Sino-MONICA project: a collaborative study on trends and determinants in cardiovascular diseases in China, Part i: morbidity and mortality monitoring

Trend of declining stroke mortality in China: reasons and analysis

Introduction

There is a downward trend of stroke-related mortality in the USA. By reviewing all published articles on stroke mortality in China, we analysed its trend and possible factors that have influenced the trend.

Methods

Both English and Chinese literatures were searched on the mortality of stroke or cerebrovascular diseases in China. Potential papers related to this topic were identified from PubMed, Medline, Embase, Cochrane Library, Wanfang Database, SINOMED and China National Knowledge Infrastructure databases.

Results

Comparing the results from the most recent population-based epidemiological survey and databank from the national Center for Disease Control and Prevention, the age-adjusted stroke mortality rate has shown a downward trend among both urban and rural population in the past 30 years in China. Comparing with 30 years ago, the rate of stroke mortality has decreased by more than 31% in urban/suburban population and 11% in rural population. In men, the age-adjusted stroke mortality rate decreased by 18.9% and in women by 24.9% between 1994 and 2013. Factors that may have contributed to the trend of decreased stroke mortality rate include (1) improved healthcare coverage and healthcare environment; (2) improved treatment options and medical technology; (3) support by government to educate the public on stroke and stroke prevention; and (4) improved public knowledge on stroke.

Conclusions

The age-adjusted stroke mortality rate in China has shown a downward trend among both urban and rural population in the past 30 years. The major influencing factors that helped in reducing stroke mortality in China included improved healthcare coverage, healthcare environment, the updated treatment options and modern medical technology.

Temporal trends in stroke incidence in South Asian, Chinese and white patients: A population based analysis

Background

Little is known about potential ethnic differences in stroke incidence. We compared incidence and time trends of ischemic stroke and primary intracerebral hemorrhage in South Asian, Chinese and white persons in a population-based study.

Methods

Population based census and administrative data analysis in the provinces of Ontario and British Columbia, Canada using validated ICD 9/ICD 10 coding for acute ischemic and hemorrhagic stroke (1997–2010).

Results

There were 3290 South Asians, 4444 Chinese and 160944 white patients with acute ischemic stroke and 535 South Asian, 1376 Chinese and 21842 white patients with intracerebral hemorrhage. South Asians were younger than whites at onset of stroke (70 vs. 74 years for ischemic and 67 vs. 71 years for hemorrhagic stroke). Age and sex adjusted ischemic stroke incidence in 2010 was 43% lower in Chinese and 63% lower in South Asian than in White patients. Age and sex adjusted intracerebral hemorrhage incidence was 18% higher in Chinese patients, and 66% lower in South Asian relative to white patients. Stroke incidence declined in all ethnic groups (relative reduction 69% in South Asians, 25% in Chinese, and 34% in white patients for ischemic stroke and for intracerebral hemorrhage, 79% for South Asians, 51% for Chinese and 30% in white patients).

Conclusion

Although stroke rates declined across all ethnic groups, these rates differed significantly by ethnicity. Further study is needed to understand mechanisms underlying the higher ischemic stroke incidence in white patients and intracerebral hemorrhage in Chinese patients.

Spanning from the West to East: An Updated Review on Endovascular Treatment of Intracranial Atherosclerotic Disease

Ischemic stroke is a major cause of morbidity and mortality, incurring significant cost. Intracranial atherosclerotic disease (ICAD) accounts for 10-15% of ischemic stroke in Western societies, but is an underlying pathology in up to 54% of ischemic strokes in Asian populations. ICAD has largely been treated with medical management, although a few studies have examined outcomes following endovascular treatment. Our objective was to summarize the major trials that have been performed thus far in regard to the endovascular treatment of ICAD and to provide direction for future management of this disease process. Systematic review of the literature from 1966 to 2015, was conducted in regard to intracranial angioplasty and stenting. Studies were analyzed from PubMed, American Heart Association and Society of Neurointerventional Surgery databases. SAMMPRIS and VISSIT are the only randomized controlled trials from which Western guidelines of intracranial stenting have been derived, which have displayed the superiority of medical management. However, pooled reviews of smaller studies and other nonrandomized trials have shown better outcomes with endovascular therapy in select patient subsets, such as intracranial vertebrobasilar stenosis or in the presence of robust collaterals. Suboptimal cases, including longer lesions, bifurcations and significant tortuosity tend to fair better with medical management. Medical management has been shown to be more efficacious with less adverse outcomes than endovascular therapy. However, the majority of studies on endovascular management included a diverse patient population without ideal selection criteria, resulting in higher adverse outcomes. Population analyses and selective utilization of endovascular therapy have shown that the treatment may be superior to other management in select patients.

Passive smoking and stroke in men and women: a national population-based case-control study in China

An association between passive smoking and stroke is unclear in China, particularly the association with hemorrhagic stroke. This study included 16205 deaths due to stroke aged ≥30 years and 16205 non-stroke controls randomly selected and frequency-matched to cases on gender and age. Smoking of spouses, defined as ≥1 cigarette per day for up to 1 year, was taken as a measure of exposure to passive smoking of subjects that was retrospectively ascertained by interviewing surviving spouses. After adjustment for variables, passive smoking increased the risk of death by 10% (odds ratio (OR), 1.10; 95% confidence interval (CI), 1.05-1.16) for all strokes, by 10% (OR, 1.10; 95% CI, 1.04-1.16) for hemorrhagic stroke, and by 12% (OR, 1.12; 95% CI, 1.03-1.23) for ischemic stroke, compared with non-exposure. This finding was highly consistent in men or women and in smokers or non-smokers, and was generally consistent among zones of China despite geographic diversity. The risk significantly increased with exposure-years and quantity of cigarettes smoked daily by spouses. This study indicated that passive smoking is associated with deaths from all-type strokes. It is highly advisable for the government to promote strong tobacco prevention and cessation programs and smoke-free environments.

Assessment of potential factors associating with costs of hospitalizing cardiovascular diseases in 141 hospitals in Guangxi, China

Background

The rising cost of healthcare is of great concern in China, as evidenced by the media features negative reports almost daily. However there are only a few studies from well-developed cities, like Beijing or Shanghai, and little is known about healthcare costs in rest of the country. In this study, we use hospitalization summary reports (HSRs) from admitted cardiovascular diseases patients in Guangxi hospitals during 2013–2016, and we investigate temporal trends of healthcare costs and associated factors.

Methods

By generalized additive model, we compute temporal trends of cost per stay (CPS), cost per day (CPD) and others. We then use generalized linear models to assess which factors associate with CPS and CPD.

Findings

Using a total of 760,000 HSRs, we find that CPS appears to be stabilized around $1040 until the middle of year 2015, before exhibiting a downward trend. Similarly, CPD exhibits similar stable pattern. Meanwhile, surgery-specific CPS showed an increase in year 2013–2014, and then stabilized. Drug costs account for over 1/3 of CPS, but they are gradually declining. Costs associated with physicians’ and nurses’ services represent less than 5% of CPS.

We found that age, sex, marital status, occupation and payment methods are significantly associated with CPS or CPD. Interestingly, we found no association between patient ethnicity and these costs. However, we did find that minority patients use more secondary hospitals than Han patients.

Interpretations

Healthcare costs in Guangxi are stable, contrary to the rise portrayed by Chinese mass media. Several factors can be associated with healthcare costs, and these may be useful for developing evidence-based policies. In particular, there is a need to encourage more Han patients to seek care in primary and secondary hospitals.

Impact of CRP gene and additional gene-smoking interaction on ischemic stroke in a Chinese Han population

AIMS

To investigate the association of C-reactive protein (CRP) gene single nucleotide polymorphisms (SNPs), additional gene-gene, and gene-smoking interaction with ischemic stroke (IS) risk.

METHODS

Logistic regression is performed to investigate association between SNPs within CRP gene and IS risk. Generalized multifactor dimensionality reduction (GMDR) was used to analyze the gene-gene and gene-smoking interaction, cross-validation consistency, the testing balanced accuracy and the sign test were calculated.

