First trimester maternal blood rheology and pregnancy induced hypertension

This study evaluates the relationship between the first trimester assessment of maternal rheology and the subsequent development of pregnancy induced hypertension. This is a prospective observational study based in the Glasgow Royal Maternity Hospital, Scotland. From an original population of 744 consecutive antenatal attendees a total of 579 women were booked at less than 14 weeks' gestation. The main study group is a further subset comprising 251 primigravid women booking with a singleton pregnancy without essential hypertension. Previously published data from a group of non-pregnant women of similar age drawn from the same local community was used for external comparison. Blood samples were collected at the booking visit, from which fibrinogen, red cell aggregation, haematocrit and plasma, whole blood, relative and corrected viscosities were recorded. Information was obtained from the case notes in retrospect starting approximately 1 year after the first patients had first been recruited into the trial. The overall outcome of the pregnancies was noted with particular reference to pregnancy induced hypertension (PIH), birth weight, antepartum haemorrhage, pre-term labour, perinatal death, condition at delivery and neonatal complication. Our results show PIH is associated with a significantly raised mean blood viscosity and fibrinogen at time of booking. All significance disappears after adjustment for smoking, diastolic blood pressure and age. Viscosity is, however, only marginally non-significant (p = 0.07). In conclusion, blood rheology, in particular blood viscosity and fibrinogen, may play a predictive role in the development of pregnancy-induced hypertension. When combined with measurement of smoking and diastolic blood pressure at booking, these measurements could be used to calculate a risk score for the development of PIH, allowing targeting of antenatal care. Further data is required.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Trying to predict 'dangerous' bladders in children: the area under the curve concept

OBJECTIVE

Children with neurological and non-neurological lower urinary tract dysfunction normally undergo video urodynamics. One reason is to try to diagnose 'dangerous' bladders. Currently, bladder compliance is used to predict 'dangerous' bladders; however, in children there are no standardized methods of measurement and thus no 'cut-off' values. Compliance may also be normal even though high-pressure detrusor overactivity waves may exist during the filling phase of urodynamics. We tried to determine whether measuring the area under the detrusor pressure curve (AUC) during the filling phase of urodynamics would be a useful parameter in predicting 'dangerous' bladders.

PATIENTS AND METHODS

Children referred to the urodynamics unit at Southmead Hospital, a tertiary referral centre, from 2000 to 2004 were investigated. Although 130 patients were identified, only 15 patients had raw data which were analysable using the available computer software.

RESULTS

There was no correlation between the AUC and predicting 'dangerous' bladders possibly due to limitations in the computer software.

CONCLUSION

Although the study did not reveal any correlation between the AUC and 'dangerous' bladders, it revealed the limitations of the available computer software in determining AUC, and highlighted the need for new standardized software and multinational, multi-centre trials to look into the concept of AUC. There is also a need for the International Continence Society to standardize methods and terminology in predicting 'dangerous' bladders.

By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease

OBJECTIVE

To examine whether the efficiency and equity of cardiovascular risk scores that identify patients at high risk for preventive interventions are compromised by omitting social deprivation, which contributes to risk.

DESIGN

Cohort study.

SETTING

The SHHEC (Scottish heart health extended cohort) study of random sample risk factor surveys across 25 districts of Scotland in 1984-87 and North Glasgow in 1989, 1992, and 1995.

PARTICIPANTS

6419 men and 6618 women aged 30-74, free of cardiovascular disease at baseline, followed up with permission for mortality and morbidity to March 1997. Participants were allocated to population fifths of the Scottish index of multiple deprivation (SIMD) and their observed coronary risk was compared with that expected from the Framingham score for all coronary heart disease.

RESULTS

The Framingham score overestimated risk overall and in each SIMD fifth. It seriously underestimated the variation in risk with deprivation. The relative risk of observed 10 year coronary risk (sexes combined) analysed across population fifths had a steep gradient, from least to most deprived, of 1.00, 1.81, 1.98, 2.22, and 2.57. Expected risk, calculated from baseline risk factor values and the Framingham score, had one quarter of that gradient, with relative risks of 1.00, 1.17, 1.19, 1.28, and 1.36.

