Trends in the incidence of coronary heart disease and stroke and their risk factors in Japan, 1964 to 2003: the Akita-Osaka study

Progression of Carotid Atherosclerosis in Two Japanese Populations with Different Lifestyles

Aim: We have conducted medical surveys on two Japanese populations (Japanese Americans living in the US and native Japanese living in Japan) to investigate the impact of westernization of lifestyles on diseases in Japanese people. A 1998 survey revealed that the progression of carotid intima-media wall thickness (IMT) was faster by approximately 20 years in Japanese Americans than in native Japanese. In this study, we compared the progression of atherosclerosis in native Japanese versus that in Japanese Americans using carotid IMT data from medical examinations conducted in the 2010s.

Methods: This study included 115 native Japanese living in Hiroshima who underwent a medical examination in 2014 and 112 Japanese Americans living in Hawaii who underwent a medical examination in 2012, excluding those receiving medication for diabetes mellitus (DM) or dyslipidemia. Carotid IMT was compared between the two Japanese populations.

Results: Serum total and low-density lipoprotein cholesterol levels were significantly higher in native Japanese than in Japanese Americans. The median carotid IMT was significantly greater in Japanese Americans than in native Japanese [median (25^th–75^th percentile): 1.27 (0.86–2.02) mm vs. 1.00 (0.80–1.30) mm, P = 0.001]. Regression curves showed that the age at which IMT exceeded 1.1 mm was estimated at > 50 years in Japanese Americans and at approximately 60 years in native Japanese.

Conclusions: According to surveys conducted in 2012 and 2014, carotid IMT was still greater in Japanese Americans than in native Japanese. However, a comparison with data from the 1998 survey showed that current native Japanese had higher serum lipid levels and more advanced atherosclerosis.

Significant association of RNF213 p.R4810K, a moyamoya susceptibility variant, with coronary artery disease

Background

The genetic architecture of coronary artery disease has not been fully elucidated, especially in Asian countries. Moyamoya disease is a progressive cerebrovascular disease that is reported to be complicated by coronary artery disease. Because most Japanese patients with moyamoya disease carry the p.R4810K variant of the ring finger 213 gene (RNF213), this may also be a risk factor for coronary artery disease; however, this possibility has never been tested.

Methods and results

We genotyped the RNF213 p.R4810K variant in 956 coronary artery disease patients and 716 controls and tested the association between p.R4810K and coronary artery disease. We also validated the association in an independent population of 311 coronary artery disease patients and 494 controls. In the replication study, the p.R4810K genotypes were imputed from genome-wide genotyping data based on the 1000 Genomes Project. We used multivariate logistic regression analyses to adjust for well-known risk factors such as dyslipidemia and smoking habits. In the primary study population, the frequency of the minor variant allele was significantly higher in patients with coronary artery disease than in controls (2.04% vs. 0.98%), with an odds ratio of 2.11 (p = 0.017). Under a dominant model, after adjustment for risk factors, the association remained significant, with an odds ratio of 2.90 (95% confidence interval: 1.37–6.61; p = 0.005). In the replication study, the association was significant after adjustment for age and sex (odds ratio = 4.99; 95% confidence interval: 1.16–21.53; p = 0.031), although it did not reach statistical significance when further adjusted for risk factors (odds ratio = 3.82; 95% confidence interval: 0.87–16.77; p = 0.076).

Conclusions

The RNF213 p.R4810K variant appears to be significantly associated with coronary artery disease in the Japanese population.

A novel cost-effectiveness model of prescription eicosapentaenoic acid extrapolated to secondary prevention of cardiovascular diseases in the United States

OBJECTIVE

Given the substantial economic and health burden of cardiovascular disease and the residual cardiovascular risk that remains despite statin therapy, adjunctive therapies are needed. The purpose of this model was to estimate the cost-effectiveness of high-purity prescription eicosapentaenoic acid (EPA) omega-3 fatty acid intervention in secondary prevention of cardiovascular diseases in statin-treated patient populations extrapolated to the US.

METHODS

The deterministic model utilized inputs for cardiovascular events, costs, and utilities from published sources. Expert opinion was used when assumptions were required. The model takes the perspective of a US commercial, third-party payer with costs presented in 2014 US dollars. The model extends to 5 years and applies a 3% discount rate to costs and benefits. Sensitivity analyses were conducted to explore the influence of various input parameters on costs and outcomes.

RESULTS

Using base case parameters, EPA-plus-statin therapy compared with statin monotherapy resulted in cost savings (total 5-year costs $29,393 vs $30,587 per person, respectively) and improved utilities (average 3.627 vs 3.575, respectively). The results were not sensitive to multiple variations in model inputs and consistently identified EPA-plus-statin therapy to be the economically dominant strategy, with both lower costs and better patient utilities over the modeled 5-year period.

LIMITATIONS

The model is only an approximation of reality and does not capture all complexities of a real-world scenario without further inputs from ongoing trials. The model may under-estimate the cost-effectiveness of EPA-plus-statin therapy because it allows only a single event per patient.

CONCLUSION

This novel model suggests that combining EPA with statin therapy for secondary prevention of cardiovascular disease in the US may be a cost-saving and more compelling intervention than statin monotherapy.

Fifty-year Time Trends in Blood Pressures, Body Mass Index and their Relations in a Japanese Community: The Circulatory Risk in Communities Study (CIRCS)

Aim: Data for long-term trends in blood pressures, body mass index (BMI), and their relations are needed to set future intervention priorities for prevention of cardiovascular disease. The objective of this study was to investigate these trends revealed by repeated cross-sectional surveys conducted from 1963 to 2013 in a Japanese community.

Methods: Men and women aged 40–79 years who participated in annual cardiovascular checkups were enrolled, and the number of participants ranged between 1,776 and 2,366 with consistently high participation rates for both sexes aged 60–69 years. Sex- and age-specific mean systolic and diastolic blood pressures were calculated using mixed effects modeling for repeated measurement, and the prevalence of hypertension with and without obesity (BMI ≥ 25 kg/m²) were also calculated.

Results: Sex- and age-specific mean systolic and diastolic blood pressures declined irrespective of antihypertensive medication use in both men and women from 1963–1966 to 2009–2013, while mean BMI increased among men of all ages and women of ages 60–69 and 70–79 years. For both sexes aged 60–69 years, the prevalence of hypertension with obesity increased, but the prevalence of hypertension without obesity was still higher that with obesity.

Conclusions: Despite the transition to increased BMI levels, targeting non to obese hypertension remains important in addition to targeting obese hypertension for cardiovascular disease prevention.