RESULTS

Logistic analysis showed that three SNPs were all associated with decreased IS risk in additive and dominant models. The IS risks were lower in carriers of homozygous mutant of rs2794521 polymorphism and heterozygous of rs3093059 and rs1205 than those with wild-type homozygotes genotype, OR (95%CI) were 0.62 (0.40-0.90), 0.68 (0.50-0.96) and 0.65 (0.46-0.97), respectively. GMDR analysis suggested a significant two-locus model (P = 0.0010) involving rs2794521 and rs3093059. We also found a significant two-locus model (P = 0.0010) involving rs2794521 and smoking. Participants with rs2794521-AG or GG and rs3093059-AG or GG genotype have the lowest IS risk, compared to participants with rs2794521-AA and rs3093059-AA genotype, OR (95%CI) was 0.4 2 (0.233-0.61). In addition, non-smokers with rs2794521-AG or GG genotype have the lowest IS risk, compared to smokers with rs2794521-AA genotype, OR (95%CI) was 0.47 (0.23-0.76).

CONCLUSIONS

We found that rs2794521, rs3093059, and rs1205 were associated with decreased IS risk; we also found that gene-gene interaction between rs2794521 and rs3093059, and gene-environment interaction between rs2794521 and smoking were associated with decreased IS risk.

Salt reduction in China: a state-of-the-art review

Objective

This study aimed to reveal the latest evidence on salt reduction initiatives in China in order to identify the contextual cost-effective interventions, as well as the barriers encountered during China’s long march to reach its population salt reduction goal.

Background

Population-based salt reduction has been considered as one of the most cost-effective strategies in the world for the prevention and control of noncommunicable diseases. China, along with its sustained economic growth, faces increasing burdens from chronic diseases such as cardiovascular and kidney diseases. With policy support and cross-sector collaboration, various salt reduction initiatives have been adopted in China in order to reduce such dietary risk, especially since the beginning of this millennium.

Methods

This study conducted structured literature reviews in both English and Chinese databases and synthesized the latest evidence on the association of salt intake and health, as well as salt intake among Chinese and population-based salt reduction strategies in China and around the world.

Findings

Dietary salt restriction has been found to contribute to the reduction of blood pressure among both the normotensives and hypertensives bringing associated reduced disease burdens and great public health benefits. With gender, ethnic, and regional variations, salt intake levels in the population in China are well above the recommended threshold and physiological need. Admittedly, excessive salt intake precipitates the high prevalence of hypertension and cardiovascular disease among the Chinese. Considering that the majority of the dietary salt is added during cooking in China, salt substitutes, salt restriction tools, and health education are the most common salt reduction initiatives with varying levels of effectiveness and acceptability among the Chinese population.

Implication

Overwhelming evidence is in support of a well-coordinated nationwide salt restriction initiative as a key public health strategy for the prevention and control of hypertension and its related diseases. Orchestrated efforts from the government, industries, academia, health professionals, and the general public are required to achieve China’s long-term goal for salt reduction.

Effects of ambient temperature on stroke hospital admissions: Results from a time-series analysis of 104,432 strokes in Guangzhou, China

BACKGROUND

Stroke is a main cause of death and public health burden in China. The evidence on the burden of different strokes attack attribute to ambient temperature in China is limited. This study aimed to show the characteristics of stroke attack and the attributable risk due to temperature based on hospital admission data in Guangzhou, one of the most developed cities in China.

MATERIAL AND METHODS

From January 1, 2013 to December 31, 2015, 104,432 stroke hospitalizations in Guangzhou residents from 67 hospitals for stroke sentinel surveillance were registered. Characteristics of hospital admissions by gender, age group, calendar year and stroke subtype were analyzed, and distributed lag non-linear models were applied to evaluate the effects of temperature on stroke attack admissions.

RESULTS

Stroke attack admissions increased from 31,851 to 36,755 through 2013 to 2015, increasing by 15.4%. An increasing trend in the risk of stroke attack with age was observed, irrespectively of stroke subtype and calendar year. People with hypertension were more likely to have an associated stroke than people without that. The effects of cold temperature on attack admissions for CBI and ICH strokes were significant. Overall, the percentages of CBI and ICH attack admissions attribute to cold temperature were 9.06% (95% CI: 1.84, 15.00) and 15.09% (95% CI: 5.86, 21.96), respectively. Besides, elderly people were more vulnerable to cold temperature than the young.

CONCLUSIONS

Measures should be taken to increase public awareness about the ill effects of cold temperature on stroke attack, and educate the public about self-protection.

Estimating the risk for atherothrombosis: are current approaches sufficient?

Atherothrombotic disease is now the leading cause of mortality in the world and there are only a few methods available to estimate risk of vascular disease. Vascular disease risk assessment methods have been developed from a variety of population based studies and the most frequently used approaches include algorithms developed by Framingham (USA), Munster (Germany), and SCORE (Europe). The field of risk estimation is dynamic and inclusion of newer factors and populations is under active consideration and methods such as discrimination and calibration are now available to evaluate the use of risk assessment tools across different world regions.

Nonoccupational Exposure to Pyrethroids and Risk of Coronary Heart Disease in the Chinese Population

Pyrethroids and the metabolites have been frequently observed in the environment. Animal data suggests that pyrethroids can induce adverse effect on the cardiovascular system but there are no human studies examining pyrethoids exposure as a risk for coronary heart disease (CHD). We analyzed three nonspecific pyrethroids metabolites in urine and studied the association with CHD risk. A total of 72 CHD patients and 136 healthy subjects were recruited in Shanxi province in China from 2013 to 2014 by matching age and gender. The median concentrations of urinary cis-CDDA (cis-3-(2,2-dichlorovinyl)-2,2-dimethyl cyclopropane carboxylic acid), trans-CDDA (trans-3-(2,2-dichlorovinyl)-2,2-dimethyl cyclopropane carboxylic acid) and 3-PBA (3-phenoxybenzoic acid) among healthy subjects were 1.03, 0.42, 0.74 μg/L respectively, while the median concentrations of the three metabolites among CHD patients were 1.93, 1.07, 1.09 μg/L respectively, significantly higher than healthy subjects. Upper tertile of urinary pyrethroid metabolites were associated with an increased risk of CHD compared with the lowest tertile (cis-CDDA: OR_T3vsT1 = 6.86, 95% CI: 2.76-17.06, p-trend = 0.000; trans-CDDA: OR_T3vsT1 = 6.94; 95% CI: 2.80-17.19; p-trend =0.000; 3-PBA: OR_T3vsT1 = 3.62; 95% CI: 1.48-8.88; p-trend = 0.009; total pyrethroid metabolites: OR_T3vsT1 = 4.55; 95% CI: 1.80-11.54; p-trend = 0.002). This study provides information on pyrethroids exposure in China and reveals a possible positive association between pyrethroids exposure and the risk of coronary heart disease.

The influence of individual socioeconomic status on the clinical outcomes in ischemic stroke patients with different neighborhood status in Shanghai, China

Objective: Socioeconomic status (SES) is being recognized as an important factor in both social and medical problems. The aim of present study is to examine the relationship between SES and ischemic stroke and investigate whether SES is a predictor of clinical outcomes among patients with different neighborhood status from Shanghai, China. Methods: A total of 471 first-ever ischemic stroke patients aged 18-80 years were enrolled in this retrospective study. The personal SES of each patient was evaluated using a summed score derived from his or her educational level, household income, occupation, and medical reimbursement rate. Clinical adverse events and all-cause mortality were analyzed to determine whether SES was a prognostic factor, its prognostic impact was then assessed based on different neighborhood status using multivariable Cox proportional hazard models after adjusting for other covariates. Results: The individual SES showed a significant positive correlation with neighborhood status (r = 0.370; P < 0.001). The incidence of clinical adverse events and mortality were significantly higher in low SES patients compared with middle and high SES patients (P = 0.001 and P = 0.037, respectively). After adjusting other risk factors and neighborhood status, Kaplan-Meier analysis showed clinical adverse events and deaths were still higher in the low SES patients (all P < 0.05). Multivariate Cox regression analysis demonstrated that both personal SES and neighborhood status are independent prognostic factors for ischemic stroke (all P < 0.05). Besides, among patients with low and middle neighborhood status, lower individual SES was significantly associated with clinical adverse events and mortality (all P < 0.05). Conclusion: Both individual SES and neighborhood status are significantly associated with the prognosis after ischemic stroke. A lower personal SES as well as poorer neighborhood status may significantly increase risk for adverse clinical outcomes among ischemic stroke patients.

