Cardiovascular disease and risk factors in Asia: a selected review

LDL-cholesterol change and goal attainment following statin intensity titration among Asians in primary care: a retrospective cohort study

Background

Clinical trials have demonstrated that either initiating or up-titrating a statin dose substantially reduce Low-Density Lipoprotein-Cholesterol (LDL-C) levels. However, statin adherence in actual practice tends to be suboptimal, leading to diminished effectiveness. This study aims to use real-world data to determine the effect on LDL-C levels and LDL-C goal attainment rates, when selected statins are titrated in Asian patients.

Methods

A retrospective cohort study over a 5-year period, from April 2014 to March 2019 was conducted on a cohort of multi-ethnic adult Asian patients with clinical diagnosis of Dyslipidaemia in a primary care clinic in Singapore. The statins were classified into low-intensity (LI), moderate-intensity (MI) and high-intensity (HI) groups according to the 2018 American College of Cardiology and American Heart Association (ACC/AHA) Blood Cholesterol Guidelines. Patients were grouped into “No statin”, “Non-titrators” and “Titrators” cohorts based on prescribing patterns. For the “Titrators” cohort, the mean percentage change in LDL-C and absolute change in LDL-C goal attainment rates were computed for each permutation of statin intensity titration.

Results

Among the cohort of 11,499 patients, with a total of 266,762 visits, there were 1962 pairs of LDL-C values associated with a statin titration. Initiation of LI, MI and HI statin resulted in a lowering of LDL-C by 21.6% (95%CI = 18.9–24.3%), 28.9% (95%CI = 25.0–32.7%) and 25.2% (95%CI = 12.8–37.7%) respectively. These were comparatively lower than results from clinical trials (30 to 63%). The change of LDL-C levels due to up-titration, down-titration, and discontinuation were − 12.4% to − 28.9%, + 13.2% to + 24.6%, and + 18.1% to + 32.1% respectively. The improvement in LDL-C goal attainment ranged from 26.5% to 47.1% when statin intensity was up-titrated.

Conclusion

In this study based on real-world data of Asian patients in primary care, it was shown that although statin titration substantially affected LDL-C levels and LDL-C goal attainment rates, the magnitude was lower than results reported from clinical trials. These results should be taken into consideration and provide further insight to clinicians when making statin adjustment recommendations in order to achieve LDL-C targets in clinical practice, particularly for Asian populations.

Risk of Cardiac Disease in Patients With Breast Cancer: Impact of Patient-Specific Factors and Individual Heart Dose From Three-Dimensional Radiation Therapy Planning

PURPOSE

This retrospective cohort study aimed to determine whether adjuvant radiation therapy increases the risk of cardiac toxicity in Asian women with breast cancer, with a focus on patient-specific factors.

METHODS AND MATERIALS

We evaluated women who underwent primary breast surgery for breast cancer with (n = 520) or without (n = 774) adjuvant radiation therapy between January 2005 and May 2013. Patients who underwent breast surgery without radiation therapy were categorized as patients who received 0 Gy to the heart. The primary endpoint was the occurrence of a breast cancer treatment-related heart disease (BCT-HD), defined as a diagnosis of angina pectoris, unstable angina, myocardial infarction, ischemic heart disease, heart failure, or atrial fibrillation.

RESULTS

In total, 1294 patients were included. The overall 5- and 10-year BCT-HD rates were 2.4% and 5.7%, respectively. The risk of an BCT-HD significantly increased per 1-Gy increase in the mean heart dose (adjusted hazard ratio: 1.23). Additionally, histories of hypertension (hazard ratio: 1.92), and diabetes (hazard ratio: 2.51) were found to be adverse risk factors, whereas regular physical exercise (hazard ratio: 0.17) was a protective factor. Subgroup analysis according to risk groups showed that the effect of increasing mean heart dose (per Gy) was similar between women without or with minimal risk factors (hazard ratio: 1.23) and women with multiple risk factors (hazard ratio: 1.27).

CONCLUSIONS

The results indicate a radiation dose-effect relationship for cardiac disease in breast cancer patients, highlighting that there remains a considerable risk of cardiac toxicity even with 3-dimensional radiation therapy planning. Thus, measures to minimize the heart dose in breast cancer patients undergoing adjuvant radiation therapy, even in those without any risk factor for cardiac disease, should be routinely implemented.

Five-Year Risk of Acute Myocardial Infarction After Acute Ischemic Stroke in Korea

Background The long-term incidence of acute myocardial infarction (AMI) in patients with acute ischemic stroke (AIS) has not been well defined in large cohort studies of various race-ethnic groups. Methods and Results A prospective cohort of patients with AIS who were registered in a multicenter nationwide stroke registry (CRCS-K [Clinical Research Collaboration for Stroke in Korea] registry) was followed up for the occurrence of AMI through a linkage with the National Health Insurance Service claims database. The 5-year cumulative incidence and annual risk were estimated according to predefined demographic subgroups, stroke subtypes, a history of coronary heart disease (CHD), and known risk factors of CHD. A total of 11 720 patients with AIS were studied. The 5-year cumulative incidence of AMI was 2.0%. The annual risk was highest in the first year after the index event (1.1%), followed by a much lower annual risk in the second to fifth years (between 0.16% and 0.27%). Among subgroups, annual risk in the first year was highest in those with a history of CHD (4.1%) compared with those without a history of CHD (0.8%). The small-vessel occlusion subtype had a much lower incidence (0.8%) compared with large-vessel occlusion (2.2%) or cardioembolism (2.4%) subtypes. In the multivariable analysis, history of CHD (hazard ratio, 2.84; 95% CI, 2.01-3.93) was the strongest independent predictor of AMI after AIS. Conclusions The incidence of AMI after AIS in South Korea was relatively low and unexpectedly highest during the first year after stroke. CHD was the most substantial risk factor for AMI after stroke and conferred an approximate 5-fold greater risk.

Sodium-glucose cotransporter 2 inhibitors compared with other glucose-lowering drugs in Japan: Subanalyses of the CVD-REAL 2 Study

There are limited data on cardiovascular efficacy and safety of type 2 diabetes therapies in Japan, where treatments are characterized by lower metformin use and higher dipeptidyl peptidase-4 inhibitor (DPP4i) use versus other countries. We investigated the cardiovascular outcomes in Japanese patients with type 2 diabetes initiating sodium-glucose cotransporter 2 inhibitors (SGLT2i) matched 1:1 to patients initiating other glucose-lowering drugs (33,890 patients/group) or DPP4i (9,876 patients/group). SGLT2i initiation was associated with lower risks (hazard ratio of in-hospital death [death] 0.56, 95% confidence interval [CI] 0.47-0.67; hospitalization for heart failure 0.75, 95% CI 0.64-0.89; composite of hospitalization for heart failure or death 0.65, 95% CI 0.58-0.74 and stroke 0.66, 95% CI 0.52-0.84 versus other glucose-lowering drugs and lower risks of death 0.52, 95% CI 0.36-0.73) and composite of hospitalization for heart failure or death (0.65, 95% CI 0.51-0.83) versus DPP4i. In conclusion, SGLT2i initiators had lower risks of cardiovascular events versus other glucose-lowering drug initiators and, uniquely, versus DPP4i initiators in Japanese real-world practice.

Long-Term PM2.5 Exposure and Risks of Ischemic Heart Disease and Stroke Events: Review and Meta-Analysis

Background

Fine particulate matter <2.5 µm in diameter (PM_2.5) has known effects on cardiovascular morbidity and mortality. However, no study has quantified and compared the risks of incident myocardial infarction, incident stroke, ischemic heart disease (IHD) mortality, and cerebrovascular mortality in relation to long‐term PM_2.5 exposure.

Methods and Results

We sought to quantitatively summarize studies of long‐term PM_2.5 exposure and risk of IHD and stroke events by conducting a review and meta‐analysis of studies published by December 31, 2019. The main outcomes were myocardial infarction, stroke, IHD mortality, and cerebrovascular mortality. Random effects meta‐analyses were used to estimate the combined risk of each outcome among studies. We reviewed 69 studies and included 42 studies in the meta‐analyses. In meta‐analyses, we found that a 10‐µg/m³ increase in long‐term PM_2.5 exposure was associated with an increased risk of 23% for IHD mortality (95% CI, 15%–31%), 24% for cerebrovascular mortality (95% CI, 13%–36%), 13% for incident stroke (95% CI, 11%–15%), and 8% for incident myocardial infarction (95% CI, −1% to 18%). There were an insufficient number of studies of recurrent stroke and recurrent myocardial infarction to conduct meta‐analyses.

