Mohammed Y Khanji

Cost-effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease

Objective There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds. Methods We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40–69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%. Results Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) −173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50. Conclusions Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced.

Lifestyle advice and interventions for cardiovascular risk reduction: A systematic review of guidelines

BACKGROUND Lifestyle factors are important in preventing cardiovascular disease (CVD) development. We aimed to systematically review guidelines on primary prevention of CVD and their recommendations on lifestyle advice or intervention, in order to guide primary prevention programs. METHODS Publications in MEDLINE, CINAHL over 7 years since May 3, 2009 were identified. G-I-N International Guideline Library, National Guidelines Clearinghouse, National Library for Health Guideline finder, Canadian Medical Association InfoBase were searched. On the February 8, 2017, we updated the search from Websites of organizations responsible for guidelines development. STUDY SELECTION 2 reviewers screened the titles and abstracts to identify Guidelines from Western countries containing recommendations for lifestyle advice and interventions in primary prevention of CVD. DATA EXTRACTION 2 reviewers independently assessed rigor of guideline development using the AGREEII instrument, and one extracted recommendations. RESULTS Of the 7 guidelines identified, 6 showed good rigor of development (range 45-86%). The guidelines were consistent in recommendations for smoking cessation, limiting saturated fat and salt intake, avoiding transaturated-fat and sugar, with particular emphasis on sugar-sweetened beverages. Guidelines generally agreed on recommendations for physical activity levels and diets rich in fruit, vegetables, fish and wholegrains. Guidelines differed on recommendations for specific dietary patterns and alcohol consumption. Recommendations on psychological factors and sleep are currently limited. CONCLUSIONS Current guidelines agree on the importance of lifestyle in the prevention of CVD with consensus on most factors including physical activity, smoking cessation and diet, which should be actively integrated in cardiovascular risk reduction programs aiming to improve clinical outcomes.

Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review

Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality globally. The most cost-effective imaging strategy to diagnose CAD in patients with stable chest pain is however uncertain. To review the evidence on comparative cost-effectiveness of different imaging strategies for patients presenting with stable chest pain symptoms suggestive for CAD. Systematic review. Studies performing a formal economic evaluation or decision analysis in the English language published between January 1995 and December 2015 were identified using PubMed, Medline (OvidSP), Embase, Web of Science, Cochrane economic evaluations library, and EconLit. Reviews and meta-analyses were excluded. Two independent reviewers assessed titles and abstracts. Of the 4498 titles identified, 70 met our selection criteria. One reviewer used a modified version of the CHEERS checklist to assess study quality. One reviewer extracted data on study details, which were checked by a second reviewer. There is a major heterogeneity between the available cost-effectiveness studies included in this study. The included studies compared very different testing strategies in very different ways and provided mostly short-term results. Strategies of no-testing and xECG were underrepresented. Nonetheless, the findings from this systematic review suggest that for patients with a low to intermediate prior probability of having obstructive CAD, computed tomography coronary angiography (CTCA) may be cost-effective as an initial diagnostic imaging test in comparison with CAG or other non-invasive diagnostic tests. If functional testing is required, stress echocardiography (SE) or single-photon emission computed tomography (SPECT) are suggested to be cost-effective initial strategies in patients with intermediate prior probability of CAD. Yet, other functional testing strategies such as xECG and positron-emission tomography (PET) scanning have not been studied as intensely. Immediate CAG is suggested to be a cost-effective strategy for patients at a high prior probability of having obstructive CAD whom may benefit from revascularization. The study emphasizes the inextricable link between clinical effectiveness and economic efficiency. Evidence suggests that the optimal diagnostic imaging strategy for individuals suspected of having CAD is CTCA for low and intermediate disease probability, followed by SE or SPECT as necessary, and invasive CAG for high disease probability. Further studies are needed to evaluate the cost-effectiveness of alternative non-invasive tests, including a no-testing strategy.

LB01.07: ELEVATED BLOOD PRESSURE WITHOUT HYPERTROPHY RAISES LEFT VENTRICULAR EJECTION FRACTION.