Intracranial hemorrhage and platelet transfusion after administration of anti-platelets agents: Fukushima Prefecture

We conducted a case series study to assess intracerebral hemorrhage (ICH) in the context of anti-platelets agents (APAs) and platelet (PLT) transfusion in Fukushima Prefecture.This study included patients who were newly diagnosed with ICH between January 2008 and June 2014 in the neurosurgical hospitals of Fukushima Prefecture.　Four of ten neurosurgical hospitals responded to our questionnaire.　Of 287 ICH patients, 51 (20.6%) were on APA therapy, of whom PLT transfusion was given to only one persistently bleeding patient who was on dual anti-platelet therapy.　In a follow-up survey, 30 out of 51 ICH patients on APA therapy, average age 75 years, were analyzed, of whom 21 (70%) were male.　The predominant underlying disease was diabetes mellitus.　It is interesting to note that peripheral artery disease and aortic aneurysm were among the indications for APAs.　ICH was mainly observed supratentorially.　Hematoma enlargement was observed in 13 (44.8%) cases.　By day 7, 3 patients (10%) had died from complications of ICH.　In this study, we show that ICH during APA therapy matched what was observed in Kanagawa Prefecture.　Whether or not a national survey differs, we anticipate greater statistical validity and an opportunity to improve patient outcomes in Japan and around the world.

Anti-inflammatory Nanoparticle for Prevention of Atherosclerotic Vascular Diseases

Recent technical innovation has enabled chemical modifications of small materials and various kinds of nanoparticles have been created. In clinical settings, nanoparticle-mediated drug delivery systems have been used in the field of cancer care to deliver therapeutic agents specifically to cancer tissues and to enhance the efficacy of drugs by gradually releasing their contents. In addition, nanotechnology has enabled the visualization of various molecular processes by targeting proteinases or inflammation. Nanoparticles that consist of poly (lactic-co-glycolic) acid (PLGA) deliver therapeutic agents to monocytes/macrophages and function as anti-inflammatory nanoparticles in combination with statins, angiotensin receptor antagonists, or agonists of peroxisome proliferator-activated receptor-γ (PPARγ). PLGA nanoparticle-mediated delivery of pitavastatin has been shown to prevent inflammation and ameliorated features associated with plaque ruptures in hyperlipidemic mice. PLGA nanoparticles were also delivered to tissues with increased vascular permeability and nanoparticles incorporating pitavastatin, injected intramuscularly, were retained in ischemic tissues and induced therapeutic arteriogenesis. This resulted in attenuation of hind limb ischemia. Ex vivo treatment of vein grafts with imatinib nanoparticles before graft implantation has been demonstrated to inhibit lesion development. These results suggest that nanoparticle-mediated drug delivery system can be a promising strategy as a next generation therapy for atherosclerotic vascular diseases.

Reduced ratio of eicosapentaenoic acid and docosahexaenoic acid to arachidonic acid is associated with early onset of acute coronary syndrome

BACKGROUND

The hospitalization rate for acute coronary syndrome (ACS) for people aged ≤50 has remained stable over the past decade. Increased serum levels of n-3 polyunsaturated fatty acids (PUFAs), such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are associated with a decreased incidence of cardiovascular events and mortality in older patients; however, it is currently unknown whether reduced serum levels of n-3 PUFAs is also a risk factor for ACS in patients aged ≤50 years.

METHODS AND RESULTS

We retrospectively reviewed 102 (male/ female 73/29) Japanese ACS patients whose serum levels of EPA/arachidonic acid (AA) and DHA/AA were evaluated on admission. The EPA/AA ratio was the lowest in patients aged ≤50 compared to patients aged 51-74 and ≥75. Pearson correlation analysis showed that early ACS onset was associated with low EPA/AA and DHA/AA ratios, and multiple regression analysis determined that decreased ratios of EPA/AA and DHA/AA, and male sex, current smoker status, increased body mass index and triglyceride levels, independently correlated with early ACS onset. Conversely, low-density and high-density lipoproteins, glycated hemoglobin, and hypertension did not correlate with early ACS onset. Subgroup analyses of male patients revealed that decreased ratios of EPA/AA and DHA/AA independently correlated with early ACS onset.

CONCLUSION

Decreased EPA/AA and DHA/AA ratios may be risk factors for early onset of ACS, suggesting that reduced EPA/AA and DHA/AA may represent targets for preventing ACS in Japanese young people.

Relationship between the ankle-brachial index and the risk of coronary heart disease and stroke: the circulatory risk in communities study

AIM

Patients with peripheral artery disease (PAD) are at a high risk of cardiovascular disease (CVD) among Western populations. However, evidence for an elevated risk in Asian populations is limited.

METHODS

This prospective cohort study examined 939 Japanese men 60-74 years of age at the time of the baseline survey. A total of 115 cases of CVD were detected during a median 9.3 years of follow-up, and the ankle brachial blood pressure index (ABI) functioned as a surrogate measurement of PAD.

RESULTS

The age-adjusted risks of coronary heart disease, ischemic stroke and ischemic CVD (coronary heart disease and ischemic stroke) were higher among men in the lowest ABI tertile compared with that observed in the men in the highest tertile (<1.08 vs. >1.17). These associations did not change substantially after adjusting for cardiovascular risk factors. The respective multivariable hazard ratios (HRs, 95% CI) for the three conditions were as follows: 2.48 (1.08-5.71), p for trend=0.03; 1.95 (0.94-4.02), p for trend=0.04; and 2.16 (1.25-3.72), p for trend=0.004. These results did not vary based on a comparison of the three ABI categories: ≤0.90, 0.91-1.10 and >1.10. The multivariable HRs (95% CI) for an ABI ≤0.90 versus >1.10 were as follows: 2.04 (0.67-6.20), p for trend=0.14 for coronary heart disease; 3.39 (1.10-10.5), p for trend=0.006 for ischemic stroke; and 2.61 (1.19-5.76), p for trend=0.003 for ischemic CVD. There were no associations between the ABI and the risk of hemorrhagic stroke.

CONCLUSIONS

A low ABI is associated with the risk of coronary heart disease, ischemic stroke and ischemic CVD in elderly Japanese men.