Conclusions

Long‐term PM_2.5 exposure is associated with increased risks of IHD mortality, cerebrovascular mortality, and incident stroke. The relationship with incident myocardial infarction is suggestive of increased risk but not conclusive. More research is needed to understand the relationship with recurrent events.

Acute decompensated heart failure in a non cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF)

Background

Data on clinical characteristics of acute decompensated heart failure (ADHF) in Malaysia especially in East Malaysia is lacking.

Methods

This is a prospective observational study in Sarawak General Hospital, Medical Department, from October 2017 to September 2018. Patients with primary admission diagnosis of ADHF were recruited and followed up for 90 days. Data on patient’s characteristics, precipitating factors, medications and short-term clinical outcomes were recorded.

Results

Majority of the patients were classified in lower socioeconomic group and the mean age was 59 years old. Hypertension, diabetes mellitus and dyslipidaemia were the common underlying comorbidities. Heart failure with ischemic aetiology was the commonest ADHF admission precipitating factor. 48.6% of patients were having preserved ejection fraction HF and the median NT-ProBNP level was 4230 pg/mL. Prescription rate of the evidence-based heart failure medication was low. The in-patient mortality and the average length of hospital stay were 7.5% and 5 days respectively. 43% of patients required either ICU care or advanced cardiopulmonary support. The 30-day, 90-day mortality and readmission rate were 13.1%, 11.2%, 16.8% and 14% respectively.

Conclusion

Comparing with the HF data from West and Asia Pacific, the short-term mortality and readmission rate were high among the ADHF patients in our study cohort. Maladaptation to evidence-based HF prescription and the higher prevalence of cardiovascular risk factors in younger patients were among the possible issues to be addressed to improve the HF outcome in regions with similar socioeconomic background.

Differences in ambulatory blood pressure profiles between Japanese and Thai patients with hypertension /suspected hypertension

Ethnic differences in the profiles of hypertension and cardiovascular risk have been reported between Asians and Westerners. However, blood pressure (BP) profiles and the risk factors for cardiovascular disease might differ even among different Asian populations because of the diversity of cultures, foods, and environments. We retrospectively examined differences in 24-h BP profiles between 1051 Japanese (mean age, 62.5 ± 12.4 years; medicated hypertension, 75.7%) and 804 Thai (mean age, 56.9 ± 18.5 years; medicated hypertension, 65.6%) by using the Japanese and Thai ambulatory BP monitoring (ABPM) databases, in order to check the BP control status in treated hypertensives and to inform the clinical diagnosis of hypertension. The two populations had similar office systolic BP (SBP) (142.7 ± 20.0 vs 142.3 ± 20.6 mm Hg, p = .679). However, the Japanese population had higher 24-hr average and daytime SBP, and the Thai population had higher nighttime SBP even after adjusting for cardiovascular risk factors (all p < .05). Greater morning BP surge was observed in Japanese (31.2 vs 22.8 mm Hg, p < .001). Regarding nocturnal BP dipping status, the prevalence of riser status (higher nighttime than daytime SBP) was higher in the Thai population (30.5% vs 10.9%). These findings suggest that a substantial difference in 24-hr BP profiles exists between even neighboring countries in Asia.

Predicting High Coronary Artery Calcium Score From Retinal Fundus Images With Deep Learning Algorithms

Purpose

To evaluate high accumulation of coronary artery calcium (CAC) from retinal fundus images with deep learning technologies as an inexpensive and radiation-free screening method.

Methods

Individuals who underwent bilateral retinal fundus imaging and CAC score (CACS) evaluation from coronary computed tomography scans on the same day were identified. With this database, performances of deep learning algorithms (inception-v3) to distinguish high CACS from CACS of 0 were evaluated at various thresholds for high CACS. Vessel-inpainted and fovea-inpainted images were also used as input to investigate areas of interest in determining CACS.

Results

A total of 44,184 images from 20,130 individuals were included. A deep learning algorithm for discrimination of no CAC from CACS >100 achieved area under receiver operating curve (AUROC) of 82.3% (79.5%–85.0%) and 83.2% (80.2%–86.3%) using unilateral and bilateral fundus images, respectively, under a 5-fold cross validation setting. AUROC increased as the criterion for high CACS was increased, showing a plateau at 100 and losing significant improvement thereafter. AUROC decreased when fovea was inpainted and decreased further when vessels were inpainted, whereas AUROC increased when bilateral images were used as input.

Conclusions

Visual patterns of retinal fundus images in subjects with CACS > 100 could be recognized by deep learning algorithms compared with those with no CAC. Exploiting bilateral images improves discrimination performance, and ablation studies removing retinal vasculature or fovea suggest that recognizable patterns reside mainly in these areas.

Translational Relevance

Retinal fundus images can be used by deep learning algorithms for prediction of high CACS.

Relationship Between Step Counts and Cerebral Small Vessel Disease in Japanese Men

BACKGROUND AND PURPOSE

Cerebral small vessel disease (CSVD) is a common subclinical feature of the aging brain. Steps per day may contribute to its prevention. We herein investigated the association between step counts and CSVD in a healthy Japanese male population.

METHODS

We analyzed data from 680 men who were free of stroke and participated in this observational study. Seven-day step counts were assessed at baseline (2006-2008) using a pedometer. CSVD was assessed at follow-ups (2012-2015) based on deep and subcortical white matter hyperintensities (WMHs), periventricular hyperintensities, lacunar infarcts, and cerebral microbleeds on magnetic resonance imaging. Using a logistic regression analysis, we computed the adjusted odds ratios, with 95% CIs, of prevalent CSVD according to quartiles of step counts (reference: Q1). We also investigated the association between step counts and WMH volumes using a quantile regression.

RESULTS

Steps per day were significantly associated with lower odds ratios, with the lowest at Q3 (8175-10 614 steps/day), of higher (versus low or no burden) deep and subcortical WMHs (odds ratio, 0.52 [95% CI, 0.30-0.89]), periventricular hyperintensities (0.50 [95% CI, 0.29-0.86]), and lacunar infarcts (0.52 [95% CI, 0.30-0.91]) compared with Q1 (≤6060 steps/day) but not cerebral microbleeds. An inverse linear association was observed between step counts and WMH volumes. These associations were independent of age and smoking and drinking status and remained consistent when adjusted for vascular risk factors.

CONCLUSIONS

We found a J-shaped relationship between step counts and prevalent CSVD in healthy Japanese men, with the lowest risk being observed among participants with ≈8000 to 10 000 steps/day. Higher steps were also associated with lower WMH volumes.

Neurocognitive impairment in Asian childhood cancer survivors: a systematic review

Childhood cancer survivors are at higher risk of developing neurocognitive deficits due to the intensive treatment they received at an early age. Most studies on childhood cancer survivorship have so far focused on the Western populations. Due to the ethnic, genetic, environmental, and cultural differences, clinical data of the Western populations may not be representative of Asian countries. This scoping review systematically summarized the existing clinical evidence of the neurocognitive impairment of Asian childhood cancer survivors. We searched the Embase and Medline databases for studies assessing the neurocognitive functions of survivors in Asia, who were diagnosed with cancer before the age of 19 and completed active treatment. The literature search identified 13 studies involving 2212 participants from five Asian countries: South Korea (n = 4, 30.8%), Taiwan (n = 3, 23.1%), Japan (n = 3, 23.1%), Hong Kong (n = 2, 15.4%), and Thailand (n = 1, 7.7%). The included studies focused on CNS tumors (n = 10, 76.9%), hematological malignancies (n = 7, 53.8%), or heterogeneous cancer diagnoses (n = 3, 23.1%). Collectively, mild-to-moderate impairment in intelligence was observed in 10.0 to 42.8% of survivors, which seemed higher than the reported rate in Western survivors. We speculate that the ethnic and genetic variations in drug responses and susceptibility to adverse chronic toxicities may have contributed to the differences in the prevalence and severity of neurocognitive impairment between these two populations. To better understand the effects of culturally relevant and region-specific environmental risk factors on the post-treatment neurocognitive development in cancer survivors, a holistic approach that addresses the complex interactions between biological, physical, and psychosocial factors is needed. This will aid the development of effective intervention strategies to improve the functional and psychosocial outcomes of cancer survivors in Asian societies.