Objective: Hypertension remains a major cause of cardiovascular morbidity and mortality worldwide. Persistent blood pressure (BP) elevation may lead to left ventricular (LV) hypertrophy and heart failure. We wanted to assess the impact of high BP on LV function in an asymptomatic cohort, with no evidence of LV hypertrophy. Design and method: We included all 96 asymptomatic volunteers scanned with cardiovascular magnetic resonance (CMR) as part of the HAPPY London primary prevention study. BP was taken sitting, from the left arm with at least 2 consistent measures. We compared those with elevated clinic BP (systolic >140mmHg and/or diastolic >90mmHg) to those with a ‘normal’ BP, regardless of whether on BP treatment. CMR at 1.5 Tesla was performed within 2 weeks of the clinic. Results: Average age was 64.5 years and 74% were males, similar in both groups. Half were taking antihypertensive medication in both groups. 31 participants had elevated clinic BP and the remaining 65 had normal BP. Mean BPs were: 150mmHg ± 8 / 86mmHg ± 11 in high BP group and 127mmHg ± 8 / 77mmHg ± 7 in the normal (Table 1). Figure. No caption available. LV ejection fraction (EF) was significantly elevated in the high BP group (68% vs. 64%, p < 0.05; Figure 1), despite similar indexed LV myocardial mass. Systolic BP was correlated with LVEF (Cor coeffeicient = 0.26, p = 0.01, t = 2.62, CI 0.06 – 0.44). In a multiple regression model both systolic BP and BP treatment, but not diastolic BP, were predictors for LV EF (r2 = 0.17, p < 0.001), independent of diastolic BP, LV myocardial mass, BP treatment, age and heart rate. Conclusions: We believe this is the first description of this relationship. Thus in the absence of LV hypertrophy, asymptomatic individuals who have elevated clinic BP have a higher EF compared to those with normal BP. Sustained hyperdynamic circulation may be a contributory mechanism for future hypertrophy, heart failure and other long-term complications. Preliminary data suggests this increased EF may settle with improved BP control. It is possible that we may need to consider an EF correction factor based on BP.

Cardiovascular magnetic resonance feature tracking in patients with acute myocarditis and normal ejection fraction: potential for improved diagnosis and prognosis

Background Myocarditis is the most common finding in patients presenting with chest pain, ECG changes, raised troponin and culprit-free coronary angiograms. Adverse events, such as arrhythmias, heart failure and death can occur in the absence of significant left ventricular (LV) impairment and myocarditis should not be considered benign when systolic function is normal at presentation. We currently do not know how to predict which patients will deteriorate. In addition, poorly understood risks of sudden death and cardiovascular events persist in this group. We sought to assess changes in cardiovascular magnetic resonance (CMR) feature tracking (FT) parameters between baseline and follow up scan in myocarditis patients with LV ejection fraction (EF) above 55% on admission to see if FT may help predict interval changes in ejection fraction and possibly adverse outcomes.

Athlete’s Heart: Diagnostic Challenges and Future Perspectives

Distinguishing between adaptive and maladaptive cardiovascular response to exercise is crucial to prevent the unnecessary termination of an athlete’s career and to minimize the risk of sudden death. This is a challenging task essentially due to the substantial phenotypic overlap between electrical and structural changes seen in the physiological athletic heart remodeling and pathological changes seen in inherited or acquired cardiomyopathies. Stress testing is an ideal tool to discriminate normal from abnormal cardiovascular response by unmasking subtle pathologic responses otherwise undetectable at rest. Treadmill or bicycle electrocardiography, transthoracic echocardiography, and cardiopulmonary exercise testing are common clinical investigations used in sports cardiology, specifically among participants presenting with resting electrocardiographic abnormalities, frequent premature ventricular beats, or non-sustained ventricular arrhythmias. In this setting, as well as in cases of left ventricular hypertrophy or asymptomatic left ventricular dysfunction, stress imaging and myocardial tissue characterization by cardiovascular magnetic resonance show promise. In this review, we aimed to reappraise current diagnostic schemes, screening strategies and novel approaches that may be used to distinguish adaptive remodeling patterns to physical exercise from early phenotypes of inherited or acquired pathological conditions commanding prompt intervention.

