JAMA cardiology最新文献

Importance: Carotid artery plaque (CAP) is commonly encountered in clinical practice. Presence of CAP predicts future atherosclerotic cardiovascular disease (ASCVD) events; however, CAP prevalence increases with age, and it is unknown how age and sex affect the association of CAP presence and ASCVD risk.

Objectives: To describe CAP prevalence by age, sex, race, and ethnicity in a multiethnic population and to investigate whether the impact of CAP detection on relative ASCVD risk declines with age and differs by sex.

Design, setting, and participants: This cohort study examines participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Adults aged 45 to 84 years who were free of clinical ASCVD at recruitment (2000-2002) were included, and follow-up for ASCVD events was conducted through December 2019. Data analysis was performed from July 2023 to April 2024.

Exposure: Presence of CAP.

Main outcomes and measures: The primary outcome was ASCVD events (coronary heart disease events, stroke, and ASCVD death). Prevalence of CAP by age, sex, race, and ethnicity was calculated. Cox proportional hazards models with age interaction terms were used to investigate associations of CAP and incident ASCVD events across sexes.

Results: Among 6814 adults in the MESA cohort, 5689 participants had complete data and were included in this analysis. Among these 5689 participants, mean (SD) age was 62.0 (10.2) years, and 3002 participants (53%) were female. The cohort included 1551 Black participants (27%), 687 Chinese participants (12%), 1276 Hispanic participants (22%), and 2165 White participants (38%). In total, participants experienced 1043 ASCVD events over a median (IQR) period of 17.6 (10.5-18.4) years. Prevalence of CAP differed by age, sex, race, and ethnicity, ranging from 15% in Chinese women younger than 50 years to 95% in non-Hispanic White men aged 80 to 84 years. CAP independently predicted ASCVD events (hazard ratio, 1.38; 95% CI, 1.20-1.58; P < .001). The strength of this association was stronger among younger participants (≤60 years) vs older (>60 years) (P for interaction = .01), especially among women (P for interaction = .005) vs men (P for interaction = .66). CAP detection in younger individuals conferred higher relative ASCVD risk than in older participants, who had higher absolute risk regardless of CAP.

Conclusions and relevance: CAP becomes very common with increasing age among individuals without clinical ASCVD, and the association of CAP with incident ASCVD events was strongest in younger ages, especially among women. These data can help guide ASCVD risk assessment in younger adults and provide perspective when CAP is detected on clinical imaging studies in older adults.

Importance: Patients with heart failure (HF) and mildly reduced ejection fraction (HFmrEF) or preserved ejection fraction (HFpEF) have a spectrum of risk, and the effect of therapies may vary by risk.

Objectives: To validate the Prognostic Models for Mortality and Morbidity in HFpEF (PREDICT-HFpEF) in the phase 3 randomized clinical trial Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients With Heart Failure (FINEARTS-HF) and to evaluate the effect of finerenone, compared with placebo, across the spectrum of risk in these patients.

Design, setting, and participants: The FINEARTS-HF trial was conducted across 653 sites in 37 countries. Participants were adults 40 years and older with symptomatic HF and left ventricular EF of 40% or greater randomized between September 2020 and January 2023.

Intervention: Finerenone (titrated to 20 mg or 40 mg) or placebo.

Main outcomes and measures: The 3 PREDICT-HFpEF risk scores for the composite outcome of cardiovascular death or HF hospitalization, cardiovascular death, and all-cause death, respectively, were calculated. Predicted risk was compared with observed outcomes. Model performance was assessed using the Harrell C statistic. The rates of the predicted outcomes (plus the composite of cardiovascular death and worsening HF events, which was the primary end point in the trial) were examined according to quintiles of risk score, as was the effect of finerenone according to risk quintiles.

Results: A total of 6001 patients (mean [SD] age, 72 [9.6] years; 3269 male [54.5%]) were randomized in the FINEARTS-HF trial. The C statistics for cardiovascular death or HF hospitalization, cardiovascular death, and all-cause death at 2 years were 0.71 (95% CI, 0.69-0.72), 0.68 (95% CI, 0.66-0.71), and 0.69 (95% CI, 0.67-0.71), respectively. The risk of the composite outcomes was approximately 8- to 10-fold higher in those in the highest compared with the lowest risk quintile. The relative risk reduction with finerenone compared with placebo was consistent across the spectrum of risk for all outcomes examined (eg, interaction P value for primary outcome = .24).

Conclusions and relevance: Results of the FINEARTS-HF randomized clinical trial demonstrate that the PREDICT-HFpEF models performed well in terms of calibration and discrimination. Baseline risk did not modify the benefit of finerenone.

Trial registration: ClinicalTrials.gov Identifier: NCT04435626.

Importance: Traditional risk factors, enhancing factors, and risk scores help clinicians assess atherosclerotic cardiovascular disease (ASCVD) risk for primary prevention. The latest cholesterol guidelines suggest measuring coronary artery calcium (CAC) score by computed tomography (CT) in those at intermediate risk when there is uncertainty about statin initiation for primary prevention. CAC testing can improve both risk estimation and adherence to cardiovascular risk-reducing behaviors.

Observations: As measuring CAC score has become more widely available, this article focuses on 3 situations where CAC testing may be omitted or deferred until a time when CAC testing can provide clinically useful information. Three clinical scenarios to facilitate the clinician-patient risk discussion are as follows: (1) when CAC testing is too early, (2) when CAC testing is too late, and (3) when CAC testing is repeated too often. The timing of CAC testing sits within the decision point of lipid-lowering therapy use. High-risk young adults may face an elevated lifetime risk of cardiovascular disease despite a CAC level of 0, whereas older adults may not see an expected benefit over a short time horizon or may already be taking lipid-lowering therapy, rendering a CAC score less valuable. Integrating a CAC score into the decision to initiate lipid-lowering therapy requires understanding of a patient's risk factors, including age, as well as the natural history of atherosclerosis and related events.

Conclusions and relevance: These clinical scenarios reflect when consideration of CAC score is of use and when it is not. Although CAC testing is becoming more widely available and sought after by clinicians and patients alike, it is only as useful as the clinical context. Understanding when assessing CAC score is too early to effectively rule out risk, too late to influence decisions, or too often to yield clinically relevant information provides important insights that optimize the clinical utility of this potentially valuable prognostic tool.