Effect of coconut oil on cardio-metabolic risk: A systematic review and meta-analysis of interventional studies

BACKGROUND AND AIMS

High total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) could be major risk factors for cardiovascular disease burden among high risk populations especially in South Asians. This systematic review and meta-analysis aimed to quantify the effects of coconut oil compared with other oils and fats on cardio-metabolic parameters.

METHODS

PubMed, Scopus and Web of Science were systematically searched. The main outcomes included are lipid and glycemic parameters. Subgroup analyses were performed to evaluate individual comparisons of vegetable oils and animal fat with coconut oil. Data were pooled using random-effects meta-analysis.

RESULTS

Coconut oil consumption significantly increased TC by 15.42 mg/dL (95% CI, 8.96-21.88, p < 0.001), LDL-C by 10.14 mg/dL (95% CI, 4.44-15.84, p < 0.001) and high density lipoprorein cholesterol (HDL-C) by 2.61 mg/dL (95% CI, 0.95-4.26, p = 0.002), and significantly decreased glycosylated hemoglobin (HbA1c) by 0.39 mg/dL (95% CI, -0.50 to -0.27, p < 0.001) but, it had no effects on triglycerides (TG), (4.25 mg/dL; 95% CI, -0.49-8.99, p = 0.08) when compared with the control group. Sub-group analysis demonstrated that coconut oil significantly increased TC and LDL-C over corn, palm, soybean and safflower oils and not over olive oil. Compared with butter, coconut oil showed a better pattern in cardio-metabolic markers by significantly increasing HDL-C (4.38 mg/dL, 95% CI, 0.40 to 8.36, p = 0.03) and decreasing LDL-C (-14.90 mg/dL, 95% CI, -23.02 to-6.77, p < 0.001).

CONCLUSIONS

Our results suggest that coconut oil consumption results in significantly higher TC, LDL-C and HDL-C than other oils. Consumption of coconut oil can be one of the risk factors for CVDs in South Asians.

Development of a Cardiovascular Disease Risk Prediction Model Using the Suita Study, a Population-Based Prospective Cohort Study in Japan

AIM

To construct a risk prediction model for cardiovascular disease (CVD) based on the Suita study, an urban Japanese cohort study, and compare its accuracy against the Framingham CVD risk score (FRS) model.

METHODS

After excluding participants with missing data or those who lost to follow-up, this study consisted of 3,080 men and 3,470 women participants aged 30-79 years without CVD at baseline in 1989-1999. The main outcome of this study was incidence of CVD, defined as the incidence of stroke or coronary heart disease. Multivariable Cox proportional hazards models with stepwise selection were used to develop the prediction model. To assess model performance, concordance statistics (C-statistics) and their 95% confidence intervals (CIs) were calculated using a bootstrap procedure. A calibration test was also conducted.

RESULTS

During a median follow-up period of 16.9 years, 351 men and 241 women developed CVD. We formulated risk models with and without electrocardiogram (ECG) data that included age, sex, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, diabetes mellitus, smoking, and urinary protein as risk factors. The C-statistics of the Suita CVD risk models with ECG data (0.782; 95% CI, 0.766-0.799) and without ECG data (0.781; 95% CI, 0.765-0.797) were significantly higher than that of the FRS model (0.768; 95% CI, 0.750-0.785).

CONCLUSIONS

The Suita CVD risk model is feasible to use and improves predictability of the incidence of CVD relative to the FRS model in Japan.

Clinical investigation of acute myocardial infarction according to age subsets

A growing number of 'Young' patients less than 40 years of age are being hospitalized with a diagnosis of acute myocardial infarction (AMI) due to increased prevalence of risk factors for atherosclerosis. The aim of this study was to compare clinical characteristics and performances of AMI between young and elderly patients. We conducted a retrospective study to compare AMI in young patients and elder patients. Based on the medical record databases in our hospital, we enrolled 114 'young' AMI patients (age ≤42 years) and 179 'elder' AMI patients (≥60 years), and then collected and analyzed their demographic information, clinical performances, and coronary angiography results. In the young AMI group, the proportion of male patients was higher than that in the elder AMI group (94.7 vs. 64.2%, P<0.05). Compared with the elder AMI patients, young patients had higher rates of smoking history and positive family medical history, but lower rates of hypertension and diabetes. Elder patients with AMI were more likely to develop various clinical performances, and multiple-branch lesions; however, young AMI patients had relatively fewer symptoms, and the tissue lesions were more limited. The clinical profiles of AMI in young patients were different from that in elder AMI patients. Specific interventions should be carried out to prevent and control the prevalence of AMI in the young population.

Cardiovascular outcome and home blood pressure in relation to silent myocardial ischemia in a clinical population: The J-HOP study

Several guidelines recommend measuring home blood pressure (BP) and lowering blood pressure than ever before. But several studies reported that lowering diastolic blood pressure (DBP) increased the incidence of coronary artery disease (CAD). We analyzed 3605 individuals who underwent both home and office BP monitoring over 14 days and baseline Hs-cTnT measurement and identified follow-up data of the Japan Morning Surge-Home Blood Pressure (J-HOP) study who had a history of or risk factors for cardiovascular disease. During a mean follow-up period of 6.4 years (23 173 person-years), 114 coronary artery disease and 81 stroke events occurred. Elevated Hs-cTnT (≥0.014 ng/mL) was observed in 298 patients (8.3%). In the group with non-elevated Hs-cTnT (<0.014 ng/mL, n = 3307), an adjusted Cox hazard model showed that home systolic BP (SBP) was associated with a risk of stroke incidence (hazard ratio [HR] per 1 SD, 1.62; 95% confidence interval [CI], 1.29-2.03). This association was also observed in office SBP (HR per 1 SD, 1.43; 95%CI, 1.07-1.91). There was no association between office or home BP and CAD events in the group with non-elevated Hs-cTnT. In the group with elevated Hs-cTnT, an adjusted Cox hazard model showed that home DBP was associated with a risk of CAD incidence (HR per 1 SD, 0.54; 95%CI, 0.30-0.99). However, this association was not observed in office DBP. In patients with elevated Hs-cTnT, which is a marker of subclinical myocardial ischemia, excessive lowering of home DBP may be associated with a risk of incident CAD.

Decreased stroke risk with combined traditional Chinese and western medicine in patients with ischemic heart disease: A real-world evidence

Both ischemic heart disease (IHD) and stroke are major causes of death worldwide. We investigated the effects of combined Traditional Chinese medicine (TCM) and western medicine (WM) on stroke risk in IHD patients.Taiwanese patients with IHD were enrolled in the TCM study during their outpatient visit. Stroke events after TCM or non-TCM treatment were examined. Chi-square tests and Student t-tests were used to examine differences between patients using and not using TCM. The Cox proportional hazards regression model was used to estimate hazard ratios (HRs). Sex, age, and comorbidities were included in a multivariable Cox model to estimate the adjusted HR (aHR). The survival probability and the probability free of stroke were calculated by the Kaplan-Meier method.There were 733 IHD patients using TCM and 733 using non-TCM treatment, with the same proportion of sex and age within each cohort. Using single Chinese herb such as Dan Shen, San Qi, or Chuan Xiong would have lower stroke events and lower aHR than non-TCM in IHD patients. There was 0.3-fold lower stroke risk in IHD patients with combination TCM and non-TCM treatment (95% CI = 0.11-0.84, P = .02). Moreover, the survival rate was higher (P < .001) and the incidence of hemorrhagic stroke was significantly lower (P = .04) in IHD patients with TCM treatment.IHD patients using combined TCM and WM had a higher survival rate and lower risk of new onset stroke, especially hemorrhagic stroke than those who did not use TCM treatment.