CONCLUSION

Cardiovascular risk estimated by the Framingham and related scores is misleading in guiding treatment decisions among people at different levels of social deprivation. Such scores foster relative undertreatment of the socially deprived, exacerbating the social gradients in disease, which national policies seek to minimise. Debate and action are needed to correct this anomaly.

Type-II diabetes and pancreatic cancer: a meta-analysis of 36 studies

Pancreatic cancer is the eighth major form of cancer-related death worldwide, causing 227 000 deaths annually. Type-II diabetes is widely considered to be associated with pancreatic cancer, but whether this represents a causal or consequential association is unclear. We conducted a meta-analysis to examine this association. A computer-based literature search from 1966 to 2005 yielded 17 case–control and 19 cohort or nested case–control studies with information on 9220 individuals with pancreatic cancer. The age and sex-adjusted odds ratio (OR) for pancreatic cancer associated with type-II diabetes was obtained from each study. The combined summary odds ratio was 1.82 (95% confidence interval (95% CI) 1.66–1.89), with evidence of heterogeneity across the studies (P=0.002 for case–control and P=0.05 for cohort studies) that was explained, in part, by higher risks being reported by smaller studies and studies that reported before 2000. Individuals in whom diabetes had only recently been diagnosed (<4 years) had a 50% greater risk of the malignancy compared with individuals who had diabetes for ⩾5 years (OR 2.1 vs 1.5; P=0.005). These results support a modest causal association between type-II diabetes and pancreatic cancer.

Is a single definition of the metabolic syndrome appropriate?--A comparative study of the USA and Asia

The metabolic syndrome has been identified as an increasingly important precursor to cardiovascular diseases in many Asian populations. Our objective was to compare the contribution of component risk factors to the diagnosis of the metabolic syndrome, as defined by the Third report of the National Cholesterol Education Program Expert Panel Adult Treatment Panel (NCEP-ATPIII), in the US and selected Asian populations. Nationally representative survey data from Hong Kong, Taiwan, Thailand and the US were used. Analyses were restricted to men and women aged > or = 35 years. The age-standardized prevalence of the NCEP-ATPIII defined metabolic syndrome was highest in the US (31% in men, 35% in women), and lowest in Taiwan (11% in men, 12% in women). The component risk factors that defined the presence of the metabolic syndrome varied between countries. As expected, abnormal waist circumference was considerably more prevalent among individuals with the metabolic syndrome in the US (72% in men, 94% in women) compared with their Asian counterparts, but substantial variation was also observed between the Asian populations (13-22% in men, 38-63% in women). Furthermore, the relative contribution of other risk factors to the metabolic syndrome was also substantially different between countries. The NCEP-ATPIII definition identifies a heterogeneous group of individuals with the metabolic syndrome in different populations.

Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region

BACKGROUND

Although smoking is a major risk factor for cardiovascular disease, it has been suggested that Asians may be less susceptible to the adverse effects of smoking than Caucasians. This may have contributed to the high prevalence of smoking, and the low quitting rates, in Asian men. Worldwide, smoking rates are increasing for women, amongst whom cardiovascular awareness is relatively poor.

METHODS

An individual participant data analysis of 40 cohort studies was carried out, involving 463 674 Asians (33% female) and 98 664 Australasians (45% female). Cox proportional hazard models, stratified by study and sex where appropriate, were employed.

RESULTS

The HR [95% confidence interval (CI)], comparing current smokers with non-smokers, for coronary heart disease (CHD) was 1.60 (1.49-1.72); haemorrhagic stroke 1.19 (1.06-1.33); ischaemic stroke 1.38 (1.24-1.54). There was a clear dose-response relationship between the number of cigarettes smoked per day and both CHD and stroke, with no significant difference (P >/= 0.20) between populations from Asia and Australia/New Zealand. Although there was no sex difference for stroke in the effect of amount smoked (P = 0.16), for CHD, women tended to have higher hazard ratios than men (P = 0.011). Quitting gave a clear benefit, which was not significantly different between the sexes or regions (P > 0.63). The HR (CI) for ex-smokers compared with current smokers was 0.71 (0.64-0.78) for CHD and 0.84 (0.76-0.92) for stroke.

