Cardiovascular disease and risk factors in Asia: a selected review

Molecular Imaging-Guided Sonodynamic Therapy

Low-intensity ultrasound-triggered sonodynamic therapy (SDT) is a promising noninvasive therapeutic modality due to its strong tissue penetration ability. In recent years, with the development of nanotechnology, nanoparticle-based sonosensitizer-mediated SDT has been widely investigated. With the increasing demand for precise and personalized treatment, abundant novel sonosensitizers with imaging capabilities have been developed for determining the optimal therapeutic window, thus significantly enhancing treatment efficacy. In this review, we focus on the molecular imaging-guided SDT. The prevalent mechanisms of SDT are discussed, including ultrasonic cavitation, sonoluminescence, reactive oxygen species, and mechanical damage. In addition, we introduce the major molecular imaging techniques and the design principles based on nanoparticles to achieve efficient imaging. Furthermore, the imaging-guided SDT for the treatment of cancer, bacterial infections, and vascular diseases is summarized. The ultimate goal is to design more effective imaging-guided SDT modalities and provide novel ideas for clinical translation of SDT.

NPAS2 ameliorates myocardial ischaemia/reperfusion injury in rats via CX3CL1 pathways and regulating autophagy

BACKGROUND

Myocardial ischemia/reperfusion (I/R) injury is common during the treatment of cardiovascular diseases. Neuronal PAS Domain Protein 2 (NPAS2) is one of the core genes that control the rhythm of the biological clock. NPAS2 also regulates the biological rhythm.

RESULTS

The rat I/R model showed that the expression of NPAS2 decreased with the increase of reperfusion time. Overexpressing NPAS2 adenovirus (ad-NPAS2) was injected into IR rat which demonstrated that ad-NPAS2 ameliorated rats I/R injury. A hypoxia/reoxygenation (H/R) model in rat cardiomyocytes showed that ad-NPAS2 inhibited cardiomyocyte apoptosis. Co-Immunoprecipitation results showed that there is an interaction between NPAS2 and Cry2. Knockdown of Cry2 aggravated the cardiomyocyte apoptosis induced by H/R. Additionally, NPAS2 directly act on the promoter region of CX3CL1. Knockdown of CX3CL1 reverse the protective effect of ad-NPAS2 on rat myocardial ischemia-reperfusion injury and H/R-induced cardiomyocyte apoptosis. CX3CL1 also regulates autophagy through the downstream AKT/mTOR pathway.

CONCLUSIONS

research demonstrated that overexpression of NPAS2 interacts with Cry2 and promotes the transcriptional activity of CX3CL1. Moreover, overexpression of NPAS2 regulates the downstream AKT/mTOR pathway to inhibit autophagy in order to improve rat cardiac I/R injury.

Predicting mortality in cardiac care unit patients: external validation of the Mayo cardiac intensive care unit admission risk score

AIMS

The Mayo Cardiac Intensive Care Unit Admission Risk Score (M-CARS) had excellent performance in predicting in-hospital mortality in the US population. We sought to validate the M-CARS for in-hospital and post-discharge mortality in Asian patients admitted to the cardiac care unit (CCU).

METHODS AND RESULTS

Patients admitted to the CCU of a tertiary care centre between July 2015 and December 2019 were included into the study. Patients with intra-hospital transfer to the CCU due to intensive care unit overflow, postoperative cardiac surgery, or for monitoring after elective procedures were excluded. Cardiac arrest, cardiogenic shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap, and red cell distribution width, were used to calculate the M-CARS. Patients were stratified into three groups, according to the M-CARS (<2, 2-6, >6). Of 1988 patients in the study, 30.1% were female with a median age of 65 years. Prevalence of cardiogenic shock and respiratory failure at admission were 2.8% and 4.5%, respectively. One hundred and seventeen patients died during the admission (mortality rate of 5.9%). The in-hospital mortality rate in patients with M-CARS of <2, 2-6, and >6 was 1.1%, 9.8%, and 35.5%, respectively. C-statistic of M-CARS for in-hospital mortality was 0.840 (95% CI 0.805-0.873); whereas, it was 0.727 (95% CI 0.690-0.761) for 1-year post-discharge mortality. Calibration plot showed good agreement between predicted and observed in-hospital mortality in the majority of patients.

CONCLUSIONS

The M-CARS was useful in our study, in terms of discrimination and calibration. M-CARS identified high-risk patients in CCU, who had unacceptably high mortality rate during hospital stay and thereafter.

Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO-RADIAT Score

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment-related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross-validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m², estimated glomerular filtration rate <60 mL/min per 1.73 m², dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m² were included in the risk prediction model. The time-dependent C-indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment-related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO-RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision-making regarding the BC treatment.

Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO-RADIAT Score

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment-related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross-validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m2, estimated glomerular filtration rate <60 mL/min per 1.73 m2, dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m2 were included in the risk prediction model. The time-dependent C-indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment-related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO-RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision-making regarding the BC treatment.

Incidence of lower limb amputation in people with and without diabetes: a nationwide 5-year cohort study in Japan

INTRODUCTION

This study was conducted to investigate the incidence and time trend of lower limb amputation (LLA) among people with and without diabetes.

RESEARCH DESIGN AND METHODS

This retrospective population-based cohort study was based on the national claims data in Japan, comprising a total population of 150 million. Data of all individuals who had LLA from April 2013 to March 2018 were obtained. We analysed the sex-adjusted and age-adjusted annual LLA rate (every fiscal year) in people with and without diabetes for major and minor amputation. To test for time trend, Poisson regression models were fitted.

RESULTS

In the 5-year period, 30 187 major and 29 299 minor LLAs were performed in Japan. The sex-adjusted and age-adjusted incidence of major and minor LLAs was 9.5 (people with diabetes, 21.8 vs people without diabetes, 2.3, per 100 000 person-years) and 14.9 (people with diabetes, 28.4 vs people without diabetes, 1.9, per 100 000 person-years) times higher, respectively, in people with diabetes compared with those without. A significant decline in the annual major amputation rate was observed (p<0.05) and the annual minor amputation rate remained stable (p=0.63) when sex, age and people with and without diabetes were included as dependent variables.

CONCLUSIONS

This is the first report of the national statistics of LLAs in Japan. The incidence of major and minor LLAs was 10 and 15 times higher, respectively, in people with diabetes compared with those without. A significant decline in the major amputation rate was observed, and the annual minor amputation rate remained stable during the observation period. This information can help to create an effective national healthcare strategy for preventing limb amputations, which affect the quality of life of patients with diabetes and add to the national healthcare expenditure.

A Simple Model for Predicting 10-Year Cardiovascular Risk in Middle-Aged to Older Chinese: Guangzhou Biobank Cohort Study

The aim of this paper is to develop 10-year cardiovascular disease (CVD) risk prediction models for the contemporary Chinese populations based on the Guangzhou Biobank Cohort Study (GBCS) and to compare its performance with models based on Framingham's general cardiovascular risk profile and the Prediction for Atherosclerotic CVD Risk in China (China-PAR) project. Subjects were randomly classified into the training (n = 15,000) and validation (n = 12,721) sets. During an average of 12.0 years' follow-up, 3,732 CVD events occurred. A 10-year sex-specific CVD risk prediction model including age, systolic blood pressure, use of antihypertensive medication, smoking, and diabetes was developed. Compared with the Framingham and China-PAR models, the GBCS model had a better discrimination in both women (c-statistic 0.72, 95% CI 0.71-0.73) and men (c-statistic 0.68, 95% CI 0.67-0.70), and the risk predicted was closer to the actual risk. This prediction model would be useful for identifying individuals at higher risks of CVD in contemporary Chinese populations.

A review of risk prediction models in cardiovascular disease: conventional approach vs. artificial intelligent approach

Cardiovascular disease (CVD) is the leading cause of death worldwide and is a global health issue. Traditionally, statistical models are used commonly in the risk prediction and assessment of CVD. However, the adoption of artificial intelligent (AI) approach is rapidly taking hold in the current era of technology to evaluate patient risks and predict the outcome of CVD. In this review, we outline various conventional risk scores and prediction models and do a comparison with the AI approach. The strengths and limitations of both conventional and AI approaches are discussed. Besides that, biomarker discovery related to CVD are also elucidated as the biomarkers can be used in the risk stratification as well as early detection of the disease. Moreover, problems and challenges involved in current CVD studies are explored. Lastly, future prospects of CVD risk prediction and assessment in the multi-modality of big data integrative approaches are proposed.

Modifiable Risk Factors for Cardiovascular Disease in Korea and Japan

Cardiovascular disease (CVD) is the leading cause of death and a major contributor to disability worldwide. Since the majority of cardiovascular events are preventable, identification of modifiable CVD risk factors and implementation of primordial prevention strategies should be a public health priority. In this aspect, the American Heart Association declared a strategic goal to reduce total CVD mortality in the US by 20% within 10 years via eliminating 7 major CVD risk factors (hypertension, diabetes, dyslipidemia, cigarette smoking, physical inactivity, obesity, and poor-quality diet) in 2010, and their strategy has been achieving. However, the applicability of similar metrics to prevent CVD among East Asians requires an in-depth investigation of the modifiable CVD risk factors based on national and regional evidence-based findings. Herein, this review article aims to discuss several modifiable risk factors for CVDs, using epidemiological evidence from cohort studies and nationally representative data of 2 East Asian countries: Korea and Japan.