Total cholesterol performance of Abell-Levy-Brodie-Kendall reference measurement procedure: Certification of Japanese in-vitro diagnostic assay manufacturers through CDC's Cholesterol Reference Method Laboratory Network

BACKGROUND

Accurate measurement of total cholesterol (TC) is important for cardiovascular disease risk management. The US Centers for Disease Control and Prevention (CDC) and Cholesterol Reference Method Laboratory Network (CRMLN) perform Abell-Levy-Brodie-Kendall (AK) reference measurement procedure (RMP) for TC as a secondary reference method, and implement Certification Protocol for Manufacturers. Japanese CRMLN laboratory at Osaka performed the AK RMP for 22 years, and conducted TC certification for reagent/calibrator/instrument systems of six Japanese manufacturers every 2 years for 16 years. Osaka TC performance was examined and compared to CDC's reference values.

METHODS

AK RMP involved sample hydrolysis, cholesterol extraction, and determination of cholesterol levels by spectrophotometry. The Certification Protocol for Manufacturers includes comparison with AK RMP using at least 40 fresh specimens. Demonstration of average bias ≤3% and total coefficient of variation ≤3% qualified an analytical system for certification.

RESULTS

In the AK RMP used in the Osaka CRMLN laboratory, the regression equation for measuring TC was y (Osaka)=1.000x (CDC)+0.032 (n=619, R(2)=1.000). Six Japanese manufacturers had allowable performance for certification.

CONCLUSIONS

The AK RMP for TC measurement was accurate, precise, and stable for 22 years. Six Japanese manufacturers were certified for 16 years.

Adult mortality or morbidity is not increased in childhood-onset growth hormone deficient patients who received pediatric GH treatment: an analysis of the Hypopituitary Control and Complications Study (HypoCCS)

BACKGROUND

The French Safety and Appropriateness of Growth Hormone treatments in Europe (SAGhE) cohort has raised concern of increased mortality risk during follow-up into adulthood in certain patients who had received growth hormone (GH) treatment during childhood. The Hypopituitary Control and Complications Study monitored mortality and morbidity of adult GH-deficient patients including those with childhood-onset GH deficiency (COGHD) who received GH treatment as children.

PURPOSE

Evaluate risk of mortality, cancer, myocardial infarction (MI) and stroke in a prospective observational study.

METHODS

COGHD patients [n = 1,204, including 389 diagnosed with idiopathic COGHD (ICOGHD)] had received pediatric GH treatment. Standardized mortality ratios (SMRs), and cancer standardized incidence ratios (SIRs) in patients without a prior cancer were estimated relative to reference populations. Crude incidence rates were estimated for MI and stroke.

RESULTS

No increased mortality or cancer incidence was observed, as compared with reference populations, during a follow-up of 3.7 ± 3.3 years (mean ± SD). The overall SMR for COGHD was 1.14 [95 % confidence interval (CI) 0.55-2.10], and for ICOGHD, 0.33 (0.01-1.84). The overall cancer SIR for COGHD was 0.27 (0.01-1.50), and for ICOGHD, 0.00 (0.00-2.45). No incident case of MI was reported. The crude stroke incidence rate [181.3 per 100,000 person-years] in COGHD patients was consistent with the rates reported in reference populations. No incident case of stroke was identified in ICOGHD patients who are presumed to have no increased stroke risk factors.

CONCLUSIONS

The results indicate no increased risk of mortality or incidence of cancer, stroke, or MI in adult GH-deficient patients who had previously received pediatric GH treatment.

Acute Case-Fatality Rates of Stroke and Acute Myocardial Infarction in a Japanese Population: Takashima Stroke and AMI Registry, 1989–2005

Background

Few comprehensive stroke and acute myocardial infarction registries of long duration exist in Japan to illustrate trends in acute case-fatality of stroke and acute myocardial infarction with greater precision. We examined 17-year case-fatality rates of stroke and acute myocardial infarction using an entire community-monitoring registration system to investigate trends in these rates over time in a Japanese population.

Methods

Data were obtained from the Takashima Stroke and AMI Registry covering a stable population of approximately 55 000 residents of Takashima County in central Japan. We divided the total observation period of 17 years into four periods, 1989–1992, 1993–1996, 1997–2000, and 2001–2005. We calculated gender, age-specific and age-adjusted acute case-fatality rates (%) of stroke and acute myocardial infarction across these four periods.

Results

During the study period of 1989–2005, there were 341 fatal cases within 28 days of onset among 2239 first-ever stroke events and 163 fatal cases among 433 first-ever acute myocardial infarction events. The age-adjusted acute case-fatality rate of stroke was 14·9% in men and 15·7% in women. The age-adjusted acute case-fatality rate of acute myocardial infarction was 34·3% in men and 43·3% in women. The age-adjusted acute case-fatality rates of stroke and acute myocardial infarction showed insignificant differences across the four time periods. The average annual change in the acute case-fatality rate of stroke (–0·2%; 95% CI: −2·4–2·1) and acute myocardial infarction (2·7%; 95% CI: −0·7–6·1) did not change significantly across the study years.

Conclusions

The acute case-fatality rates of stroke and acute myocardial infarction have remained stable from 1989 to 2005 in a rural and semi-urban Japanese population.

Cross-sectional comparison of coronary artery calcium scores between Caucasian men in the United States and Japanese men in Japan: the multi-ethnic study of atherosclerosis and the Shiga epidemiological study of subclinical atherosclerosis

The incidence of coronary heart disease in the United States has declined, and prevalences of several coronary disease risk factors have become comparable to those in Japan. Therefore, the burden of coronary atherosclerosis may be closer among younger persons in the 2 countries. We aimed to compare prevalences of coronary atherosclerosis, measured with coronary artery calcium scores, between men in the 2 countries by age group (45-54, 55-64, or 65-74 years). We used community-based samples of Caucasian men in the United States (2000-2002; n = 1,067) and Japanese men in Japan (2006-2008; n = 832) aged 45-74 years, stratifying them into groups with 0, 1, 2, or ≥3 of the following risk factors: current smoking, overweight, diabetes, dyslipidemia, and hypertension. We calculated adjusted odds ratios of US Caucasian men's having Agatston scores of ≥10, ≥100, and ≥400 with reference to Japanese men. Overall, the odds of Caucasian men having each Agatston cutoff point were greater. The ethnic difference, however, became smaller in younger age groups. For example, adjusted odds ratios for Caucasian men's having an Agatston score of ≥100 were 2.05, 2.43, and 3.86 among those aged 45-54, 55-64, and 65-74 years, respectively. Caucasian men in the United States had a higher burden of coronary atherosclerosis than Japanese men, but the ethnic difference was smaller in younger age groups.

