02648nas a2200373 4500008004100000022001400041245018200055210006900237260001600306300001000322490000800332520153700340653000901877653002201886653001901908653002801927653001901955653001101974653002201985653001102007653001702018653001602035653002502051653000902076653001602085653001702101100001902118700002102137700001802158700002002176700001502196700002702211856003602238 2012 eng d a1524-453900aImpact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease: the cardiovascular lifetime risk pooling project.0 aImpact of blood pressure and blood pressure change during middle c2012 Jan 03 a37-440 v1253 a

BACKGROUND: Prior estimates of lifetime risk (LTR) for cardiovascular disease (CVD) examined the impact of blood pressure (BP) at the index age and did not account for changes in BP over time. We examined how changes in BP during middle age affect LTR for CVD, coronary heart disease, and stroke.

METHODS AND RESULTS: Data from 7 diverse US cohort studies were pooled. Remaining LTRs for CVD, coronary heart disease, and stroke were estimated for white and black men and women with death free of CVD as a competing event. LTRs for CVD by BP strata and by changes in BP over an average of 14 years were estimated. Starting at 55 years of age, we followed up 61 585 men and women for 700 000 person-years. LTR for CVD was 52.5% (95% confidence interval, 51.3-53.7) for men and 39.9% (95% confidence interval, 38.7-41.0) for women. LTR for CVD was higher for blacks and increased with increasing BP at index age. Individuals who maintained or decreased their BP to normal levels had the lowest remaining LTR for CVD, 22% to 41%, compared with individuals who had or developed hypertension by 55 years of age, 42% to 69%, suggesting a dose-response effect for the length of time at high BP levels.

CONCLUSIONS: Individuals who experience increases or decreases in BP in middle age have associated higher and lower remaining LTR for CVD. Prevention efforts should continue to emphasize the importance of lowering BP and avoiding or delaying the incidence of hypertension to reduce the LTR for CVD.

10aAged10aAged, 80 and over10aBlood Pressure10aCardiovascular Diseases10aCohort Studies10aFemale10aFollow-Up Studies10aHumans10aHypertension10aLife Tables10aLongitudinal Studies10aMale10aMiddle Aged10aRisk Factors1 aAllen, Norrina1 aBerry, Jarett, D1 aNing, Hongyan1 aVan Horn, Linda1 aDyer, Alan1 aLloyd-Jones, Donald, M uhttps://chs-nhlbi.org/node/608503609nas a2200397 4500008004100000022001400041245007200055210006900127260001600196300001300212490000800225520257600233653001002809653000902819653001902828653002802847653001902875653002202894653001102916653001602927653001102943653002602954653000902980653001602989653001403005653000903019653001703028653001203045100002103057700001803078700001803096700001603114700001803130700002703148856003603175 2012 eng d a1538-359800aLifetime risk and years lived free of total cardiovascular disease.0 aLifetime risk and years lived free of total cardiovascular disea c2012 Nov 07 a1795-8010 v3083 a

CONTEXT: Estimates of lifetime risk for total cardiovascular disease (CVD) may provide projections of the future population burden of CVD and may assist in clinician-patient risk communication. To date, no lifetime risk estimates of total CVD have been reported.

OBJECTIVES: To calculate lifetime risk estimates of total CVD by index age (45, 55, 65, 75 years) and risk factor strata and to estimate years lived free of CVD across risk factor strata.

DESIGN, SETTING, AND PARTICIPANTS: Pooled survival analysis of as many as 905,115 person-years of data from 1964 through 2008 from 5 National Heart, Lung, and Blood Institute-funded community-based cohorts: Framingham Heart Study, Framingham Offspring Study, Atherosclerosis Risk in Communities Study, Chicago Heart Association Detection Project in Industry Study, and Cardiovascular Health Study. All participants were free of CVD at baseline with risk factor data (blood pressure [BP], total cholesterol [TC], diabetes, and smoking status) and total CVD outcome data.

MAIN OUTCOME MEASURES: Any total CVD event (including fatal and nonfatal coronary heart disease, all forms of stroke, congestive heart failure, and other CVD deaths).

