Plasma lipid profiles and epidemiology of atherosclerotic diseases in Taiwan--a unique experience

Investigation of the Therapeutic Potential of Organic Nitrates in Mortality Reduction Following Acute Myocardial Infarction in Hyperlipidemia Patients: A Population-Based Cohort Study

BACKGROUND

Dyslipidemia is a known risk factor for cardiac dysfunction, and lipid-lowering therapy with statins reduces symptoms and reduces hospitalization related to left ventricular heart failure. Acute myocardial infarction (AMI) is a cause of morbidity and mortality worldwide. In this study, we aimed to determine the real-world AMI treatment drug combination used in Taiwan by using the NHI database to understand the treatment outcomes of current clinical medications prescribed for hyperlipidemia patients with AMI.

METHODS

Using the NHI Research Database (NHIRD), we conducted a retrospective cohort study that compared different treatments for AMI in hyperlipidemia patients in the period from 2016 to 2018. We compared the survival outcomes between those treated with and without organic nitrates in this cohort.

RESULTS

We determined that most hyperlipidemia patients were aged 61-70 y (29.95-31.46% from 2016 to 2018), and the annual AMI risk in these patients was <1% (0.42-0.68% from 2016 to 2018). The majority of hyperlipidemia patients with AMI were women, and 25.64% were aged 61-70 y. Receiving organic nitrates was associated with lower all-cause mortality rates (HR, 95% CI, p-value = 0.714, 0.674-0.756, p < 0.0001). After multivariate analysis, the overall survival in four groups (beta-blockers, beta-blocker + diuretics, diuretics, and others) receiving an organic nitrate treatment was significantly higher than in the groups that were not treated with organic nitrates (beta-blockers HR = 0.536, beta-blocker + diuretics HR = 0.620, diuretics HR = 0.715, and others HR = 0.690).

CONCLUSIONS

The survival benefit was significantly greater in patients treated with organic nitrates than in those treated without organic nitrates, especially when combined with diuretics. A combination of organic nitrates could be a better treatment option for hyperlipidemia patients with AMI.

Perinatal Taurine Supplementation Prevents the Adverse Effects of Maternal Dyslipidemia on Growth and Cardiovascular Control in Adult Rat Offspring

Maternal dyslipidemia induces metabolic and cardiovascular disorders in adult offspring. This study tests the hypothesis that perinatal taurine supplementation prevents the adverse effects of maternal dyslipidemia on growth and cardiovascular function in adult rat offspring. Female Wistar rats were fed normal rat chow and water with (Dyslipidemia) or without dyslipidemia induction (Control) by intraperitoneal Triton WR-1339 injection, three times a week for 4 weeks. The female Control and Dyslipidemia rats were supplemented with (Control+T, Dyslipidemia+T) or without 3% taurine in water from conception to weaning. After weaning, male and female offspring were fed normal rat chow and water throughout the experiment. At 16 weeks of age, body weights significantly increased in male but not female Dyslipidemia compared to other groups, while visceral fat content significantly increased in both male and female Dyslipidemia groups. Further, both sexes displayed similar high fasting blood sugar and normal plasma leptin levels among the groups. While plasma total cholesterol and triglycerides significantly increased only in female Dyslipidemia, low-density lipoprotein cholesterol increased in both male and female Dyslipidemia groups. Mean arterial pressures and heart rates significantly increased, while baroreflex sensitivity decreased in male and female Dyslipidemia compared to all other groups. High-density lipoprotein cholesterol did not significantly different among male or female groups. These changes of the male and female Dyslipidemia group were ameliorated by perinatal taurine supplementation. The present study indicates that perinatal taurine supplementation prevents the adverse effects of maternal dyslipidemia on growth and cardiovascular function in both male and female, adult offspring.

Oolong Tea Extract and Citrus Peel Polymethoxyflavones Reduce Transformation of l-Carnitine to Trimethylamine-N-Oxide and Decrease Vascular Inflammation in l-Carnitine Feeding Mice