The incidence of coronary heart disease and the population attributable fraction of its risk factors in Tehran: a 10-year population-based cohort study

BACKGROUND

Data on incidence of coronary heart disease (CHD) is scarce in the Middle East and little is known about the contribution of known risk factors in this area.

METHODS

The incidence of CHD and the effect of modifiable risk factors were explored in 2889 men and 3803 women aged 30-74 years in the population based cohort of the Tehran Lipid and Glucose Study, during 1999-2010. Average population attributable fraction (aPAF) was calculated for any risk factor using direct method based on regression model.

RESULTS

The crude incidence rate in men was about twice that in women (11.9 vs. 6.5 per 1000 person-years). The aPAF of hypertension, diabetes, high total cholesterol and low-HDL cholesterol was 9.4%, 6.7%, 7.3% and 6.1% in men and 17%, 16.6%, 12% and 4.6% in women respectively. This index was 7.0% for smoking in men. High risk age contributed to 42% and 22% of risk in men and women respectively.

CONCLUSIONS

The incidence in this population of Iran was comparable to those in the US in the seventies. Well known modifiable risk factors explained about 40% and 50% of CHD burden in men and women respectively. Aging, as a reflection of unmeasured or unknown risk factors, bears the most burden of CHD, especially in men; indicating more age-related health care is required.

Ambulance calls and prehospital transportation time of emergency patients with cardiovascular events in Osaka City

AIM

This study investigated the association between the number of phone calls made to hospitals from ambulances requesting if they can accept prehospital emergency patients with cardiovascular events, and the prehospital transportation time.

METHODS

Using ambulance records, we retrospectively enrolled adult patients suffering acute myocardial infarction from 1998 to 2007, and out-of-hospital cardiac arrest of cardiac origin from 2000 to 2007, transported to medical institutions by the emergency medical service in Osaka City.

RESULTS

During the study period, 8,596 patients with acute myocardial infarction without arrest and 9,283 out-of-hospital cardiac arrests of cardiac origin were registered. The hospital arrival time (from patient's call until hospital arrival) increased along with the increasing number of phone calls to hospitals from ambulances for patients with acute myocardial infarction (from 23.2 min with one phone call to 39.7 min with ≥5 phone calls; P for trend <0.001), and for those with out-of-hospital cardiac arrest (from 24.4 min with one phone call to 36.6 min with ≥5 phone calls; P for trend <0.001). In a multivariable analysis, chronological factors such as weekend and night-time were significantly associated with an increment in the phone calls to hospitals from ambulances.

CONCLUSIONS

From ambulance records in Osaka City, we showed that the increased number of phone calls to hospitals from ambulances led to prolongation of the hospital arrival time.

Heart rate variability and blood pressure among Japanese men and women: a community-based cross-sectional study

Heart rate variability (HRV) is associated with blood pressure levels; however, very few studies have correlated HRV to lifestyle in the general population. We investigated 1418 men and 2040 women aged 40-74 years and measured the HRV indices in the time and frequency domains using a 5-min R-R interval recording. Multiple linear regression analyses were used to estimate the association between HRV and blood pressure levels after adjustment for major confounders. HRV indices were not associated with systolic blood pressure levels in men, whereas in women, one-s.d. (1-s.d.) increment of s.d. of normal R-R intervals (SDNN) was associated with a 1.21-mm Hg decrease in systolic blood pressure after adjusting for several confounders (P<0.05). In addition, a 1-s.d. increment of SDNN corresponded with 1.00 and 1.10 mm Hg reductions in diastolic blood pressure in men and women, respectively (P<0.05). When stratified by the use or nonuse of antihypertensive medication, these inverse associations were more evident in the nonuser group. Furthermore, among men not using antihypertensive medication, reduced HRV was associated with increased systolic blood pressure levels in nondrinkers. The data suggest that HRV reflects diastolic blood pressure better than systolic blood pressure levels for both sexes and that alcohol intake strongly affects systolic blood pressure levels in men, which may have weakened the association with HRV.

Treated and untreated hypertension, hospitalization, and medical expenditure: an epidemiological study in 314622 beneficiaries of the medical insurance system in Japan

OBJECTIVE

This study investigated the effect of hypertension on hospitalization risk and medical expenditure according to treatment status in a Japanese population.

METHODS

A total of 314 622 beneficiaries of the medical insurance system in Japan, aged 40-69 years, without a history of cardiovascular, cerebrovascular, or end-stage renal disease were classified into seven blood pressure categories. These categories were used to compare the risk of undergoing hospitalization in the 1 year after the baseline survey and to examine the percentage of inpatient medical expenditure attributable to overall hypertension relative to total medical expenditure in the study population.

RESULTS

During the follow-up period, 6.6% of men and 5.1% of women were hospitalized. In men and women aged 40-54 years, cases of hypertension, especially grade 3 untreated hypertension, led to more frequent hospitalization, compared with optimal blood pressure. Individuals who were hospitalized, especially long-term, incurred considerably higher medical expenditure compared with those who were not hospitalized, regardless of their hypertension status. In women aged 55-69 years, there was little variation in hospitalization risk across blood pressure categories. The inpatient medical expenditure attributable to overall hypertension represented 7.2 and 6.9% of the total medical expenditure for men aged 40-54 and 55-69 years, whereas it represented 2.8 and 3.8% for women, respectively.

CONCLUSION

Although cases of hypertension were an economic burden especially in men, grade 3 untreated hypertension was more likely to incur extremely high medical expenditure as a result of hospitalization, compared with other cases.

Alcohol consumption and risk of stroke and coronary heart disease among Japanese women: the Japan Public Health Center-based prospective study

OBJECTIVE

The study aims to examine the association between a wide range of alcohol consumption and risk of stroke and coronary heart disease.

METHODS

The Japan Public Health Center-based prospective study was initiated in 1990 in Cohort I and in 1993 in Cohort II, with follow-up until 2009. The sample consisted of 47,100 women aged 40-69 years.

RESULTS

During an average of 16.7-years, the incidence of 1846 strokes and 292 coronary heart diseases was observed. Heavy drinking (≥ 300 gethanol/week) was associated with increased risk of total stroke. The multivariable hazard ratios for heavy versus occasional drinkers were 2.19 (95% confidence interval: 1.45-3.30) for total stroke, 2.25 (1.29-3.91) for hemorrhagic stroke, 2.24 (1.05-4.76) for intraparenchymal hemorrhage, 2.26 (1.01-5.09) for subarachnoid hemorrhage and 2.04 (1.09-3.82) for ischemic stroke. In the exposure-updated analysis, the positive association between heavy drinking and risks of total stroke, hemorrhagic stroke and intraparenchymal hemorrhage became more evident. Light drinking (<150 gethanol/week) was not associated with risk of ischemic stroke. There was also no association between alcohol consumption and risk of coronary heart disease.