CONCLUSIONS

Unless urgent public health measures are put into place, the impact of the smoking epidemic in Asia, and among women, will be enormous. Tobacco control policies that specifically target these populations are essential.

A Comparison of Lipid Variables as Predictors of Cardiovascular Disease in the Asia Pacific Region

PURPOSE

Many guidelines advocate measurement of total or low density lipoprotein cholesterol (LDL), high density lipoprotein cholesterol (HDL), and triglycerides (TG) to determine treatment recommendations for preventing coronary heart disease (CHD) and cardiovascular disease (CVD). This analysis is a comparison of lipid variables as predictors of cardiovascular disease.

METHODS

Hazard ratios for coronary and cardiovascular deaths by fourths of total cholesterol (TC), LDL, HDL, TG, non-HDL, TC/HDL, and TG/HDL values, and for a one standard deviation change in these variables, were derived in an individual participant data meta-analysis of 32 cohort studies conducted in the Asia-Pacific region. The predictive value of each lipid variable was assessed using the likelihood ratio statistic.

RESULTS

Adjusting for confounders and regression dilution, each lipid variable had a positive (negative for HDL) log-linear association with fatal CHD and CVD. Individuals in the highest fourth of each lipid variable had approximately twice the risk of CHD compared with those with lowest levels. TG and HDL were each better predictors of CHD and CVD risk compared with TC alone, with test statistics similar to TC/HDL and TG/HDL ratios. Calculated LDL was a relatively poor predictor.

CONCLUSIONS

While LDL reduction remains the main target of intervention for lipid-lowering, these data support the potential use of TG or lipid ratios for CHD risk prediction.

Fat distribution is strongly associated with plasma glucose levels and diabetes in Thai adults-the InterASIA study

AIMS/HYPOTHESIS

Asian populations have high risks of disease at low levels of BMI and weight, possibly because of high rates of abdominal obesity. In such populations, waist circumference and WHR (measures of fat distribution) may better capture the effects of adiposity.

METHODS

The strengths of the associations between different measures of adiposity and glucose levels and diabetes were investigated in the Thai component of the International Collaborative Study of Cardiovascular Disease in Asia (InterASIA), a multi-stage cross-sectional survey of risk factors in Thai adults aged 35 years or over. The analyses included 5,302 men and women.

RESULTS

All four measures of adiposity were positively associated with plasma glucose and the odds of having diabetes (all p<0.001), but the associations were stronger for measures of fat distribution. The age- and sex-adjusted fasting plasma glucose level increased linearly across each fifth of weight, BMI, waist and WHR by 0.12 mmol/l (SE 0.02), 0.12 (0.02), 0.17 (0.02) and 0.16 (0.02), respectively. The corresponding odds ratios for diabetes were 1.41 (95% CI 1.27-1.56), 1.43 (1.28-1.59), 1.64 (1.47-1.83) and 1.70 (1.52-1.90), respectively. Multivariate analyses incorporating different combinations of adiposity measures, as well as analyses of receiver operating characteristics, confirmed the greater predictive value of measures of fat distribution.

CONCLUSIONS/INTERPRETATION

Waist circumference and WHR were more strongly associated with fasting plasma glucose and diabetes than were weight and BMI. These measures of abdominal adiposity are likely to be more useful for assessing the obesity-related risk of cardiovascular diseases in Asian populations.

Blood glucose and risk of cardiovascular disease in the Asia Pacific region

OBJECTIVE

To assess the shape and strength of the association between usual blood glucose and cardiovascular disease (CVD) in Asian and Australasian cohorts and to determine the impact of adjusting for other determinants of CVD risk and excluding people with diabetes.

RESEARCH DESIGN AND METHODS

Relative risk estimates and 95% CIs were calculated from Cox models, stratified by sex and cohort, and adjusted for age at risk on individual participant data from 17 cohort studies. Repeat measurements of blood glucose were used to adjust for regression dilution bias.