Cardiovascular outcomes with sodium-glucose cotransporter-2 inhibitors vs other glucose-lowering drugs in 13 countries across three continents: analysis of CVD-REAL data

Background

Randomized, controlled cardiovascular outcome trials may not be fully representative of the management of patients with type 2 diabetes across different geographic regions. We conducted analyses of data from the multinational CVD-REAL consortium to determine the association between initiation of sodium–glucose cotransporter-2 inhibitors (SGLT-2i) and cardiovascular outcomes, including subgroup analyses based on patient characteristics.

Methods

De-identified health records from 13 countries across three continents were used to identify patients newly-initiated on SGLT-2i or other glucose-lowering drugs (oGLDs). Propensity scores for SGLT-2i initiation were developed in each country, with 1:1 matching for oGLD initiation. In the matched groups hazard ratios (HRs) for hospitalization for heart failure (HHF), all-cause death (ACD), the composite of HHF or ACD, myocardial infarction (MI) and stroke were estimated by country, and pooled using a weighted meta-analysis. Multiple subgroup analyses were conducted across patient demographic and clinical characteristics to examine any heterogeneity in treatment effects.

Results

Following matching, 440,599 new users of SGLT-2i and oGLDs were included in each group. Mean follow-up time was 396 days for SGLT-2i initiation and 406 days for oGLDs initiation. SGLT-2i initiation was associated with a lower risk of HHF (HR: 0.66, 95%CI 0.58–0.75; p < 0.001), ACD (HR: 0.52, 95%CI 0.45–0.60; p < 0.001), the composite of HHF or ACD (HR: 0.60, 95%CI 0.53–0.68; p < 0.001), MI (HR: 0.85, 95%CI 0.78–0.92; p < 0.001), and stroke (HR: 0.78, 95%CI 0.72–0.85; p < 0.001); regardless of patient characteristics, including established cardiovascular disease, or geographic region.

Conclusions

This CVD-REAL study extends the findings from the SGLT-2i clinical trials to the broader setting of an ethnically and geographically diverse population, and across multiple subgroups.

Trial registration NCT02993614

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01345-z.

Relationship between different air pollutants and total and cause-specific emergency ambulance dispatches in Shanghai, China

OBJECTIVE

Air pollutants play a crucial role in human health and disease. Emergency ambulance dispatch data have excellent potential for public and environmental health research. This study aimed at investigating the impact of short-term exposure to air pollutants on the emergency ambulance dispatches.

METHODS

We used data on emergency ambulance dispatches in Shanghai Municipality, China, from April 1, 2016 to December 31, 2017. The association of the daily emergency ambulance dispatches with air pollutants including PM_2.5 (particles ≤ 2.5 μm in aerodynamic diameter), PM₁₀, O₃, NO₂ and SO₂ was analyzed with the use of time-series analyses.

RESULTS

A total of 310,825 emergency ambulance dispatches for acute illness occurred in Shanghai during the study period. An increase in PM_2.5 by 10 μg/m³ at lag1 and lag2 was shown to increase the risk of emergency ambulance dispatches (RR for lag1 = 1.05, 95% CI 1.00-1.11, RR for lag2 = 1.07, 95% CI 1.01-1.12). PM₁₀, NO₂, and SO₂ also showed significant associations with emergency ambulance dispatches in single-pollutant models. Cause-specific analyses showed an elevation in PM_2.5 by 10 μg/m³ was associated with an increased risk of emergency ambulance dispatches related to respiratory diseases on the current day (lag0, RR 1.17, 95% CI 1.01-1.33), while the impact on emergency ambulance dispatches related to other diseases presented 1-3 days later. The other pollutants have the similar trend.

CONCLUSIONS

Our findings show a strong relationship between ambient air pollutants and emergency ambulance dispatches. Our study contributes to the growing body of evidence describing the adverse health effects of ambient air pollution and will benefit ambulance services for early warning and effective ambulatory planning.

Case-control study of hypertension and Parkinson's disease

We evaluate the association of hypertension with PD in an Asian population and performed a meta-analysis on similar studies to address the effect of hypertension on PD risk. A matched case-control study involving 1342 Chinese subjects (671 PD and 671 age and gender-matched controls (with a mean age of 63.9 ± 9.7 and 63.5 ± 9.8 years, and identical proportion of gender distribution) was conducted. Hypertension increases PD risk by 1.9 times [OR 1.86 (1.46–2.38)]. The literature search identified 618 studies initially; however, only three matched case-control studies (all in Caucasians) met the inclusion criteria for meta-analysis. Overall analysis showed that hypertension decreases PD risk by 0.2 times [OR 0.80 (0.66–0.96)]. Hypertension increases PD risk by 1.9 times in our Asian population. However, a meta-analysis comprising of Caucasian populations showed a protective effect of hypertension suggesting that ethnic differences or other genetic or environmental factors may contribute to the divergent observation. Early diagnosis and treatment of hypertension may potentially reduce the risk of PD, at least in our population.

Place of cardiovascular risk prediction models in South Asians; agreement between Framingham risk score and WHO/ISH risk charts

INTRODUCTION AND OBJECTIVES

There are no cardiovascular risk prediction models developed in South Asian cohorts. Therefore, different risk models not validated in South Asians are being used. We aimed to compare cardiovascular risk predictions of Framingham risk score (FRS) and World Health Organization/International Society of Hypertension (WHO/ISH) charts for agreement in a sample of South Asians.

METHODS

Ten-year cardiovascular risk predictions of patients without previous cardiovascular diseases attending a non-communicable disease clinic were calculated using FRS (with BMI and with cholesterol) and WHO/ISH charts (with and without cholesterol). Patients were categorised into low (<20%) and high (≥20%) cardiovascular risk groups on risk predictions. Agreement in risk categorisation with different prediction models was compared using Cohen's kappa coefficient (κ).

RESULTS

One hundred sixty-nine patients (females 130 (81.1%)) mean age 65 ± 6.9 years were studied. Of the participants, 80 (47.3%), 62 (36.7%), 18 (10.7%), 16 (9.5%), were predicted high risk by FRS BMI-based, FRS cholesterol-based, WHO/ISH without-cholesterol and WHO/ISH with-cholesterol models, respectively. Agreement between the two FRS models (κ = 0.736, P < .0001) and the two WHO/ISH models (κ = 0.804, P < .0001) in stratifying patients into high and low-risk groups, was "good." However, the agreements between FRS BMI-based and WHO/ISH without-cholesterol models (κ = 0.234, P < .0001) and FRS cholesterol-based and WHO/ISH with-cholesterol models (κ = 0.306, P < .0001) were only "fair."

CONCLUSION

Cardiovascular risk predictions of FRS were higher than WHO/ISH charts and the agreement in risk stratification was not satisfactory in Sri Lankans. Therefore, different cardiovascular risk prediction models should not be used interchangeably in the follow-up of South Asians.

Association of self-measured home, ambulatory, and strictly measured office blood pressure and their variability with intracranial arterial stenosis

OBJECTIVE

Hypertension and intracranial artery stenosis (ICAS) are closely related; however, few studies have compared the strength of the relationship between strictly measured office and out-of-office blood pressure (BP) measurements. The relationship of day-by-day or short-term variability in BP to asymptomatic ICAS also remains unclear.

METHODS

In apparently healthy 677 men (mean age, 70 years) from a population-based cohort, we examined the association of strictly measured office BP and 7-day home BP with ICAS on magnetic resonance angiography. We conducted 24-h ambulatory BP monitoring in 468 of the men. Variability indices included day-by-day, daytime, and night-time variability, nocturnal decline, and morning pressor surge. Any ICAS was defined as either mild (1-49%) or severe (≥50%) stenosis.

RESULTS

We observed mild and severe ICAS in 153 (22.6%) and 36 (5.3%) participants, respectively. In multivariable-adjusted Poisson regression with robust error variance, higher SBP in office, home, or ambulatory BP monitoring was associated with the presence of any or severe ICAS. The associations with ICAS were comparable between office, home, and ambulatory SBP (all heterogeneity P values >0.1). Independent of mean SBP, greater nocturnal decline or morning pressor surge, but not day-by-day, daytime, or night-time variability, in SBP was associated with higher burden of any or severe ICAS.

CONCLUSION

The magnitude of association of strictly measured office BP for asymptomatic ICAS was comparable with that of BP measured at home or in ambulatory BP monitoring. Circadian BP variation based on ambulatory BP monitoring was positively associated with asymptomatic ICAS burden.

Isolated systolic hypertension and 29-year cardiovascular mortality risk in Japanese adults aged 30--49 years

OBJECTIVE

The prognostic implication of isolated systolic hypertension (ISH), defined as SBP at least 140 mmHg and DBP less than 90 mmHg, among young-to-middle-aged adults remains controversial. We examined the association of ISH with cardiovascular disease (CVD) risk in adults aged 30-49 years.