RESULTS: At an index age of 45 years, overall lifetime risk for total CVD was 60.3% (95% CI, 59.3%-61.2%) for men and 55.6% (95% CI, 54.5%-56.7%) for women. Men had higher lifetime risk estimates than women across all index ages. At index ages 55 and 65 years, men and women with at least 1 elevated risk factor (BP, 140-149/90-99 mm Hg; or TC, 200-239 mg/dL; but no diabetes or smoking), 1 major risk factor, or at least 2 major risk factors (BP, ≥160/100 mm Hg or receiving treatment; TC, ≥240 mg/dL or receiving treatment; diabetes mellitus; or current smoking) had lifetime risk estimates to age 95 years that exceeded 50%. Despite an optimal risk factor profile (BP, <120/80 mm Hg; TC, <180 mg/dL; and no smoking or diabetes), men and women at the index age of 55 years had lifetime risks (through 85 years of age) for total CVD of greater than 40% and 30%, respectively. Compared with participants with at least 2 major risk factors, those with an optimal risk factor profile lived up to 14 years longer free of total CVD.

CONCLUSIONS: Lifetime risk estimates for total CVD were high (>30%) for all individuals, even those with optimal risk factors in middle age. However, maintenance of optimal risk factor levels in middle age was associated with substantially longer morbidity-free survival.

10aAdult10aAged10aBlood Pressure10aCardiovascular Diseases10aCohort Studies10aDiabetes Mellitus10aFemale10aForecasting10aHumans10aKaplan-Meier Estimate10aMale10aMiddle Aged10aMorbidity10aRisk10aRisk Factors10aSmoking1 aWilkins, John, T1 aNing, Hongyan1 aBerry, Jarett1 aZhao, Lihui1 aDyer, Alan, R1 aLloyd-Jones, Donald, M uhttps://chs-nhlbi.org/node/586103127nas a2200421 4500008004100000022001400041245004600055210004500101260001600146300001000162490000800172520205200180653001002232653002202242653000902264653002802273653001802301653004002319653001102359653001102370653000902381653001602390653000902406653002002415653001702435653001802452100002102470700001502491700001402506700002302520700001802543700001702561700002202578700002002600700002202620700002702642856003602669 2012 eng d a1533-440600aLifetime risks of cardiovascular disease.0 aLifetime risks of cardiovascular disease c2012 Jan 26 a321-90 v3663 a

BACKGROUND: The lifetime risks of cardiovascular disease have not been reported across the age spectrum in black adults and white adults.

METHODS: We conducted a meta-analysis at the individual level using data from 18 cohort studies involving a total of 257,384 black men and women and white men and women whose risk factors for cardiovascular disease were measured at the ages of 45, 55, 65, and 75 years. Blood pressure, cholesterol level, smoking status, and diabetes status were used to stratify participants according to risk factors into five mutually exclusive categories. The remaining lifetime risks of cardiovascular events were estimated for participants in each category at each age, with death free of cardiovascular disease treated as a competing event.

RESULTS: We observed marked differences in the lifetime risks of cardiovascular disease across risk-factor strata. Among participants who were 55 years of age, those with an optimal risk-factor profile (total cholesterol level, <180 mg per deciliter [4.7 mmol per liter]; blood pressure, <120 mm Hg systolic and 80 mm Hg diastolic; nonsmoking status; and nondiabetic status) had substantially lower risks of death from cardiovascular disease through the age of 80 years than participants with two or more major risk factors (4.7% vs. 29.6% among men, 6.4% vs. 20.5% among women). Those with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal myocardial infarction (3.6% vs. 37.5% among men, <1% vs. 18.3% among women) and fatal or nonfatal stroke (2.3% vs. 8.3% among men, 5.3% vs. 10.7% among women). Similar trends within risk-factor strata were observed among blacks and whites and across diverse birth cohorts.

CONCLUSIONS: Differences in risk-factor burden translate into marked differences in the lifetime risk of cardiovascular disease, and these differences are consistent across race and birth cohorts. (Funded by the National Heart, Lung, and Blood Institute.).