RESULTS

Fasting blood glucose data were available for 237,468 participants, and during approximately 1.2 million person-years of follow-up, there were 1,661 stroke and 816 ischemic heart disease (IHD) events. Data were also available on 27,996 participants with nonfasting glucose measurements. Continuous positive associations were demonstrated between usual fasting glucose and the risks of CVD down to at least 4.9 mmol/l. Overall, each 1 mmol/l lower usual fasting glucose was associated with a 21% (95% CI 18-24%) lower risk of total stroke and a 23% (19-27%) lower risk of total IHD. The associations were similar in men and women, across age-groups, and in Asian compared with Australasian (Australia and New Zealand) populations. Adjusting for potential confounders or removing those with diabetes as baseline did not substantially affect the associations. Associations for nonfasting glucose were weaker than those with fasting glucose.

CONCLUSIONS

Fasting blood glucose is an important determinant of CVD burden, with considerable potential benefit of usual blood glucose lowering down to levels of at least 4.9 mmol/l.

Plasma lipid peroxides: relationships to cardiovascular risk factors and prevalent cardiovascular disease

BACKGROUND

The epidemiology of plasma lipid peroxides, which may play a role in atherogenesis, has not been well defined.

AIM

To study the relationships of plasma lipid peroxides to cardiovascular risk factors in a random population sample.

DESIGN

Random, age- and sex-stratified population sample.

METHODS

We studied 739 men and women aged 25-74 years. Lipid peroxides were assayed by the thiobarbituric acid (TBA) assay for malondialdehyde (MDA) in stored plasma samples.

RESULTS

Lipid peroxide levels increased with age. In men, lipid peroxides were significantly associated with smoking habit. Lipid peroxides correlated with non-fasting serum triglycerides (r = 0.33; p < 0.0001) in both sexes. Weaker associations were observed for cholesterol, high-density lipoprotein cholesterol (inversely), body mass index, fibrinogen and white cell count; as well as an inverse association with serum vitamin C in men.

DISCUSSION

These findings clarify the relationships of plasma lipid peroxides to cardiovascular risk factors; and are consistent with the hypothesis that lipid peroxidation may be one mechanism through which several risk factors may promote cardiovascular disease.

Overall alcohol intake, beer, wine, and systemic markers of inflammation in western Europe: results from three MONICA samples (Augsburg, Glasgow, Lille)

AIM

Anti-inflammatory effects of moderate alcohol consumption have been proposed to explain why moderate alcohol intake lowers coronary heart disease risk. We investigated the relationship between overall alcohol, beer or wine consumption and markers of systemic inflammation in three different geographical areas in Europe.

METHODS AND RESULTS

Cross-sectional samples, each representative of the general population from Germany, Scotland, and France (MONICA Augsburg 1994/95, 2275 men and 2186 women, 25-74 years; Glasgow MONICA 1994/95, 561/616, 25-74 years, and MONICA Lille 1994/95, 581/574, 35-64 years) were studied. Alcohol intake was assessed by standardized interview. Adjusted means of C-reactive protein (CRP), fibrinogen, white blood cell (WBC) count, plasma viscosity (PV), and albumin were calculated among categories of alcohol intake, and separately for beer or wine consumption, by multiple linear regression. Self-reported moderate daily alcohol intake up to 40 g was associated with lower concentrations of CRP, fibrinogen, PV and WBC count, compared to non-drinking and heavy drinking, even after adjustment for various potential confounders.

CONCLUSIONS

Moderate consumption of either wine or beer is associated with lower levels of systemic inflammatory markers in three different European areas, suggesting that ethanol itself might be largely responsible for the potential anti-inflammatory effects of these beverages.

A randomized comparison of the effects of aspirin and clopidogrel on thrombotic risk factors and C-reactive protein following myocardial infarction: the CADET trial