Carnitine, a dietary quaternary amine mainly from red meat, is metabolized to trimethylamine (TMA) by gut microbiota and subsequently oxidized to trimethylamine-N-oxide (TMAO) by host hepatic enzymes, flavin monooxygenases (FMOs). The objective of this study aims to investigate the effects of flavonoids from oolong tea and citrus peels on reducing TMAO formation and protecting vascular inflammation in carnitine-feeding mice. The results showed that mice treated with 1.3% carnitine in drinking water significantly (p < 0.05) increased the plasma levels of TMAO compared to control group, whereas the plasma TMAO was remarkedly reduced by flavonoids used. Meanwhile, these dietary phenolic compounds significantly (p < 0.05) decreased hepatic FMO3 mRNA levels compared to carnitine only group. Additionally, oolong tea extract decreased mRNA levels of vascular inflammatory markers such as tissue necrosis factor-alpha (TNF-α), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin. Polymethoxyflavones significantly lowered the expression of VCAM-1 and showed a decreasing trend in TNF-α and E-selectin mRNA expression compared to the carnitine group. Genus-level analysis of the gut microbiota in the cecum showed that these dietary phenolic compounds induced an increase in the relative abundances of Bacteroides. Oolong tea extract-treated group up-regulated Lactobacillus genus, compared to the carnitine only group. Administration of polymethoxyflavones increased Akkermansia in mice.

Effect of Yoga on Lipid Profile and C-reactive Protein in Women

BACKGROUND

Few scientific studies have been conducted about the effect of yoga on biochemical variables such as total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), and C-reactive protein (CRP) to lay a scientific foundation regarding benefits of yoga, but its effect is not clearly detected yet. This study was conducted to assess the effect of yoga on lipid profile and CRP in women.

METHODS

This research was designed as an interventional study. After reviewing inclusion and exclusion criteria, selected biochemical variables such as TC, HDL-C, LDL-C, TG, and CRP were measured for each participant. Yoga instruction was done three times a week for 26 weeks by an experienced yoga instructor. After 26 weeks of yoga intervention, the above-mentioned dependent variables were assessed. SPSS Ver. 16 was used for data analysis.

RESULTS

After a 26-week follow-up for participants, only 24 women had the necessary criteria to be included in the study. The mean TG was 157.33 ± 68.416 mg/dL and 134.33 ± 58.80 mg/dL before and after the intervention (P = 0.108), respectively. The mean TC was 234.83 ± 48.47 mg/dL and 183.33 ± 55.09 mg/dL before and after the intervention (P = 0.014), respectively. The mean HDL-C was 31.58 ± 14.22 mg/dL and 38.25 ± 13.5 mg/dL before and after the intervention (P = 0.118), respectively. The mean LDL-C was 171.75 ± 42.69 mg/dL and 142.91 ± 36.4 mg/dL before and after the intervention (P = 0.030), respectively. The mean CRP was 0.57 ± 0.22 mg/L and 0.71 ± 0.77 mg/L before and after the intervention (P = 0.779), respectively.

CONCLUSIONS

The result showed that yoga reduced TC and LDL-C significantly, but had no significant effect on TG, HDL-C, and CRP.

2017 Taiwan lipid guidelines for high risk patients

In Taiwan, the prevalence of hyperlipidemia increased due to lifestyle and dietary habit changes. Low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (non-HDL-C) are all significant predicting factors of coronary artery disease in Taiwan. We recognized that lipid control is especially important in patients with existed atherosclerotic cardiovascular diseases (ASCVD), including coronary artery disease (CAD), ischemic stroke and peripheral arterial disease (PAD). Because the risk of ASCVD is high in patients with diabetes mellitus (DM), chronic kidney disease (CKD) and familial hypercholesterolemia (FH), lipid control is also necessary in these patients. Lifestyle modification is the first step to control lipid. Weight reduction, regular physical exercise and limitation of alcohol intake all reduce triglyceride (TG) levels. Lipid-lowering drugs include HMG-CoA reductase inhibitors (statins), cholesterol absorption inhibitors (ezetimibe), proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, nicotinic acids (niacin), fibric acids derivatives (fibrates), and long-chain omega-3 fatty acids. Statin is usually the first line therapy. Combination therapy with statin and other lipid-lowering agents may be considered in some clinical settings. For patients with acute coronary syndrome (ACS) and stable CAD, LDL-C < 70 mg/dL is the major target. A lower target of LDL-C <55 mg/dL can be considered in ACS patients with DM. After treating LDL-C to target, non-HDL-C can be considered as a secondary target for patients with TG ≥ 200 mg/dL. The suggested non-HDL-C target is < 100 mg/dL in ACS and CAD patients. For patients with ischemic stroke or transient ischemic attack presumed to be of atherosclerotic origin, statin therapy is beneficial and LDL-C < 100 mg/dL is the suggested target. For patients with symptomatic carotid stenosis or intracranial arterial stenosis, in addition to antiplatelets and blood pressure control, LDL-C should be lowered to < 100 mg/dL. Statin is necessary for DM patients with CV disease and the LDL-C target is < 70 mg/dL. For diabetic patients who are ≥ 40 years of age, or who are < 40 years of age but have additional CV risk factors, the LDL-C target should be < 100 mg/dL. After achieving LDL-C target, combination of other lipid-lowering agents with statin is reasonable to attain TG < 150 mg/dL and HDL-C >40 in men and >50 mg/dL in women in DM. LDL-C increased CV risk in patients with CKD. In adults with glomerular filtration rate (GFR) < 60 mL/min/1.73m² without chronic dialysis (CKD stage 3-5), statin therapy should be initiated if LDL-C ≥ 100 mg/dL. Ezetimibe can be added to statin to consolidate the CV protection in CKD patients. Mutations in LDL receptor, apolipoprotein B and PCSK9 genes are the common causes of FH. Diagnosis of FH usually depends on family history, clinical history of premature CAD, physical findings of xanthoma or corneal arcus and high levels of LDL-C. In addition to conventional lipid lowering therapies, adjunctive treatment with mipomersen, lomitapide, or PCSK9 inhibitors become necessary to further reduce LDL-C in patients with FH. Overall, these recommendations are to help the health care professionals in Taiwan to treat hyperlipidemia with current scientific evidences. We hope the prescription rate of lipid lowering drugs and control rate of hyperlipidemia in high risk patients could be increased by implementation of the clinical guidelines. The major purpose is to improve clinical outcomes of these high risk patients through the control of hyperlipidemia.

