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Scholarly Works (119 results)

  • Article
  • Peer Reviewed
UC Irvine Previously Published Works (2022)
Lipoprotein(a) is an underrecognized, but significant genetic risk factor for atherosclerotic cardiovascular disease (ASCVD), shown to be causal from data from prospective epidemiologic studies, Mendelian randomization, and genome wide association studies [...].
    Cover page: Is Lipoprotein(a) the Most Important Predictor of Residual Atherosclerotic Cardiovascular Disease Risk?
    • Article
    • Peer Reviewed
    UC Irvine Previously Published Works (2022)

    Purpose of review

    Coronary artery calcium (CAC) is an important measure of subclinical atherosclerosis and strongly predicts atherosclerotic cardiovascular disease (ASCVD) outcomes. The purpose of this review is to discuss the key studies that have helped to establish its role as an important screening tool and its place in preventive cardiology.

    Recent findings

    Epidemiologic studies document a strong relation of age, race/ethnicity, and risk factors with the prevalence and extent of CAC. Large-scale registry and prospective investigations show CAC to be the strongest subclinical disease predictor of ASCVD outcomes, with higher CAC scores associated with successively higher risks and those with a CAC score of 0 having a long-term "warranty" against having events. Moreover, CAC is associated with greater initiation of preventive health behaviors and therapy. Current US guidelines utilize CAC to inform the treatment decision for statin therapy. Further study is underway to document whether CAC screening will ultimately improve clinical outcomes. CAC is well established as the most important subclinical cardiovascular disease measure for prediction of future ASCVD outcomes and can be used for informing the treatment decision for preventive therapies.
      Cover page: Evolution of Coronary Calcium Screening for Assessment of Atherosclerotic Cardiovascular Disease Risk and Role in Preventive Cardiology
      • Article
      • Peer Reviewed
      UC Irvine Previously Published Works (2020)
      The foundation of preventive cardiology begins with knowing the patient's baseline cardiovascular disease (CVD) risk from which the patient-clinician risk discussion informs on the best ways to lower risk through lifestyle management, as well as a decision about the initiation and intensity of pharmacologic therapy. Global CVD risk assessment involves estimation of cardiovascular risk using a basic panel of risk factors. The Framingham Heart Study championed the first such risk scores, followed by others around the world. Most recently, the Pooled Cohort Equations (PCE) have been recommended in the United States as a starting point in CVD risk assessment. Persons at low (<5%) 10-year risk are generally recommended for lifestyle management only and those at highest (>20%) 10-year risk are recommended for both lifestyle and pharmacologic therapy to reduce risk. Assessing the presence of one or more "risk enhancing" factors is intended to inform the treatment decision in those at borderline (5-<7.5%) or intermediate (7.5-20%) risk, with the use of coronary calcium scores to further refine the treatment decision. Moreover, not all those with ASCVD are treated equal, and recent guidelines provide criteria for identifying those at very high risk. While current techniques best predict long-term risk of CVD events, biomarkers strategies are being developed to predict near-term events, and other imaging techniques such as coronary CT angiography and vascular MRI hold promise to identify vulnerable plaque. Validation and incorporating into clinical practice such state of the art techniques will be vital to moving CVD risk assessment to the next level.
        Cover page: Cardiovascular risk assessment: The foundation of preventive cardiology
        • Thesis
        • Peer Reviewed
        UC Irvine Electronic Theses and Dissertations (2023)