Estimation of 10-Year Risk of Death from Coronary Heart Disease, Stroke, and Cardiovascular Disease in a Pooled Analysis of Japanese Cohorts: EPOCH-JAPAN

AIMS

We aimed to develop and validate risk prediction models to estimate the absolute 10-year risk of death from coronary heart disease (CHD), stroke, and cardiovascular disease (CVD).

METHODS

We evaluated a total of 44,869 individuals aged 40-79 years from eight Japanese prospective cohorts to derive coefficients of risk equations using cohort-stratified Cox proportional hazard regression models. Discrimination (C-index) of the equation was examined in each cohort and summarised using random-effect meta-analyses. Calibration of the equation was assessed using Hosmer-Lemeshow chi-squared statistic.

RESULTS

Within a median follow-up of 12.7 years, we observed 765 deaths due to CVD (276 CHDs and 489 strokes). After backward selection, age, sex, current smoking, systolic blood pressure (SBP), proteinuria, prevalent diabetes mellitus, the ratio of total cholesterol to high-density lipoprotein cholesterol (TC/HDLC), interaction terms of age by SBP, and age by current smoking were retained as predictors for CHD. Sex was excluded in the stroke equation. We did not consider TC/HDLC as a risk factor for the stroke and CVD equations. The pooled C-indices for CHD, stroke, and CVD were 0.83, 0.80, and 0.81, respectively, and the corresponding p-values of the Hosmer-Lemeshow tests were 0.18, 0.003, and 0.25, respectively.

CONCLUSIONS

Risk equations in the present study can adequately estimate the absolute 10-year risk of death from CHD, stroke, and CVD. Future work will evaluate the system as an education and risk communication tool for primary prevention of CHD and stroke.

Comprehensive laboratory reference intervals for routine biochemical markers and pro-oxidant-antioxidant balance (PAB) in male adults

Background

Reference values of biochemical markers are influenced by various parameters including age, sex, region, and lifestyle. Hence, we aimed to determine age‐ and BMI‐specific reference intervals (RIs) for important clinical biomarkers in a healthy adult male population from northeastern Iran. This is also the first study to investigate reference values for pro‐oxidant‐antioxidant balance (PAB).

Methods

Seven hundred and twenty (720) healthy men, aged 20‐60 years, were recruited from Sarakhs in the northeast region of Iran. Reference values for lipid profiles (total cholesterol, triglyceride, HDL‐C and LDL‐C), fasting blood glucose, inflammatory factors (hs‐CRP and PAB), minerals (zinc and copper), uric acid, and blood pressure were measured and statistically analyzed to establish accurate age‐ and BMI‐specific RIs in alignment with CLSI Ep28‐A3 guidelines.

Results

RIs for lipid profiles, inflammatory factors, minerals, and uric acid required no age partitioning with the exception of fasting blood glucose and blood pressure, which demonstrated significantly higher values in subjects aged 50 years and older. Among these biomarkers, only uric acid, blood pressure, and triglycerides demonstrated statistically significant increases in reference value concentrations with increasing BMI.

Conclusion

In this study, age‐ and BMI‐specific RIs for several biochemical markers were determined in healthy adult Iranian men. Partitioning by age and BMI was only required for a few analytes with most demonstrating no statistically significant changes with these covariates. These data can be useful to monitor various diseases in male adults with varying BMI in this region and others.

Prevalence of Intracranial Artery Stenosis in Patients with Acute Ischemic Stroke in a Tertiary Care Hospital of China

Introduction:

Intracranial artery stenosis is the most common cause of acute ischemic stroke, especially among people in Asia. About its epidemiology, however little is understood. The goal of our research is to establish the prevalence of intracranial artery stenosis in patients with acute ischemic stroke in a tertiary care hospital.

Methods:

A descriptive cross-sectional study was done in 1006 acute ischemic stroke patients at Affiliated Zhongda Hospital, School of Medicine, Southeast University China from May 2018 to May 2019. Ethical approval was taken from the Ethical review committee of the institution. A convenient sampling method was done. Intracranial artery stenosis was diagnosed when evidence of acute ischemic stroke was found in the territory of approximately ≥50% stenosis identified by Transcranial Doppler ultrasound and confirmed by magnetic resonance angiography or computed tomography. Statistical analysis was done using the Statistical Package for the Social Sciences version 20.

Results:

The prevalence of intracranial artery stenosis was found in 331 (32.90%) patients at 95% Confidence interval (0.24-0.42%). Among 331 cases the anterior circulation artery stenosis was present on 201 (19.98%) patients, followed by posterior circulation artery stenosis on 80 (7.95%) patients, then anterior plus posterior circulation artery stenosis on 50 (4.97%) patients.

Conclusions:

Intracranial artery stenosis is one of the most causes of acute ischemic stroke in China. The proportion of anterior circulation artery stenosis was higher than that in the posterior circulation.

Isometric handgrip training reduces blood pressure and wave reflections in East Asian, non-medicated, middle-aged and older adults: a randomized control trial

PURPOSE

The aim of this study was to investigate the effects of isometric handgrip (IHG) training on central and peripheral blood pressure (BP) and wave reflections in East Asian non-medicated middle-aged and older adults.

METHODS

Twenty-two men and women (mean age 65 ± 11 years) who were not actively involved in regular resistance or endurance training were randomly assigned to a group that did IHG and a control (CON) group. The IHG training was comprised of four unilateral 2-min isometric contractions at 30% of maximal voluntary contraction using a programmed handgrip dynamometer with 1-min rest periods for 5 days per week for 8 weeks.

RESULTS

Baseline central systolic BP (cSBP), brachial systolic BP (bSBP), brachial diastolic BP (bDBP), and the augmentation index (AIx) (via an automated applanation tonometric system) did not differ significantly between the groups. Compared to baseline, cSBP, bSBP, bDBP, and AIx decreased significantly after the 8-week study period in the IHG group (P < 0.05). No significant changes in central and peripheral BP and AIx were observed in the CON group.

CONCLUSIONS

These results suggest that IHG training could reduce central and peripheral BP and wave reflections in East Asian non-medicated middle-aged and older adults.

Association between hemoglobin variability and incidence of hypertension over 40 years: a Korean national cohort study

Hemoglobin level determines blood viscosity and as hemoglobin level rises, blood pressure rises. However, hemoglobin level in individuals is not fixed and change in hemoglobin is affected by various clinical conditions. The purpose of this study is to investigate whether the hemoglobin variability affects the development of hypertension using Korean cohort database. This study was conducted with 94,798 adults (age ≥ 40 years) who visited the health screening in 2006 or 2007 (index year) and had at least 3 health screenings from 2002 to 2007. Hemoglobin variability was assessed by 3 indices of coefficient of variation (CV), standard deviation, and variability independent of the mean. Cox proportional hazard regression analysis was performed for each index of quartile groups (Q1–Q4). A total of 29,145 participants (30.7%) had the incidence of hypertension during a median follow-up of 7.4 ± 2.5 years. In the multivariable adjusted model, the hazard ratio and 95% confidence interval for incidence of hypertension of Q2, Q3, and Q4 compared with Q1 of hemoglobin variability CV were 1.014 [0.981–1.047], 1.064 [1.030–1.099] and 1.094 [1.059–1.131] respectively. The results were consistent in various sensitivity and subgroup analyses. This study showed that hemoglobin variability could be associated with hypertension development.

Long-Term Exposure to Particulate Matter and Mortality from Cardiovascular Diseases in Japan: The Ibaraki Prefectural Health Study (IPHS)

Aim: To examine the association between long-term exposure to suspended particulate matter (SPM) and cardiovascular mortality in Japan after controlling for known major confounding factors among a large middle and elderly cohort study in Ibaraki Prefecture, Japan.

Methods: We followed 91,808 residents (men 34%) who undertook a national health check-up at age 40–79 years for 17 years (1993–2010). Two different exposure indices were adopted: baseline SPM concentration (in the year 1990) and average SPM concentration for the first (average of 1990 and 1995) and the second half (average of 2005 to 2009) of the study period. Sex-specific adjusted risk ratios (RRs) for cardiovascular mortality were calculated using general mixed Poisson regression models after adjusting the age, BMI, history of diabetes mellitus and hypertension, creatinine, glutamic pyruvic transaminase, total cholesterol, high-density lipoprotein cholesterol, smoking, alcohol, and temperature. The variation between seven medical administration areas was also taken into account as a random effect.