CONCLUSION

Heavy drinking was associated with increased risk of hemorrhagic and ischemic strokes among Japanese women.

Do differences in risk factors explain the lower rates of coronary heart disease in Japanese versus U.S. women?

BACKGROUND

Mortality from coronary heart disease (CHD) in women in Japan is one of the lowest in developed countries. In an attempt to shed some light on possible reasons of lower CHD in women in Japan compared with the United States, we extensively reviewed and analyzed existing national data and recent literature.

METHODS

We searched recent epidemiological studies that reported incidence of acute myocardial infarction (AMI) and examined risk factors for CHD in women in Japan. Then, we compared trends in risk factors between women currently aged 50-69 years in Japan and the United States, using national statistics and other available resources.

RESULTS

Recent epidemiological studies have clearly shown that AMI incidence in women in Japan is lower than that reported from other countries, and that lipids, blood pressure (BP), diabetes, smoking, and early menopause are independent risk factors. Comparing trends in risk factors between women in Japan and the United States, current levels of serum total cholesterol are higher in women in Japan and levels have been similar at least since 1990. Levels of BP have been higher in in Japan for the past 3 decades. Prevalence of type 2 diabetes has been similar in Japanese and white women currently aged 60-69 for the past 2 decades. In contrast, rates of cigarette smoking, although low in women in both countries, have been lower in women in Japan.

CONCLUSIONS

Differences in risk factors and their trends are unlikely to explain the difference in CHD rates in women in Japan and the United States. Determining the currently unknown factors responsible for low CHD mortality in women in Japan may lead to new strategy for CHD prevention.

Cohort profile: the Fangshan Cohort Study of cardiovascular epidemiology in Beijing, China

Background

Urbanizing rural areas in China face a rapidly growing cardiovascular disease burden. Epidemiologic studies and effective preventive strategies are urgently needed.

Methods

The Fangshan Cohort Study is a prospective study that began in 2008 and targets local residents aged 40 years or older living in 3 towns in the Fangshan district of Beijing. The baseline examination included a questionnaire on medical history, health knowledge, and behaviors related to cardiovascular disease, as well as physical and blood biochemical examinations. The questionnaire survey will be readministered every 2 years. A system for surveillance of mortality and morbidity of cardiovascular disease is under development.

Results

A total of 20 115 adults (6710 men and 13 405 women) were investigated at baseline (participation rate = 84.5%). The data indicate that overweight/obesity is a serious public health issue in Fangshan: average body mass index was 25.4 kg/m² among men and 26.5 kg/m² among women, and the prevalences of overweight and obesity were 43.6% and 10.3% among men and 47.0% and 17.7% among women.

Conclusions

The Fangshan Cohort Study will provide data on cardiovascular risk factors and disease profile, which will assist in developing appropriate prevention and control strategies for cardiovascular disease in rural Chinese communities.

Hypertriglyceridemia is frequent in endometrial cancer survivors

Objective

Previous studies have reported an association between endometrial cancer and the risk of metabolic syndrome; however, the pattern of endometrial cancer-associated dyslipidemia is not well understood. The standard therapy for endometrial cancer is total abdominal hysterectomy and bilateral salpingo-oophorectomy. Premenopausal bilateral salpingo-oophorectomy may cause adverse events, including dyslipidemia. Gynecologists have to care dyslipidemia in endometrial cancer survivors at cancer follow-up clinic.

Methods

This study included 693 patients who had undergone bilateral salpingo-oophorectomy, and included 412 women with incident endometrial cancer and 281 controls. We divided the patients into two categories according to whether they had a premenopausal or postmenopausal bilateral oophorectomy. Serum lipid levels were measured and statistically analyzed.

Results

Hypertriglyceridemia was statistically more frequent in patients who had undergone bilateral salpingo-oophorectomy both before and after menopause than in the corresponding non-endometrial cancer controls. High levels of low-density lipoprotein cholesterol and a high low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio were statistically more frequent in patients who had undergone bilateral salpingo-oophorectomy before menopause than in non-endometrial cancer controls.

Conclusions

Our report highlights the importance of the relationship between endometrial cancer and lipid metabolism, which may aid in preventing cerebrovascular or cardiovascular diseases due to dyslipidemia and improving the quality of life in endometrial cancer survivors.

Carotid intima-media thickness progression predicts cardiovascular events in Japanese patients with type 2 diabetes

AIMS

The aim of this retrospective study was to investigate the relationship between progression of carotid intima-media thickness (cIMT) and cardiovascular events in Japanese patients with type 2 diabetes mellitus (T2DM) and free of history of cardiovascular events.

METHODS

Patients with T2DM (n=342) without history of cardiovascular events whose cIMT was assessed more than twice by ultrasonography were recruited and followed up for cardiovascular events.

RESULTS

During a mean follow-up of 7.6 years, 56 (16.4%) cardiovascular events (27 coronary events and 29 cerebrovascular events) were recorded. Multivariate analysis with the Cox proportional hazard model identified cIMT progression as a significant determinant of cardiovascular events, with a hazard ratio (HR) of 2.24 (95% confidence interval; CI, 1.25-4.03, P<0.01), in addition to baseline cIMT. The Kaplan-Meier curves also showed significantly higher event rate in patients with high cIMT progression compared with those with low cIMT progression (log-rank χ(2)=6.65; P<0.01). Furthermore, the combination of high baseline cIMT and high cIMT progression was a significant predictor of cardiovascular events.

CONCLUSION

Our findings suggest that cIMT progression, in addition to baseline cIMT, is a predictor of cardiovascular events in patients with T2DM without history of cardiovascular events, and that the combination of cIMT progression and baseline cIMT has a strong predictive power for such events.

Secular trends in cardiovascular disease and its risk factors in Japanese: half-century data from the Hisayama Study (1961-2009)

BACKGROUND

Changes in lifestyle and advances in medical technology during the past half century are likely to have affected the incidence and mortality of cardiovascular disease and the prevalence of its risk factors in Japan.