METHODS

In a prospective cohort of representative Japanese general populations from the NIPPON DATA80 (1980-2009), we studied 4776 participants (mean age, 39.4 years; 55.4% women) without clinical CVD or antihypertensive medication. Participants were classified as follows: normal blood pressure (BP) (SBP/DBP, <120/<80 mmHg), high-normal BP (120-129/<80 mmHg), elevated BP (130-139/80-89 mmHg), ISH, isolated diastolic hypertension (IDH) (<140/≥90 mmHg), and systolic--diastolic hypertension (SDH) (≥140/≥90 mmHg).

RESULTS

ISH was observed in 389 (8.1%) participants. During the 29-year follow-up, 115 participants died of CVD, 28 of coronary heart disease, and 49 of stroke. Cox proportional hazards models adjusted for demographics and CVD risk factors showed that participants with ISH had higher risk of CVD mortality than those with normal BP [hazard ratio (confidence interval), 4.10 (1.87-9.03)]. The magnitude of CVD mortality risk related to ISH was comparable with that related to IDH [3.38 (1.31-8.72)] and not as great as that related to SDH [5.41 (2.63-11.14)]. We found significant associations of ISH with coronary and stroke mortality. The association of ISH with CVD mortality was consistent across men and women and those aged 30-39 and 40-49 years.

CONCLUSION

ISH among young-to-middle-aged Japanese adults was independently associated with higher risk of CVD mortality later in life.

Prognostic value of nocturnal blood pressure dipping on cardiovascular outcomes in Chinese patients with hypertension in primary care

Meta‐analyses showed that non‐dipping of nocturnal blood pressure on ambulatory blood pressure monitoring (ABPM) was associated with adverse cardiovascular prognosis. However, these prognostic studies were mainly conducted in Caucasian and Japanese populations. Whether this association applies to Chinese patients remained uninvestigated. A total of 1199 Chinese patients with hypertension undergoing ABPM between January 2012 and December 2014 were recruited retrospectively from five public hypertension referral clinics in Hong Kong. Patients were followed up for a mean 6.42 years for cardiovascular morbidity and mortality and all‐cause mortality. Time to event of different dipping patterns was compared by Kaplan‐Meier curves. Hazard ratios (HR) were obtained by Cox proportional hazard models with patient demographics and confounding factors adjusted in multivariate regression. A total of 163 end point events occurred in the period. Normal dipping was observed in 446 patients (37.2%), non‐dipping in 490 (40.9%), reverse dipping in 161 (13.4%), and extreme dipping in 102 (8.5%). Kaplan‐Meier analyses showed inferior survival in non‐dippers and reverse dippers for total cardiovascular events and coronary events but not cerebrovascular events. After adjusting for confounding factors, Cox regressions showed HRs 1.166 (CI 0.770‐1.764) and 1.173 (CI 0.681‐2.021) in non‐dippers and reverse dippers for total cardiovascular events, and HRs 1.320 (CI 0.814‐2.141) and 1.476 (CI 0.783‐2.784) for coronary events. Nocturnal blood pressure non‐dipping, and to a greater extent reverse dipping, demonstrated adverse cardiovascular prognosis in a cohort of Chinese patients with hypertension in Hong Kong. Further focused studies on cerebrovascular events and reverse dippers were warranted to refine risk stratification.

Evidence-based oral antiplatelet therapy among hospitalized Chinese patients with acute myocardial infarction: results from the Chinese acute myocardial infarction registry

Background

Oral antiplatelet therapy is the cornerstone of treatment for acute myocardial infaction (AMI). However, detailed usage data on oral antiplatelet therapy are lacking.

Methods

Using data from a nationally representative sample of patients with AMI, the detailed usage of oral antiplatelet therapy was analyzed in 40,202 consecutive eligible patients.

Results

The proportions of patients with AMI taking loading doses of aspirin and P2Y12 inhibitors were relatively low (62.2% and 63.6%, respectively), whereas approximately 90% of patients received maintenance doses of aspirin, P2Y12 inhibitors, and dual antiplatelet therapy. The proportions of patients taking loading doses of aspirin and P2Y12 inhibitors gradually decreased with age. Male sex, an educational level of at least college, an interval from onset to treatment of < 24 h, and primary PCI use were associated with a higher proportion of patients taking a loading dose of antiplatelet therapy, whereas those receiving conservative treatment had a lower rate of antiplatelet use (all P < 0.05). The proportion of patients taking loading doses of aspirin was highest in the western region, and that of patients taking loading doses of P2Y12 inhibitors was highest in the eastern region (P < 0.05). In addition, 76.7% of patients with ST-elevation MI and 91% of patients with non-ST-elevation MI received 300-mg loading dose of clopidogrel.

Conclusions

The proportion of patients with AMI receiving loading doses of aspirin and P2Y12 inhibitors during hospitalization was relatively low, and this rate was affected by many factors, such as age, sex, educational level, region of residence, and the interval from onset to treatment. The underutilization of guideline-based P2Y12 inhibitors was also problematic. Hence, quality improvement initiatives are needed to enhance adherence to guidelines to improve consistent use of oral antiplatelet therapy.

Trial registration The Chinese Acute Myocardial Infarction Registry; Trial registration number: ChiCTR-ONC-12002636; Registered 31 October 2012; http://www.chictr.org.cn/showproj.aspx?proj=6916

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02115-1.

Current Status and Future Perspectives of Renal Denervation

Despite the availability of numerous antihypertensive medications, hypertension treatment and control rates remain low, and uncontrolled hypertension is well-known to be one of the most important cardiovascular risk factors. Endovascular catheter-based renal denervation (RDN) has been developed to be a complementary or alternative treatment option for patients who cannot take medication, poor adherence, or have resistant hypertension despite the use of maximal doses of medications. Recently, several randomized trials for evaluating the efficacy and safety of second-generation RDN devices consistently show solid evidence for their blood pressure-lowering efficacy. This review summarizes the current evidence and future perspectives of RDN.

Catheter-based renal denervation (RDN) therapy, a new procedure that uses radiofrequency ablation to interrupt efferent and afferent renal sympathetic nerve fibers, is a complementary or alternative treatment to antihypertensive medications for optimal control of blood pressure (BP). Although several single-arm early proof-of-concept studies showed significant BP reduction, the largest sham-controlled study using the first-generation RDN device (SYMPLICITY HTN-3) failed to significantly reduce BP in patients with resistant hypertension who were taking the guideline-based combination of antihypertensive medications. Since then, new devices and techniques have been developed to improve the efficacy and safety of RDN procedures. Sham-controlled trials using second-generation RDN devices (radiofrequency- and ultrasound-based) have provided solid evidence for their BP-lowering efficacy with and without the use of concomitant antihypertensive medication. Moreover, the safety profile of RDN in several registries and clinical trials appears to be excellent. This review summarizes the current evidence for RDN and discusses its current issues, future trials, Asian perspectives, and potential roles in both hypertension and other morbidities.

Validation of the World Health Organization/ International Society of Hypertension (WHO/ISH) cardiovascular risk predictions in Sri Lankans based on findings from a prospective cohort study

Introduction and objectives

There are no cardiovascular (CV) risk prediction models for Sri Lankans. Different risk prediction models not validated for Sri Lankans are being used to predict CV risk of Sri Lankans. We validated the WHO/ISH (SEAR-B) risk prediction charts prospectively in a population-based cohort of Sri Lankans.

Method

We selected 40–64 year-old participants from the Ragama Medical Officer of Health (MOH) area in 2007 by stratified random sampling and followed them up for 10 years. Ten-year risk predictions of a fatal/non-fatal cardiovascular event (CVE) in 2007 were calculated using WHO/ISH (SEAR-B) charts with and without cholesterol. The CVEs that occurred from 2007–2017 were ascertained. Risk predictions in 2007 were validated against observed CVEs in 2017.

Results

Of 2517 participants, the mean age was 53.7 year (SD: 6.7) and 1132 (45%) were males. Using WHO/ISH chart with cholesterol, the percentages of subjects with a 10-year CV risk <10%, 10–19%, 20%-29%, 30–39%, ≥40% were 80.7%, 9.9%, 3.8%, 2.5% and 3.1%, respectively. 142 non-fatal and 73 fatal CVEs were observed during follow-up. Among the cohort, 9.4% were predicted of having a CV risk ≥20% and 8.6% CVEs were observed in the risk category. CVEs were within the predictions of WHO/ISH charts with and without cholesterol in both high (≥20%) and low(<20%) risk males, but only in low(<20%) risk females. The predictions of WHO/ISH charts, with-and without-cholesterol were in agreement in 81% of subjects (ĸ = 0.429; p<0.001).

Conclusions

WHO/ISH (SEAR B) risk prediction charts with-and without-cholesterol may be used in Sri Lanka. Risk charts are more predictive in males than in females and for lower-risk categories. The predictions when stratifying into 2 categories, low risk (<20%) and high risk (≥20%), are more appropriate in clinical practice.