10aAdult10aAfrican Americans10aAged10aCardiovascular Diseases10aCohort Effect10aEuropean Continental Ancestry Group10aFemale10aHumans10aMale10aMiddle Aged10aRisk10aRisk Assessment10aRisk Factors10aUnited States1 aBerry, Jarett, D1 aDyer, Alan1 aCai, Xuan1 aGarside, Daniel, B1 aNing, Hongyan1 aThomas, Avis1 aGreenland, Philip1 aVan Horn, Linda1 aTracy, Russell, P1 aLloyd-Jones, Donald, M uhttps://chs-nhlbi.org/node/154103266nas a2200421 4500008004100000022001400041245022000055210006900275260001600344300000900360490000800369520191700377653003902294653001602333653000902349653002202358653002002380653002802400653001902428653003402447653001802481653004002499653001102539653002202550653001102572653002502583653000902608653001602617653003002633653001702663100002302680700001802703700001702721700001902738700002402757700002702781856003602808 2012 eng d a1524-453900aRacial differences in risks for first cardiovascular events and noncardiovascular death: the Atherosclerosis Risk in Communities study, the Cardiovascular Health Study, and the Multi-Ethnic Study of Atherosclerosis.0 aRacial differences in risks for first cardiovascular events and  c2012 Jul 03 a50-90 v1263 a

BACKGROUND: No studies have compared first cardiovascular disease (CVD) events and non-CVD death between races in a competing risks framework, which examines risks for numerous events simultaneously.

METHODS AND RESULTS: We used competing Cox models to estimate hazards for first CVD events and non-CVD death within and between races in 3 multicenter, National Heart, Lung, and Blood Institute-sponsored cohorts. Of 14 569 Atherosclerosis Risk in Communities (ARIC) study participants aged 45 to 64 years with mean follow-up of 10.5 years, 11.6% had CVD and 5.0% had non-CVD death as first events; among 4237 Cardiovascular Health Study (CHS) study participants aged 65 to 84 years and followed for 8.5 years, these figures were 43.2% and 15.7%, respectively. Middle-aged blacks were significantly more likely than whites to experience any CVD as a first event; this disparity disappeared by older adulthood and after adjustment for CVD risk factors. The pattern of results was similar for Multi-Ethnic Study of Atherosclerosis (MESA) participants. Traditional Cox and competing risks models yielded different results for coronary heart disease risk. Black men appeared somewhat more likely than white men to experience coronary heart disease with use of a standard Cox model (hazard ratio 1.06; 95% CI 0.90, 1.26), whereas they appeared less likely than white men to have a first coronary heart disease event with use of a competing risks model (hazard ratio, 0.77; 95% CI, 0.60, 1.00).

CONCLUSIONS: CVD affects blacks at an earlier age than whites; this may be attributable in part to elevated CVD risk factor levels among blacks. Racial disparities in first CVD incidence disappear by older adulthood. Competing risks analyses may yield somewhat different results than traditional Cox models and provide a complementary approach to examining risks for first CVD events.

10aAfrican Continental Ancestry Group10aAge Factors10aAged10aAged, 80 and over10aAtherosclerosis10aCardiovascular Diseases10aCohort Studies10aContinental Population Groups10aEthnic Groups10aEuropean Continental Ancestry Group10aFemale10aFollow-Up Studies10aHumans10aLongitudinal Studies10aMale10aMiddle Aged10aResidence Characteristics10aRisk Factors1 aFeinstein, Matthew1 aNing, Hongyan1 aKang, Joseph1 aBertoni, Alain1 aCarnethon, Mercedes1 aLloyd-Jones, Donald, M uhttps://chs-nhlbi.org/node/139003229nas a2200541 4500008004100000022001400041245011500055210006900170260001600239300001100255490000700266520172200273653001501995653001002010653002202020653001602042653000902058653001802067653002002085653002802105653001902133653004002152653001102192653001902203653001802222653001102240653002602251653000902277653001602286653003002302653001402332653002002346653003002366653001602396653002202412653001702434653001802451653001602469100002102485700002102506700001802527700001802545700002302563700001402586700002402600700002702624856003602651 2013 eng d a1558-359700aLifetime risk for heart failure among white and black Americans: cardiovascular lifetime risk pooling project.0 aLifetime risk for heart failure among white and black Americans  c2013 Apr 09 a1510-70 v613 a

OBJECTIVES: This study sought to estimate lifetime risk for heart failure (HF) by sex and race.