A randomized, double-blind multicenter trial-the Clopidogrel and Aspirin: Determination of the Effects on Thrombogenicity (CADET) trial-was carried out to compare the effects of clopidogrel vs. aspirin on thrombotic variables and C-reactive protein (CRP), over a 6-month period of treatment, in patients with an acute myocardial infarction within the previous 3-7 days, who were not scheduled for major surgery including coronary artery bypass grafting. Patients (n = 184) were randomly allocated to aspirin (75 mg day(-1)) or clopidogrel (75 mg day(-1)). Blood samples were taken at baseline and then at clinic visits at 1, 3 and 6 months. By 1 month, clottable and immunonephelometric fibrinogen, D-dimer, von Willebrand factor, factor VIII and CRP were significantly (P < 0.05) reduced from baseline values in both treatment groups; as well as tissue plasminogen activator antigen in the aspirin group only. At 6 months, there were no differences between treatment groups (P > 0.05) for any of the variables, whether or not potential confounding variables were adjusted for. Similarly, there were no differences between treatments in the difference between baseline and final values for any of the variables. Aspirin and clopidogrel were thus found to have similar effects on thrombotic variables and CRP in this patient population.

Serum triglycerides as a risk factor for cardiovascular diseases in the Asia-Pacific region

BACKGROUND

The importance of serum triglyceride levels as a risk factor for cardiovascular diseases is uncertain.

METHODS AND RESULTS

We performed an individual participant data meta-analysis of prospective studies conducted in the Asia-Pacific region. Cox models were applied to the combined data from 26 studies to estimate the overall and region-, sex-, and age-specific hazard ratios for major cardiovascular diseases by fifths of triglyceride values. During 796,671 person-years of follow-up among 96,224 individuals, 670 and 667 deaths as a result of coronary heart disease (CHD) and stroke, respectively, were recorded. After adjustment for major cardiovascular risk factors, participants grouped in the highest fifth of triglyceride levels had a 70% (95% CI, 47 to 96) greater risk of CHD death, an 80% (95% CI, 49 to 119) higher risk of fatal or nonfatal CHD, and a 50% (95% CI, 29% to 76%) increased risk of fatal or nonfatal stroke compared with those belonging to the lowest fifth. The association between triglycerides and CHD death was similar across subgroups defined by ethnicity, age, and sex.

CONCLUSIONS

Serum triglycerides are an important and independent predictor of CHD and stroke risk in the Asia-Pacific region. These results may have clinical implications for cardiovascular risk prediction and the use of lipid-lowering therapy.

Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants

BACKGROUND

Few prospective data from the Asia-Pacific region are available relating body mass index (BMI) to the risks of stroke and ischaemic heart disease (IHD). Our objective was to assess the age-, sex-, and region-specific associations of BMI with cardiovascular disease using individual participant data from prospective studies in the Asia-Pacific region.

METHODS

Studies were identified from literature searches, proceedings of meetings, and personal communication. All studies had at least 5000 person-years of follow-up. Hazard ratios were calculated from Cox models, stratified by sex and cohort, and adjusted for age at risk and smoking. The first 3 years of follow-up were excluded in order to reduce confounding due to disease at baseline.

RESULTS

A total of 33 cohort studies, including 310 283 participants, contributed 2 148 354 person-years of follow-up, during which 3332 stroke and 2073 IHD events were observed. There were continuous positive associations between baseline BMI and the risks of ischaemic stroke, haemorrhagic stroke, and IHD, with each 2 kg/m(2) lower BMI associated a 12% (95% CI: 9, 15%) lower risk of ischaemic stroke, 8% (95% CI: 4, 12%) lower risk in haemorrhagic stroke, and 11% (95% CI: 9, 13%) lower risk of IHD. The strengths of all associations were strongly age dependent, and there was no significant difference between Asian and Australasian cohorts.

CONCLUSIONS

This overview provides the most reliable estimates to date of the associations between BMI and cardiovascular disease in the Asia-Pacific region, and the first direct comparisons within the region. Continuous relationships of approximately equal strength are evident in both Asian and Australasian populations. These results indicate considerable potential for cardiovascular disease reduction with population-wide lowering of BMI.

Vehicle year and the risk of car crash injury

OBJECTIVE

To quantify the association between vehicle age and risk of car crash injury.

DESIGN AND SETTING

Data from a population based case-control study conducted in the Auckland region in 1998/99 was used to examine the adjusted risk of car crash injury or death due to vehicle age, after controlling for a range of known confounders. Cases were all cars involved in crashes in which at least one occupant was hospitalized or killed anywhere in the Auckland region, and controls were randomly selected cars on Auckland roads. The drivers of the 571 case vehicles and 588 control vehicles completed a structured interview.