Metabolic phenotyping for discovery of urinary biomarkers of diet, xenobiotics and blood pressure in the INTERMAP Study: an overview

The etiopathogenesis of cardiovascular diseases (CVDs) is multifactorial. Adverse blood pressure (BP) is a major independent risk factor for epidemic CVD affecting ~40% of the adult population worldwide and resulting in significant morbidity and mortality. Metabolic phenotyping of biological fluids has proven its application in characterizing low-molecular-weight metabolites providing novel insights into gene-environmental-gut microbiome interaction in relation to a disease state. In this review, we synthesize key results from the INTERnational study of MAcro/micronutrients and blood Pressure (INTERMAP) Study, a cross-sectional epidemiologic study of 4680 men and women aged 40-59 years from Japan, the People's Republic of China, the United Kingdom and the United States. We describe the advancements we have made regarding the following: (1) analytical techniques for high-throughput metabolic phenotyping; (2) statistical analyses for biomarker identification; (3) discovery of unique food-specific biomarkers; and (4) application of metabolome-wide association studies to gain a better understanding into the molecular mechanisms of cross-cultural and regional BP differences.

Urban and Rural Differences of Acute Cardiovascular Disease Events: A Study from the Population-Based Real-Time Surveillance System in Zhejiang, China in 2012

Zhejiang province, China, has implemented a population based, real-time surveillance system that tracks acute cardiovascular diseases (CVDs) events since 2001. This study aimed to describe the system and report CVD incidence, mortality and case-fatality between urban and rural areas in Zhejiang in 2012. The surveillance system employs a stratified random sampling method covering all permanent residents of 30 counties/districts in Zhejiang. Acute CVD events such as coronary heart disease (CHD) and stroke were defined, registered and reviewed based on the adapted MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) definitions. Data were collected from health facilities, vital registries, supplementary surveys, and additional investigations, and were checked for data quality before input in the system. We calculated the rates and compared them by gender, age and region. In 2012, the incidence, mortality and case-fatality of total acute CVD events were 367.0 (CHD 59.1, stroke 307.9), 127.1 (CHD 43.3, stroke 83.8) per 100,000 and 34.6% (CHD 73.2%, stroke 27.2%), respectively. Compared with rural areas, urban areas reported higher incidence and mortality but lower case-fatality rates for CHD (P<0.001), while lower incidence but higher mortality and case-fatality rates for stroke (P<0.001). We found significant differences on CHD and stroke epidemics between urban and rural areas in Zhejiang. Special attentions need to be given to stroke control, especially in rural areas.

The Epidemiology of Stroke in the East Asian Region: A Literature-Based Review

Stroke is a leading cause of morbidity and mortality in the developed world. Our objective was to review comparable studies of stroke incidence, prevalence, and subtypes in the East Asian region. English language epidemiologic studies of stroke published from 1984 through 2004 were identified for the East Asian region (China, Hong Kong, Taiwan, Japan, North and South Korea and the ASEAN countries). The Sudlow–Warlow criteria were modified to identify comparable studies. Stroke epidemiology is relatively well characterized in China, Taiwan, and Japan; however, little information is available for other countries. Four studies of stroke incidence, from China, Taiwan, and Japan, were identified, which reported a total of 4995 first-ever stroke events. There was an over twofold difference in the age-adjusted incidence of stroke between the Chinese Seven Cities and Okinawa study (483 vs 201 per 100 000). The 1-month case fatality rate ranged from 12·7% to 17·3%. Only one population-based study on stroke prevalence, from Taiwan, was identified: Studies show the relatively high proportion of hemorrhagic stroke (30%). Stroke epidemiology is relatively well characterized in China, Japan, and Taiwan but not in other countries in the region. More recent data are needed to monitor stroke prevention efforts and guide planning of health care resources in the region.

Influence of heart failure on the prognosis of patients with acute myocardial infarction in southwestern China

The impact of heart failure (HF) on acute myocardial infarction (AMI) in patients from southwestern China remains unclear. The present study aimed to compare in-hospital cardiovascular events, mortality and clinical therapies in AMI patients with or without HF in southwestern China. In total, 591 patients with AMI hospitalized between February 2009 and December 2012 were examined; those with a history of HF were excluded. The patients were divided into four groups according to AMI type (ST-elevated or non-ST-elevated AMI) and the presence of HF during hospitalization. Clinical characteristics, in-hospital cardiovascular events, mortality, coronary angiography and treatment were compared. Clinical therapies, specifically evidence-based drug use were analyzed in patients with HF during hospitalization, including angiotensin converting enzyme inhibitors (ACEIs) and β-blockers (BBs). AMI patients with HF had a higher frequency of co-morbidities, lower left ventricular ejection fraction, longer length of hospital stay and a greater risk of in-hospital mortality compared with AMI patients without HF. AMI patients with HF were less likely to be examined by cardiac angiography or treated with reperfusion therapy or recommended medications. AMI patients with HF co-treated with ACEIs and BBs had a significantly higher survival rate (94.4 vs. 67.5%; P<0.001) compared with untreated patients or patients treated with either ACEIs or BBs alone. Logistic regression analysis revealed that HF and cardiogenic shock in patients with AMI were the strongest predictors of in-hospital mortality. AMI patients with HF were at a higher risk of adverse outcomes. Cardiac angiography and timely standard recommended medications were associated with improved clinical outcomes.

Age, period and cohort effects on adult physical activity levels from 1991 to 2011 in China

BACKGROUND

To date no work has differentiated the effects of age, period, and cohort on physical activity (PA) among Chinese adults, while also considering biological, behavioral, economic, and environmental factors over time.

METHODS

We used data from the China Health and Nutrition Survey (CHNS) between 1991 and 2011 (20 years). The outcomes of interest are metabolic equivalent of task (MET) hours per week from work and domestic activities. Age, individual characteristics, household size, asset ownership, urbanization were included as covariates. Analyses for adult (≥20y) males (n = 29,343) and females (n = 31,094) was conducted to explicitly assess differences in PA due to age vs period effects, and implicitly assess differences by cohorts due to the period-specific experiences across individuals of varying ages.

RESULTS

The mean age of the sample rose from 41.31 to 50.8 years and PA decreased from 427.75 ± 264.35 MET hours per week (MET-hr/wk) in 1991 to 245.99 ± 206.65 MET-hr/wk in 2011, with much steeper declines for women compared to men. For both genders, we found non-linear decreases in PA with age over time. Controlling for age effects, negative period effects on PA were observed in each survey year, and were substantial from 1993 to 2000 for males and from 1993 to 2011 for females. The interaction between survey year and age (P < 0.05) were observed from 2004 to 2011. Higher community urbanicity, vehicle ownership, TV and computer ownership, overweight and obese, higher education served as negative predictors. Bicycle ownership, bigger household size, non-professional jobs, being married and having more children (for women) were positive predictors of PA (P < 0.05). Furthermore, at any given age, individuals who were younger at baseline had higher mean PA compared with individuals older at baseline.

CONCLUSION

This study followed a large cohort of adults over a significant portion of their lives. Strong age and secular trends were observed, resulting in an increasing number of participants who have or are likely to lower their PA levels. These trends suggest that tackling the rapid PA decline among its population is of high priority for China's public health outlook as its population ages and continues to experience significant economic and environmental changes.

Association between plasma PCSK9 levels and 10-year progression of carotid atherosclerosis beyond LDL-C: A cohort study

BACKGROUND

To evaluate the association of plasma proprotein convertase subtilisin/kexin type 9 (PCSK9) levels with the progression of carotid atherosclerosis and identify additional PCSK9-lipoprotein-atherosclerosis pathway beyond low-density lipoprotein cholesterol (LDL-C).

METHODS

Among 643 participants (aged from 45 to 74years) free of cardiovascular disease at baseline, carotid ultrasound examinations were performed in 2002 (baseline) and 2012 (follow-up). None of the participants were taking lipid-lowering drugs or had detectable carotid plaques at baseline. Carotid plaque formation and total plaque area (TPA) were used to reflect 10-year progression of atherosclerosis.