METHODS AND RESULTS

We established 5 cohorts consisting of residents aged ≥40 years in a Japanese community, in 1961 (n=1618), 1974 (n=2038), 1983 (n=2459), 1993 (n=1983), and 2002 (n=3108), and followed up each cohort for 7 years. The age-adjusted incidence of stroke decreased greatly, by 51% in men and by 43% in women, from the 1960s to the 1970s, but this decreasing trend slowed from the 1970s to the 2000s. Among the stroke subtypes, ischemic stroke in both sexes and intracerebral hemorrhage in men showed a similar pattern. Stroke mortality decreased as a result of the decline in incidence and a significant improvement in survival rate. Although the incidence of acute myocardial infarction did not change in either sex, disease mortality declined slightly in women. From the 1960s to the 2000s, blood pressure control among hypertensive individuals improved significantly and the smoking rate decreased, but the prevalence of glucose intolerance, hypercholesterolemia, and obesity increased steeply.

CONCLUSIONS

Our findings suggest that in Japanese, the decreasing trends in the incidence of ischemic stroke have recently slowed down, and there has been no clear change in the incidence of acute myocardial infarction, probably because the benefits of hypertension control and smoking cessation have been negated by increasing metabolic risk factors.

Temporal trends in sudden unexpected death in a general population: the Hisayama study

BACKGROUND

Studies addressing the temporal trends in the prevalence of sudden unexpected death (SUD) and its underlying causes in the general population are limited.

METHODS

Among a total of 1934 residents aged ≥20 years of the town of Hisayama, Japan, who died of endogenous causes of death and underwent autopsy examination (autopsy rate 78.5%) from 1962 to 2009, 204 were determined to be cases of SUD within 24 hours.

RESULTS

The trend in the age- and sex-adjusted prevalence of SUD among all autopsy subjects was stable over four 12-year periods (13.1% in 1962-1973, 13.4% in 1974-1985, 15.0% in 1986-1997, and 14.6% in 1998-2009; P for trend = .80). Regarding causes of death, the prevalence of SUD from stroke significantly declined with time (8.0%, 5.0%, 2.3%, and 2.1%, respectively; P for trend < .001), whereas significant increments were observed in the prevalence of SUD from heart disease (4.0%, 6.2%, 8.6%, and 9.7%; P for trend = .02) and from aortic aneurysm and dissection (0.2%, 1.2%, 2.9%, and 2.8%; P for trend = .01). In particular, the prevalence of ischemic heart disease increased 3-fold from 2.1% in 1962-1973 to 6.6% in 1998-2009 (P = .04). Reflecting the increment of ischemic heart disease, SUD within 1 hour increased significantly from 2.5% to 7.6% during this period (P = .01).

CONCLUSIONS

The trend in the prevalence of SUD was stable across a half century in a general Japanese population. Despite the decrement in the prevalence of SUD from stroke, that from heart disease, especially ischemic heart disease, increased significantly with time.

Retinal vascular features associated with risk of branch retinal vein occlusion

PURPOSE/AIM

To identify retinal vascular features that precede the development of branch retinal vein occlusion (BRVO) by comparing case eyes and fellow eyes.

MATERIALS AND METHODS

We identified 25 persons who attended an annual health screening program at Osaka Health Science Center, Osaka, Japan, and then developed BRVO in one eye between 1995 and 2009. We retrospectively reviewed retinal images of these subjects taken 1-5 years prior to the development of BRVO and compared the prevalence of retinal vascular features between case eyes and contralateral fellow eyes. Potential local retinal vascular features considered were (1) severe arterio-venous (AV) nicking, (2) a smaller angle at the crossing of the arteriole and venule, (3) double crossing, (4) crossing near venular bifurcation and (5) isolated retinopathy. The central retinal artery equivalent (CRAE), vein equivalent (CRVE) and AV ratio (CRAE divided by CRVE) were quantitatively estimated using a standardized imaging software (University of Wisconsin).

RESULTS

Compared to the fellow eye, severe AV nicking (39.1% versus 2.6%, <0.001), isolated retinopathy (47.8% versus 7.69%, p < 0.001) and a smaller angle at the crossing site (82.6% versus 46.2%, p = 0.005) were more prevalent in eyes with BRVO compared with fellow eyes. Case eyes had a significantly smaller AV ratio at 1-5 years prior to the development of BRVO compared with fellow eyes (0.68 versus 0.73, p = 0.03).

CONCLUSIONS

In addition to severe AV nicking, a well-known sign linked to BRVO, this study identified two new potential retinal vascular features--isolated retinopathy and a smaller angle at the crossing site--associated with BRVO development. We also found that a discrepancy in the AV ratio between eyes (i.e. a smaller AV ratio than the fellow eye) can be a quantitative indicator of a higher BRVO risk. These findings warrant further validation in longitudinal studies.

Statin use in patients with diabetes and kidney disease: the Japanese experience

Diabetes is a leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in developed nations, including Japan and the United States. Japan has the unenviable distinction of having one of the world's highest rates of dialysis: in 2011, there were over 300,000 dialysis patients (2,383 per million people), with diabetic patients accounting for almost half of all incident cases. Concomitance of CKD and diabetes predicts a greater risk of cardiovascular disease (CVD) than either condition in isolation. Hence, appropriate management of modifiable cardiovascular (CV) risk factors, including dyslipidemia, is paramount in this high-risk group. The United States and Japan have distinct approaches to cholesterol management, with more stringent therapeutic targets for lipid control advocated in US guidelines. However, upward trends in cholesterol levels and coronary heart disease incidence in Japan may provide justification for more intensive CV risk factor management strategies by Japanese physicians to achieve maximum benefit. Attainment of recommended lipid goals in Japan is poor, particularly in patients with diabetes and/or CKD in whom CV risk factors are often undertreated. Statin therapy has been shown to be safe and effective in reducing CV risk in patients with diabetes and/or CKD stages 1-5. Moreover, statins may impart a renoprotective effect by preventing or delaying progressive loss of kidney function. This review summarizes evidence from studies in Western and Japanese populations to highlight the CV and renal benefits of lipid-lowering agents in CKD patients, including those with diabetes.

Cost-effectiveness and budget impact analyses of a long-term hypertension detection and control program for stroke prevention

OBJECTIVES

The nation-wide, community-based intensive hypertension detection and control program, as well as universal health insurance coverage, may well be contributing factors for helping Japan rank near the top among countries with the longest life expectancy. We sought to examine the cost-effectiveness of such a community-based intervention program, as no evidence has been available for this issue.

METHODS

The hypertension detection and control program was initiated in 1963 in full intervention and minimal intervention communities in Akita, Japan. We performed comparative cost-effectiveness and budget-impact analyses for the period 1964-1987 of the costs of public health services and treatment of patients with hypertension and stroke on the one hand, and incidence of stroke on the other in the full intervention and minimal intervention communities.