MAIN OUTCOME MEASURE

Hospitalisation or death of a vehicle occupant due to car crash injury.

RESULTS

Vehicles constructed before 1984 had significantly greater chance of being involved in an injury crash than those constructed after 1994 (odds ratio 2.88, 95% confidence interval (CI) 1.20 to 6.91), after adjustment for potential confounders. There was also a trend for increasing crash risk with each one year increase in vehicle age after adjustment for potential confounders (odds ratio 1.05, 95% CI 0.99 to 1.11; p = 0.09).

CONCLUSION

This study quantifies the increased risk of car crash injury associated with older vehicle year and confirms this as an important public health issue.

Effects of a Perindopril-Based Blood Pressure–Lowering Regimen on the Risk of Recurrent Stroke According to Stroke Subtype and Medical History

BACKGROUND AND PURPOSE

The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) showed that blood pressure lowering reduced stroke risk in patients with a history of cerebrovascular events. Here, we report the consistency of treatment effects across different stroke subtypes and among major clinical subgroups.

METHODS

PROGRESS was a randomized, double-blind trial among 6105 people with a prior history of cerebrovascular events. Participants were assigned to active treatment (perindopril for all participants and indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo(s).

RESULTS

During a mean of 3.9 years of follow-up, active treatment reduced the absolute rates of ischemic stroke from 10% to 8% (relative risk reduction [RRR], 24%; 95% confidence interval [CI], 10 to 35) and the absolute rates of intracerebral hemorrhage from 2% to 1% (RRR, 50%; 95% CI, 26 to 67). The relative risk of any stroke during follow-up was reduced by 26% (95% CI, 12 to 38) among patients whose baseline cerebrovascular event was an ischemic stroke and by 49% (95% CI, 18 to 68) among those whose baseline event was an intracerebral hemorrhage. There was no evidence that treatment effects were modified by other drug therapies (antiplatelet or other antihypertensive agents), residual neurological signs, atrial fibrillation, or the time since the last cerebrovascular event.

CONCLUSIONS

Beneficial effects of a perindopril-based treatment regimen were observed for all stroke types and all major clinical subgroups studied. These data suggest that effective blood pressure-lowering therapy should be routinely considered for all patients with a history of cerebrovascular events.

Associations of plasma fibrinogen assays, C-reactive protein and interleukin-6 with previous myocardial infarction

BACKGROUND

The association of plasma fibrinogen with myocardial infarction (MI) may (like that of C-reactive protein, CRP) be a marker of subclinical inflammation, mediated by cytokines such as interleukin-6 (IL-6). There are well-recognized discrepancies between commonly performed fibrinogen assays. Increased ratio of clottable fibrinogen to intact fibrinogen (measured by a recently developed immunoassay) has been proposed as a measure of hyperfunctional fibrinogen, and is elevated in acute MI.

OBJECTIVE

To compare the associations of intact fibrinogen and four routine fibrinogen assays (two von Clauss assays; one prothrombin-time derived; and one immunonephelometric) in a case-control study of previous MI.

PATIENTS/METHODS

Cases (n=399) were recruited 3-9 months after their event; 413 controls were age- and sex- matched from the case-control study local population. Intact fibrinogen was measured in 50% of subjects.

RESULTS

All routine fibrinogen assays showed high intercorrelations (r=0.82-0.93) and significant (P<0.0001) increased mean levels in cases vs. controls. These four routine assays correlated only moderately with intact fibrinogen (r=0.45-0.62), while intact fibrinogen showed only a small, nonsignificant increase in cases vs. controls. Consequently, the ratio of each of the four routine assays to the intact fibrinogen assay was significantly higher (P<0.0003) in cases vs. controls. Each fibrinogen assay correlated with plasma levels of CRP and IL-6 (which were also elevated in cases vs. controls). Each routine fibrinogen assay remained significantly elevated in cases vs. controls after further adjustment for C-reactive protein and interleukin-6.

CONCLUSIONS

These data provide evidence for acquired, increased hyperfunctional plasma fibrinogen in MI survivors, which is not associated with markers of inflammatory reactions. The causes and significance of these results remain to be established in prospective studies.