RESULTS

Baseline plasma PCSK9 levels have a wide variation, ranged from 64.60-532.20ng/mL (median: 192.57ng/mL). PCSK9 levels were significantly associated with new plaque formation after adjusting for LDL-C levels and other risk factors (relative risk for per quartile increase=1.09, 95% confidence interval: 1.03-1.15). PCSK9 levels were also linearly associated with TPA after multivariate adjustment including LDL-C (P=0.008). Among participants with the lowest or second tertile of LDL-C, PCSK9 quartiles were linearly associated with TPA (P=0.021), but the association lost significance after additional adjustment for very low-density lipoprotein cholesterol (VLDL-C) tertiles (P=0.072). Further stepwise linear regression (entry, 0.05; removal, 0.05) indicated that VLDL-C tertiles could be entered into the model but PCSK9 quartiles could not.

CONCLUSIONS

Plasma PCSK9 levels are associated with 10-year progression of atherosclerosis. The LDL-independent association of PCSK9 levels may through its ability to regulate VLDL-C levels. Further research is needed to systematically investigate the role of PCSK9 for the pathogenesis of atherosclerosis, beyond LDL-C metabolism.

Fresh Fruit Consumption and Major Cardiovascular Disease in China

BACKGROUND

In Western populations, a higher level of fruit consumption has been associated with a lower risk of cardiovascular disease, but little is known about such associations in China, where the consumption level is low and rates of stroke are high.

METHODS

Between 2004 and 2008, we recruited 512,891 adults, 30 to 79 years of age, from 10 diverse localities in China. During 3.2 million person-years of follow-up, 5173 deaths from cardiovascular disease, 2551 incident major coronary events (fatal or nonfatal), 14,579 ischemic strokes, and 3523 intracerebral hemorrhages were recorded among the 451,665 participants who did not have a history of cardiovascular disease or antihypertensive treatments at baseline. Cox regression yielded adjusted hazard ratios relating fresh fruit consumption to disease rates.

RESULTS

Overall, 18.0% of participants reported consuming fresh fruit daily. As compared with participants who never or rarely consumed fresh fruit (the "nonconsumption" category), those who ate fresh fruit daily had lower systolic blood pressure (by 4.0 mm Hg) and blood glucose levels (by 0.5 mmol per liter [9.0 mg per deciliter]) (P<0.001 for trend for both comparisons). The adjusted hazard ratios for daily consumption versus nonconsumption were 0.60 (95% confidence interval [CI], 0.54 to 0.67) for cardiovascular death, and 0.66 (95% CI, 0.58 to 0.75), 0.75 (95% CI, 0.72 to 0.79), and 0.64 (95% CI, 0.56 to 0.74), respectively, for incident major coronary events, ischemic stroke, and hemorrhagic stroke. There was a strong log-linear dose-response relationship between the incidence of each outcome and the amount of fresh fruit consumed. These associations were similar across the 10 study regions and in subgroups of participants defined by baseline characteristics.

CONCLUSIONS

Among Chinese adults, a higher level of fruit consumption was associated with lower blood pressure and blood glucose levels and, largely independent of these and other dietary and nondietary factors, with significantly lower risks of major cardiovascular diseases. (Funded by the Wellcome Trust and others.).

Cardiovascular diseases and risk factors among Chinese immigrants

The aim of this study is to identify the prevalence of cardiovascular disease (CVD) and major CVD risk factors, including diabetes, hypertension, dyslipidemia, obesity and smoking among Chinese immigrants by a systematic review of studies from various countries. PubMed and the China National Knowledge Infrastructure databases were searched for studies of the prevalence of major CVDs and risk factors, and of CVD mortality among Chinese immigrants. The search identified 386 papers, 16 of which met the inclusion criteria for this review. In mainland China, there is a pattern of high stroke prevalence but low coronary heart disease (CHD) prevalence. Among Chinese immigrants, there is a much lower prevalence and mortality of stroke, but a higher prevalence and mortality of CHD, even though these are lower than the rates in immigrants of other ethnicities in the host country. The prevalence of CVD risk factors is also markedly different in immigrants. Compared with mainland Chinese, Chinese immigrants have a higher prevalence of diabetes and hypertension, higher serum cholesterol, poorer dietary patterns, and higher prevalence of obesity and smoking. Thus, the epidemiological pattern of CVD among Chinese immigrants changes compared with resident mainland Chinese. The less healthy environmental factor after immigration may be a major trigger in the adverse CVD status of Chinese immigrants. It is important for policy-makers to pay more attention to specific minority immigrant groups, and to implement more effective preventive measures to improve the health of immigrant populations.

Stent treatment for basilar artery dissection: A single-center experience of 21 patients

Basilar artery dissection is a rare disease with high morbidity and mortality. No well-established management strategy exists for this lesion. Endovascular reconstructive therapy using stents (with or without coiling) may be the optimum strategy.We describe our center's experience for this treatment strategy in 21 patients with basilar artery dissection from January 2009 to July 2014 (17 men, four women; age range, 18-70 years; median age, 56 years). We divided patients into two groups: Group 1 patients received stent-assisted coiling treatment, and Group 2 patients received stent-only treatment. Pre-treatment, peri-operation and follow-up evaluation were investigated for complications, clinical outcome and angiographic results. The median follow-up time was 20 months (range, 3-67 months).All patients were treated endovascularly by stent-assisted coiling (14 patients) or stent only (seven patients). Immediate angiography showed: in Group 1, five of 14 lesions were completely occluded, five were partially occluded, four revealed retention of contrast media; in Group 2, all patients (seven of seven) had contrast retention. At the follow-up visit (median seven months, 3-29 months), the aneurysms were angiographically improved in five of 13 patients in Group 1 compared with immediately post-operation, while six of sevenimproved in Group 2. Five patients (all in Group 1) had ischemic or hemorrhage peri-operation complications. Long-term good clinical outcomes (modified Rankin Scale score (mRS) ≤ 2) were achieved in all patients except three death cases (two in Group1, one in Group 2).In our experience, endovascular reconstructive therapy using stents (with or without coiling) for basilar artery dissection is effective and safe. Stent-only treatment seems have a better safety profile during the peri-operation period.

Recent Trends in Hospitalization for Acute Myocardial Infarction in Beijing: Increasing Overall Burden and a Transition From ST-Segment Elevation to Non-ST-Segment Elevation Myocardial Infarction in a Population-Based Study

Comparable data on trends of hospitalization rates for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) remain unavailable in representative Asian populations.To examine the temporal trends of hospitalization for acute myocardial infarction (AMI) and its subtypes in Beijing.Patients hospitalized for AMI in Beijing from January 1, 2007 to December 31, 2012 were identified from the validated Hospital Discharge Information System. Trends in hospitalization rates, in-hospital mortality, length of stay (LOS), and hospitalization costs were analyzed by regression models for total AMI and for STEMI and NSTEMI separately. In total, 77,943 patients were admitted for AMI in Beijing during the 6 years, among whom 67.5% were males and 62.4% had STEMI. During the period, the rate of AMI hospitalization per 100,000 population increased by 31.2% (from 55.8 to 73.3 per 100,000 population) after age standardization, with a slight decrease in STEMI but a 3-fold increase in NSTEMI. The ratio of STEMI to NSTEMI decreased dramatically from 6.5:1.0 to 1.3:1.0. The age-standardized in-hospital mortality decreased from 11.2% to 8.6%, with a significant decreasing trend evident for STEMI in males and females (P < 0.001) and for NSTEMI in males (P = 0.02). The rate of percutaneous coronary intervention increased from 28.7% to 55.6% among STEMI patients. The total cost for AMI hospitalization increased by 56.8% after adjusting for inflation, although the LOS decreased by 1 day.The hospitalization burden for AMI has been increasing in Beijing with a transition from STEMI to NSTEMI. Diverse temporal trends in AMI subtypes from the unselected "real-world" data in Beijing may help to guide the management of AMI in China and other developing countries.

Qingdao Port Cardiovascular Health Study: a prospective cohort study

PURPOSE

In China, efforts are underway to respond to rapidly increasing rates of heart disease and stroke. Yet the epidemiology of cardiovascular disease in China may be different from that of other populations. Thus, there is a critical need for population-based studies that provide insight into the risk factors, incidence and outcomes of cardiovascular disease in China. The Qingdao Port Cardiovascular Health Study is designed to investigate the burden of cardiovascular disease and the sociodemographic, biological, environmental and clinical risk factors associated with disease onset and outcomes.