Familial hypercholesterolemia in Southeast and East Asia

Familial hypercholesterolemia (FH) is a relatively common autosomal dominant disorder associated with a significantly increased risk of coronary heart disease (CHD). Most (~85-90%) cases are due to pathogenic variants in the LDL-receptor gene (LDLR), while the remaining are due to pathogenic variants in the apolipoprotein B (APOB) and proprotein convertase subtilisin/kexin type 9 (PCSK9) genes, though the proportion may vary depending on geographic location. Even though at least a quarter of the world's FH population lives in Southeast and East Asia, there are substantial gaps in knowledge regarding the epidemiology of FH due to low awareness, the absence of national screening programs, and limited availability of genetic testing. In this review, we discuss the most recent and relevant information available related to diagnostic criteria, prevalence, awareness, clinical characteristics, genetic epidemiology, and treatment in the FH population of Southeast and East Asia. Increasing awareness and improving the diagnosis and management of FH will reduce the burden of premature CHD in these regions of the world.

Predicting Coronary Artery Disease in Primary Care: Development and Validation of a Diagnostic Risk Score for Major Ethnic Groups in Southeast Asia

BACKGROUND

Coronary artery disease (CAD) risk prediction tools are useful decision supports. Their clinical impact has not been evaluated amongst Asians in primary care.

OBJECTIVE

We aimed to develop and validate a diagnostic prediction model for CAD in Southeast Asians by comparing it against three existing tools.

DESIGN

We prospectively recruited patients presenting to primary care for chest pain between July 2013 and December 2016. CAD was diagnosed at tertiary institution and adjudicated. A logistic regression model was built, with validation by resampling. We validated the Duke Clinical Score (DCS), CAD Consortium Score (CCS), and Marburg Heart Score (MHS).

MAIN MEASURES

Discrimination and calibration quantify model performance, while net reclassification improvement and net benefit provide clinical insights.

KEY RESULTS

CAD prevalence was 9.5% (158 of 1658 patients). Our model included age, gender, type 2 diabetes mellitus, hypertension, smoking, chest pain type, neck radiation, Q waves, and ST-T changes. The C-statistic was 0.808 (95% CI 0.776-0.840) and 0.815 (95% CI 0.782-0.847), for model without and with ECG respectively. C-statistics for DCS, CCS-basic, CCS-clinical, and MHS were 0.795 (95% CI 0.759-0.831), 0.756 (95% CI 0.717-0.794), 0.787 (95% CI 0.752-0.823), and 0.661 (95% CI 0.621-0.701). Our model (with ECG) correctly reclassified 100% of patients when compared with DCS and CCS-clinical respectively. At 5% threshold probability, the net benefit for our model (with ECG) was 0.063. The net benefit for DCS, CCS-basic, and CCS-clinical was 0.056, 0.060, and 0.065.

CONCLUSIONS

PRECISE (Predictive Risk scorE for CAD In Southeast Asians with chEst pain) performs well and demonstrates utility as a clinical decision support for diagnosing CAD among Southeast Asians.

Impact of Age and Sex on Subclinical Coronary Atherosclerosis in a Healthy Asian Population

Background

The influence of age and sex on clinical atherosclerotic cardiovascular disease is well reported, but literature remains sparse on whether these extend to the disease in its preclinical stage.

Objectives

The purpose of this study was to report the prevalence, risk factors, and impact of age and sex on the burden of subclinical coronary atherosclerosis in a healthy Asian population.

Methods

Healthy subjects age 30 to 69 years, with no history of cardiovascular disease or diabetes were recruited from the general population. Subclinical coronary atherosclerosis was quantified via the coronary artery calcium score (CAC) with CAC of 0 indicating absence of calcified plaque, 1 to 10 minimal plaque, 11 to 100 mild plaque, and >100 moderate to severe plaque.

Results

A total of 663 individuals (mean age 49.4 ± 9.2 years; 44.8% men) were included. The prevalence of any CAC was 29.3%, with 9% having CAC >100. The prevalence was significantly higher in men than women (43.1% vs 18.0%; P < 0.001). Multivariable analysis revealed significant associations of increasing age, male sex, higher blood pressure, increased glucose levels, and higher low-density lipoprotein cholesterol levels with the presence of any CAC. Low-density lipoprotein cholesterol was more significantly associated with CAC in women compared with men (P_interaction = 0.022).

Conclusions

The prevalence of preclinical atherosclerosis increased with age, and was higher in men, with sex-specific differences in associated risk factors. These results will better inform individualized future risk management strategies to prevent the development and progression of coronary artery disease within healthy individuals.

Complications Associated With Catheter Ablation in Patients With Atrial Fibrillation: A Report From the JROAD-DPC Study

Background Aging is one of the major concerns and determinants of the indications for catheter ablation (CA) for atrial fibrillation. This study aimed to assess the safety of CA in older patients with atrial fibrillation undergoing CA. Methods and Results The JROAD-DPC (Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination) is a nationwide claims database using data from the Japanese Diagnosis Procedure Combination/Per Diem Payment System. Among 6 632 484 records found between April 2012 and March 2018 from 1058 hospitals, 135 299 patients with atrial fibrillation (aged 65±10 years, 38 952 women) who underwent CA in 456 hospitals were studied and divided into the following age groups: <60, 60 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, and ≥85 years. The overall in-hospital complication rate was 3.4% (cardiac tamponade 1.2%), and in-hospital mortality was 0.04%. Older patients had a higher prevalence of women, lower body mass index, and a higher burden of comorbidities such as hypertension, and all of those characteristics were predictors for complications in multivariate analysis. A multivariate adjusted odds ratio revealed that increased age was independently and significantly associated with overall complications (60-64 years, 1.19; 65-69 years, 1.29; 70-74 years, 1.57; 75-79 years, 1.63; 80-84 years, 1.90; and ≥85 years, 2.86; the reference was <60 years). Conclusions The nationwide JROAD-DPC database demonstrated that the frequency of complications following CA in patients with atrial fibrillation increased according to age.

Clinical and Biomarker Profiles and Prognosis of Elderly Patients With Coronavirus Disease 2019 (COVID-19) With Cardiovascular Diseases and/or Risk Factors

BACKGROUND

This study investigated the effects of age on the outcomes of coronavirus disease 2019 (COVID-19) and on cardiac biomarker profiles, especially in patients with cardiovascular diseases and/or risk factors (CVDRF).

METHODS AND RESULTS

A nationwide multicenter retrospective study included 1,518 patients with COVID-19. Of these patients, 693 with underlying CVDRF were analyzed; patients were divided into age groups (<55, 55-64, 65-79, and ≥80 years) and in-hospital mortality and age-specific clinical and cardiac biomarker profiles on admission evaluated. Overall, the mean age of patients was 68 years, 449 (64.8%) were male, and 693 (45.7%) had underlying CVDRF. Elderly (≥80 years) patients had a significantly higher risk of in-hospital mortality regardless of concomitant CVDRF than younger patients (P<0.001). Typical characteristics related to COVID-19, including symptoms and abnormal findings on baseline chest X-ray and computed tomography scans, were significantly less prevalent in the elderly group than in the younger groups. However, a significantly (P<0.001) higher proportion of elderly patients were positive for cardiac troponin (cTn), and B-type natriuretic peptide (BNP) and N-terminal pro BNP (NT-proBNP) levels on admission were significantly higher among elderly than younger patients (P<0.001 and P=0.001, respectively).

CONCLUSIONS

Elderly patients with COVID-19 had a higher risk of mortality during the hospital course, regardless of their history of CVDRF, were more likely to be cTn positive, and had significantly higher BNP/NT-proBNP levels than younger patients.

The Effect of a Persian Herbal Medicine Compound on the Lipid Profiles of Patients with Dyslipidemia: A Randomized Double-Blind Placebo-Controlled Clinical Trial

INTRODUCTION

It has been well established in the world that lipid disorders promote the development of atherosclerosis and its clinical consequences. This study aimed to assess the impacts of a Persian medicinal (PM) compound on lipid profile.

MATERIALS AND METHODS

From June 21 to October 21, 2020, a randomized double-blind controlled clinical trial was conducted with 74 dyslipidemic patients, who were randomly divided into two equally populated groups: one prescribed with a Persian medicinal herbal compound (n = 37) and a placebo group (n = 37). A Persian herbal medicine including fenugreek, sumac, and purslane is introduced. Biochemical parameters including 12-hour fasting serum levels of total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), very-low-density lipoprotein (VLDL), and triglyceride (TG) were measured before the initiation and after the completion of study protocol.

RESULTS

Percent changes of biochemical parameters include the following: intervention group = cholesterol: 35.22, Tg: 45.91, LDL: 24.81, HDL: 2.05, VLDL: 8.94 and placebo group = cholesterol: 6.94, Tg: -7.3, LDL: 7.37, HDL: 2.88, VLDL: -0.14. The serum levels of total cholesterol (p=0.01) and LDL (p=0.01) significantly decreased and no increase was recorded in HDL (p=0.03) levels over time in the intervention group. Furthermore, between-group analysis showed a statistically significant difference between the intervention and placebo groups in this regard. VLDL (p=0.2) and TG (p=0.2) levels also decreased, however not significantly.

CONCLUSION

This study showed that a Persian medicinal herbal compound could be safe and beneficial to decrease the levels of serum cholesterol and LDL in dyslipidemic patients. However, larger long-term studies are recommended to clarify this effect.