Results: Baseline SPM concentration was associated with an increased risk of mortality from all cardiovascular diseases, coronary artery disease, and stroke. The adjusted RRs (95% confidence interval [CI]) per 10 µg/m³ increase in SPM concentration for all cardiovascular mortality were 1.147 (1.014–1.300) for men and 1.097 (0.985–1.222) for women. The point estimate of RR was highest for non-hemorrhagic stroke in men (1.248 [0.991–1.571]), although CI overlapped the unity. The RRs seemed slightly lower in the second half than in the first half, though the CIs widened in the second half.

Conclusion: Our results suggest that long-term exposure to SPM is associated with an increased risk of all cardiovascular mortality for men in Ibaraki, Japan.

Impact of hypertension stratified by diabetes on the lifetime risk of cardiovascular disease mortality in Japan: a pooled analysis of data from the Evidence for Cardiovascular Prevention from Observational Cohorts in Japan study

Lifetime risk is an informative estimate to motivate people to change lifestyle behaviors, especially from a younger age, in public health education. The impact of the combination of hypertension and diabetes on the lifetime risk of cardiovascular mortality has not been investigated in Asian populations. A pooled analysis of individual data from nine cohorts was performed. A total of 57,339 Japanese men and women were eligible for the analysis. We used the modified Kaplan-Meier approach and estimated the remaining lifetime risk of cardiovascular mortality starting from the index age of 35 years. Participants were classified into four categories defined by hypertension and diabetes. The lifetime risk was increased in the order of those without either risk, those without hypertension but with diabetes, those with hypertension but without diabetes, and those with both risks. The lifetime risk of cardiovascular mortality at the 35-year index age was as follows: 7.8% in men and 6.2% in women for those without either hypertension or diabetes, 13.2% in men and 9.5% in women for those without hypertension but with diabetes, 17.2% in men and 11.7% in women for those with hypertension but without diabetes, and 19.4% in men and 15% in women for those with both risks. These findings reinforce the need for a life-course perspective in the management of hypertension and diabetes from a younger age.

Myocardial Fluid Balance and Pathophysiology of Myocardial Edema in Coronary Artery Bypass Grafting

Myocardial edema is one of the most common complications of coronary artery bypass grafting (CABG) that is linearly related to many coronary artery diseases. Myocardial edema can cause several consequences including systolic dysfunction, diastolic dysfunction, arrhythmia, and cardiac tissue fibrosis that can increase mortality in CABG. Understanding myocardial fluid balance and tissue and systemic fluid regulation is crucial in order to ultimately link how coronary artery bypass grafting can cause myocardial edema in such a setting. The identification of susceptible patients by using imaging modalities is still challenging. Future studies about the technique of imaging modalities, examination protocols, prevention, and treatment of myocardial edema should be carried out, in order to limit myocardial edema occurrence and prevent complications.

Two-Year Recurrence After First-Ever Stroke in a General Population of 1.4 Million Japanese Patients - The Shiga Stroke and Heart Attack Registry Study

BACKGROUND

Despite many effective strategies for the prevention of recurrent stroke, individuals who survive an initial stroke have been shown to be at high risk of recurrent stroke. The aim of this study was to investigate the current status of stroke recurrence after first-ever stroke using a population-based stroke registry in Japan.

METHODS AND RESULTS

As part of the Shiga Stroke and Heart Attack Registry, the Shiga Stroke Registry is an ongoing population-based stroke registry study that covers approximately 1.4 million residents of Shiga Prefecture, Japan. A total of 1,883 first-ever stroke survivors at 28 days was registered in 2011 and followed-up until the end of 2013. Recurrence was defined as any type of stroke after 28 days from the onset of an index event. Two-year cumulative recurrence rates were estimated using cumulative incidence function methods. Over a mean 2.1-year follow-up period, 120 patients experienced recurrent stroke and 389 patients died without recurrence. The 2-year cumulative recurrence rate was higher in patients with index ischemic stroke (6.8%) than in those with index hemorrhagic stroke (3.8%).

CONCLUSIONS

Two-year cumulative recurrence rate after first-ever stroke remained high, particularly among patients with ischemic stroke, in the present population-based registry study in a real-world setting in Japan. Further intensive secondary prevention strategies are required for these high-risk individuals.

The EMPOWER-SUSTAIN e-Health Intervention to improve patient activation and self-management behaviours among individuals with Metabolic Syndrome in primary care: study protocol for a pilot randomised controlled trial

Background

Epidemiological studies conducted in various parts of the world have clearly demonstrated that metabolic syndrome (MetS) is an increasing global health problem, not only in Western societies but also in Asian populations. Web-based and mobile phone-based self-management applications have been proven to be effective in improving self-management behaviour of patients with MetS components (i.e., diabetes or hypertension). However, evidence is lacking in terms of their effectiveness specifically for patients with MetS. The aim of this pilot study is to evaluate the feasibility and potential effectiveness of the EMPOWER-SUSTAIN Self-Management e-Health Intervention in improving activation and self-management behaviours among patients with MetS. This paper presents the study protocol.

Methods

A pilot randomised controlled trial will be conducted in a university primary care clinic. A total of 232 patients aged 18–60 years with MetS will be recruited; 116 will be randomised to receive the EMPOWER-SUSTAIN intervention for 6 months, and another 116 patients will continue with usual care. The EMPOWER-SUSTAIN intervention is a multifaceted chronic disease management strategy based on the Chronic Care Model and persuasive technology theory. It consists of training primary care physicians, nurses and patients to use the EMPOWER-SUSTAIN web-based self-management mobile app, strengthening the patient–physician relationship and reinforcing the use of relevant clinical practice guidelines to guide management and prescribing. The primary outcome is the mean change in patient activation score using the Patient Activation Measure short form Malay version (PAM-13-M) questionnaire. The secondary outcomes include the changes in waist circumference, body mass index, blood pressure, patient physical activity level, eating behaviour, perception of chronic illness care, satisfaction with patient–physician interaction, and perceived absolute 10-year cardiovascular disease risk. Feasibility of implementing the intervention will be evaluated. This includes acceptability of the intervention, estimating the likely rate of participant recruitment and retention, appropriateness of the outcome measures, calculation of sample size, and the intervention’s potential effectiveness.

Conclusion

To our knowledge, this is the first study in Malaysia that aims to determine the feasibility of a multifaceted e-health intervention, as well as to indicate more useful aspects of this intervention for further exploration in a larger trial.

Trial registration

ClinicalTrials.gov, NCT04120779. Registered on 9 October 2019, protocol version 1.

Effect of tomato consumption on fasting blood glucose and lipid profiles: A systematic review and meta-analysis of randomized controlled trials

Tomato (Solanum lycopersicum) phytochemicals, which include phytoene, phytofluene, beta-carotene, flavonoids, lycopene, and polyphenols, have been shown to improve the effects of fasting on plasma triglyceride (TG), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), total cholesterol (TC), and fasting blood sugar (FBS). The aim of this study was to systematically evaluate the effects of Tomato TC, TG, HDL, LDL, and FBS in humans. A systematic literature search was conducted in PubMed/MEDLINE, Web of sciences, and SCOPUS databases by two researchers for studies published until August of 2019 without language and time limitations. Results were combined with random effect models. Six studies were included in this meta-analysis. Combined results reveal a significant reduction in cholesterol (weighted mean difference [WMD]: -4.39 mg/dl, 95% CI: -7.09, -1.68, I² = % 48, p heterogeneity: .05), TG (WMD: -3.94 mg/dl, 95% CI: -7.67, -0.21, I² = % 90, p heterogeneity: .001), LDL levels (WMD: -2.09 mg/dl, 95% CI: -3.73, -0.81, I² = % 78, p heterogeneity: .001), and increasing in HDL levels (WMD: 2.25 mg/dl, 95% CI: 0.41, 4.10, I² = % 97, p heterogeneity: .001). Tomato was found to have a higher reduction effect on TG and LDL in younger participants. While pooled results indicate no significant effect on FBS levels (WMD: 0.59 mg/dl, 95% CI: -0.28, 1.46, I² = % 95, p heterogeneity: .001). In conclusion, the results indicate a significant reduction in total cholesterol, TG, and LDL and increase in HDL levels that is caused by tomato consumption.