Supervised Phase II Cardiac Exercise Therapy Shortens the Recovery of Exercise Capacity in Patients with Acute Myocardial Infarction

[Purpose] To investigate the effects of Phase II cardiac exercise therapy (CET) on exercise capacity and changes in coronary risk factors (CRFs) of patients with acute myocardial infarction (AMI). [Subjects] Thirty male subjects with AMI were divided into an experimental group (EG) and a control group (CG). Another 30 age-matched subjects with patent coronary arteries served as a normal-control group (NCG). [Methods] Subjects in EG (n=20) trained using a stationary bicycle for 30 min at their target heart rate twice a week for 8 weeks. Exercise capacity was defined as the maximal metabolic equivalents (METs) that subjects reached during the symptom-limited maximal exercise test. HR, BP and RPP were recorded. Subjects in EG and CG received exercise tests and screening for CRFs at the beginning of, end of, and 3 months after Phase II CET, while subjects in NCG participated only in the 1st test. [Results] METs of CG did not improve until the 3rd test, while RPP at the 2nd test showed a significant increase. However, EG showed increased METs at the 2nd test without increase of RPP, and increased their high density lipoprotein cholesterol (HDL-C) during the follow-up period between the 2nd and 3rd tests. [Conclusion] Phase II CET shortens the recovery time of exercise capacity, helps to maintain the gained exercise capacity and increases HDL-C in phase III.

Therapeutic approaches to drug targets in atherosclerosis

Non-communicable diseases such as cancer, atherosclerosis and diabetes are responsible for major social and health burden as millions of people are dying every year. Out of which, atherosclerosis is the leading cause of deaths worldwide. The lipid abnormality is one of the major modifiable risk factors for atherosclerosis. Both genetic and environmental components are associated with the development of atherosclerotic plaques. Immune and inflammatory mediators have a complex role in the initiation and progression of atherosclerosis. Understanding of all these processes will help to invent a range of new biomarkers and novel treatment modalities targeting various cellular events in acute and chronic inflammation that are accountable for atherosclerosis. Several biochemical pathways, receptors and enzymes are involved in the development of atherosclerosis that would be possible targets for improving strategies for disease diagnosis and management. Earlier anti-inflammatory or lipid-lowering treatments could be useful for alleviating morbidity and mortality of atherosclerotic cardiovascular diseases. However, novel drug targets like endoglin receptor, PPARα, squalene synthase, thyroid hormone analogues, scavenger receptor and thyroid hormone analogues are more powerful to control the process of atherosclerosis. Therefore, the review briefly focuses on different novel targets that act at the starting stage of the plaque form to the thrombus formation in the atherosclerosis.

Blood lipid profiles and peripheral blood mononuclear cell cholesterol metabolism gene expression in patients with and without methotrexate treatment

BACKGROUND

Methotrexate (MTX) is the most commonly prescribed disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis. ATP-binding cassette transporter-A1 (ABCA1) and 27-Hydroxylase (HY27) are known antiatherogenic proteins that promote cellular cholesterol efflux. In THP-1 macrophages, MTX can promote the reversal of cholesterol transport, limit foam cell formation and also reverse COX-2 inhibitor-mediated downregulation of ABCA1. Despite its antiatherogenic potential in vitro, the impact of clinical use of low-dose MTX on cholesterol metabolism in humans is unknown. Objective of the study was to examine whether clinical MTX use is associated with altered blood lipids and/or ABCA1/HY27 expressions.