Doxorubicin and subsequent risk of cardiovascular diseases among survivors of diffuse large B-cell lymphoma in Hong Kong

Evidence regarding the dose-related impact of doxorubicin on subsequent cardiovascular diseases (CVDs) in Asian patients with diffuse large B-cell lymphoma (DLBCL) without preexisting CVDs is lacking. From a territory-wide electronic database in Hong Kong, we identified adults who were diagnosed with DLBCL and treated with chemotherapy between 2000 and 2018. We evaluated the patients for incident CVDs (including ischemic heart disease, heart failure, and cardiomyopathy). We evaluated the cause-specific cumulative incidence (csCI) of CVD with levels of doxorubicin exposure by using flexible parametric competing risk analysis and adjusting for demographics, comorbidities, therapeutic exposure, cardiovascular risk factors, and lifestyle factors. Controls were age- and sex-matched to DLBCL patients. We analyzed 2600 patients and 13 000 controls. The adjusted cause-specific hazard ratio (HR) for CVD in patients treated with >500 mg doxorubicin compared with non-doxorubicin regimens was 2.65 (95% confidence interval [CI], 1.23-5.74; P = .013). The 5-, 10-, and 15-year csCIs were 8.2%, 11.3%, and 12.8% in patients vs 3.1%, 4.4%, and 5.2% in controls, respectively. Hypertension (HR, 6.20; 95% CI, 0.79-48.44; P = .082) and use of aspirin/angiotensin-converting enzyme inhibitor/beta-blocker at baseline (HR, 2.13-4.63; P < .001 to .002) might confer a higher risk of subsequent CVDs. In this Hong Kong population-based study, doxorubicin exposure (absolute dose >500 mg), together with hypertension or baseline use of medication for cardiovascular risk factors, was found to be associated with an increase in csCIs of CVDs. Tailoring therapeutic strategies to underlying CVD risk factors and risk-adapted monitoring and follow-up of susceptible DLBCL patients are advisable.

CA.ME.LI.A. An epidemiological study on the prevalence of CArdiovascular, MEtabolic, LIver and Autoimmune diseases in Northern Italy

BACKGROUND AND AIMS

CA.ME.LI.A (CArdiovascular risks, MEtabolic syndrome, LIver and Autoimmune disease) is a cross-sectional, epidemiological study performed between 2009-2011 in Abbiategrasso (Milan, Italy) to estimate the prevalence of cardiovascular risk factors, metabolic syndrome, liver and autoimmune diseases in the general adult population. This report focuses on the description and presentation of baseline characteristics of the population.

METHODS AND RESULTS

Citizens were randomly selected from the city electoral registers (n = 30903), yielding a sample of 2554 subjects (M = 1257, F = 1297; age, 47 ± 15 yrs; range 18-77 yrs). Men had higher prevalence of overweight or obesity (60.8% vs 41.6%; p < 0.0001) and greater thickness of visceral adipose tissue (40 ± 19 vs 27 ± 17 mm; p < 0.0001); no gender difference was found in subcutaneous adipose tissue thickness. Men also showed higher levels of serum triglycerides, γ-GT, fasting blood glucose, insulin and Homa-IR Index, while HDL, CRP, and prevalence of elevated (>5.0 mg/L) CRP were lower. Compared to normal weight men, risk-ratio (RR) of CRP elevation was 1.32 (ns) in overweight and 2.68 (p < 0.0001) in obese subjects. The corresponding figures in females were 2.68 (p < 0.0001) and 5.18 (p < 0.0001). Metabolic syndrome was more frequent in men (32.7% vs 14.5%; RR: 2.24, p < 0.0001). Interadventitia common carotid artery diameter was higher in men and increased with age and BMI.

CONCLUSIONS

The present study reports on the overall characteristics of a large population from Northern Italy. It aims to identify the associations among cardiovascular risk factors to prevent their development and progression, improve healthy lifestyle and identify subjects liable to pharmacological interventions.

Do neuroticism and extraversion personality traits influence disease-specific risk factors for mortality from cancer and cardiovascular disease in a Japanese population?

OBJECTIVE

Although many reports discussing the associations between personality traits and mortality have been published internationally, those evaluating the relationships among personality, risk factors, and mortality of cancer and CVD are limited.

METHODS

In a prospective cohort study, we assessed the relationship of neuroticism and extraversion traits with mortality from cancer and cardiovascular disease (CVD) in 11,554 Japanese residents (male, n = 4995; female, n = 6559), and whether the risk factors that have been validated in the Japanese population mediated the relationship. The baseline survey was conducted between February 2004 and August 2007, and the participants were followed until the date of death or December 31, 2013.

RESULTS

Neuroticism was positively associated with risk factors for cancer and negatively associated with the risk score for CVD in both sexes. The relationship between extraversion and cancer risk factors differed depending on the factors, and a positive association between extraversion and the CVD risk score was observed only in men. Among cancer mortality, CVD mortality, and mortality due to other causes, cancer mortality showed remarkably negative association with neuroticism in women; unadjusted hazard ratio for the highest tertile versus the lowest tertile was 0.41 (95% confidence interval [CI], 0.23-0.73). While the logistic regression coefficients changed 19% after adjustment for age, it changed no more than 19% after adjustment for age and risk factors.

CONCLUSION

While neuroticism was negatively associated with cancer mortality in women, the mediating effect of the risk factors was small.

Antiplatelet regimens for Asian patients with ischemic stroke or transient ischemic attack: a systematic review and network meta-analysis

BACKGROUND

The optimal antiplatelet treatment for the secondary prevention of non-cardioembolic stroke or transient ischemic attack (TIA) remains uncertain in Asians.

METHODS

We searched for eligible randomized control trials in Medline, Embase, and the Cochrane Library. A Bayesian network meta-analysis (NMA) was performed to assess the efficacy and safety of antiplatelet regimens with placebo as the control. Each therapy was compared using relative risk ratios (RR) and 95% credible intervals (CrI), and ranked according to the value of the surface under the cumulative ranking curve.

RESULTS

A total of 84,103 patients from 32 studies were included: patients in used aspirin (n=26,834); cilostazol (n=3,303); clopidogrel (n=12,406); prasugrel (n=1,885); sarpogrelate (n=752); ticagrelor (n=1,933); ticlopidine (n=1,644); triflusal (n=391); aspirin plus cilostazol (n=1,120), aspirin plus clopidogrel (n=4,623); aspirin plus dipyridamole (n=10,853); aspirin plus ticagrelor (n=5,859); aspirin plus ticlopidine (n=132). Patients who used aspirin plus clopidogrel and cilostazol had a lower risk of recurrent stroke than those who used placebo. Patients administered with aspirin plus ticagrelor, aspirin plus clopidogrel, and cilostazol had a lower risk of composite vascular events than those administered placebo. Patients administered aspirin plus ticagrelor had a higher risk of major bleeding than those administered placebo. Clustered three-dimensional rank plots of recurrent stroke, major bleeding, and composite vascular events demonstrated that cilostazol had higher values of the surface under the cumulative ranking curve than other treatments.

CONCLUSIONS

Of the antiplatelet regimens, cilostazol showed the best net clinical benefits than other antiplatelet regimens in Asians with non-cardioembolic stroke or TIA.

Periprocedural and In-Hospital Outcomes Among Percutaneous Coronary Intervention in Saphenous Vein Graft: A Retrospective Observational Study at a Tertiary Care Hospital in South Asian Country

Background

Saphenous vein graft (SVG) may occlude either early or several months to years after coronary artery bypass graft (CABG) surgery. Doing re-do CABG surgery is associated with higher complication and mortality rate as compared to percutaneous coronary intervention (PCI) in SVG. However, PCI of SVG is associated with more periprocedural and in-hospital complications as compared to PCI of native coronary arteries. Due to the scarcity of local data in this regard, this study was designed to estimate the periprocedural and in-hospital outcomes among PCI in SVG.

Objectives

We aim to study the periprocedural and in-hospital outcomes among patients who underwent PCI in SVG.

Methods

It is a retrospective observational study. We reviewed hospital record files of 167 consecutive patients, admitted to Aga Khan University Hospital, Karachi, from January 2010 to December 2019, who underwent PCI in SVG.

Results

Out of 167 patients, 145 (86.8%) were male with a mean age of 72.26 (±8.46) years. Hypertension was the most common comorbid condition. Majority of 141(84.4%) patients presented within 6-10 years since the last CABG done. Seventy-eight (46.7%) patients presented with non-ST elevation myocardial infarction (NSTEMI). Patients who presented with acute coronary syndrome (ACS), 51 (36.9%), and 21 (15.2%) had congestive heart failure and cardiogenic shock on presentation respectively. Coronary angiography was performed in the majority of 155 (92.8%) patients through the femoral artery. The body of the SVG was the most common site affected by the disease. In 88 (52.7%) patients stents were deployed in SVG to obtuse marginal (OM). Drug-eluting stents (DES) were used in 124 (74.3%) patients. 22 (13.2%) of patients developed periprocedural complications, predominantly slow flow and 7 (4.2)% patients had in-hospital complications.

Conclusions

PCI of SVG is associated with a high procedural success rate and acceptable risk for periprocedural and in-hospital complications. PCI of SVG may be considered as a safe and efficacious option for the percutaneous intervention of SVG lesions.

