Incremental predictive value of vascular assessments combined with the Framingham Risk Score for prediction of coronary events in subjects of low intermediate risk
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Incremental predictive value of vascular assessments combined with the Framingham Risk Score for prediction of coronary events in subjects of low intermediate risk

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Kui-Kai Lau, Yap-Hang Chan, Kai-Hang Yiu, MBBS, Sidney Tam, MD, Sheung-Wai Li, MBBS, Chu-Pak Lau, MD, Hung-Fat Tse, MD,PhD.

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Incremental predictive value of vascular assessments combined with the Framingham Risk Score for prediction of coronary events in subjects of low intermediate risk Incremental predictive value of vascular assessments combined with the Framingham Risk Score for prediction of coronary events in subjects of low intermediate risk Presentation Transcript

  • Incremental Predictive Value of Vascular Assessments Combined with the Framingham Risk Score for Prediction of Coronary Events in Subjects of Low Intermediate Risk Kui-Kai Lau, 1 Yap-Hang Chan, 1 Kai-Hang Yiu, MBBS, 1 Sidney Tam, MD, 2 Sheung-Wai Li, MBBS, 3 Chu-Pak Lau, MD, 1 Hung-Fat Tse, MD,PhD. 1 1 Cardiology Division, The University of Hong Kong, 2 Department of Clinical Biochemistry Unit, Queen Mary Hospital, and 3 Department of Medicine, Tung Wah Hospital, Hong Kong, China.
  • Background
    • In the past, clinical prediction of cardiovascular disease has mainly relied on evaluating its risk factors.
    • Various risk scores have been developed to improve the prediction of coronary risk.
    • The Framingham Risk Score (FRS) is one of the most common scoring systems – subjects are stratified into low, intermediate or high risk of developing a future coronary event.
  • Background
    • However, a large and heterogeneous population of subjects are stratified into low-intermediate risk category by using the FRS.
    • The decision to initiate primary prevention in such subjects remain unclear.
    • Additional methods for risk stratification of cardiovascular disease are therefore needed in such subjects.
  • Background
    • Previous studies have already shown that coronary artery calcium score has incremental benefit in risk stratification when used with the FRS.
    • However, measurement of the coronary artery calcium score may not be readily accessible in the primary care setting.
    • The incremental benefits of markers obtained from vascular ultrasonography has yet to be investigated.
  • Objectives
    • To investigate the potential added benefits of non-invasive vascular sonographic assessments (brachial endothelial function, carotid IMT, carotid plaque) in conjunction with FRS for coronary risk prediction.
  • Methodology Vascular Markers Flow mediated dilatation (FMD) Carotid-Intima Media Thickness (IMT) Carotid plaque
    • CAD
    • N = 70
    • Low-Intermediate risk of coronary event
    • Symptomatic significant CAD with a recent history of acute coronary syndrome
    Age & sex matched 2:1
    • Controls
    • N = 35
    • CT Ca Score<10
    • No history of CVD
    • No history of DM
  • Brachial Artery Flow Mediated Dilatation
    • (BAD hyperaemia – BAD at rest )
          • BAD at rest
    = X 100 FMD%
  • Carotid Intima-Media Thickness and Plaque Detection
    • Intima-Media Thickness (IMT)
    • Defined as distance between the blood-intima interface and media-adventitia interface
    • Measurements from near and far wall of the left and right common carotid, carotid bifurcation and internal carotid artery were taken
    • Mean maximum IMT was used for analysis
    • Carotid Plaque
    • Endoluminal protrusion of ≧1.5mm or 2 times adjacent IMT
    Blood-intima interface Media-adventitia interface IMT Carotid Plaque
  • Clinical Characteristics of Study Population 1.0 35 (100) 70 (100) Males, n (%) <0.001 1 (3) 55 (79) Lipid lowering therapy, n (%) <0.001 10 (29) 62 (89) Anti-hypertensives, n (%) 0.10 1 (3) 9 (13) Family history of cardiovascular disease, n (%) 0.27 15 (43) 38 (54) Smoking, n (%) 1.0 0 (0) 0 (0) Diabetes, n (%) 0.002 19 (54) 58 (83) Hypercholesterolemia, n (%) 0.001 9 (26) 42 (60) Hypertension, n (%) 0.12 24.0  3.1 25.1  3.3 Body-Mass Index, kg/m 2 0.11 59.5  8.9 62.4  8.5 Age, years P Value Controls (N=35) CAD (N=70) Characteristic
  • Vascular Assessments of Study Population 0.008 14 (40) 47 (67) Carotid plaque (%) 0.32 0.96  0.14 1.01  0.28 mmIMT (mm) 0.003 5.18  2.69 3.56  2.41 FMD (%) P Value Controls (N=35) CAD (N=70)
  • Correlations between FRS and Vascular Markers r= 0.314, p=0.001 r= -0.246, p=0.016 r= -0.226, p=0.026
  • Diagnostic Values of FRS & Vascular Markers According to Specified Cut-off Values 54.5 80.7 68.6 69.7 - 0.000 0.69 FRS + mmIMT  1.05 47.3 80.9 74.3 56.7  2.50 0.007 0.66 FRS 83.3 82.3 81.2 81.4 80 .0 77.0 79.1 PPV 71.4 68.6 62.9 68.6 82.9 60.0 60.0 SP 60.0 81.5  4.75 0.001 0.70 FMD, % 66.7 81.0 - 0.000 0.75 FRS + FMD  4.75 + Carotid Plaque 61.0 75.8 - 0.000 0.73 FRS + Carotid plaque + mmIMT  1.05 66.7 83.6 - 0.000 0.72 FRS + Carotid Plaque 61.5 76.2 - 0.000 0.78 FRS + FMD  4.75 39.2 34.8  1.05 0.492 0.54 mm IMT, mm 47.7 67.1 - 0.033 0.64 Carotid plaque NPV SN Cut-off values P Value AUC Marker
  • Incremental Benefit of Vascular Markers in Addition to FRS for Coronary Risk Prediction FRS, AUC=0.66 FRS + Carotid plaque, AUC=0.72 (P=0.008 vs. FRS) FRS + FMD ≤4.75%, AUC=0.78 (P=0.007 vs. FRS) 1-Specificity Sensitivity 0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
  • Univariate and Multivariate Predictors of an Acute Coronary Event 0.001 4.33 (1.77-10.62) Hypertension 0.003 4.80 (1.67-13.65) 0.000 5.28 (2.20-12.68) Hypercholesterolemia 0.27 1.58 (0.70-3.59) Smoking 0.009 3.07 (1.32-7.10) Carotid plaque 0.066 2.58 (0.94-7.07) mmIMT  1.05mm <0.001 7.97 (2.69-23.59) <0.001 6.63 (2.64-16.66) FMD  4.75% 0.034 1.45 (1.03-2.05) 0.006 1.50 (1.13-2.00) FRS P Value OR (95% CI) P Value OR (95% CI) Multivariable Univariable Risk Variables
  • Conclusions
    • In subjects with low-intermediate risk of developing a coronary event, detection of an impaired FMD response or presence of carotid plaque provides incremental value when used with the FRS for risk stratification.
    • Larger scaled prospective studies are required to confirm the benefit of using such markers in coronary risk stratification and cardiovascular disease prevention.
  • Limitations of Study
    • This was a retrospective study which consisted of a small number of patients
    • Only male Chinese subjects were recruited, thus our results might not be applicable to women or other ethnic groups