METHODS

In all, 100 rheumatoid arthritis subjects were recruited from a medical center in central Taiwan. Plasma lipid profiles and peripheral blood mononuclear cell HY27 and ABCA1 expressions were compared between subjects taking MTX (MTX+) and other disease-modifying antirheumatic drugs (DMARDs) (MTX-). Dietary intake was assessed by a registered dietician.

RESULTS

Though no difference observed in the blood lipids between MTX+ and MTX- subjects, the expressions of ABCA1 and HY27 were significantly elevated in MTX+ subjects (n = 67) compared to MTX- subjects (n = 32, p < 0.05). ABCA expression correlated with MTX doses (r = 0.205, p = 0.042), and MTX+ subjects are more likely to have increased HY27 compared to MTX- subjects (OR = 2.5, p = 0.038). Prevalence of dyslipidemia and overweight, and dietary fat/cholesterol intake were lower than that of the age-matched population. Although no differences were observed in the blood lipids, the potential impacts of MTX on cholesterol metabolism should not be overlooked and the atheroprotective effects from MTX induced HY27 and ABCA1 expressions may still be present in those persons with pre-existing dyslipidemia.

CONCLUSIONS

We demonstrated novel findings on the increased gene expressions of atheroprotective protein HY27 and ABCA1 in human peripheral blood mononuclear cells (PBMCs) with clinical use of low-dose MTX. Whether MTX induced HY27 and ABCA1 expressions can protect against cardiovascular disease in patients with chronic inflammation through the facilitation of cholesterol export remains to be established. Further studies on the impacts of low-dose MTX on hypercholesterolemic patients are underway.

Hypertension is the most important component of metabolic syndrome in the association with ischemic heart disease in Taiwanese type 2 diabetic patients

BACKGROUND

To evaluate the association between components of metabolic syndrome (MS) and ischemic heart disease (IHD) in Taiwanese patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

A total of 1,296 (604 men and 692 women) subjects with T2DM aged 62.5+/-11.7 (14-87) years were studied. MS was defined using the World Health Organization modified criteria and included more than 2 of hypertension, obesity, dyslipidemia and microalbuminuria. IHD was diagnosed through history or ischemic electrocardiogram according to the Minnesota codes. Results showed that MS was present in 76.2% and IHD in 36.3% of the patients, respectively. MS increased with age for both sexes, but there was no difference between men and women in the age groups of <45, 45-54 and 55-64 years. However, the prevalence of MS was significantly higher in women (87.7% vs 78.0%) in the age group>or=65 years. IHD prevalence was significantly higher in patients with MS, hypertension, dyslipidemia and obesity (p<0.01), and was higher with borderline significance for microalbuminuria (0.05<p<0.1). The respective age-adjusted odds ratios were 3.61 (2.57-5.08), 7.10 (5.38-9.38), 1.70 (1.32-2.18), 1.75 (1.33-2.28), and 1.11 (0.88-1.41).

CONCLUSIONS

The prevalence of MS in subjects with T2DM is high and increases with age. The impact of different risk factors on IHD is diverse, with hypertension being the most important.

Effects of a lifestyle program on risks for cardiovascular disease in women

OBJECTIVE

The aim of this study was to evaluate the effects of a weight reduction lifestyle program on risk factors for cardiovascular disease in women.

MATERIALS AND METHODS

The present study was a pilot clinical trial designed to test the effects of a weight reduction lifestyle program on risk factors for cardiovascular disease in women. Obese and overweight women were recruited from April 2006 to November 2006. The data collected included age, body weight, body mass index (BMI), abdominal circumference, hip circumference, serum lipid profile, as well as levels of high-sensitivity C-reactive protein and homocysteine. The subjects underwent a 3-month lifestyle program, including diet education, balanced diet with caloric restriction of 1,200 kcal/day, aerobic exercise (1 hour) twice weekly and jogging for at least 10,000 steps daily. Physical examination and blood tests were performed at the beginning and at the end of the study.

RESULTS

A total of 29 subjects were included in the present study. Significant reductions were observed in body weight, BMI, abdominal circumference, hip circumference, systolic blood pressure, diastolic blood pressure, fasting insulin, total cholesterol, low-density lipoprotein cholesterol, triglycerides and high-sensitivity C-reactive protein. No significant differences were observed in the levels of fasting sugar, high-density lipoprotein cholesterol or homocysteine.