Coronary lipid-rich plaque characteristics in Japanese patients with acute coronary syndrome and stable angina: A near infrared spectroscopy and intravascular ultrasound study

BACKGROUND

Asians have a much lower incidence of adverse coronary events than Caucasians. We sought to evaluate the characteristics of coronary lipid-rich plaques (LRP) in Asian patients with acute coronary syndrome (ACS) and stable angina (SA). We also aimed to identify surrogate markers for the extent of LRP.

METHODS

We evaluated 207 patients (ACS, n = 75; SA, n = 132) who underwent percutaneous coronary intervention under near infrared spectroscopy intravascular ultrasound (NIRS-IVUS). Plaque characteristics and the extent of LRP [defined as a long segment with a 4-mm maximum lipid-core burden index (maxLCBI4mm)] on NIRS in de-novo culprit and non-culprit segments were analyzed.

RESULTS

The ACS culprit lesions had a significantly higher maxLCBI4mm (median [interquartile range (IQR)]: 533 [385-745] vs. 361 [174-527], p < 0.001) than the SA culprit lesions. On multivariate logistic analysis, a large LRP (defined as maxLCBI4mm ≥ 400) was the strongest independent predictor of the ACS culprit segment (odds ratio, 3.87; 95% confidence interval, 1.95-8.02). In non-culprit segments, 19.8% of patients had at least one large LRP without a small lumen. No significant correlation was found between the extent of LRP and systematic biomarkers (hs-CRP, IL-6, TNF-α), whereas the extent of LRP was positively correlated with IVUS plaque burden (r = 0.24, p < 0.001).

CONCLUSIONS

We confirmed that NIRS-IVUS plaque assessment could be useful to differentiate ACS from SA culprit lesions, and that a threshold maxLCBI4mm ≥ 400 was clinically suitable in Japanese patients. No surrogate maker for a high-risk LRP was found; consequently, direct intravascular evaluation of plaque characteristics remains important.

Healthcare resource utilization after initiation of sodium-glucose co-transporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors or other glucose-lowering drugs in Japanese patients with type 2 diabetes

AIM

To examine healthcare resource utilization in type 2 diabetes (T2D) patients after initiation of sodium-glucose co-transporter-2 inhibitors (SGLT-2is) versus dipeptidyl peptidase-4 inhibitors (DPP-4is) or other glucose-lowering drugs (oGLDs).

MATERIALS AND METHODS

A cost-utilization analysis was performed using a nationwide hospital-based administrative claims database (Medical Data Vision) during 2014-2018 in Japan, where universal healthcare coverage is maintained under a single-payer system. Data on T2D patients initiated on either SGLT-2is or oGLDs during the study period (228 514 patients) were extracted and subjected to a 1:1 propensity score-matching analysis (7626 patient pairs for DPP-4is and 28 484 for oGLDs). Direct healthcare resource utilizations and inpatient and outpatient costs were compared.

RESULTS

After matching, baseline characteristics were well balanced, including healthcare costs within 3 and 12 months before the index date (standardized difference <5% for all variables), with a mean age of 61.6-64.1 years. While diabetes medication costs were higher in patients initiated with SGLT-2is than in those initiated with DPP-4is or oGLDs, further breakdown of individual cost components showed that SGLT-2is were associated with a lower hospitalization frequency and a shorter total hospital stay (by 213.0 or 204.6 days/100 patient-years compared with DPP-4is or oGLDs, respectively; P < .001). Accordingly, overall mean cumulative cost per patient at the 2.5-year postindex date was lower in patients with SGLT-2is than in those with DPP-4is or oGLDs by $2545 (1384.6-3759.7) and $2330 (1793.1-2882.9), respectively (P < .001).

CONCLUSIONS

Our results show the benefits in healthcare resource utilization associated with SGLT-2i use in Japanese T2D patients.

Prevention of atherosclerotic cardiovascular disease in South Asians in the US: A clinical perspective from the National Lipid Association

It is now well recognized that South Asians living in the US (SAUS) have a higher prevalence of atherosclerotic cardiovascular disease (ASCVD) that begins earlier and is more aggressive than age-matched people of other ethnicities. SA ancestry is now recognized as a risk enhancer in the US cholesterol treatment guidelines. The pathophysiology of this is not fully understood but may relate to insulin resistance, genetic and dietary factors, lack of physical exercise, visceral adiposity and other, yet undiscovered biologic mechanisms. In this expert consensus document, we review the epidemiology of ASCVD in this population, enumerate the challenges faced in tackling this problem, provide strategies for early screening and education of the community and their healthcare providers, and offer practical prevention strategies and culturally-tailored dietary advice to lower the rates of ASCVD in this cohort.

Lifetime risk of stroke stratified by chronic kidney disease and hypertension in the general Asian population: the Ohasama study

Lifetime risk (LTR) evaluates the absolute risk of developing a disease during the remainder of one's life. It can be a useful tool, enabling the general public to easily understand their risk of stroke. No study has been performed to determine the LTR of cardiovascular disease in patients with chronic kidney disease (CKD) with or without hypertension; therefore, we performed this study in an Asian population. We followed 1525 participants (66.0% women; age 63.1 years) in the general population of Ohasama, Japan. We defined CKD as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² and/or proteinuria. Hypertension was defined as a systolic/diastolic blood pressure ≥140/≥90 mmHg and/or the use of antihypertensive medication. We calculated the sex-specific LTR of stroke adjusted for the competing risk of death. During the mean follow-up period of 16.5 years, a first stroke occurred in 238 participants. The 10-year risk of stroke at the age of 45 years was 0.0% for men and women. The LTRs of stroke at the index age of 45 years (men/women) were 20.9%/14.5% for participants without CKD and hypertension, 34.1%/29.8% for those with CKD but not hypertension, 37.9%/27.3% for those with hypertension but not CKD, and 38.4%/36.4% for those with CKD and hypertension. The LTRs of stroke tended to be higher in younger participants than in older participants with CKD and/or hypertension. CKD contributed to the LTR of stroke, as did hypertension. The prevention of CKD and hypertension can reduce the LTR of stroke, especially in young populations.

An ecological study of the relationship between urban built environment and cardiovascular hospital admissions (2004-2016) in an Asian developing country

This study aims to evaluate the relationship between urban built environment and hospital admissions from cardiovascular diseases in Kuala Lumpur, Malaysia. Hospital admission data from 2004 to 2016 for cardiovascular diseases were used with patient residential postcodes as the unit of analysis. Data was split into 2004-2009 (12,551 cases) and 2010-2016 (17,154 cases) periods corresponding to land use data. We used generalized linear mixed model to analyse population density, property value, entropy index, and the kernel density (800 m) of specific land use, bus and rail stations, and road junctions, with time period and postcodes as the random effects to generate incidence rate ratios (IRRs). Results indicated that entropy index and recreational area density were associated with fewer hypertensive disease and ischemic heart disease hospital admissions (IRR range: 0.49-0.68, 95%CI: 0.27, 0.97). Population density and property value were associated with fewer cerebrovascular disease hospital admissions (IRR range: 0.29-0.34, 95%CI: 0.11, 0.75). Contrarily, density of road junctions was associated with 2.5-6.3 times more hospital admissions for cardiovascular disease hospital admissions (IRR range: 2.53-6.34, 95%CI: 1.07,17.91). There were no significant association between hospital admission and density of residential area, undeveloped land, rail and bus stations. The shapes of relationships for all attributes were non-linear, and changed markedly at the third quartile except for recreational area density. The findings suggest that land use attributes have some protective effects on the cardiovascular disease admission cases as compared to the transport attributes. These findings have important merits for integrating health into urban planning.

Compatibility between an overnight fasting and random cholesterol tests in Asians

Recent Western guidelines recommend non-fasting lipid profiles to manage dyslipidaemia. We explored its applicability to an Asian population. We determined the differences between an overnight fasting and non-fasting cholesterol profiles of patients with type-2 diabetes mellitus (T2DM) in Singapore. We studied 470 multi-ethnic Asian adult patients with T2DM and dyslipidaemia from 2 primary care clinics in Singapore. Non-fasting blood specimens were collected within 6 h after their last meal and within 14 days of a fasting specimen. The intraclass correlation coefficient (ICC) was used to compare the intraindividual lipid profiles. An ICC value > 0.75 implies good correlation. The mean age and T2DM duration of the study population were 62.5 years and 9.8 years respectively. Their mean non-fasting period was 2.46 h. The mean differences between non-fasting and fasting total cholesterol (TC), high-density lipoprotein (HDL-C), triglyceride (TG), low-density lipoprotein (LDL-C), and non HDL-C were + 0.04 mmol/l, - 0.001 mmol/l, + 0.48 mmol/l, - 0.15 mmol/l, and - 0.05 mmol/l respectively. The ICC (95% CI) for TC, HDL-C, TG, LDL-C and non-HDL-C were 0.820 (0.788-0.847), 0.873 (0.850-0.893), 0.579 (0.516-0.636), 0.764 (0.723-0.799), and 0.825 (0.794-0.852) respectively. The fasting and non-fasting lipid profiles were similar in our local Asian patients with T2DM taking statin. Their non-fasting lipid profile can be used to assess their cholesterol treatment status.

