89, 95% CI 0.83 – 0.95). Similarly, significant reductions were also observed among those breastfeeding for CHD (HR = 0.86), stoke (HR = 0.88) and fatal CVD (HR = 0.83).
The authors calculated that each additional year of breastfeeding resulted in significant reduced risk, based on hazard ratios, for CVD (HR = 0.91) and CHD (HR = 0.89) and although the risk for stroke was reduced (HR = 0.91) this was non-significant.
Commenting on these results, the authors noted how the relationship between breastfeeding and cardiovascular risk had been overlooked for a long time and that in general, the maternal health benefits are less well known. They suggested that interventions to promote and facilitate breastfeeding should be reinforced.
Tschiderer L et al. Breastfeeding Is Associated With a Reduced Maternal Cardiovascular Risk: Systematic Review and Meta‐Analysis Involving Data From 8 Studies and 1 192 700 Parous Women. J Am Heart Assoc 2022