Effects of a perindopril-based blood pressure-lowering regimen on disability and dependency in 6105 patients with cerebrovascular disease: a randomized controlled trial

BACKGROUND AND PURPOSE

We sought to quantify the effects of blood pressure lowering on long-term disability and dependency among patients with cerebrovascular disease.

METHODS

We performed a randomized, double-blind, placebo-controlled trial. A total of 6105 participants with a history of stroke or transient ischemic attack in the past 5 years were recruited from 172 hospital outpatient clinics in 10 countries. Subjects were randomly assigned to the following groups: active treatment (angiotensin-converting enzyme inhibitor perindopril [4 mg/d] for all patients, with the diuretic indapamide added at the discretion of treating physicians) or matching placebo(s). Measurements were disability (defined as a Barthel Index score < or =99/100) and dependency (a positive response to the following question: "In the last 2 weeks has the patient required regular help with everyday activities?").

RESULTS

The median duration of follow-up was 4 years. At the last available assessment, 19% of the active treatment group and 22% of the placebo group were disabled (adjusted odds ratio, 0.76; 95% CI, 0.65 to 0.89; P<0.001). Twelve percent of the active treatment group and 14% of the placebo group were dependent (adjusted odds ratio, 0.84; 95% CI, 0.71 to 0.99; P=0.04). The effects of treatment appeared to be mediated primarily through the prevention of disability and dependency associated with recurrent stroke. Four-year treatment with the study drug regimen would be expected to result in the avoidance of 1 case of long-term disability for every 30 (95% CI, 19 to 79) patients.

CONCLUSIONS

Among individuals with cerebrovascular disease, a perindopril-based blood pressure-lowering regimen not only reduced the risk of stroke and major vascular events but also substantially reduced the risks of associated long-term disability and dependency.

Cholesterol, coronary heart disease, and stroke in the Asia Pacific region

BACKGROUND

Cholesterol levels in many Asian countries are rising. Predictions of the likely effects of this on the incidence of cardiovascular diseases have mostly relied on data from Western populations. Whether the associations between total cholesterol and cardiovascular diseases are similar in Asia is not established.

METHODS

The Asia Pacific Cohort Studies Collaboration (APCSC) is an individual-participant data meta-analysis of prospective studies from the Asia-Pacific region. Cox models were applied to the combined data from 29 cohorts to estimate the region-, sex-, and age-specific hazard ratios of major cardiovascular diseases by the fifths of total cholesterol.

RESULTS

At baseline, the age/sex-adjusted mean value of total cholesterol was higher in Australia and New Zealand (ANZ) (5.52 +/- 1.05 mmol/l) than in Asia (4.87 +/- 1.05 mmol/l). During 2 million person-years of follow-up among 352 033 individuals, 4841 cardiovascular deaths were recorded. The association of total cholesterol with coronary heart disease and stroke was similar in Asian and ANZ cohorts. Overall, each 1-mmol/l higher level of total cholesterol was associated with 35% (95% CI: 26-44%) increased risk of coronary death, 25% (95% CI: 13-40%) increased risk of fatal or non-fatal ischaemic stroke, and 20% (95% CI: 8-30%) decreased risk of fatal haemorrhagic stroke.

CONCLUSIONS

In both Asian and non-Asian populations in the Asia-Pacific region, total cholesterol is similarly strongly associated with the risk of CHD and ischaemic, but not haemorrhagic, stroke. Rising population-wide levels of cholesterol would be expected to contribute to a substantial increase in the overall burden of cardiovascular diseases in this region.

Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI-Prevenzione trial

OBJECTIVE

To ascertain whether simple dietary advice to increase the consumption of Mediterranean foods, given in a clinical setting, leads to reduced mortality after a myocardial infarction.

DESIGN

Data were used from the GISSI-Prevenzione clinical trial, analysed as a cohort study with adjustment for treatment allocation.

SETTING

A total of 172 centres in Italy.

SUBJECTS

A total of 11323 men and women with myocardial infarction. All subjects received advice to increase their consumption of fish, fruit, raw and cooked vegetables and olive oil.