PARTICIPANTS

For this study, from 2000 through 2013, 32,404 employees aged 18 years or older were recruited from the Qingdao Port Group in China, contributing 221,923 annual health assessments. The mean age at recruitment was 43.4 (SD=12.9); 79% were male. In this ongoing study, annual health assessments, governed by extensive quality control mechanisms, include a questionnaire (capturing demographic and employment information, medical history, medication use, health behaviours and health outcomes), physical examination, ECG, and blood and urine analysis. Additional non-annual assessments include an X-ray, echocardiogram and carotid ultrasound; bio-samples will be collected for future genetic and proteomic analyses. Cardiovascular outcomes are accessed via self-report and are actively being verified with medical insurance claims; efforts are underway to adjudicate outcomes with hospital medical records.

FINDINGS TO DATE

Early findings reveal a significant increase in cardiovascular risk factors from 2000 to 2010 (hypertension: 26.4-39.4%; diabetes: 3.3-8.9%; hyperlipidaemia: 5.0-33.6%; body mass index >28 m/kg(2): 14.1-18.6%).

FUTURE PLANS

We aim to generate novel insights about the epidemiology and outcomes of cardiovascular disease in China, with specific emphasis on the potentially unique risk factor profiles of this Chinese population. Knowledge generated will be disseminated in the peer-reviewed literature, and will inform population-based strategies to improve cardiovascular health in China.

TRIAL REGISTRATION NUMBER

NCT02329886.

The High Prevalence of Low HDL-Cholesterol Levels and Dyslipidemia in Rural Populations in Northwestern China

BACKGROUND

Dyslipidemia is a major health problem in China and an important modifiable cardiovascular disease (CVD) risk factor. This study aimed to describe the prevalence of dyslipidemia and low high density lipoprotein cholesterol (HDL-cholesterol) and associated risk factors among adults in rural northwest China.

METHODS

In a cross-sectional analyses involving 2,980 adults aged >18 years, information on the demographics, cigarette smoking, alcohol consumption, education, and medical history was collected via face-to-face interviews. Blood samples were collected to determine total cholesterol (TC), low-density lipoprotein cholesterol (LDL-cholesterol), and HDL-cholesterol, and triglycerides (TG) levels.

RESULTS

The prevalence of high TC, high LDL-cholesterol, low HDL-cholesterol, and high TG were 1.0%, 0.6%, 60.9%, and 13.7%, respectively. TC, LDL-cholesterol, and TG increased with age in females. Elevated TC was more common in females than in males. The prevalence of low HDL-cholesterol was 67.6% in males and 55.4% in females. Current smokers, those with less education, those who were overweight or obese, and those with large waist circumference were more likely to have low HDL-cholesterol (p<0.05). Multivariable regression showed that male gender showed an association with low HDL-cholesterol (OR 2.10, 95%CI 1.68-2.61), age ≥60 years (OR 0.80, 95% CI 0.64-0.99), BMI (BMI = 24-27.9, OR 1.27, 95%CI 1.04-1.54, p = 0.02 and BMI≥28, OR 1.56, 95%CI 1.10-2.20, p = 0.01) and enlarged waist circumference (OR 2.10, 95%CI 1.51-2.92). Non-alcohol drinker was associated with low HDL-cholesterol levels (OR 0.72, 95%CI 0.53-0.99, p = 0.04).

CONCLUSIONS

This study found that the prevalence of low HDL-cholesterol was 67.6% and 55.4% for males and females. Male gender, non-alcohol drinker, BMI and central obesity were important risk factors for low HDL-cholesterol in Chinese adults.

Association between NINJ2 gene polymorphisms and ischemic stroke: a family-based case-control study

Novel susceptibility genes related to ischemic stroke (IS) are proposed in recent literatures. Population-based replicate studies would cause false positive results due to population stratification. 229 recruit IS patients and their 229 non-IS siblings were used in this study to avoid population stratification. The family-based study was conducted in Beijing from June 2005 to June 2012. Association between SNPs and IS was found in the sibship discordant tests, and the conditional logistic regression was performed to identify effect size and explore gene-environment interactions. Significant allelic association was identified between NINJ2 gene rs11833579 (P = 0.008), protein kinase C η gene rs2230501 (P = 0.039) and IS. The AA genotype of rs11833579 increased 1.51-fold risk (95% CI 1.04-3.46; P = 0.043) of IS, and it conferred susceptibility to IS only in a dominant model (OR 2.69; 95% CI 1.06-6.78; P = 0.036]. Risk of IS was higher (HR 3.58; 95% CI 1.54-8.31; P = 0.003) especially when the carriers of rs11833579 AA genotype were smokers. The present study suggests A allele of rs11833579 may play a role in mediating susceptibility to IS and it may increase the risk of IS together with smoking.

Risk Factors for Ischemic Stroke and its Subtypes in Chinese vs. Caucasians: Systematic Review and Meta-Analysis

Background

Chinese populations are reported to have a different distribution of ischemic stroke subtypes compared with Caucasians.

Aims

To understand this better, we aimed to evaluate the differences in prevalence of risk factors in ischemic stroke and their distributions among ischemic stroke subtypes in Chinese vs. Caucasians.

Summary or review

We systematically sought studies conducted since 1990 with data on frequency of risk factors among ischemic stroke subtypes in Chinese or Caucasians. For each risk factor, we calculated study-specific and random effects pooled estimates in Chinese and Caucasians separately for: prevalence among ischemic stroke; odds ratios, comparing prevalence for each ischemic stroke subtype vs. all others. We included seven studies among 16 199 Chinese, and eleven among 16 189 Caucasian ischemic stroke patients. Risk factors studied were hypertension, diabetes, atrial fibrillation, ischemic heart disease, hypercholesterolemia, smoking and alcohol. Chinese ischemic stroke patients had younger onset of stroke than Caucasians, similar prevalence of hypertension, diabetes, smoking and alcohol, and significantly lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia. Risk factor associations with ischemic stroke subtypes were mostly similar among Chinese and Caucasian ischemic stroke patients. Compared with all other ischemic subtypes, diabetes was more common in large artery stroke, atrial fibrillation and ischemic heart disease in cardioembolic stroke, and hypertension and diabetes in lacunar stroke.

Conclusion

Our study showed a lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia in Chinese, and mostly similar risk factor associations in Chinese and Caucasian ischemic stroke patients. Further analyses of individual patient data to allow adjustment for confounders are needed to confirm and extend these findings.

Associations between serum potassium and sodium levels and risk of hypertension: a community-based cohort study

Objective

Several studies have examined the relationships between dietary potassium and sodium and hypertension, but few have evaluated the association between serum potassium or sodium and risk of incident hypertension. We therefore investigated the associations between serum potassium and sodium and risk of incident hypertension in a Chinese community-based population.

Methods

A total of 839 normotensive individuals without cardiovascular disease from the Chinese Multi-Provincial Cohort Study who took part in the baseline examination in 2007–2008 and the follow-up survey in 2012–2013 were included in this study. Odds ratios (OR) and 95% confidence intervals (95%CI) for baseline serum potassium and sodium in relation to the risk of new-onset hypertension were evaluated using multivariate logistic regression models.

Results

During five years of follow-up, 218 (26.0%) individuals progressed to hypertension. Logistic regression adjusting for multiple confounders showed that every 1 mEq/L increment in baseline serum potassium level was associated with a 75% increased risk of hypertension (OR: 1.75; 95%CI: 1.01–3.04; P = 0.04). Compared with adults with serum potassium level of 4.20–4.79 mEq/L, adults with level ≥ 4.80 mEq/L had an 84% increased risk of hypertension (OR: 1.84; 95%CI: 1.14–2.96; P = 0.01). There was no significant association between serum sodium and risk of hypertension (OR: 0.96; 95%CI: 0.89–1.04; P = 0.33).

Conclusions

Baseline serum potassium level, but not baseline serum sodium level, was positively related to the risk of incident hypertension in the Chinese population.