        Cardiovascular disease (CVD) stands as the predominant cause of mortality on a global scale, with diabetes mellitus (DM) emerging as a prominent risk factor for CVD. Notably, adults afflicted by DM face a nearly twofold increased risk of CVD-related mortality compared to their non-DM counterparts. The present dissertation undertakes the task of formulating pre- ventive strategies for CVD within the DM patient population. The first chapter of this study endeavors to ascertain the residual risk of CVD stemming from hypertriglyceridemia (HTG) in the DM population, drawing data from the National Health Nutrition and Examination Survey (NHANES) spanning the years 2007 to 2014. Interestingly, it is observed that despite the implementation of first-line lipid-lowering therapy involving statin usage and optimal low- density lipoprotein cholesterol (LDL-C) control, approximately one-fifth of this population continues to exhibit HTG. Additionally, three-quarters of DM patients possess a moderate to high 10-year risk for CVD. The second chapter aims to assess the potential impact of two novel DM medications, namely liraglutide (glucagon-like peptide-1 receptor agonists (GLP-1 RAs)) (Chapter 2) and empagliflozin (sodium-glucose cotransporter 2 inhibitor (SGLT-2i)) (Chapter 3), on CVD prevention. The evaluation is conducted in terms of the preventive capacity for CVD events while on treatment, utilizing the NAHNES database. Followingix the meticulous application of key inclusion and exclusion criteria derived from corresponding clinical trials, an estimated 4.2 million and 1.86 million US DM patients are deemed eligi- ble for these treatments, respectively. Moreover, approximately 21,209 and 12,066 major cardiovascular events, comprising a composite outcome of cardiovascular death, myocardial infarction, and stroke, could be averted annually, respectively. The forth chapter endeav- ors to explore the impact of multifactorial risk control—encompassing body mass index, blood glucose, blood pressure, blood lipid levels, physical activity, nicotine exposure, sleep health, and dietary patterns—on the relative risk of CVD development among DM patients based on the UK Biobank database. Notably, a strikingly low percentage of only 2.2% of DM patients demonstrate ideal control over at least six of the above risk factors, and this achievement is associated with an 84% lower risk of incident CVD when compared to individ- uals without any risk factor control. The combined findings of the four chapters underscore the paramount importance of adopting an integrative approach to CVD prevention, partic- ularly in the context of DM patients. The insights gained from this research endeavor hold significant implications for shaping comprehensive strategies aimed at mitigating CVD risks and enhancing patient outcomes within this vulnerable population.

          Creative Commons 'BY-NC-ND' version 4.0 license
          • Article
          • Peer Reviewed
          UC Irvine Previously Published Works (2020)

          Aim

          We examined eligibility and preventable cardiovascular disease events in US adults with diabetes mellitus from the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME).

          Methods

          We identified adults with diabetes mellitus eligible for EMPA-REG OUTCOME based on trial eligibility criteria available from the National Health and Nutrition Examination Surveys, 2007-2016. We estimated composite cardiovascular disease endpoints, as well as all-cause deaths, death from cardiovascular disease and hospitalizations for heart failure from trial treatment and placebo event rates, the difference indicating the preventable events.

          Results

          Among 29,629 US adults aged ⩾18 years (representing 231.9 million), 4672 (27.3 million) had diabetes mellitus, with 342 (1.86 million) meeting eligibility criteria of EMPA-REG OUTCOME. We estimated from trial primary endpoint event rates of 10.5% and 12.1% in the empagliflozin and placebo groups, respectively, that based on the 'treatment' of our 1.86 million estimated EMPA-REG OUTCOME eligible subjects, 12,066 (95% confidence interval: 10,352-13,780) cardiovascular disease events could be prevented annually. Estimated annual preventable deaths from any cause, cardiovascular causes and hospitalizations from heart failure were 17,078 (95% confidence interval: 14,652-19,504), 14,479 (95% confidence interval: 12,422-16,536) and 9467 (95% confidence interval: 8122-10,812), respectively.