Clinical Profile and Health Disparities in a Multiethnic Cohort of Patients With Hypertrophic Cardiomyopathy

BACKGROUND

Clinical studies of hypertrophic cardiomyopathy are over-represented by individuals of European ethnicity, with less known about other ethnic groups. We investigated differences between patients in a multiethnic Australian hypertrophic cardiomyopathy population.

METHODS

We performed a retrospective cohort study of 836 unrelated hypertrophic cardiomyopathy probands attending a specialized clinic between 2002 and 2020. Major ethnic groups were European (n=611), East Asian (n=75), South Asian (n=58), and Middle Eastern and North African (n=68). The minor ethnicity groups were Oceanian (n=9), People of the Americas (n=7), and African (n=8). One-way ANOVA with Dunnett post hoc test and Bonferroni adjustment were performed.

RESULTS

Mean age of the major ethnic groups was 54.9±16.9 years, and 527 (65%) were male. Using the European group as the control, East Asian patients had a lower body mass index (29 versus 25 kg/m², P<0.0001). South Asians had a lower prevalence of atrial fibrillation (10% versus 31%, P=0.024). East Asians were more likely to have apical hypertrophy (23% versus 6%, P<0.0001) and Middle Eastern and North African patients more likely to present with left ventricular outflow tract obstruction (46% versus 34%, P=0.0003). East Asians were less likely to undergo genetic testing (55% versus 85%, P<0.0001) or have an implantable cardioverter-defibrillator implanted (19% versus 36%, P=0.037). East Asians were more likely to have a causative variant in a gene other than MYBPC3 or MYH7, whereas Middle Eastern and North African and South Asians had the highest rates of variants of uncertain significance (27% and 21%, P<0.0001).

CONCLUSIONS

There are few clinical differences based on ethnicity, but importantly, we identify health disparities relating to access to genetic testing and implantable cardioverter-defibrillator use. Unless addressed, these gaps will likely widen as we move towards precision-medicine-based care of individuals with hypertrophic cardiomyopathy.

Regional differences in office and self-measured home heart rates in Asian hypertensive patients: AsiaBP@Home study

Increased heart rate is a predictor of cardiovascular disease, heart failure, and all‐cause mortality. In those with high heart rates, interventions for heart rate reduction have been associated with reductions in coronary events. Asia is a diverse continent, and the prevalences of hypertension and cardiovascular disease differ among its countries. The present analysis of AsiaBP@Home study data investigated differences among resting heart rates (RHRs) in 1443 hypertensive patients from three Asian regions: East Asia (N = 595), Southeast Asia (N = 680), and South Asia (N = 168). This is the first study to investigate self‐measured RHR values in different Asian countries/regions using the same validated home BP monitoring device (Omron HEM‐7130‐AP/HEM‐7131‐E). Subjects in South Asia had higher RHR values compared with the other two regions, and the regional tendency found in RHR values was different from that found in BP values. Even after adjusting for age, sex, BMI, habitual alcohol consumption, current smoking habit, shift worker, hyperlipidemia, diabetes, chronic kidney disease, history of heart failure, and beta‐blocker use, both office and home RHR values in South Asia were the highest among Asia (mean values ± SE of office: East Asia [E] 75.2 ± 1.5 bpm, Southeast Asia [Se] 76.7 ± 1.5 bpm, South Asia [S] 81.9 ± 1.4 bpm; home morning: [E] 69.0 ± 1.2 bpm, [Se] 72.9 ± 1.2 bpm, [S] 74.9 ± 1.1 bpm; home evening: [E] 74.6 ± 1.2 bpm, [Se] 78.3 ± 1.2 bpm, [S] 83.8 ± 1.1 bpm). Given what is known about the impact of RHR on heart disease, our findings suggest the possible benefit of regionally tailored clinical strategies for cardiovascular disease prevention.

Changes in survival and causes of death among people living with HIV: Three decades of surveys from Tokyo, one of the Asian metropolitan cities

INTRODUCTION

Survival among people living with HIV (PLWH) has dramatically improved in the antiretroviral therapy (ART) era. This is the first study in Asia to describe three decades of surveys on survival and causes of death among PLWH.

METHODS

We included 1121 HIV-infected patients, categorized into three period groups according to date of first visit: 1986-1996 (Pre-ART); 1997-2007 (Early-ART); and 2008-2018 (Late-ART).

RESULTS

Ten-year all-cause mortality has reduced from Pre-ART (49.6/1000 person-years) to Late-ART (6.3/1000 person-years). Mortality for AIDS-defining illnesses (ADIs) has also reduced from Pre-ART (34.4/1000 person-years) to Late-ART (2.9/1000 person-years), and mortality for non-ADIs has reduced from Pre-ART (11.7/1000 person-years) to Late-ART (2.9/1000 person-years). In the ART-era, deaths from non-AIDS-defining malignancies and unnatural events including suicide represented the majority of non-ADI-related deaths and mortality rates of non-AIDS defining malignancies and unnatural cause event were not different between each group (3.4, 1.9 and 2.5/1000 person-years). Crude cumulative survival improved over the study period, and 10-year survival ratios of HIV-infected patients to the general Japanese population approached 1.00, from Pre-ART (0.66) to Late-ART (0.99). Even in the Late-ART period, survival remained lower in patients with a history of ADIs than in those without, but the difference in 5-year mortality between these groups has shrunk in the Late-ART compared to the Pre-ART.

CONCLUSIONS

Mortality for ADIs and non-ADIs in PLWH has reduced in the Early-ART and Late-ART. To improve survival for PLWH further, early HIV detection and treatment and good management of non-AIDS-defining malignancies and mental disorders are needed. (248/250).

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Impact of Chronic Kidney Disease Under Nephrology Care on Outcomes of Carotid Endarterectomy

OBJECTIVE

This study aimed to investigate the impact of chronic kidney disease (CKD) and the delivery of nephrology care on outcomes of carotid endarterectomy (CEA).

METHODS

This was a single centre, retrospective observational study. Between January 2007 and December 2014, 675 CEAs performed on 613 patients were stratified by pre-operative estimated glomerular filtration rate (eGFR) values (CKD [eGFR < 60 mL/min/1.73m²] and non-CKD [eGFR ≥ 60 mL/min/1.73m²] groups) for retrospective analysis. The study outcomes included the occurrence of major adverse cardiovascular events (MACEs), defined as fatal or non-fatal stroke, myocardial infarction, or all cause mortality, during the peri-operative period and within four years after CEA.

RESULTS

The CKD group consisted of 112 CEAs (16.6%), and the non-CKD group consisted of 563 CEAs (83.4%). The MACE incidence was higher among patients with CKD compared with non-CKD patients during the peri-operative period (4.5% vs. 1.8%; p = .086) and within four years after CEA (17.9% vs. 11.5%; p = .066), with a non-statistically significant trend. In a subgroup analysis of patients with CKD under nephrology care (63/112, 56.3%; with better controlled risk factors and tighter medical surveillance by a nephrologist), patients with CKD without nephrology care (49/112, 43.8%), and non-CKD patients, the risk of both peri-operative (4.1% vs. 0.4%; p = .037) and four year post-operative (20.4% vs. 7.3%; p = .004) all cause mortality was statistically significantly higher among patients with CKD without nephrology care compared with non-CKD patients. However, there were no statistically significant differences between patients with CKD who received nephrology care and non-CKD patients in peri-operative and four year post-operative MACE occurrence, both in terms of the composite MACE outcome and the individual MACE components.

CONCLUSION

Despite the higher risk of peri-operative and four year MACE after CEA among patients with CKD, and the statistically significantly higher peri-operative and four year post-operative all cause mortality rates among patients with CKD without nephrology care, patients with CKD under nephrology care had similar outcomes to non-CKD patients.

Severe contralateral carotid stenosis or occlusion drive 30-day risk after carotid endarterectomy

OBJECTIVES

The significant effects on the treatment of severe carotid stenosis by carotid endarterectomy have been widely recognized. However, it is controversial whether patients with severe contralateral carotid stenosis or occlusion (SCSO) can benefit from carotid endarterectomy surgery. This study aimed to estimate the SCSO effects on early outcomes after carotid endarterectomy with selective shunting.

METHODS

Between August 2011 and October 2019, a total of 617 patients who underwent carotid endarterectomy with selective shunting were analyzed. SCSO was defined as >70% luminal narrowing of the contralateral extracranial carotid stenosis or occlusion. Of these patients, 116 were categorized into an SCSO group while the rest were assigned to the non-SCSO group. Primary study outcomes were the occurrence of major adverse events, defined as stroke, all-cause mortality, and myocardial infarction during the perioperative period after carotid endarterectomy. Traditional multivariable logistic regression model and logistic regression model adjusted for propensity scores were used to estimate the SCSO effects on primary outcomes. Interaction and stratified analyses were conducted according to age, sex, comorbidities (hypertension, diabetes), preoperative neurological deficit, preoperative symptoms, and shunt use.