RESULTS

The program provided in the full intervention community was found to be cost saving 13 years after the beginning of program in addition to the fact of effectiveness that; the prevalence and incidence of stroke were consistently lower in the full intervention community than in the minimal intervention community throughout the same period. The incremental cost was minus 28,358 yen per capita over 24 years.

CONCLUSION

The community-based intensive hypertension detection and control program was found to be both effective and cost saving. The national government's policy to support this program may have contributed in part to the substantial decline in stroke incidence and mortality, which was largely responsible for the increase in Japanese life expectancy.

Non-fasting blood glucose and risk of incident coronary heart disease in middle-aged general population: the Circulatory Risk in Communities Study (CIRCS)

OBJECTIVE

The objective was to determine whether non-fasting glucose concentration is a predictor for incident coronary heart disease.

METHODS

We investigated a cohort data of 9,900 40- to 69-year-old residents in four Japanese communities for 1975-1986 baseline surveys of the Circulatory Risk in Communities Study (CIRCS). Non-fasting blood glucose concentrations were available for 7,332 participants. Diabetic type was defined as a glucose level of ≥ 11.1 mmol/L and/or the use of medication for diabetes mellitus.

RESULTS

A total of 170 coronary heart disease including 113 myocardial infarctions occurred in non-fasting participants within the median 22-year follow-up period. Multivariable hazard ratios (HRs) of incident coronary heart disease for the participants with diabetic type compared with the normal type were 1.98 (0.84-4.68) for men, 3.39 (1.47-7.81) for women, and 2.47 (1.37-4.46) for total subjects. Corresponding HRs for myocardial infarction were 2.14 (0.83-5.55), 5.70 (2.21-14.67) and 3.17 (1.65-6.10), respectively. Multivariable HRs of incident coronary heart disease per one standard deviation of serum glucose levels were 1.17 (1.02-1.36), 1.19 (1.03-1.38), and 1.19 (1.08-1.32), respectively. The corresponding HRs for myocardial infarction were 1.18 (1.00-1.38), 1.27 (1.07-1.49) and 1.23 (1.10-1.37).

CONCLUSION

Non-fasting glucose concentration, either as diagnosis of diabetic type or as continuous variable, proved to be an independent predictor for incident coronary heart disease in middle-aged general population.

Relation between serum total cholesterol level and cardiovascular disease stratified by sex and age group: a pooled analysis of 65 594 individuals from 10 cohort studies in Japan

BACKGROUND

The relation between serum total cholesterol (TC) and cardiovascular disease in women and in the elderly is unclear, especially in Asian populations.

METHODS AND RESULTS

We examined this relation in the largest-scale pooled analysis of the Japanese population, the Evidence for Cardiovascular Prevention from Observational Cohorts in Japan (EPOCH-JAPAN) study. A total of 65 594 participants who were 40 to 89 years of age and did not have a past history of cardiovascular disease were examined. Cox proportional-hazards models were used to estimate hazard ratios for death from total stroke, cerebral infarction, intracranial cerebral hemorrhage, or coronary heart disease. The mean follow-up period was 10.1 years, with the number of deaths from total stroke, cerebral infarction, cerebral hemorrhage, and coronary heart disease being 875, 457, 212, and 374, respectively. The participants were divided into 2 age groups: middle-aged (40 to 69 years; mean age 55 years) and elderly (70 to 89 years; mean age 75 years). In men, the multivariate-adjusted hazard ratios for coronary heart disease in the highest TC category (≥6.21 mmol/L) compared with the lowest category (<4.14 mmol/L) were 2.52 (95% confidence interval: 1.15-5.07) in middle-aged participants and 2.77 (1.09-7.03) in elderly participants. In women, the hazard ratios of the highest TC category (≥6.72 mmol/L) compared with the lowest category (<4.66 mmol/L) were 3.20 (1.44-7.09) in middle-aged participants and 1.02 (0.42-2.49) in elderly participants. TC levels were not associated with cerebral infarction in any age or sex group and were associated negatively with total stroke and cerebral hemorrhage.

CONCLUSION

High serum TC levels are associated with coronary heart disease in middle-aged Japanese men and women, but evidence in elderly Japanese individuals is still limited.

Risk factors for sudden cardiac death among Japanese: the Circulatory Risk in Communities Study

OBJECTIVE

There is little evidence concerning risk factors for sudden cardiac death (SCD) among Asians.

PATIENTS AND METHODS

A prospective, nested, case-control study of Japanese patients aged between 30 and 84 years was undertaken using data collected from 26 870 participants in cardiovascular risk surveys conducted in four communities between 1975 and 2005. The incidence of SCD was ascertained by systematic surveillance, with 239 cases of SCD identified over this period. For each case of SCD, three control patients were selected, matched by age, sex, examination year, follow-up time, and community.

RESULTS

Hypertension, diabetes mellitus, smoking, major ST-T abnormalities, left high amplitude R waves, and increased heart rate (≥77 beat/min) were all independently associated with a 1.5-3.2-fold increase in SCD risk, whereas no associations were observed for body mass index and hypercholesterolemia. The population-attributable fraction [95% confidence interval (CI)] was 23.0% (2.9-39.0) for hypertension, 15.3% (3.8-25.5) for current smoking, 14.5% (8.0-20.5) for major ST-T abnormalities, and 8.1% (2.2-13.7) for diabetes mellitus. The number of SCD risk factors (hypertension, diabetes, smoking, and ECG abnormalities) was positively associated with increased SCD risk. The odds ratio for increased SCD risk with three or more risk factors versus zero risk factors was 5.76 (95% CI 3.20-10.39).

CONCLUSIONS

Among the Japanese population, hypertension, smoking, major ST-T abnormalities, left high amplitude R waves, and diabetes mellitus were associated with an increased incidence of SCD, whereas there were no associations of body mass index or hypercholesterolemia with SCD incidence.