Prevalence of post-stroke cognitive impairment in china: a community-based, cross-sectional study

International hospital-based studies have indicated a high risk of cognitive impairment after stroke, evidence from community-based studies in China is scarce. To determine the prevalence of post-stroke cognitive impairment (PSCI) and its subtypes in stroke survivors residing in selected rural and urban Chinese communities, we conducted a community-based, cross-sectional study in 599 patients accounting for 48% of all stroke survivors registered in the 4 communities, who had suffered confirmed strokes and had undergone cognitive assessments via the Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), and Hachinski Ischemia Scale (HIS). Detection of PSCI was based on scores in these neuropsychological scales. Factors potentially impacting on occurrence of PSCI were explored by comparing demographic characteristics, stroke features, and cardiovascular risk factors between patients with and without PSCI. The overall prevalence of PSCI was 80.97% (95%CI: 77.82%-84.11%), while that of non-dementia PSCI (PSCI-ND) and post-stroke vascular dementia (PSD) was 48.91% (95%CI: 44.91%-52.92%) and 32.05% (95%CI: 28.32%-35.79%), respectively. Prior stroke and complications during the acute phase were independent risk factors for PSCI. The risk of recurrent stroke survivors having PSCI was 2.7 times higher than for first-episode survivors, and it was 3 times higher for those with complications during the acute phase than for those without. The higher prevalence of PSCI in this study compared with previous Chinese studies was possibly due to the combined effects of including rural stroke survivors, a longer period from stroke onset, and different assessment methods. There is an urgent need to recognize and prevent PSCI in stroke patients, especially those with recurrent stroke and complications during the acute phase.

Establishment of Population-Based Stroke Registry in Ludhiana City, Northwest India: Feasibility and Methodology

Background/Aims: The Indian Council of Medical Research (ICMR) initiated the Task Force Project to evaluate the feasibility of conducting a population-based stroke registry in Ludhiana city, Punjab, Northwest India. Methods: All first-ever, stroke patients over 18 years from the city of Ludhiana were included in the study from March 26th 2010 to March 25th 2011. Stroke information was collected based on the WHO STEPS approach from the participating hospitals, scan centres and doctors. Modified Rankin Scale (mRS) was administered by telephonic interview at 28 days after stroke. The information on stroke deaths was obtained from the Municipal Corporation (MC) office. Results: A total of 905 first-ever stroke patients were documented. After excluding duplicate cases and patients from outside the city, 493 patients were included. The practical issues identified in data collection from these centres were reluctance to take informed consent, lack of willingness to share the data, difficulty to identify key persons from each centre, retrieving medical records from public hospitals and poor documentation of deaths in MC office. Conclusion: Population-based stroke registry was feasible in an urban population with the above methodology. The issues related to feasibility were identified and necessary changes were made for the main phase of the registry.

High prevalence of dyslipidemia and associated risk factors among rural Chinese adults

BACKGROUND

Dyslipidemia is a key independent modifiable risk factor for Cardiovascular Disease, which is a leading contributor to morbidity and mortality in most developed and developing countries. This study was designed to investigate the current epidemiological features of dyslipidemia among adults in rural China.

METHODS

Between January 2013 and August 2013, we conducted a cross-sectional study involving 11,956 subjects with age≥35 years in a general Chinese population. Permanent residents of the population were invited to participate in the study and the response rate was at 85.3%. Dyslipidemia was identified based on serum lipids levels following the standards proposed by the National Cholesterol Education Program Adult Treatment Panel III. Multivariate logistic regression analysis was used to evaluate the associated risk factors for dyslipidemia.

RESULTS

Within the study population, 16.4% had high TC, 13.8% had low HDL-C, 7.6% had high LDL-C, and 17.3% had high TG concentrations. Prevalence of lipid abnormality (including borderline dyslipidemia and dyslipidemia) was 47.8%, 13.8%, 25.7% and 30.7% for TC, HDL-C, LDL-C and TG, respectively. Detailed analysis indicated that 36.9% of this population had at least one type of dyslipidemia and 64.4% had at least one type of abnormal lipid concentration. Thus, this study observed an alarmingly higher prevalence of lipid abnormality, in a relatively large population, compared to previous studies. Further, we determined that not all of the risk factors studied, including age, gender, hypertension, diabetes mellitus, obesity, smoking, drinking, education level, marital status, and family income, influenced dyslipidemia to the same extent.

CONCLUSIONS

Our present study, in a population of 11,956 adults in Liaoning Providence, demonstrated a very high prevalence of dyslipidemia, which represented an alarming rise since the publication of our previous study and other similar studies around the world, which report lower levels. We also examined various risk factors for dyslipidemia, many of which are modifiable risk factors for Cardiovascular Disease (CVD), to provide a comprehensive view that will help in designing strategies to slow the rapid spread and promote effective measures to treat dyslipidemia. Our ultimate goal is to prevent the increasing prevalence of lipid abnormality and reduce the burden of CVD in rural China.

Evaluation of the Recognition of Stroke in the Emergency Room (ROSIER) scale in Chinese patients in Hong Kong

BACKGROUND AND PURPOSE

The objective of this study was to determine the performance of the Recognition Of Stroke In the Emergency Room (ROSIER) scale in risk-stratifying Chinese patients with suspected stroke in Hong Kong.

METHODS

This was a prospective cohort study in an urban academic emergency department (ED) over a 7-month period. Patients over 18 years of age with suspected stroke were recruited between June 2011 and December 2011. ROSIER scale assessment was performed in the ED triage area. Logistic regression analysis was used to estimate the impacts of diagnostic variables, including ROSIER scale, past history and ED characteristics.

FINDINGS

715 suspected stroke patients were recruited for assessment, of whom 371 (52%) had acute cerebrovascular disease (302 ischaemic strokes, 24 transient ischaemic attacks (TIA), 45 intracerebral haemorrhages), and 344 (48%) had other illnesses i.e. stroke mimics. Common stroke mimics were spinal neuropathy, dementia, labyrinthitis and sepsis. The suggested cut-off score of>0 for the ROSIER scale for stroke diagnosis gave a sensitivity of 87% (95%CI 83-90), a specificity of 41% (95%CI 36-47), a positive predictive value of 62% (95%CI 57-66), and a negative predictive value of 75% (95%CI 68-81), and the AUC was 0.723. The overall accuracy at cut off>0 was 65% i.e. (323+141)/715.

INTERPRETATION

The ROSIER scale was not as effective at differentiating acute stroke from stroke mimics in Chinese patients in Hong Kong as it was in the original studies, primarily due to a much lower specificity. If the ROSIER scale is to be clinically useful in Chinese suspected stroke patients, it requires further refinement.

Common variants in TGFBR2 and miR-518 genes are associated with hypertension in the Chinese population

BACKGROUND

An animal study reported that TGF-β1 maturation was linked to the homeostasis of blood pressure and elastogenesis of essential hypertension (EH). Recent advances require further research of TGF-β1 receptor in EH.

METHODS

A case-control study comprised of 2,012 adult hypertension case patients and 2,210 adult control subjects was conducted, and the association with blood pressure was further tested in children. Logistic regression and calculated genetic risk score were used to evaluate the effects of one single nucleotide polymorphism (SNP) and multiple SNPs on EH, respectively.

RESULTS

The genetic risk score of 10 SNPs showed a significant association with hypertension; the odds ratio of the upper quartile vs. the lower quartile was 1.282 (P = 4.67 × 10(-3)). rs7256241 in miR-518 was significantly associated with diastolic blood pressure (DBP) change in control subjects (P = 0.002), and this association was also observed in children (P = 0.04). The systolic blood pressure (SBP) and DBP of female patients taking reserpine were higher with the C and G alleles of rs3773661 (P = 0.004) and rs7256241 (P = 0.002), respectively. In patients taking Zhen Ju Jiang Ya tablets, SBP and DBP decreased linearly with rs749794 (P = 0.004 and P = 0.048, respectively). SBP decreased linearly with rs1155705 (P = 0.007) and rs11709624 (P = 0.04), but increased with rs1036096 (P = 0.03) in male patients. In male patients taking Jiang Ya tablets, SBP increased linearly with rs11709624 (P = 0.007), DBP increased linearly with rs1155705 (P = 0.03) whereas decreased with rs7256241 (P = 0.04).

CONCLUSIONS

Our results suggest that TGFBR2 and miR-518 harbor variants that increase the risk of EH and affect blood pressure homeostasis as well as efficacy of antihypertensive agents.

Relationship Between Alcohol Consumption and Serum Lipid Profiles Among Middle-Aged Population in China: A Multiple-Center Cardiovascular Epidemiological Study

We assessed the relationship between alcohol consumption and serum lipids in a middle-aged Chinese population. The overall prevalence of drinking among 10 154 participants was 34.07% in males and 3.61% in females. Heavy alcohol drinkers (≥ 30 g/d) tended to be older, smokers, hypertensive, do heavy physical activity, and have a lower body mass index. Levels of high-density lipoprotein cholesterol (HDL-C), apolipoprotein (apo) A1, low-density lipoprotein cholesterol-HDL-C ratio, and apo B-apo A1 ratio rose with increase in alcohol intake in males. An increase of 0.27 mmol/L in triglycerides and a decrease of 2.10 mg/dL in lipoprotein(a), Lp(a), were observed in male alcohol drinkers who consumed ≥30 g alcohol/d compared with abstainers after controlling for all confounders. Levels of total cholesterol, HDL-C, and apo A1 increased with increase in alcohol intake in both genders and Lp(a) decreased with the increase in alcohol intake in males.