MEASUREMENTS

The intakes of the five foods were assessed at baseline, 6, 18 and 42 months. Associations of food intakes, a combined dietary score, and the risk of death over 6.5 y were estimated adjusting for several non-dietary variables, using pooled logistic regression.

RESULTS

Subjects generally improved their diet according to the advice given. All foods were associated with a significant reduction in risk of death. Compared with people in the worst dietary score quarter, the odds ratio for those in the best score quarter was 0.51 (95% CI 0.44-0.59). A good diet had a protective effect in sub-groups defined by age, sex, smoking, randomized treatment and concomitant drug therapy.

CONCLUSIONS

Myocardial infarction patients can respond positively to simple dietary advice, and this can be expected to lead to a substantial reduction in the risk of early death. Regardless of any drug treatment prescribed, clinicians should routinely advise patients with myocardial infarction to increase their frequency of consumption of Mediterranean foods.

A one-quarter reduction in the salt content of bread can be made without detection

OBJECTIVE

To determine if it is possible to deliver a one-quarter reduction in the sodium content of bread without detection.

DESIGN

Single-blind, randomized, controlled trial.

SETTING

The Royal North Shore Hospital in Sydney, Australia.

PARTICIPANTS

One-hundred and ten volunteers from the hospital staff that completed 94% of scheduled assessments.

INTERVENTION

Six consecutive weeks of bread with usual sodium content or six consecutive weeks of bread with cumulating 5% reductions in sodium content each week.

MAIN OUTCOME MEASURE

The proportion of participants reporting a difference in the salt content of the study bread from week to week.

RESULTS

The intervention group were no more likely than the control group to report a difference in the salt content of the bread from week to week (P=0.8). Similarly, there were no differences between randomized groups in the scores for flavour (P=0.08) or liking of the bread (P=0.95) over the study follow-up period. However, the saltiness scores recorded on a visual analogue scale did decline in the intervention group compared with the control group (P=0.01)

CONCLUSIONS

A one-quarter reduction in the sodium content of white bread can be delivered over a short time period, while maintaining consumer acceptance. Over the long term, and particularly if achieved for multiple foods, a decrease in sodium content of this magnitude would be expected to reduce population levels of blood pressure and the risks of stroke and heart attack.

The effects of diabetes on the risks of major cardiovascular diseases and death in the Asia-Pacific region

OBJECTIVE

To provide reliable age- and region-specific estimates of the associations between diabetes and major cardiovascular diseases and death in populations from the Asia-Pacific region.

RESEARCH DESIGN AND METHODS

Twenty-four cohort studies from Asia, Australia, and New Zealand (median follow-up, 5.4 years) provided individual participant data from 161,214 people (58% from Asia) of whom 4,873 had a history of diabetes at baseline. The associations of diabetes with the risks of coronary heart disease, stroke, and cause-specific mortality during follow-up were estimated using time-dependent Cox models, stratified by study cohort and sex and adjusted for age at risk.

RESULTS

In all, 9,277 deaths occurred (3,635 from cardiovascular disease). The hazard ratio (95% CI) associated with diabetes was 1.97 (1.72-2.25) for fatal cardiovascular disease; there were similar hazard ratios for fatal coronary heart disease, fatal stroke, and composites of fatal and nonfatal outcomes. For all cardiovascular outcomes, hazard ratios were similar in Asian and non-Asian populations and in men and women, but were greater in younger than older individuals. For noncardiovascular death, the hazard ratio was 1.56 (1.38-1.77), with separately significant increases in the risks of death from renal disease, cancer, respiratory infections, and other infective causes. The hazard ratio for all-causes mortality was 1.68 (1.55-1.84), with similar ratios in Asian and non-Asian populations, but with significantly higher ratios in younger than older individuals.

CONCLUSIONS

The relative effect of diabetes on the risks of cardiovascular disease and death in Asian populations is much the same as that in the largely Caucasian populations of Australia and New Zealand. Hazard ratios were severalfold greater in younger people than older people. The rapidly growing prevalence of diabetes in Asia heralds a large increase in the incidence of diabetes-related death in the coming decades.