BACKGROUND: Prior estimates of lifetime risk for developing HF range from 20% to 33% in predominantly white cohorts. Short-term risks for HF appear higher for blacks than whites, but only limited comparisons of lifetime risk for HF have been made.

METHODS: Using public-release and internal datasets from National Heart, Lung, and Blood Institute-sponsored cohorts, we estimated lifetime risks for developing HF to age 95 years, with death free of HF as the competing event, among participants in the CHA (Chicago Heart Association Detection Project in Industry), ARIC (Atherosclerosis Risk in Communities), and CHS (Cardiovascular Health Study) cohorts.

RESULTS: There were 39,578 participants (33,652 [85%] white; 5,926 [15%] black) followed for 716,976 person-years; 5,983 participants developed HF. At age 45 years, lifetime risks for HF through age 95 years in CHA and CHS were 30% to 42% in white men, 20% to 29% in black men, 32% to 39% in white women, and 24% to 46% in black women. Results for ARIC demonstrated similar lifetime risks for HF in blacks and whites through age 75 years (limit of follow-up). Lifetime risk for HF was higher with higher blood pressure and body mass index at all ages in both blacks and whites, and did not diminish substantially with advancing index age.

CONCLUSIONS: These are among the first data to compare lifetime risks for HF between blacks and whites. Lifetime risks for HF are high and appear similar for black and white women, yet are somewhat lower for black compared with white men due to competing risks.

10aAdolescent10aAdult10aAfrican Americans10aAge Factors10aAged10aAnthropometry10aBody Mass Index10aCardiovascular Diseases10aCohort Studies10aEuropean Continental Ancestry Group10aFemale10aHealth Surveys10aHeart Failure10aHumans10aKaplan-Meier Estimate10aMale10aMiddle Aged10aPredictive Value of Tests10aPrognosis10aRisk Assessment10aSeverity of Illness Index10aSex Factors10aSurvival Analysis10aTime Factors10aUnited States10aYoung Adult1 aHuffman, Mark, D1 aBerry, Jarett, D1 aNing, Hongyan1 aDyer, Alan, R1 aGarside, Daniel, B1 aCai, Xuan1 aDaviglus, Martha, L1 aLloyd-Jones, Donald, M uhttps://chs-nhlbi.org/node/584702696nas a2200421 4500008004100000022001400041245008100055210006900136260001600205300001200221490000600233520156000239653000901799653001501808653002101823653002101844653001101865653001101876653001801887653000901905653001601914653002601930653001401956653003201970653002002002653001702022653001702039653001802056653001802074100002102092700001802113700001902131700002302150700001602173700002202189700002702211856003602238 2014 eng d a2047-998000aCoronary heart disease risks associated with high levels of HDL cholesterol.0 aCoronary heart disease risks associated with high levels of HDL  c2014 Mar 13 ae0005190 v33 a

BACKGROUND: The association between high-density lipoprotein cholesterol (HDL-C) and coronary heart disease (CHD) events is not well described in individuals with very high levels of HDL-C (>80 mg/dL).

METHODS AND RESULTS: Using pooled data from 6 community-based cohorts we examined CHD and total mortality risks across a broad range of HDL-C, including values in excess of 80 mg/dL. We used Cox proportional hazards models with penalized splines to assess multivariable, adjusted, sex-stratified associations of HDL-C with the hazard for CHD events and total mortality, using HDL-C 45 mg/dL and 55 mg/dL as the referent in men and women, respectively. Analyses included 11 515 men and 12 925 women yielding 307 245 person-years of follow-up. In men, the association between HDL-C and CHD events was inverse and linear across most HDL-C values; however at HDL-C values >90 mg/dL there was a plateau effect in the pattern of association. In women, the association between HDL-C and CHD events was inverse and linear across lower values of HDL-C, however at HDL-C values >75 mg/dL there were no further reductions in the hazard ratio point estimates for CHD. In unadjusted models there were increased total mortality risks in men with very high HDL-C, however mortality risks observed in participants with very high HDL-C were attenuated after adjustment for traditional risk factors.

