Louise Artels

Aims: Current guidelines recommend targeting systolic blood pressure (SBP) below 130 mmHg in patients at high cardiovascular risk, including after acute coronary syndrome (ACS), although evidence specific to the post-ACS setting remains limited. We evaluated the prognostic value of SBP measured 1 year after ACS on subsequent cardiovascular outcomes. Methods and results: The ELIPS cohort prospectively enrolled ACS patients across four Swiss tertiary-care centres (2009–2017). Patients alive at 1 year with available SBP measurements were included. The association between SBP at 1 year and 3-point major adverse cardiovascular events (MACE; cardiovascular death, non-fatal stroke/transient ischaemic attack, or non-fatal myocardial infarction) was modelled using restricted cubic splines, adjusted for age, sex, renal function, cardiovascular risk factors, index-event type, coronary revascularization, cardiac rehabilitation, heart failure history, and antihypertensive medication classes. Among 2074 patients (age 63 ± 12 years; 82% male; 53% STEMI), 229 MACE events occurred over a median follow-up of 4.0 years (2.7 per 100 patient-years). The SBP–MACE relationship was non-linear and J-shaped (P-non-linearity = 0.007), with lowest risk between ∼130 and 140 mmHg (formally estimated nadir 138 mmHg [95% CI 116–152]). Above 140 mmHg, each 5-mmHg increase was associated with a borderline increase in MACE risk (adjusted HR 1.08; 95% CI 1.00–1.17). The pattern was broadly consistent across sex, age and hypertension status, with a possible interaction with diabetes that could not be excluded (P-interaction = 0.08). Conclusion: In this large, predominantly male, well-characterized post-ACS cohort, SBP measured 1 year after ACS showed a J-shaped association with cardiovascular risk, with lowest risk at 130–140 mmHg.

Aims: The Systematic Coronary Risk Evaluation 2 (SCORE2)/Systematic Coronary Risk Evaluation 2–Older Person (SCORE2-OP), recommended for estimating 10 year risk of first atherosclerotic cardiovascular disease (ASCVD), does not include lifestyle factors. We investigated whether adding self-reported physical activity and Mediterranean diet adherence improves prediction beyond SCORE2/SCORE2-OP. Methods and results: We included participants from the population-based CoLaus|PsyCoLaus cohort with data for the Physical Activity Frequency Questionnaire (PAFQ) and Mediterranean Diet Score (MedDietScore). We fitted Cox regression models including SCORE2 or SCORE2-OP as covariates, depending on the participants’ age, alone or in addition to PAFQ, MedDietScore, or both. We assessed discrimination (Harrell’s C), calibration slope, and net reclassification improvement (NRI) for all models. A total of 2587 participants (59% women) were followed for a median duration of 9.0 years (interquartile range: 8.13–11.6), during which 145 ASCVD events occurred. 2348 were younger than 70 years and evaluated using SCORE2, with 106 ASCVD events. The remaining 239 were aged 70 years or older and assessed with SCORE2-OP, with 39 ASCVD events. Adding physical activity or diet or both to SCORE2 did not improve discrimination (Harrell’s C: 0.74 for all models), calibration (slope: 1.06 for all), or reclassification (continuous total NRI: −8.8 to 2.5%). Adding both lifestyle factors to SCORE2-OP improved discrimination (Harrell’s C: 0.63–0.66), calibration (slope: 1.34 for SCORE2-OP to 1.16 for full model), and reclassification [continuous total NRI: 41% (95% CI 7%–74%) with event NRI of 28% and non-event NRI of 13%]. Conclusion: The addition of self-reported physical activity and Mediterranean diet may provide modest incremental value to improve ASCVD risk prediction in older adults beyond the traditional SCORE2-OP.

Aims: Overweight and obesity are common among patients with acute coronary syndromes (ACS), yet the long-term cardiovascular consequences of post-ACS weight change remain uncertain. We investigated the association between 1-year weight change after ACS and 5-year clinical outcomes in overweight and obese patients. Methods and results: We analysed 1473 overweight and obese ACS participants from the Swiss ELIPS cohort with available weight measurements. Hazard ratios (HRs) were estimated per 1% and 5% weight change for the 5-year risk of major adverse cardiovascular events (MACE), defined as cardiovascular death, non-fatal myocardial infarction, coronary revascularization, stroke, or transient ischaemic attack. Models were adjusted for age, sex, body mass index (BMI), smoking, total cholesterol, hypertension, diabetes, and estimated glomerular filtration rate. Predefined subgroups included BMI ≥ 27 kg/m2 vs. 25–27 kg/m2. Among the participants (15.1% women, mean age 61.5 years), the median BMI was 28.1 kg/m2 (67% BMI ≥ 27 kg/m2). Median 1-year weight change was 0%; 47.5% lost weight and 18.7% achieved >5% weight loss. Patient characteristics associated with weight loss were older age, higher BMI, non-smoking status, and participation in cardiac rehabilitation. During follow-up, 278 MACE events occurred. Weight loss was associated with a lower risk of MACE [multivariate-adjusted HR per 5%: 0.90, 95% confidence interval (CI): 0.82–1.00, P = 0.04]. The association was stronger in patients with BMI ≥ 27 kg/m2 (adj HR per 5% 0.87, 95% CI: 0.77–0.97) compared to those with BMI 25–27 kg/m2 (adj HR per 5% 1.01, 95% CI: 0.85–1.20, interaction P = 0.16). Conclusion: Overweight and obese ACS patients who lose weight may have a lower risk of cardiovascular events.