A comparison of cardiac motion analysis software packages: application to left ventricular deformation analysis in healthy subjects

Background Feature tracking (FT) software packages measure myocardial wall motion deformation parameters through the cardiac cycle. Myocardial tagging technique is currently considered the gold standard for myocardial deformation measurements. This study compares 2 FT-software packages with a tagging software package and investigates the differences in strain deformation parameters measured in healthy subjects.

The applicability of current global cardiovascular risk scores and cardiovascular surrogates in chronic obstructive pulmonary disease

Background Chronic obstructive pulmonary disease (COPD) is a complex disorder associated with significant cardiovascular morbidity and mortality. Despite this, current cardiovascular scoring systems do not include COPD in their risk prediction models. The aims of this casecontrol study were to assess whether differences in cardiovascular surrogate markers exist in COPD to further understand the relationship of COPD to cardiovascular structure and function.

84 Cardiovascular Risk Reduction Using Contemporary Guideline Recommendations: Outcomes of the Heart Attack Prevention Programme for You (Happy) London Study

Introduction Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality globally. The importance of primary prevention (PP) of CVD is now well recognised and can potentially improve quality of life and survival cost-effectively. Aim To assess benefits of contemporary guideline based PP recommendations for CVD risk reduction in those with elevated global cardiovascular risk. Methods 402 participants aged 40–74 years were recruited as part of the HAPPY London study. Eligible participants had an elevated 10-year risk based on a QRISK2 score of 10% or more. Internet access was required to be able to register and complete questionnaires online. Individualised one-off cardiovascular risk reduction advice was provided, based on the JBS3 and ESC 2012 CVD prevention guidelines. Follow-up at 3 months assessed changes in risk factors and risk scores using paired t-test statistical analysis. Results Mean age 65 years; 37% females and 370 (92%) completed the 3-months follow up. There was a small but significant improvement in mean blood pressure from 132/80 mmHg to 129/78 mmHg (p < 0.001). Other improvements included weight, waist circumference, fasting glucose, total cholesterol, physical activity, Framingham and QRISK2 scores (Table 1). QRISK2 score dropped from 18.9% to 18.5% at follow-up. This was a 0.7% absolute reduction compared to expected resulting in about 660 less CVD events per 100,000 over 10 years. Conclusions Implementing guideline recommendation for CVD PP can produce modest improvements in risk factors in the medium term in patients at high cardiovascular risk. Promoting long-term compliance should help lower future cardiovascular events.Abstract 84 Table 1 Baseline and follow up measurements Variable (mean) Baseline 3 Months P value 95% CI of differences Systolic BP (mmHg) 132.4 129 <0.001 2.36 4.77 Diastolic BP (mmHg) 79.6 78 <0.001 1.00 2.35 Weight (kg) 80.3 79.2 <0.001 0.55 1.02 BMI (kg/cm2) 27.7 27.4 <0.001 0.18 0.34 Waist circumference (cm) 95.6 93.8 <0.001 0.96 1.92 Framingham score (%) 17.4 15.8 <0.001 1.04 2.1 QRISK2 score (%) 18.9 18.5 0.016 0.06 0.57 Total cholesterol 5.0 4.8 <0.001 0.17 0.31 Glucose 5.8 5.6 <0.001 0.1 0.3 LDL 2.8 2.7 <0.001 0.09 0.22

Splenic switch-off, a potential novel marker of lack of adenosine response: prevalence and measurement reproducibility

Background The sensitivity of adenosine stress perfusion CMR scans is reduced by inadequate response to adenosine. This can be due to a variety of environmental and pharmacological factors, including recent caffeine intake. Manisty et al (2014) observed that splenic blood flow is attenuated by adenosine, as the splanchnic circulation contains vasoconstrictor adenosine receptors, and may provide a simple visual marker of adequate pharmacological stress. The aim of this study was to validate measurement of splenic switch-off (SSO) in both a quantitative and qualitative manner and examine its prevalence in an East London tertiary cardiac centre.