RESULTS

Mean age was 68.5 ± 9.2 years (86.1% men). Overall major adverse events rate within 30 days was 2.5%. Major adverse events rates in SCSO and non-SCSO groups were 9.5% and 1.6%, respectively. This difference was statistically significant (p < 0.001). In multivariable regression analysis, patients with SCSO had a higher risk of major adverse events (non-SCSO vs. SCSO: aOR 5.05 [95% CI, 1.78-14.55]). In 342 propensity score matched patients, results were consistent (propensity score: aOR, 3.78 [95% CI, 1.13-12.64]).

CONCLUSIONS

SCSO is an independent predictor of 30-day major adverse events. Whether these patients with SCSO are suitable for carotid endarterectomy should be carefully considered.

Polygenic risk score validation using Korean genomes of 265 early-onset acute myocardial infarction patients and 636 healthy controls

Background

The polygenic risk score (PRS) developed for coronary artery disease (CAD) is known to be effective for classifying patients with CAD and predicting subsequent events. However, the PRS was developed mainly based on the analysis of Caucasian genomes and has not been validated for East Asians. We aimed to evaluate the PRS in the genomes of Korean early-onset AMI patients (n = 265, age ≤50 years) following PCI and controls (n = 636) to examine whether the PRS improves risk prediction beyond conventional risk factors.

Results

The odds ratio of the PRS was 1.83 (95% confidence interval [CI]: 1.69–1.99) for early-onset AMI patients compared with the controls. For the classification of patients, the area under the curve (AUC) for the combined model with the six conventional risk factors (diabetes mellitus, family history of CAD, hypertension, body mass index, hypercholesterolemia, and current smoking) and PRS was 0.92 (95% CI: 0.90–0.94) while that for the six conventional risk factors was 0.91 (95% CI: 0.85–0.93). Although the AUC for PRS alone was 0.65 (95% CI: 0.61–0.69), adding the PRS to the six conventional risk factors significantly improved the accuracy of the prediction model (P = 0.015). Patients with the upper 50% of PRS showed a higher frequency of repeat revascularization (hazard ratio = 2.19, 95% CI: 1.47–3.26) than the others.

Conclusions

The PRS using 265 early-onset AMI genomes showed improvement in the identification of patients in the Korean population and showed potential for genomic screening in early life to complement conventional risk prediction.

Measuring Quality of Care for Ischemic Stroke Treated With Acute Reperfusion Therapy in Japan - The Close The Gap-Stroke

BACKGROUND

In Japan there is no consensus on how to efficiently measure quality indicators (QIs), defined as a standard of care, for acute ischemic stroke (AIS). Using information from a health insurance claims database and electronic medical records, we evaluated the feasibility and validity of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (IV rt-PA) or endovascular therapy (EVT).

METHODS AND RESULTS

AIS patients receiving rt-PA or EVT between 2013 and 2015 were identified. We selected 17 AIS QI measures for primary stroke centers (PSCs) and 8 for comprehensive stroke centers (CSCs). Defined QIs were calculated for each hospital and then averaged. In total, the data of 8,206 patients (rt-PA 83.7%, EVT 34.9%) from 172 hospitals were obtained. Median National Institute of Health Stroke Scale score at admission was 14, and 37.7% of the patients were functionally independent at discharge. All target QIs were successfully measured with fewer missing values, and the accuracy of preset data was about 90%. Adherence rates were low (<50%) in 5 QI measures among PSCs, including door-to-needle time ≤1 h, and in 1 QI measure among CSCs (door-to-brain and vascular imaging time ≤30 min).

CONCLUSIONS

Measuring QIs for AIS by this novel approach was feasible and reliable in the provision of a national benchmark.

Gender differences in the risk factors associated with atherosclerosis by carotid intima-media thickness, plaque score, and pulse wave velocity

Cardiovascular disease (CVD) remains the leading cause of death, but the risk factors for CVD differ between men and women. Although carotid intima-media thickness (IMT), carotid plaque, and pulse wave velocity (PWV) are useful atherosclerotic parameters, patient backgrounds have differed in previous reports. Therefore, this study aimed to investigate gender differences in associations between these three parameters and traditional risk factors in the same population. We enrolled 3888 participants (women: 743) who underwent routine health checkups. High IMT, high carotid plaque score (PS), or high brachial-ankle PWV (baPWV) were defined by the median values for each gender. We analyzed the association between each parameter and atherosclerotic risk factors, such as obesity, smoking, blood pressure (BP) elevation, impaired fasting glucose (IFG), and dyslipidemia (DL). In both sexes, BP elevation was the only common risk factor for high IMT, high PS, and high baPWV in the multivariate logistic regression analysis adjusted for age. In men, IFG and DL were common risk factors for the three parameters. Furthermore, obesity was an additional risk factor for high IMT and smoking was an additional risk factor for high IMT and high PS. In contrast, in women, obesity, DL, or IFG was an additional risk factor for high IMT, high PS, or high baPWV, respectively. The risk factors for IMT, PS, and baPWV differ in in men and women. The management for atherosclerotic risk factors on early stage should be considered in terms of gender-specific risk factors.

Cardiovascular disease history and β-blocker prescription patterns among Japanese and American patients with CKD: a cross-sectional study of the CRIC and CKD-JAC studies

Cardiovascular disease (CVD) is a major complication in individuals with chronic kidney disease (CKD). In Japan, the incidence of CVD among persons with CKD is lower than that in the United States. Although various classes of antihypertensive agents are prescribed to prevent CVD, the proportion varies between the United States and Japan. Until now, few studies have compared clinical practices and CVD prevalence among patients with CKD in the United States vs. Japan. In this study, we performed a cross-sectional comparison of the prevalence of CVD and the prescription of β-blockers at study entry to the Chronic Kidney Disease Japan Cohort (CKD-JAC) Study and the Chronic Renal Insufficiency Cohort (CRIC) Study. The mean patient age was 58.2 and 60.3 years, the mean estimated glomerular filtration rate (eGFR) was 42.8 and 28.9 (mL/min/1.73 m²), and the median urinary albumin:creatinine ratio was 51.9 and 485.9 (mg/g) among 3939 participants in the CRIC Study and 2966 participants in the CKD-JAC Study, respectively. The prevalence of any CVD according to a self-report (CRIC Study) was 33%, while that according to a medical chart review (CKD-JAC Study) was 24%. These findings were consistent across eGFR levels. Prescriptions for β-blockers differed between the CRIC and CKD-JAC Studies (49% and 20%, respectively). The odds ratios for the association of any history of CVD and β-blocker prescription were 3.0 [2.6-3.5] in the CRIC Study and 2.0 [1.6-2.5] in the CKD-JAC Study (P < 0.001 for the interaction). In conclusion, the prevalence of CVD and treatment with β-blockers were higher in the CRIC Study across eGFR levels.

Validity and reliability of an adapted questionnaire measuring knowledge, awareness and practice regarding familial hypercholesterolaemia among primary care physicians in Malaysia

BACKGROUND

Primary care physicians (PCP) play an important role in detecting Familial Hypercholesterolaemia (FH) early. However, knowledge, awareness and practice (KAP) regarding FH among Malaysian PCP are not well established, and there was no validated tool to assess their FH KAP. Thus, the aim of this study was to adapt an FH KAP questionnaire and determine its validity and reliability among Malaysian PCP.

METHODS

This cross-sectional validation study involved Malaysian PCP with ≥ 1-year work experience in the primary care settings. In Phase 1, the original 19-item FH KAP questionnaire underwent content validation and adaptation by 7 experts. The questionnaire was then converted into an online survey instrument and was face validated by 10 PCP. In Phase 2, the adapted questionnaire was disseminated through e-mail to 1500 PCP. Data were collected on their KAP, demography, qualification and work experience. The construct validity was tested using known-groups validation method. The hypothesis was PCP holding postgraduate qualification (PCP-PG-Qual) would have better FH KAP compared with PCP without postgraduate qualification (PCP-noPG-Qual). Internal consistency reliability was calculated using Kuder Richardson formula-20 (KR-20) and test-retest reliability was tested on 26 PCP using kappa statistics.

RESULTS

During content validation and adaptation, 10 items remained unchanged, 8 items were modified, 1 item was moved to demography and 7 items were added. The adapted questionnaire consisted of 25 items (11 knowledge, 5 awareness and 9 practice items). A total of 130 out of 1500 PCP (response rate: 8.7%) completed the questionnaire. The mean percentage knowledge score was found to be significantly higher in PCP-PG-Qual compared with PCP-noPG-Qual (53.5, SD ± 13.9 vs. 35.9, SD ± 11.79), t(128) = 6.90, p < 0.001. The median percentage awareness score was found to be significantly higher in PCP-PG-Qual compared with PCP-noPG-Qual (15.4, IqR ± 23.08 vs. 7.7, IqR ± 15.38), p = 0.030. The mean percentage practice score was significantly higher in PCP-PG-Qual compared with PCP-noPG-Qual (69.2, SD ± 17.62 vs. 54.4, SD ± 19.28), t(128) = 3.79, p < 0.001. KR-20 value was 0.79 (moderate reliability) and average Kappa was 0.796 (substantial agreement).

CONCLUSION

This study has proven that the 25-item adapted FH KAP questionnaire is valid and reliable. It can be used to measure and establish FH KAP among PCP in Malaysia.