          Conclusion

          Empagliflozin, if provided to EMPA-REG OUTCOME eligible US adults, may prevent many cardiovascular disease events, cardiovascular and total deaths, as well as heart failure hospitalizations.
            Cover page: Estimating the number of preventable cardiovascular disease events in the United States using the EMPA-REG OUTCOME trial results and National Health and Nutrition Examination Survey
            • Article
            • Peer Reviewed
            UC Irvine Previously Published Works (2019)
            The recent development of monoclonal antibodies targeted to proprotein convertase subtilisin/kexin type 9 (PCSK9), e.g., PCSK9 inhibitors has revolutionized the landscape of lipid management. Many clinical trials assessing this class have demonstrated remarkable and consistent reductions in low-density lipoprotein-cholesterol. Moreover, the GLAGOV trial demonstrated the efficacy of evolocumab, when added to statin therapy, in reducing the progression of atherosclerosis measured by serial intravascular ultrasound, with the first suggestion of continued benefit down to LDL-C levels of 0.5 mmol/L (20 mg/dL). This trial was followed by the FOURIER Cardiovascular Outcomes trial in more than 27,000 patients with stable atherosclerotic cardiovascular disease (ASCVD) where evolocumab reduced the primary endpoint of atherosclerotic events by 15%, without significant safety differences between treatment groups. Furthermore, subgroup analyses suggested greater benefits seen in those with longer exposure to evolocumab recent acute coronary syndrome, multiple myocardial infarctions, multivessel coronary artery disease, peripheral arterial disease, as well as the subgroup who achieved very low low-density lipoprotein-cholesterol levels of below 0.3 mmol/L (10 mg/dL). Moreover, the EBBINGHAUS substudy demonstrated no differences in objectively measured cognitive function between treatment groups. The SPIRE 2 trial evaluating bococizumab in high-risk patients with baseline LDL-C ≥2.6 mmol/L (100 mg/dL) demonstrated significant atherosclerotic risk reduction, but the trial and further development of the drug was prematurely discontinued due to substantial attenuation of the LDL-C effect over time due to the development of neutralizing antibodies. Finally, the ODYSSEY Cardiovascular Outcomes trial testing alirocumab in subjects with recent (<1 year) acute coronary syndrome demonstrated a 15% relative risk reduction in the primary composite outcome, as well as a significant reduction in total mortality. Greater benefits were noted in those whose LDL-C at baseline was 2.6 mmol/L (100 mg/dL) or greater. These trials collectively demonstrate the added efficacy of PCSK9 inhibitors over moderate and high-intensity statin therapy for unprecedented low-density lipoprotein-cholesterol reduction and incremental ASCVD risk reduction.
              Cover page: Interpreting the Findings From the Recent PCSK9 Monoclonal Antibody Cardiovascular Outcomes Trials
              • Thesis
              • Peer Reviewed
              UC Irvine Electronic Theses and Dissertations (2024)

              Atherosclerotic Cardiovascular Disease (ASCVD) remains the leading cause of death in diabetes mellitus (DM) adult patients. I investigated the current status of ASCVD and DM risk factor control for DM adult patients in the UCI health system, stratified by sex, race/ethnicity, and ASCVD status, A total of 34,207 DM adult patients were identified in the UCI electronic health records (EHR) through ICD-10 code during the timeframe of January 1st, 2022 – June 30th, 2023. Of these patients, within a year after their last DM diagnosis, while 91.3% received a blood pressure (BP) measurement, only 55.3% received a hemoglobin A1c (HbA1c) measurement and less than 50% received any kind of lipid profile measurement (total cholesterol, HDL-C, LDL-C, and triglycerides). Only 56.5% of patients were on any kind of DM drugs, with just 34.1% on metformin, even lower (29.6%) for patients with ASCVD. Only 15.6 % and 10.7% were on newer DM therapies of SGLT2i and GLP1-RA drugs, respectively. Only 46.6% were on statins, and non-statin use was infrequent (<3%). Statin usage was much higher in DM patients with ASCVD (72.5%) than those without (38.7%). 84.6% of DM patients reached control for BP. 94.0% of DM patients with ASCVD reached target control for BP, which was significantly higher compared to 81.6% for DM patients without ASCVD (p<0.00001). However, only 48.9% were at target control for HbA1c, 23.0% for LDL-C and 10.1% for composite control (HbA1c + BP + LDL-C). Some of these findings differed by race/ethnicity, such as only 36.4% of Hispanic patients being at target control for HbA1c, compared to 48.9% for the overall sample. A substantial number of DM patients in the UCI EHR are not receiving recommended risk factor measurements and treatment. Improving the frequency of yearly testing and drug therapies in these patients could prove invaluable in optimizing care in DM patients.