Distribution and determinants of non communicable diseases among elderly Uyghur ethnic group in Xinjiang, China

Background

Non-communicable diseases (NCDs) are showing an increasing trend globally as well as in China. Elderly population are more prone to these NCDs. Situation in China is worse owing to the higher proportion of geriatric population. Burden of NCDs and the role of their socio-demographic and behavioral predictors among these elderly and more so among the ethnic minority groups among them, need to be investigated specifically, owing to their distinct genetic background, lifestyles and behavior.

Methods

A cross-sectional study was conducted among 1329 randomly selected persons of Uyghur ethnicity, aged 60 years or more in Xinjiang, the largest administrative division in China to measure the burden of NCDs, understand the distribution of socio-demographic, behavioral and life event-related potential correlates of them and to estimate the association of the NCDs with these correlates.

Results

Among these participants 54.2% were female, 86.8% were married and more than half had only attended elementary school or less. 41.46% was suffering from at least one NCD. 20.22% had one NCD, 12.11% had two and 8.58% had three or more. 27.3% had hypertension, 4.06% had diabetes, 6.02% had hyperlipidemia, 7.37% had angina, 14.52% had cardiovascular diseases, 11.59% had any kind of cancers and 9.78% had chronic obstructive pulmonary diseases. Rural residents (OR = 1.45, 95% CI: 1.17–1.80, AOR = 2.00, 95% CI: 1.53–2.61) and current smokers had higher odds of having more NCDs (AOR = 1.53, 95% CI: 1.00–2.34). Additionally not being satisfied with current life, not being able to take care of self in daily life, currently not being involved in farm work, less intake of fresh vegetables, fruits and garlic, too less or too much salt intake, not having hobbies were found to be positively associated with having more NCDs.

Conclusion

Implementation of effective intervention strategies to promote healthy life styles among the Uyghur elderly population of China seems urgent.

Protocol for a prospective, multicentre registry study of stenting for symptomatic intracranial artery stenosis in China

INTRODUCTION

The SAMMPRIS trial suggested that aggressive treatment was superior to endovascular stenting in patients with severe symptomatic intracranial atherosclerotic stenosis (ICAS) due to high complication rates in patients in the stenting group. Given that 12.2% patients failed aggressive medical therapy in the SAMMPRIS study, it is imperative to perform a multicentre prospective registry study of stenting for patients with ICAS in China. This study aims to evaluate the safety and efficacy of endovascular stenting for patients with symptomatic intracranial artery stenosis and poor collaterals in China and to identify the characteristics of the population that would benefit the most from endovascular stenting in Chinese patients.

METHODS AND ANALYSIS

This multicentre prospective registry study will involve 20 stroke centres in China, and plans to recruit 300 patients into the registry. Patients with ≥70% stenosis and symptomatic intracranial atherosclerotic disease caused by hypoperfusion combined with poor collaterals who met the inclusion criteria and exclusion criteria would be enrolled for this study. The primary outcome is the target vessel stroke event (including haemorrhagic or ischaemic stroke) or death within 30 days after stenting. The secondary outcomes include the successful recanalisation rate, the incidence of recurrent ischaemic stroke in the territory of the stented artery between 30 days and 1 year postoperatively, the restenosis rate and health-related quality of life.

ETHICS AND DISSEMINATION

The protocol is approved by the ethics committee at the coordinating centre and by the local institutional review board at each participating centre. Findings will be shared with participating hospitals, policymakers and the academic community to promote quality monitoring, quality improvement and the efficient allocation and use of cerebral catheterisation and intracranial artery stenting in China.

TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov (NCT01968122).

Development and validation of the coronary heart disease scale under the system of quality of life instruments for chronic diseases QLICD-CHD: combinations of classical test theory and Generalizability Theory

Background

Quality of life (QOL) for patients with coronary heart disease (CHD) is now concerned worldwide with the specific instruments being seldom and no one developed by the modular approach.

Objectives

This paper is aimed to develop the CHD scale of the system of Quality of Life Instruments for Chronic Diseases (QLICD-CHD) by the modular approach and validate it by both classical test theory and Generalizability Theory.

Methods

The QLICD-CHD was developed based on programmed decision procedures with multiple nominal and focus group discussions, in-depth interview, pre-testing and quantitative statistical procedures. 146 inpatients with CHD were used to provide the data measuring QOL three times before and after treatments. The psychometric properties of the scale were evaluated with respect to validity, reliability and responsiveness employing correlation analysis, factor analyses, multi-trait scaling analysis, t-tests and also G studies and D studies of Genralizability Theory analysis.

Results

Multi-trait scaling analysis, correlation and factor analyses confirmed good construct validity and criterion-related validity when using SF-36 as a criterion. The internal consistency α and test-retest reliability coefficients (Pearson r and Intra-class correlations ICC) for the overall instrument and all domains were higher than 0.70 and 0.80 respectively; The overall and all domains except for social domain had statistically significant changes after treatments with moderate effect size SRM (standardized response mea) ranging from 0.32 to 0.67. G-coefficients and index of dependability (Ф coefficients) confirmed the reliability of the scale further with more exact variance components.

Conclusions

The QLICD-CHD has good validity, reliability, and moderate responsiveness and some highlights, and can be used as the quality of life instrument for patients with CHD. However, in order to obtain better reliability, the numbers of items for social domain should be increased or the items’ quality, not quantity, should be improved.

Reduced risk of dyslipidaemia with oolong tea consumption: a population-based study in southern China

Experimental studies have suggested that tea consumption could lower the risk of dyslipidaemia. However, epidemiological evidence is limited, especially in southern China, where oolong tea is the most widely consumed beverage. We conducted a population-based case-control study to evaluate the association between consumption of tea, especially oolong tea, and risk of dyslipidaemia in Shantou, southern China, from 2010 to 2011. Information on tea consumption, lifestyle characteristics and food consumption frequency of 1651 patients with newly diagnosed dyslipidaemia and 1390 controls was obtained using a semi-quantitative questionnaire. Anthropometric variables and serum biochemical indices were determined. Drinking more than 600 ml (2 paos) of green, oolong or black tea daily was found to be associated with the lowest odds of dyslipidaemia risk (P< 0.001) when compared with non-consumption, but only oolong tea consumption was found to be associated with low HDL-cholesterol levels. A dose-response relationship between duration of tea consumption and risk of dyslipidaemia (OR 0.10, 95% CI 0.06, 0.16), as well as that between amount of dried tea leaves brewed and risk of dyslipidaemia (OR 0.34, 95% CI 0.24, 0.48), was found. Moreover, consumption of oolong tea for the longest duration was found to be associated with 3.22, 11.99 and 6.69% lower blood total cholesterol, TAG and LDL-cholesterol levels, respectively. In conclusion, the present study indicates that long-term oolong tea consumption may be associated with a lower risk of dyslipidaemia in the population of Shantou in southern China.

Population impact of a high cardiovascular risk management program delivered by village doctors in rural China: design and rationale of a large, cluster-randomized controlled trial

Background

The high-risk strategy has been proven effective in preventing cardiovascular disease; however, the population benefits from these interventions remain unknown. This study aims to assess, at the population level, the effects of an evidence-based high cardiovascular risk management program delivered by village doctors in rural China.

Methods

The study will employ a cluster-randomized controlled trial in which a total of 120 villages in five northern provinces of China, will be assigned to either intervention (60 villages) or control (60 villages). Village doctors in intervention villages will be trained to implement a simple evidence-based management program designed to identify, treat and follow-up as many as possible individuals at high-risk of cardiovascular disease in the village. The intervention will also include performance feedback as well as a performance-based incentive payment scheme and will last for 2 years. We will draw two different (independent) random samples, before and after the intervention, 20 men aged ≥ 50 years and 20 women aged ≥60 years from each village in each sample and a total of 9,600 participants from 2 samples to measure the study outcomes at the population level. The primary outcome will be the pre-post difference in mean systolic blood pressure, analyzed with a generalized estimating equations extension of linear regression model to account for cluster effect. Secondary outcomes will include monthly clinic visits, provision of lifestyle advice, use of antihypertensive medications and use of aspirin. Process and economic evaluations will also be conducted.

