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Cardiovascular Disease Risk Prediction in Indigenous AustraliansELIZABETH LM BARR (MPH, PHD)
NATIONAL HEART FOUNDATION POST-DOC FELLOW
MENZIES SCHOOL OF HEALTH RESEARCH
Cardiac Care in the NT Annual Workshop
2017 is proudly supported by:
Overview
▪ Primary prevention of cardiovascular disease (CVD) in Indigenous Australians
▪ Limitations of CVD risk scores in Indigenous Australians
▪ Cardiovascular Risk in IndigenouS People (CRISP) Study
Cardiac Care in the NT Annual Workshop - June 2017
Primary prevention of cardiovascular disease in Indigenous Australians
Cardiovascular disease in Indigenous Australians
Cardiovascular disease (CVD) remains a major public health problem for Indigenous populations globally including Aboriginal and Torres Strait Islander Australians
Cardiac Care in the NT Annual Workshop - June 2017AIHW 2015
Primary prevention of CVD
Cardiac Care in the NT Annual Workshop - June 2017
CVD primary prevention largely focuses on management of well-established risk factors: smoking, high cholesterol, high blood pressure and diabetes
Two potential clinical scenarios for Indigenous Australians
Cardiac Care in the NT Annual Workshop - June 2017
Woman
▪ 35 years
▪ Systolic BP: 135 mmHg
▪ uACR: 25 mg/mmol
▪ Pre-diabetes
▪ Smoker
▪ TC: HDL ratio: 4.0 mmol/l
Man
▪ 43 years
▪ Systolic BP: 155 mmHg
▪ uACR: 20 mg/mmol
▪ Diabetes
▪ Non-smoker
▪ TC: HDL ratio: 6.0 mmol/l
LOW RISK FOR 5 YR CVD ?
Limitations of CVD risk scores in Indigenous Australians
Cardiovascular co-morbidities in Indigenous Australians
AIHW data show a much
greater overlap of diabetes,
kidney disease and CVD for
Indigenous Australians
Cardiac Care in the NT Annual Workshop - June 2017
Proportion of people with CVD, diabetes and chronic kidney disease (AIHW 2015)
Indigenous Australians
Non-Indigenous Australians
Diabetes and albuminuria strongly linked to the development of CVD
Longitudinal studies show strong associations of diabetes and related metabolic factors, and kidney disease with the development of CVD
Cardiac Care in the NT Annual Workshop - June 2017
CVD risk associated with traditional risk factors:DRUID follow-up
Cardiac Care in the NT Annual Workshop - June 2017Barr ELM et al. Diabetic Medicine 2017 (in press)
Low HDL
Cholesterol
Smoking High total
cholesterol
BP Diabetes
Adjusting for age and sex
6.4 (2.4 – 16.5)
CVD risk associated with abnormal glycaemia: DRUID follow-up study
Cardiac Care in the NT Annual Workshop - June 2017Barr ELM et al. Diabetic Medicine 2017 (in press)
Adjusted baseline age and sex
Impaired
fasting
glucose
Impaired
glucose
tolerance
DiabetesNormal
glycaemia
3.3 (0.7 – 16.3)
2.7(0.8 – 8.7)
6.4 (2.4 – 16.5)
CVD risk associated with other risk factors: DRUID follow-up study
Cardiac Care in the NT Annual Workshop - June 2017Barr ELM et al. Diabetic Medicine 2017 (in press)
Poor
diet Obesity
High CRP
Low income
Dyslipidaemia
Microalb
Macroalb
Adjusted baseline age and sex
Population
attributable risk %
for CVD in this
cohort:
- 32% Diabetes
- 21% Albuminuria
Coronary artery disease incidence underestimated in Indigenous Australians
Cardiac Care in the NT Annual Workshop - June 2017
Total cohort Women Men
Wang and Hoy. MJA 2015
Limitations of individual studies
▪ Individual studies have limited generalisability
▪Smaller studies have limited statistical power to assess risk among specific groups (eg. women and men, younger and older people, populations in urban and remote settings)
▪Comparison of study results between studies is limited by different methods and analyses
Cardiac Care in the NT Annual Workshop - June 2017
Can we improve current CVD risk scores for Indigenous Australians?