                Cover page: Evaluating Cardiometabolic Risk Management in Multiethnic Adult Patients with Diabetes in the UCI Health System
                • Article
                • Peer Reviewed
                UC Irvine Previously Published Works (2017)
                Examination of the current the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines on the prevention of cardiovascular disease and the management of dyslipidemias finds much common ground. Both note that Atherosclerotic cardiovascular disease (ASCVD) is, in most people, the product of a number of risk factors, notably tobacco exposure, hyperlipidemia, hypertension, inactivity, overweight and diabetes. They stress that risk calculators can help in the assessment of risk in apparently healthy persons. Persons with established ASCVD and many with diabetes or renal impairment are at high to very high risk and warrant intensive risk factor advice and guideline-based preventive therapies. The ACC/AHA guidelines favor the universal use of statins in all high-risk subjects and in primary prevention where the global risk exceeds 7.5% in 10 years, with a percentage reduction in low-density lipoprotein cholesterol (LDL-C) based on statin intensity as the "goal". In contrast, the ESC/EAS guidelines favor a goal or percentage-based reduction in LDL-C based on total risk and baseline LDL-C level. Both guidelines consider certain imaging and other measures to stratify risk as well as the use of non-statin therapies in those not achieving recommended targets. Perhaps the most important challenges are to stress similarities rather than differences, and to simplify communications with both healthcare professionals and the public.
                  Cover page: Current guidelines on prevention with a focus on dyslipidemias
                  • Article
                  • Peer Reviewed
                  UC Irvine Previously Published Works (2023)
                  Real-world data on lipid levels and treatment among adults with diabetes mellitus (DM) are relatively limited. We studied lipid levels and treatment status in patients with DM across cardiovascular disease (CVD) risk groups and sociodemographic factors. In the All of Us Research Program, we categorized DM as (1) moderate risk (≤1 CVD risk factor), (2) high risk (≥2 CVD risk factors), and (3) DM with atherosclerotic CVD (ASCVD). We examined the use of statin and non-statin therapy as well as LDL-C and triglyceride levels. We studied 81,332 participants with DM, which included 22.3% non-Hispanic Black and 17.2% Hispanic. A total of 31.1% had ≤1 DM risk factor, 30.3% had ≥2 DM risk factors, and 38.6% of participants had DM with ASCVD. Only 18.2% of those with DM and ASCVD were on high-intensity statins. Overall, 5.1% were using ezetimibe and 0.6% PCSK9 inhibitors. Among those with DM and ASCVD, only 21.1% had LDL-C < 70 mg/dL. Overall, 1.9% of participants with triglycerides ≥ 150 mg/dL were on icosapent ethyl. Those with DM and ASCVD were more likely to be on high-intensity statins, ezetimibe, and icosapent ethyl. Guideline-recommended use of high-intensity statins and non-statin therapy among our higher risk DM patients is lacking, with LDL-C inadequately controlled.
                    Cover page: Dyslipidemia Treatment and Lipid Control in US Adults with Diabetes by Sociodemographic and Cardiovascular Risk Groups in the NIH Precision Medicine Initiative All of Us Research Program
                    • Article
                    • Peer Reviewed
                    UC Irvine Previously Published Works (2016)

                    Background

                    Angina pectoris (AP) is common in coronary artery disease (CAD), but whether those with diabetes mellitus (DM) experience AP as often as those without DM is unclear.

                    Hypothesis

                    AP prevalence is similar in those with vs without DM in a community sample with CAD.

                    Methods

                    In adults with CAD in the US NHANES 2001-2010, AP was determined by self-report and Rose questionnaire and compared by DM status. Physical functioning and medication use were also evaluated.

                    Results

                    Of 1957 adults with CAD, 619 (28.2%) had DM. Prevalence of AP was similar in those with vs without DM (48.9% vs 46.3%; P = 0.38). There was a trend toward more severe AP in those with glycated hemoglobin ≥7% (50.4%) vs <7% (27.1%; P = 0.09). Adjusted logistic regression showed a similar odds of AP (1.06, 95% CI: 0.84-1.33) in those with vs without DM, although among DM, a 2-fold greater odds of AP in women vs men. Physical functioning was worse in those with vs without AP overall (score of 25.9 vs 24.3; P < 0.001) and further diminished within those with comorbid DM (26.7 vs 24.0; P < 0.001). Among those with AP, those with vs without DM were more likely on β-blockers, statins, angiotensin-converting enzyme inhibitors, and antiplatelet therapy.

                    Conclusions

                    AP in CAD patients is similar among those with vs without DM, despite greater use of evidence-based therapies in DM patients. Greater physical limitations exist in those with vs without AP, and further diminish with comorbid DM.
                      Cover page: Angina in Coronary Artery Disease Patients With and Without Diabetes: US National Health and Nutrition Examination Survey 2001–2010
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