Discussion

This trial will be the first implementation trial in the world to evaluate the population impact of the high-risk strategy in prevention and control of cardiovascular disease. The results are expected to provide important information (effectiveness, cost-effectiveness, feasibility and acceptability) to guide policy making for rural China as well as other resource-limited countries.

Trial registration

The trial is registered at ClinicalTrials.gov (NCT01259700). Date of initial registration is December 13, 2010.

Association between serum uric acid levels and cardiovascular disease in middle-aged and elderly Chinese individuals

BACKGROUND

A link between uric acid (UA) levels and cardiovascular diseases has been previously reported. However, its importance as a risk factor is still controversial. This study sought to determine whether elevated serum uric acid levels are associated with cardiovascular disease (CVD) in middle-aged and elderly Chinese individuals.

METHODS

We conducted a population-based cross-sectional study in Shanghai, with a total of 8510 participants aged ≥40 years. The CVD included diagnosed coronary heart disease (CHD) and stroke. MetS was defined according to the updated National Cholesterol Education Program Adult Treatment Panel III criteria for Asian Americans.

RESULTS

Uric acid levels were positively associated with BMI, waist circumference, triglycerides, systolic blood pressure, diastolic blood pressure, glycohemoglobin, fasting plasma glucose, postprandial 2-hour plasma glucose (all P < 0.05), and negatively associated with HDL-cholesterol (P < 0.001). The prevalence of CVD significantly increased with increasing quartiles of UA in those without MetS group (p trend < 0.001), but not necessarily increased in those with MetS. After adjustment for metabolic syndrome and other cardiovascular risk factors, multivariate logistic regression analysis showed that odds ratios (OR) for CHD, stroke, and CVD in those in the fourth quartiles were 2.34 (95% confidence interval [CI] 1.73 to 3.45), 2.18 (95% CI 1.86 to 3.28), and 2.16 (95% CI 1.80 to 3.29), respectively, compared with those in the first quartile of UA.

CONCLUSIONS

Elevated serum uric acid level was associated with CVD, independent of conventional cardiovascular disease risk factors and metabolic syndrome.

Hypertension prevalence, awareness, treatment and control in Dakar (Senegal)

The prediction of risk profile trends associated with non-communicable diseases in developing countries is among the greatest global health challenges. The aim of this study is to estimate prevalence, awareness, treatment and control of hypertension in Dakar (Senegal). This study was carried out between January and June 2009 on a population sample of 600 individuals living in the department of Dakar. This sample was constructed using the quota method in order to strive for representativeness. Sociodemographic characteristics, hypertension, hypertension awareness, treatment and control, and body mass index of individuals were collected during face-to-face interviews. Statistical analyses used were χ2-tests and binary logistic regressions. Prevalence of hypertension was 27.50%. Prevalence of awareness, treatment and control among hypertensives were 27.88%, 16.97% and 5.45%, respectively. Logistic regression showed that the prevalence, awareness and treatment of hypertension increased with increasing age. Overweight and obese subjects were more often hypertensive but did not differ from others in awareness and treatment. This could be linked to the social valorization of stoutness in West Africa, which explains that excess weight is not perceived as a risk factor for hypertension. In conclusion, given the very low rates of awareness, treatment and control in our sample, developing strategies for averting a hypertension epidemic must be a priority objective.

Lifetime risk for cardiovascular disease in a Chinese population: the Chinese Multi-Provincial Cohort Study

BACKGROUND

Lifetime risk estimation is used to predict long-term cardiovascular disease (CVD) risk across the entire life span. However, most of the lifetime risk estimation came from the studies based on western population. This study aimed to assess the lifetime risk of CVD and the impact of risk factors on lifetime risk of CVD in Chinese population.

DESIGN

Prospective population-based cohort study.

METHODS

The study sample came from the Chinese Multi-Provincial Cohort Study (CMCS), 21,953 participants aged 35 to 84 years without CVD at the baseline were included. The modified Kaplan-Meier method was used to calculate the lifetime risk of CVD.

RESULTS AND CONCLUSIONS

During follow-up years from 1992 to 2010, 1,280 participants developed acute CVD events and 1,401 died. The lifetime CVD risk, up to age 80 for men and women at age 35, were 24.4% and 20.2% respectively. A very low lifetime risk was found in individuals with an optimal profile of risk factors which modified the effect of aging. By contrast, with two or more high risk factors the lifetime risk up to age 80 reached 51.1% for men and 38.6% for women at age 35. The integrated status of major CVD risk factors can determine lifetime cardiovascular health and CVD risk in Chinese. Early prevention with a goal of all risk factors at optimal levels should become the priority of CVD prevention in the future.

The China Patient-Centered Evaluative Assessment of Cardiac Events (China PEACE) retrospective study of acute myocardial infarction: study design

BACKGROUND

Cardiovascular diseases are rising as a cause of death and disability in China. To improve outcomes for patients with these conditions, the Chinese government, academic researchers, clinicians, and >200 hospitals have created China Patient-Centered Evaluative Assessment of Cardiac Events (China PEACE), a national network for research and performance improvement. The first study from China PEACE, the Retrospective Study of Acute Myocardial Infarction (China PEACE-Retrospective AMI Study), is designed to promote improvements in acute myocardial infarction (AMI) quality of care by generating knowledge about the characteristics, treatments, and outcomes of patients hospitalized with AMI across a representative sample of Chinese hospitals during the past decade.

METHODS AND RESULTS

The China PEACE-Retrospective AMI Study will examine >18 000 patient records from 162 hospitals identified using a 2-stage cluster sampling design within economic-geographic regions. Records were chosen from 2001, 2006, and 2011 to identify temporal trends. Data quality will be monitored by a central coordinating center and will, in particular, address case ascertainment, data abstraction, and data management. Analyses will examine patient characteristics, diagnostic testing patterns, in-hospital treatments, in-hospital outcomes, and variation in results by time and site of care. In addition to publications, data will be shared with participating hospitals and the Chinese government to develop strategies to promote quality improvement.

CONCLUSIONS

The China PEACE-Retrospective AMI Study is the first to leverage the China PEACE platform to better understand AMI across representative sites of care and during the past decade in China. The China PEACE collaboration among government, academicians, clinicians, and hospitals is poised to translate research about trends and patterns of AMI practices and outcomes into improved care for patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01624883.

Features of complementary and alternative medicine use by patients with coronary artery disease in Beijing: a cross-sectional study

Background

Complementary and alternative medicine (CAM) is commonly used in China for the management of coronary artery disease (CAD). However, few studies have been conducted to investigate the prevalence, perceived effectiveness, types, and reasons of CAM use in patients diagnosed with CAD.

Methods

A cross-sectional study design was adopted. Questionnaires were distributed at the outpatient cardiac clinics of four tertiary-level teaching general hospitals in Beijing. Quantitative data were analyzed using Student’s t-test. Categorical data were analyzed using chi-square test. Logistic regression was employed to explore factors associated with the use of CAM as well as CAM use features in Chinese medicine (CM) hospitals when significant differences were found upon comparisons.

Results

From May to July, 2009, a total of 600 questionnaires were distributed, and 546 patients with a diagnosis of CAD responded with valid values and were included in the present study. CAM was used by 69.1% of the patients with CAD; the majority (75.9%) of these CAM users believes that CAM is effective. “Few side effects” (49.6%) was the main reason of CAM use; whereas “doubt of effect” (61.5%) was the main reason for non-use. Patent herbal medicine (90.7%) was the most commonly used CAM type. Compared with non-CAM users, CAM users tended to be older (p < 0.01), have a longer disease duration (p = 0.02) and better current health status. In addition, CAM users had significant lower odds for emergency admission and hospitalization within the past one year. Patients with CAD from CM and WM hospitals differ in CAM use frequency, types, perceived effectiveness, as well as reasons for CAM use or non-CAM use.

Conclusion

The present study suggested a group of significant factors which could influence the use of CAM in patients with CAD. CAM use patterns differ in patients from CM and WM hospitals.

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.