CONCLUSIONS: We did not observe further reductions in CHD risk with HDL-C values higher than 90 mg/dL in men and 75 mg/dL in women.

10aAged10aBiomarkers10aCholesterol, HDL10aCoronary Disease10aFemale10aHumans10aLinear Models10aMale10aMiddle Aged10aMultivariate Analysis10aPrognosis10aProportional Hazards Models10aRisk Assessment10aRisk Factors10aTime Factors10aUnited States10aUp-Regulation1 aWilkins, John, T1 aNing, Hongyan1 aStone, Neil, J1 aCriqui, Michael, H1 aZhao, Lihui1 aGreenland, Philip1 aLloyd-Jones, Donald, M uhttps://chs-nhlbi.org/node/636603863nas a2200397 4500008004100000022001400041245014600055210006900201260001600270520264500286100001902931700003002950700001802980700002002998700001903018700001803037700002203055700002003077700001903097700001903116700001803135700001903153700002003172700001803192700002403210700002303234700002503257700002103282700002003303700002403323700002103347700001503368700002403383700002203407856003603429 2017 eng d a2380-659100aAssociation of Coronary Artery Calcium Score vs Age With Cardiovascular Risk in Older Adults: An Analysis of Pooled Population-Based Studies.0 aAssociation of Coronary Artery Calcium Score vs Age With Cardiov c2017 Jul 263 a

Importance: Besides age, other discriminators of atherosclerotic cardiovascular disease (ASCVD) risk are needed in older adults.

Objectives: To examine the predictive ability of coronary artery calcium (CAC) score vs age for incident ASCVD and how risk prediction changes by adding CAC score and removing only age from prediction models.

Design, Setting, and Participants: We conducted an analysis of pooled US population-based studies, including the Framingham Heart Study, the Multi-Ethnic Study of Atherosclerosis, and the Cardiovascular Health Study. Results were compared with 2 European cohorts, the Rotterdam Study and the Heinz Nixdorf Recall Study. Participants underwent CAC scoring between 1998 and 2006 using cardiac computed tomography. The participants included adults older than 60 years without known ASCVD at baseline.

Exposures: Coronary artery calcium scores.

Main Outcomes and Measures: Incident ASCVD events including coronary heart disease (CHD) and stroke.

Results: The study included 4778 participants from 3 US cohorts, with a mean age of 70.1 years; 2582 (54.0%) were women, and 2431 (50.9%) were nonwhite. Over 11 years of follow-up (44 152 person-years), 405 CHD and 228 stroke events occurred. Coronary artery calcium score (vs age) had a greater association with incident CHD (C statistic, 0.733 vs 0.690; C statistics difference, 0.043; 95% CI of difference, 0.009-0.075) and modestly improved prediction of incident stroke (C statistic, 0.695 vs 0.670; C statistics difference, 0.025; 95% CI of difference, -0.015 to 0.064). Adding CAC score to models including traditional cardiovascular risk factors, with only age being removed, provided improved discrimination for incident CHD (C statistic, 0.735 vs 0.703; C statistics difference, 0.032; 95% CI of difference, 0.002-0.062) but not for stroke. Coronary artery calcium score was more likely than age to provide higher category-free net reclassification improvement among participants who experienced an ASCVD event (0.390; 95% CI, 0.312-0.467 vs 0.08; 95% CI -0.001 to 0.181) and to result in more accurate reclassification of risk for ASCVD events among these individuals. The findings were similar in the 2 European cohorts (n = 4990).

Conclusions and Relevance: Coronary artery calcium may be an alternative marker besides age to better discriminate between lower and higher CHD risk in older adults. Whether CAC score can assist in guiding the decision to initiate statin treatment for primary prevention in older adults requires further investigation.