Coronary artery calcification by computed tomography in epidemiologic research and cardiovascular disease prevention

Both American and European guidelines recommend coronary artery calcification (CAC) as a tool for screening asymptomatic individuals at intermediate risk for coronary heart disease (CHD). These recommendations are based on epidemiologic studies mostly in the United States. We review (1) the use of CAC in primary prevention of CHD in the United States, (2) epidemiologic studies of CAC in asymptomatic adults outside of the United States, and (3) international epidemiologic studies of CAC. This review will not consider clinical studies of CAC among patients or symptomatic individuals. US studies have shown that CAC is a strong independent predictor of CHD in both sexes among middle-aged and old age groups, various ethnic groups, and individuals with and without diabetes and that CAC plays an important role in reclassifying individuals from intermediate to high risk. Studies in Europe support these conclusions. The Electron-Beam Tomography, Risk Factor Assessment Among Japanese and US Men in the Post-World-War-II birth cohort (ERA JUMP) Study is the first international study to compare subclinical atherosclerosis, including CAC among Japanese, Japanese Americans, Koreans, and whites. It showed that as compared with whites, Japanese had lower levels of atherosclerosis, whereas Japanese Americans had similar or higher levels. CAC is being increasingly used as a screening tool for asymptomatic individuals in Europe and the United States. CAC is a powerful research tool, because it enables us to describe differences in atherosclerotic burden across populations. Such research could identify factors responsible for differences among populations, which may improve CHD prevention.

High serum total cholesterol levels is a risk factor of ischemic stroke for general Japanese population: the JPHC study

BACKGROUND

High serum total cholesterol levels represent a risk factor of ischemic stroke in Western countries. However, this association has not been thoroughly investigated in Asian populations where the incidence of stroke is high.

METHODS

Participants were 11,727 men and 21,742 women aged 40-69 years, all free of cardiovascular disease and cancer at baseline. During the median 12-year follow-up, we documented 612 ischemic stroke (293 lacunar infarction, 107 large-artery occlusive infarctions, and 168 embolic infarctions).

RESULTS

Excess risk of ischemic stroke was observed in men with serum total cholesterol levels of ≥ 6.21 mmol/L than those with the lowest category (<4.65 mmol/L), but not in women. The multivariable hazard ratios (HRs) and 95% confidence interval (95% CI) were 1.63 (1.14-2.35) for men and 1.03 (0.69-1.55) for women. The corresponding HRs of large-artery occlusive infarction were 2.86 (1.31-6.27) for men and 0.75 (0.28-2.01) for women. Serum total cholesterol levels were not associated with risk of lacunar or embolic infarction for either sex.

CONCLUSIONS

High serum total cholesterol is a risk factor of ischemic stroke, specifically large-artery occlusive infarction for Japanese men.

Prevalence of cardiovascular disease and risk factors in a rural district of Beijing, China: a population-based survey of 58,308 residents

Background

Cardiovascular disease (CVD) is the leading cause of global disease burden. Although stroke was thought to be more prevalent than coronary heart disease (CHD) in Chinese, the epidemic pattern might have been changed in some rural areas nowadays. This study was to estimate up-to-date prevalence of CVD and its risk factors in rural communities of Fangshan District, Beijing, China.

Methods

A cross-sectional population survey was carried out by stratified cluster sampling. A total of 58,308 rural residents aged over 40 years were surveyed by face-to-face interview and physical examination during 2008 and 2010. The standardized prevalence was calculated according to adult sample data of China's 5th Population Census in 2000, and the adjusted prevalence odds ratio (POR) was calculated for the association of CHD/stroke with its cardiovascular risk factors in multivariate logistic regression models.

Results

Age- and sex-standardized prevalence was 5.6% for CHD (5.2% in males and 5.9% in females), higher than the counterpart of 3.7% (4.7% in males and 2.6% in females) for stroke. Compared with previous studies, higher prevalence of 7.7%, 47.2%, 53.3% in males and 8.2%, 44.8%, 60.7% in females for diabetes, hypertension and overweight/obesity were presented accordingly. Moreover, adjusted POR (95% confidence interval) of diabetes, obesity, stage 1 and stage 2 hypertension for CHD as 2.51 (2.29 to 2.75), 1.53 (1.38 to 1.70), 1.13 (1.02 to 1.26) and 1.35 (1.20 to 1.52), and for stroke as 2.24 (1.98 to 2.52), 1.25 (1.09 to 1.44), 1.44 (1.25 to 1.66) and 1.70 (1.46 to 1.98) were shown respectively in the multivariate logistic regression models.

Conclusions

High prevalence of CVD and probably changed epidemic pattern in rural communities of Beijing, together with the prevalent cardiovascular risk factors and population aging, might cause public health challenges in rural Chinese population.

Trends in sudden cardiac death and its risk factors in Japan from 1981 to 2005: the Circulatory Risk in Communities Study (CIRCS)

OBJECTIVE

There is little evidence whether sudden cardiac death (SCD) is increasing in Asia, although the incidence of coronary heart disease among urban middle-aged Japanese men has increased recently. We examined trends in the incidence of SCD and its risk factors in the Circulatory Risk in Communities Study.

DESIGN AND SETTING

This was a population-based longitudinal study. Surveillance of men and women for SCD incidence and risk factors was conducted from 1981 to 2005.

SUBJECTS

The surveyed population was all men and women aged 30-84 years who lived in three rural communities and one urban community in Japan.

MAIN OUTCOME MEASURES

Trends in SCD incidence and its risk factors.

RESULTS

Age-adjusted and sex-adjusted incidence of SCD decreased from 1981-1985 to 1991-1995, and plateaued thereafter. The annual incidence per 100 000 person-years was 76.0 in 1981-1985, 57.9 in 1986-1990, 39.3 in 1991-1995, 31.6 in 1996-2000 and 36.8 in 2001-2005. The prevalence of hypertension decreased from 1981-1985 to 1991-1995, and plateaued thereafter for men and women. The age-adjusted prevalence of current smoking for men decreased while that of diabetes mellitus increased for both sexes from 1981-1985 to 2001-2005.

CONCLUSIONS

The incidence of SCD decreased from 1981 to 1995 but was unchanged from 1996 to 2005. Continuous surveillance is necessary to clarify future trends in SCD in Japan because of an increasing incidence of diabetes mellitus.

Underweight is an important risk factor for coronary heart disease in the population of Ceningan Island, Bali

A study on the prevalence of coronary heart disease (CHD) and its risk factors in Ceningan Island was conducted. The prevalence of CHD was 11.5%. Older age (odds ratio, OR, 27.0), underweight (OR, 3.6), systolic hypertension (OR, 4.6), high total cholesterol (OR, 5.9), and high low-density lipoprotein cholesterol (OR, 3.1) were risk factors for a history of myocardial infarction (MI). By logistic regression analysis, only age (B=3.937) and underweight (B=1.275) consistently appeared to be risk factors for MI. The prevalence of CHD in the population was comparatively high.