Cardiac Care in the NT Annual Workshop - June 2017
Cardiovascular Risk in IndigenouS People (CRISP) Study
What is the CRISP study?
▪ Individual-level meta-analysis combines participant study data
▪ Not aggregate meta-analysis which combines summary study results
▪ Create large epidemiological cohort of Indigenous Australians
▪ Many advantages!▪ Improves statistical power
▪ Consistent and standardize analysis
Cardiac Care in the NT Annual Workshop - June 2017
Study cohorts contributing data to CRISP
Northern Territory surveys
▪ Galiwin’ku Healthy Lifestyle Study
▪ Bathurst Island Renal Disease Studies (BIRDS)
▪ Darwin Region Urban Indigenous Diabetes (DRUID) Study
▪ Heart of the Heart Study
Cardiac Care in the NT Annual Workshop - June 2017
Study cohorts contributing data to CRISP
Studies in Western Australia and Queensland
▪ Perth Aboriginal Atherosclerosis Risk Study (PAARS)
▪ Well Persons Health Check (WPHC) study
Cardiac Care in the NT Annual Workshop - June 2017
~ 6,000 PARTICIPANTS
CRISP aims: Enhance the accuracy of absolute CVD risk assessment for Indigenous Australians
▪ To explore the associations of “non-traditional” risk factors
(abdominal obesity, metabolic disorders and albuminuria)
compared to “traditional” risk factors (smoking, cholesterol and
blood pressure) to mortality and CVD in Indigenous Australians
▪ To identify the profiles of individuals who are at high risk of CVD but
currently not identified as being at high risk with existing clinical
risk scores
▪ To analyse the accuracy of CVD risk scores currently recommended
for Indigenous Australians, and where possible, develop an
improved CVD risk score
Cardiac Care in the NT Annual Workshop - June 2017
CRISP study longitudinal follow-up
▪ Obtaining CVD outcomes over the period between baseline testing and current follow-up
▪ CVD outcomes obtained from state-based hospital databases and the National Death Index
Cardiac Care in the NT Annual Workshop - June 2017
FOLLOW-UP PERIOD
Baseline
surveys and
health
examinations
CVD
Hospitalisation
Deaths
2017Cohort 1 1994
Cohort 2 1998
Cohort 3 1998
Cohort 4 2001
Cohort 5 2003
Cohort 6 2008
CRISP study investigator collaboration
InvestigatorsElizabeth Barr Steve Guthridge
Louise Maple-Brown Christine Connors
Alan Cass Wendy Hoy
Joan Cunningham Pamela Bradshaw
Shawn Tatipata Peter Thompson
Julie Brimblecombe Lyn Dimer
Robyn McDermott Alex Brown
Kerin O’Dea Jonathan Shaw
Cardiac Care in the NT Annual Workshop - June 2017
Summary
▪ There is an overwhelming burden of diabetes and
albuminuria in CVD risk for Indigenous Australians
▪ Current CVD risk scores may not adequately
capture future CVD risk in Indigenous Australians
▪ CVD risk equations need to be evaluated using
Australian data to assess the effects of
albuminuria, diabetes and other related factors
on CVD risk in Indigenous Australians
Cardiac Care in the NT Annual Workshop - June 2017
Thank you
PRESENTATION AT THE CARDIAC CARE IN THE NT ANNUAL WORKSHOP
DARWIN, JUNE 2017
FUNDING
NATIONAL HEART FOUNDATION VANGUARD GRANT
NATIONAL HEART FOUNDATION POST-DOCTORAL FELLOWSHIP