1 aYano, Yuichiro1 aO'Donnell, Christopher, J1 aKuller, Lewis1 aKavousi, Maryam1 aErbel, Raimund1 aNing, Hongyan1 aD'Agostino, Ralph1 aNewman, Anne, B1 aNasir, Khurram1 aHofman, Albert1 aLehmann, Nils1 aDhana, Klodian1 aBlankstein, Ron1 aHoffmann, Udo1 aMöhlenkamp, Stefan1 aMassaro, Joseph, M1 aMahabadi, Amir-Abbas1 aLima, João, A C1 aIkram, Arfan, M1 aJöckel, Karl-Heinz1 aFranco, Oscar, H1 aLiu, Kiang1 aLloyd-Jones, Donald1 aGreenland, Philip uhttps://chs-nhlbi.org/node/744204049nas a2200253 4500008004100000022001400041245020400055210006900259260001600328300001200344490000600356520318300362100002103545700001803566700001903584700001803603700002703621700002203648700002003670700002103690700002703711700002103738856003603759 2021 eng d a2380-659100aPerformance of the American Heart Association/American College of Cardiology Pooled Cohort Equations to Estimate Atherosclerotic Cardiovascular Disease Risk by Self-reported Physical Activity Levels.0 aPerformance of the American Heart AssociationAmerican College of c2021 Jun 01 a690-6960 v63 a

Importance: The American Heart Association/American College of Cardiology pooled cohort equations (PCEs) are used for predicting 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Pooled cohort equation risk prediction capabilities across self-reported leisure-time physical activity (LTPA) levels and the change in model performance with addition of LTPA to the PCE are unclear.

Objective: To evaluate PCE risk prediction performance across self-reported LTPA levels and the change in model performance by adding LTPA to the existing PCE model.

Design, Setting, and Participants: Individual-level pooling of data from 3 longitudinal cohort studies-Atherosclerosis Risk in Communities, Multi-Ethnic Study of Atherosclerosis, and Cardiovascular Health Study-was performed. A total of 18 824 participants were stratified into 4 groups based on self-reported LTPA levels: inactive (0 metabolic equivalent of task [MET]-min/wk), less than guideline-recommended (<500 MET-min/wk), guideline-recommended (500-1000 MET-min/week), and greater than guideline-recommended (>1000 MET-min/wk). Pooled cohort equation risk discrimination was studied using the C statistic and reclassification capabilities were studied using the Greenwood Nam-D'Agostino χ2 goodness-of-fit test. Change in risk discrimination and reclassification on adding LTPA to PCEs was evaluated using change in C statistic, integrated discrimination index, and categorical net reclassification index.

Main Outcomes and Measures: Adjudicated ASCVD events during 10-year follow-up.

Results: Among 18 824 participants studied, 10 302 were women (54.7%); mean (SD) age was 57.6 (8.2) years. A total of 5868 participants (31.2%) were inactive, 3849 (20.4%) had less than guideline-recommended LTPA, 3372 (17.9%) had guideline-recommended LTPA, and 5735 (30.5%) had greater than guideline-recommended LTPA level. Higher LTPA levels were associated with a lower risk of ASCVD after adjustment for risk factors (hazard ratio [HR] per 1-SD higher LTPA, 0.91; 95% CI, 0.86-0.96). Across LTPA groups, PCE risk discrimination (C statistic, 0.76-0.78) and risk calibration (all χ2 P > .10) was similar. Addition of LTPA to the PCE model resulted in no significant change in the C statistic (0.0005; 95% CI, -0.0004 to 0.0015; P = .28) and categorical net reclassification index (-0.003; 95% CI, -0.010 to 0.010; P = .95), but a minimal improvement in the integrated discrimination index (0.0008; 95% CI, 0.0002-0.0013; P = .005) was observed. Similar results were noted when cohort-specific coefficients were used for creating the baseline model.

Conclusions and Relevance: Higher self-reported LTPA levels appear to be associated with lower ASCVD risk and increasing LTPA promotes cardiovascular wellness. These findings suggest the American Heart Association/American College of Cardiology PCEs are accurate at estimating the probability of 10-year ASCVD risk regardless of LTPA level. The addition of self-reported LTPA to PCEs does not appear to be associated with improvement in risk prediction model performance.

1 aPandey, Ambarish1 aMehta, Anurag1 aPaluch, Amanda1 aNing, Hongyan1 aCarnethon, Mercedes, R1 aAllen, Norrina, B1 aMichos, Erin, D1 aBerry, Jarett, D1 aLloyd-Jones, Donald, M1 aWilkins, John, T uhttps://chs-nhlbi.org/node/8788