An overview of hypertension and cardiac involvement in Asia: Focus on heart failure

Cardiovascular Disease (CVD) is the leading cause of deaths worldwide, contributing to about 30% of all deaths. Half of the cases of CVD are estimated in Asia, the world's most populous continent. Hypertension, a major modifiable risk factor for CVD, results in more deaths than any other CV risk factors in the Asian regions. The total number of patients with hypertension is likely to grow as the population ages. The proportion of the elderly population aged 65 years or more in Asia is expected to increase from 7.4% in 2015 to 10.9% in 2030. It is important to note that more than half (54%) of the world's population live in Asia. Aside of being the biggest single risk factor for global deaths, hypertension is also an important precursor and most common risk factor of heart failure (HF). An increase in HF prevalence is clearly related to the rapid epidemiological transition caused by changes in lifestyle in Asian countries. However, the availability of data on HF burden and health care delivery is limited in Asia compared with Europe and North America. This reality has driven the working group of Asian experts for example the HOPE Asia Network to concentrate on hypertension as risk factors for CVD, with the mission to improve the management of hypertension resulting in organ protection toward a goal of achieving "ZERO" CV event in Asia. This paper aims to give an overview regarding the heart problems caused by hypertension in Asia, focus on HF.

Renal Denervation in Asia: Consensus Statement of the Asia Renal Denervation Consortium

The Asia Renal Denervation Consortium consensus conference of Asian physicians actively performing renal denervation (RDN) was recently convened to share up-to-date information and regional perspectives, with the goal of consensus on RDN in Asia. First- and second-generation trials of RDN have demonstrated the efficacy and safety of this treatment modality for lowering blood pressure in patients with resistant hypertension. Considering the ethnic differences of the hypertension profile and demographics of cardiovascular disease demonstrated in the SYMPLICITY HTN (Renal Denervation in Patients With Uncontrolled Hypertension)-Japan study and Global SYMPLICITY registry data from Korea and Taiwan, RDN might be an effective hypertension management strategy in Asia. Patient preference for device-based therapy should be considered as part of a shared patient-physician decision process. A practical population for RDN treatment could consist of Asian patients with uncontrolled essential hypertension, including resistant hypertension. Opportunities to refine the procedure, expand the therapy to other sympathetically mediated diseases, and explore the specific effects on nocturnal and morning hypertension offer a promising future for RDN. Based on available evidence, RDN should not be considered a therapy of last resort but as an initial therapy option that may be applied alone or as a complementary therapy to antihypertensive medication.

Diversity of and initiatives for hypertension management in Asia-Why we need the HOPE Asia Network

The Hypertension Cardiovascular Outcome Prevention and Evidence in Asia (HOPE Asia) Network was set up to improve the management of hypertension in Asia with the ultimate goal of achieving "zero" cardiovascular events. Asia is a diverse continent, and the prevalence of hypertension has increased over the last 30 years. There are a number of Asia-specific features of hypertension and hypertension-related cardiovascular complications, which means that a region-specific approach is needed. White-coat hypertension will become more of an issue over time as Asian populations age, and masked hypertension is more prevalent in Asian than in Western countries. Identifying and treating masked hypertension is important to reduce cardiovascular risk. Abnormal patterns of blood pressure (BP) variability common in Asia include exaggerated early morning BP surge and nocturnal hypertension. These are also important cardiovascular risk factors that need to be managed. Home blood pressure monitoring (HBPM) is an important tool for detecting white-coat and masked hypertension, and monitoring BP variability, and practices in Asia are variable. Use of HBPM is important given the Asia-specific features of hypertension, and strategies are needed to improve and standardize HBPM usage. Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology-based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. Region-wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices.

Target blood pressure and control status in Asia

It is widely accepted that hypertension constitutes a significant cardiovascular risk factor and that treating high blood pressure (BP) effectively reduces cardiovascular risk. An important issue in Asia is not just the high prevalence of hypertension, particularly in some countries, but also the low level of awareness and treatment rates in many regions. The 2017 update of the American College of Cardiology/American Heart Association hypertension guidelines raised the question about which BP threshold should be used to diagnose and treat hypertension. Although there is a theoretical rationale for a stricter BP criterion in Asia given the ethnic-specific features of hypertension in the region, the majority of countries in Asia have retained a diagnostic BP threshold of ≥140/90 mm Hg. Although lowering thresholds might make theoretical sense, this would increase the prevalence of hypertension and also markedly reduce BP control rates. In addition, there are currently no data from robust randomized clinical trials of the benefits of the lower targets in preventing cardiovascular disease and reducing cardiovascular risk, particularly in high-risk patients and especially for Asian populations. There is also no defined home BP treatment target level for an office BP treatment target of 130/80 mm Hg. However, in this regard, in the interim, lifestyle modifications, including reducing body weight and salt intake, should form an important part of hypertension management strategies in Asia, while studies on treating at lower BP threshold level in Asians and getting to lower BP targets will be helpful to inform and optimize the management of hypertension in the region.

Highlights of the 2019 Japanese Society of Hypertension Guidelines and perspectives on the management of Asian hypertensive patients

Unlike other international guidelines but in accord with the earlier Japanese Society of Hypertension (JSH) guidelines, the 2019 JSH guidelines ("JSH 2019") continue to emphasize the importance of out-of-office blood pressure (BP) measurements obtained with a home BP device. Another unique characteristic of JSH 2019 is that it sets clinical questions about the management of hypertension that are based on systematic reviews of updated evidence. JSH 2019 states that individuals with office BP < 140/90 mm Hg do not have normal BP. The final decisions regarding the diagnosis and treatment of hypertension should be performed based on out-of-office BP values together with office BP measurements. For hypertensive adults with comorbidities, the office BP goal is usually <130/80 mm Hg and the home BP goal is <125/75 mm Hg. Recommendations of JSH 2019 would be valuable for not only Japanese hypertensive patients but also Asian hypertensive patients, who share the same features including higher incidence of stroke compared with that of myocardial infarction and a steeper blood pressure-vascular event relationship.

Rationale, design, and baseline characteristics of the Cardiovascular Prognostic COUPLING Study in Japan (the COUPLING Registry)

Vascular biomarkers, including the cardio-ankle vascular index (CAVI), are increasingly being recognized as important indicators of cardiovascular risk. CAVI has been shown to have good discriminative ability for detecting new-onset hypertension, but results of studies investigating cardiovascular risk prediction are inconsistent. Furthermore, there is a lack of data on the prognostic value of changes in CAVI over time. The Cardiovascular Prognostic Coupling study was designed to determine the impact of baseline CAVI and changes in CAVI on cardiovascular events in a Japanese cohort. The design of the ongoing, multicenter, prospective, observational registry and baseline characteristics of the enrolled population are reported. Eligible consecutive patients were aged ≥30 years, had ≥1 cardiovascular risk factor, and were being treated according to relevant Japanese guidelines. The primary outcome is time to onset of a major cardiovascular event (a composite of cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, stroke of unknown etiology, myocardial infarction, cardiovascular intervention for angina pectoris, and sudden death). Screening and enrollment occurred over a period of 3 years, followed by ≥7 years of follow-up, with CAVI determined annually. A total of 5279 patients were registered, of whom 5109 had baseline data available and will be included in future analyses. Mean CAVI at baseline was 8.8 ± 1.4. The proportion of patients with CAVI of <8, 8-10 or >10 was 25.3%, 57.0%, and 17.7%, respectively. Data from this registry should provide information on the significance of baseline CAVI and change in CAVI as indicators of cardiovascular prognosis in a representative patient population.

The Association between Metabolically Healthy Obesity, Cardiovascular Disease, and All-Cause Mortality Risk in Asia: A Systematic Review and Meta-Analysis

We investigated the association among metabolically healthy obesity (MHO), cardiovascular disease (CVD)risk, and all-cause mortality in the Asian population. We searched databases from inception to 16 November, 2019 and pooled data using a random-effects model. Subgroup analysis was conducted according to the following comparison groups: MHNW (without overweight or underweight participants) and MHNO (non-obese, including overweight and underweight participants). Nineteen studies were included. The mean Newcastle-Ottawa Scale score was 7.8. Participants with MHO had a significantly higher CVD risk (odds ratio (OR) = 1.36, 95% confidence interval (CI) = 1.13-1.63) and significantly lower risk of all-cause mortality (OR = 0.88, 95% CI = 0.78-1.00) than the comparison group. Subgroup analyses revealed participants with MHO had a significantly higher CVD risk than MHNW participants (OR = 1.61; 95% CI = 1.24-2.08; I² = 73%), but there was no significant difference compared with MHNO participants (OR, 1.04; 95% CI, 0.80-1.36; I² = 68%). Participants with MHO had a significantly lower risk of all-cause mortality (OR = 0.83; 95% CI = 0.78-0.88; I² = 9%) than MHNO participants, but a borderline significantly higher risk of all-cause mortality than MHNW participants (OR = 1.30; 95% CI = 0.99-1.72; I² = 0%). The CVD risk and all-cause mortality of the MHO group changed depending on the control group. Thus, future studies should select control groups carefully.

Blood Pressure Measurement and Treatment Decisions

White-coat and masked hypertension are important hypertension phenotypes. Out-of-office blood pressure measurement is essential for the accurate diagnosis and monitoring of these conditions. This review summarizes literature related to the detection and diagnosis, prevalence, epidemiology, prognosis, and treatment of white-coat and masked hypertension. Cardiovascular risk in white-coat hypertension appears to be dependent on the presence of coexisting risk factors, whereas patients with masked hypertension are at increased risk of target organ damage and cardiovascular events. There is an unmet need for robust data to support recommendations around the use of antihypertensive treatment for the management of white-coat and masked hypertension.

Lipoprotein particles and coronary artery calcium in middle-aged US-White and Japanese men

Objective

This cross-sectional study examined whether contrasting distributions of nuclear magnetic resonance (NMR)-measured lipoproteins contribute to differences in the prevalence of subclinical atherosclerosis measured using coronary artery calcium (CAC) between the two groups of middle-aged males: the US-residing Caucasian (US-White) and Japan-residing Japanese (Japanese).

Methods

In a population-based study of 570 randomly selected asymptomatic men aged 40–49 years (270 US-White and 300 Japanese), we examined the relationship between race/ethnicity, NMR-measured lipoproteins and CAC (measured by Electron Beam CT and quantified using the Agatston method) using multivariable robust Poisson regression adjusting for traditional and novel risk factors for coronary heart disease (CHD).

Results

The US-White compared with the Japanese had significantly different NMR-measured lipoprotein particle distributions. The US-White had a significantly higher prevalence of CAC≥10 (CAC-prevalence) compared with the Japanese adjusting for CHD risk factors (prevalence ratio (PR)=2.10; 95% CI=1.24 to 3.48), and this difference was partially attenuated (~18%) with further adjustment for lipoprotein levels (PR=1.73; 95% CI=1.02 to 3.08). There was no reclassification improvement with further addition of lipoproteins particle concentrations/size to a model that already included traditionally measured lipids (low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides), cardiovascular risk factors, and inflammatory markers (net reclassification improvement index=−2% to 3%).

Conclusions

Variations in the distribution of NMR-measured lipoprotein particles partially accounted for the difference in the CAC-prevalence between middle-aged US-White and Japanese men.

The Diagnostic Process for the Evaluation of Acute Abdominal Pain by Resident Trainees in Japan: A Cross-sectional Study

Objective Acute abdominal pain (AAP) of diverse etiology is a common chief complaint of patients who present to the emergency department (ED). AAP may pose a diagnostic challenge to physicians in training. We aimed to evaluate whether or not resident trainee doctors examine patients presenting with AAP in a Japanese acute-care hospital following Kendall's diagnostic algorithm. Methods We conducted a retrospective medical chart review from January 2015 to December 2016. Patients Patients ≥50 years old who presented to the ED within 7 days of the onset of AAP who were evaluated by residents at the ED of an acute care hospital were enrolled in this study. Patients transported by ambulance and referred from other hospitals and classified as level 1 or 2 according to the Japanese version of the Canadian Triage and Acuity Scale were excluded. Data, including the clinical history, location and character of pain, and age and gender of patients as well as the level of experience of residents, were abstracted from charts. We evaluated the concordance rate between the actual diagnostic process followed by residents and Kendall's diagnostic algorithm for AAP. Results We analyzed 466 patients (mean age 67.6 years) in the study who were evaluated and diagnosed by 123 residents. The concordance rate between the diagnostic procedures performed by residents and those suggested by Kendall's diagnostic algorithm was 61.2%. A low concordance rate was observed among patients with peritoneal signs, shock or toxic appearance (25.0%), suggested acute coronary syndromes (ACS) (55.1%), epigastric or right upper-quadrant pain (52.8%), and left upper-quadrant pain (55.6%). Abdominal ultrasonography is one of the recommended examinations for patients with signs of peritoneal irritation, shock or toxic appearance, right lower-quadrant pain, and left upper- or lower-quadrant pain, but the rates were relatively low at 25.0%, 34.4%, 31.8%, and 26.7%, respectively. Conclusion Abdominal ultrasonography required by Kendall's diagnostic algorithm was not performed appropriately in patients with symptoms and signs of peritonitis, shock or toxic appearance, right lower-quadrant pain, and left upper- or lower-quadrant pain or in female patients by resident trainees. Our findings underscore the importance of providing resident doctors with focused training concerning ultrasonography by attending physicians.

Precision Medicine and Cardiovascular Health: Insights from Mendelian Randomization Analyses

Cardiovascular disease (CVD) is considered a primary driver of global mortality and is estimated to be responsible for approximately 17.9 million deaths annually. Consequently, a substantial body of research related to CVD has developed, with an emphasis on identifying strategies for the prevention and effective treatment of CVD. In this review, we critically examine the existing CVD literature, and specifically highlight the contribution of Mendelian randomization analyses in CVD research. Throughout this review, we assess the extent to which research findings agree across a range of studies of differing design within a triangulation framework. If differing study designs are subject to non-overlapping sources of bias, consistent findings limit the extent to which results are merely an artefact of study design. Consequently, broad agreement across differing studies can be viewed as providing more robust causal evidence in contrast to limiting the scope of the review to a single specific study design. Utilising the triangulation approach, we highlight emerging patterns in research findings, and explore the potential of identified risk factors as targets for precision medicine and novel interventions.

Coronary Artery Calcium Progression Among the US and Japanese Men

Background The risk of coronary heart disease remains low in Japan, although distributions of several coronary risk factors have become comparable with those in the United States. We prospectively compared coronary atherosclerosis burden, measured with coronary artery calcium (CAC) progression, between men in the 2 countries. Methods In 2 population-based samples of 1712 US White, Black, Hispanic, Chinese men (baseline, 2000-2002) and 697 Japanese men in Japan (2006-2008) aged 45-74 years without clinical cardiovascular disease, we quantified CAC progression by serial computed tomography with medians of 3.4 and 5.2 years between scans, respectively. Results Among White, Black, Hispanic, Chinese, and Japanese men free of baseline CAC, CAC incidence was observed in 35.2%, 26.9%, 29.2%, 18.9%, and 29.2%, respectively. After adjustment for times between scans, demographics, behaviors, coronary risk factors, and their changes between scans, White men had significantly higher CAC incidence than Japanese men (relative risk, 1.68; 95% CI, 1.13-2.50). Among those with detectable baseline CAC, after similar adjustments, all the US race/ethnic groups had significantly greater annual changes in CAC score (mean [95% CI]: 39.4 [35.2-43.6] for White, 26.9 [21.4-32.4] for Black, 30.6 [24.7-36.5] for Hispanic, and 30.2 [22.6-37.8] for Chinese men) than Japanese men (15.9 [10.1-21.8]). Conclusions We found a higher CAC incidence among US White men and greater increases in existing CAC among all the US race/ethnic groups than among Japanese men in Japan. These differences persisted despite adjustment for differences in coronary risk factors.

Risk of coronary artery disease according to glucose abnormality status and prior coronary artery disease in Japanese men

OBJECTIVE

Although glucose abnormality status (GAS), prior coronary artery disease (CAD), and other traditional risk factors affect the incidence of subsequent CAD, their impact in the same cohort has been scantly studied.

RESEARCH DESIGN AND METHODS

We analyzed data from a nationwide claims database in Japan that was accumulated during 2008-2016 involving 138,162 men aged 18-72 years. Participants were classified as having normoglycemia, borderline glycemia, or diabetes mellitus (DM) with prior CAD (CAD+) or without prior CAD (CAD-). Cox regression model identified variables related to the incidence of CAD.

RESULTS

Among CAD-, management of traditional risks differed from those with and without subsequent CAD events. On the other hand, such differences were weaker in borderline glycemia and DM CAD+, and the influence of traditional risk factors on subsequent CAD was not observed. Cox regression model showed that borderline glycemia and DM confer approximately 1.2- and 2.8-fold excess risks of CAD, respectively, compared with CAD- with normoglycemia. CAD+ confers approximately a 5- to 8-fold increased risk. The impacts of DM and prior CAD additively reached a hazard ratio (HR) of 15.74 (95% confidence interval [CI]: 11.82-21.00). However, the HR in those with borderline glycemia and CAD+ was 7.20 (95% CI: 5.01-10.34), which was not different from those with normoglycemia and CAD+.

CONCLUSION

Control status of traditional risk factors and impact on subsequent CAD differ among categories of glycemic status with and without prior CAD. Individualizing treatment strategies is needed in consideration of risk factors, such as GAS and CAD+.

Contribution of Mitochondrial DNA Variation to Chronic Disease in East Asian Populations

Mitochondria are the main producers of energy in eukaryotic cells. Mitochondrial dysfunction is associated with specific mitochondrial DNA (mtDNA) variations (haplogroups), and these variations can contribute to human disease. East Asian populations show enrichment of many mitochondrial haplogroups, including A, B, D, G, M7, M8, M9, N9, R9, and exhibit half of the known haplogroups of worldwide. In this review, we summarize the current research in the field of mtDNA variation and associated disease in East Asian populations and discuss the physiological and pathological relevance of mitochondrial biology. mtDNA haplogroups are associated with various metabolic disorders ascribed to altered oxidative phosphorylation. The same mitochondrial haplogroup can show either a negative or positive association with different diseases. Mitochondrial dynamics, mitophagy, and mitochondrial oxidative stress, ultimately influence susceptibility to various diseases. In addition, mitochondrial retrograde signaling pathways may have profound effects on nuclear-mitochondrial interactions, affecting cellular morphology, and function. Other complex networks including proteostasis, mitochondrial unfolded protein response and reactive oxygen species signaling may also play pivotal roles in metabolic performance.

Comparison of outcomes between type 2 diabetic and non-diabetic incident hemodialysis patients with functioning arteriovenous fistulas

This study compared clinical outcomes of patient survival and arteriovenous fistula (AVF) patency between incident hemodialysis patients with and without type 2 diabetes mellitus (T2DM).Between January 2011 and December 2013, 384 consecutive incident hemodialysis patients with confirmed first upper-extremity AVF placement were divided into a T2DM group (n = 180, 46.9%) and a non-DM group (n = 204, 53.1%) and analyzed retrospectively. The primary outcome was all-cause mortality, and secondary outcome was AVF patency.Patients in the T2DM group had a higher prevalence of hypertension (P = .02), smoking (P < .01), cardiovascular disease (P < .01), history of cerebrovascular accident (CVA) (P < .01), and peripheral arterial occlusive disease (P < .01) than those in the non-DM group. On Kaplan-Meier survival analysis, the overall survival and AVF patency rates were significantly higher in the non-DM group relative to the T2DM group (both P < .01). In the adjusted model, older age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .01), T2DM (HR, 1.76; 95% CI, 1.12-2.77; P = .014), and history of CVA (HR, 1.76; 95% CI, 1.04-2.98; P = .04) were significantly associated with an increased risk of mortality. Older age and T2DM were independently associated with decreased primary (HR, 1.03; 95% CI, 1.02-1.04; P < .01, HR, 1.69; 95% CI, 1.22-2.33; P < .01, respectively) and secondary (HR, 1.03; 95% CI, 1.01-1.04; P < .01, HR, 2.07; 95% CI, 1.42-3.00; P < .01, respectively) AVF patency during follow-up.Compared with patients in the non-DM group, patients in the T2DM group had a higher mortality rate and worse AVF patency rates.

Knowledge, awareness and practice regarding familial hypercholesterolaemia among primary care physicians in Malaysia: The importance of professional training

BACKGROUND AND AIMS

This study aimed to determine knowledge, awareness and practice (KAP) regarding familial hypercholesterolaemia (FH) among Malaysian primary care physicians (PCP), and to compare KAP between PCP with postgraduate qualification (PCP-PG-Qual) and PCP without PG qualification (PCP-noPG-Qual).

METHODS

This was a cross-sectional study involving PCP with ≥1-year working experience in Malaysian primary care settings. An adapted and validated 25-item FH-KAP questionnaire was disseminated during primary care courses. Total score for each domain was calculated by summing-up the correct responses, converted into percentage scores. Normality distribution was examined and comparisons of mean/median percentage scores were made between the two groups of PCP.

RESULTS

A total of 372 PCP completed the questionnaire. Regarding knowledge, 77.7% correctly defined FH. However, only 8.3% correctly identified coronary artery disease risk in untreated FH. The mean percentage knowledge score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (48.9, SD ± 13.92 vs. 35.2, SD ± 14.13), t(370) = 8.66, p < 0.001. Regarding awareness, 39% were aware of the NICE FH guideline and only 27.2% were aware of FH diagnostic criteria. The median percentage awareness score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (15.4, IqR ± 23.08 vs. 7.7, IqR ± 11.54), p = 0.013. Regarding practice, only 19.1% stratified FH patients as high risk irrespective of other risk factors. The mean percentage practice score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (52.4, SD ± 12.92 vs. 42.7, SD ± 16.63), t(370) = 9.65, p < 0.001.

CONCLUSIONS

Substantial gaps in FH-KAP among Malaysian PCP were identified, with PCP-PG-Qual having better knowledge, awareness and practice than PCP-noPG-Qual, emphasising the importance of professional training and certification.

Outcomes of acute coronary syndrome patients with concurrent extra-cardiac vascular disease in the era of transradial coronary intervention: A retrospective multicenter cohort study

Background

Extra-cardiac vascular diseases (ECVDs), such as cerebrovascular disease (CVD) or peripheral arterial disease (PAD), are frequently observed among patients with acute coronary syndrome (ACS). However, it is not clear how these conditions affect patient outcomes in the era of transradial coronary intervention (TRI).

Methods and results

Among 7,980 patients with ACS whose data were extracted from the multicenter Japanese percutaneous coronary intervention (PCI) registry between August 2008 and March 2017, 888 (11.1%) had one concurrent ECVD (either PAD [345 patients: 4.3%] or CVD [543 patients; 6.8%]), while 87 patients (1.1%) had both PAD and CVD. Overall, the presence of ECVD was associated with a higher risk of mortality (odds ratio [OR]: 1.728; 95% confidence interval [CI]: 1.183–2.524) and bleeding complications (OR: 1.430; 95% CI: 1.028–2.004). There was evidence of interaction between ECVD severity and procedural access site on bleeding complication on the additive scale (relative excess risk due to interaction: 0.669, 95% CI: -0.563–1.900) and on the multiplicative scale (OR: 2.105; 95% CI: 1.075–4.122). While the incidence of death among patients with ECVD remained constant during the study period, bleeding complications among patients with ECVD rapidly decreased from 2015 to 2017, in association with the increasing number of TRI.

Conclusions

Overall, the presence of ECVD was a risk factor for adverse outcomes after PCI for ACS, both mortality and bleeding complications. In the most recent years, the incidence of bleeding complications among patients with ECVD decreased significantly coinciding with the rapid increase of TRI.