CONCLUSION

An appropriate weight reduction lifestyle program may effectively reduce body weight and decrease most of the risk factors for cardiovascular disease.

Diabetic nephropathy and risk factors for peripheral artery disease in Chinese with type 2 diabetes mellitus

The risk for peripheral arterial disease (PAD) is increased in patients with chronic kidney disease. We investigated the effects of renal function on PAD in Chinese with type 2 diabetes mellitus. This study enrolled a total of 2983 (1342 men and 1641 women) Chinese adults with diabetes. The mean age was 63.2 +/- 11.9 years. Peripheral arterial disease was diagnosed by an ankle-brachial index less than 0.9. Renal function was evaluated by serum creatinine (SCr), estimated glomerular filtration rate, and urinary albumin-creatinine ratio (ACR). Risk factors for PAD were evaluated using multiple logistic regression analysis. Age, cholesterol, and high-density lipoprotein cholesterol (HDL-C) (inverse association) were significant risk factors in men, whereas age, body mass index (inverse association), low-density lipoprotein cholesterol, and HDL-C (inverse association) were significant risk factors for diabetic women. After adjustment for age, body mass index, blood pressure, glycosylated hemoglobin, cholesterol, HDL-C, low-density lipoprotein cholesterol, and triglyceride levels, we found that SCr levels greater than 1.5 mg/dL, estimated glomerular filtration rate less than 60 mL/min, and urinary ACR greater than 30 mg/g were independent risk factors for PAD in diabetic men and that SCr levels greater than 1.4 mg/dL and urinary ACR greater than 30 mg/g were independently associated with PAD in diabetic women. The risk factors for PAD are somewhat different between men and women with diabetes in Chinese population in Taiwan. Diabetic nephropathy is significantly associated with PAD in this patient population.

Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis from the INTERHEART Study

OBJECTIVES

This study sought to determine the prevalence of lipid and lipoprotein abnormalities and their association with the risk of a first acute myocardial infarction (AMI) among Asians.

BACKGROUND

Patterns of lipid abnormalities among Asians and their relative impact on cardiovascular risk have not been well characterized.

METHODS

In a case-control study, 65 centers in Asia recruited 5,731 cases of a first AMI and 6,459 control subjects. Plasma levels of lipids and apolipoproteins in the different Asian subgroups (South Asians, Chinese, Southeast Asians, and Japanese) were determined and correlated with the risk of AMI.

RESULTS

Among both cases and controls, mean low-density lipoprotein cholesterol (LDL-C) levels were about 10 mg/dl lower in Asians compared with non-Asians. A greater proportion of Asian cases and controls had LDL-C </=100 mg/dl (25.5% and 32.3% in Asians vs. 19.4% and 25.3% in non-Asians, respectively). High-density lipoprotein cholesterol (HDL-C) levels were slightly lower among Asians compared with non-Asians. There was a preponderance of people with low HDL-C among South Asians (South Asia vs. rest of Asia: cases 82.3% vs. 57.4%; controls 81% vs. 51.6%; p < 0.0001 for both comparisons). However, despite these differences in absolute levels, the risk of AMI associated with increases in LDL-C and decreases in HDL-C was similar for Asians and non-Asians. Among South Asians, changes in apolipoprotein (Apo)A1 predicted risk better than HDL-C. ApoB/ApoA1 showed the strongest association with the risk of AMI.

CONCLUSIONS

The preserved association of LDL-C with risk of AMI among Asians, despite the lower baseline levels, suggests the need to rethink treatment thresholds and targets in this population. The low HDL-C level among South Asians requires further study and targeted intervention.

LDLR and ApoB are major genetic causes of autosomal dominant hypercholesterolemia in a Taiwanese population

BACKGROUND/PURPOSE

Autosomal dominant hypercholesterolemia (ADH) is an autosomal dominant inherited disease characterized by an increase in low-density lipoprotein cholesterol levels and premature coronary heart disease, which can be caused by mutations in genes encoding the low-density lipoprotein receptor (LDLR), apolipoprotein B (APOB) and proprotein convertase subtilisin/kexin type 9 (PCSK9). There is scant information with regard to the role played by each gene in the Taiwanese ADH population, especially the newly discovered PCSK9 gene.

METHODS

We used coupling heteroduplex analysis based on a denaturing high performance liquid chromatography system and DNA sequencing to screen for the LDLR gene, APOB gene and PCSK9 gene in 87 ADH cases recruited from 30 unrelated Taiwanese families.

RESULTS

We did not find any mutation-causing variant of the PCSK9 gene in our cases and thus excluded PCSK9 as the major culprit mutation in these families. On the other hand, we identified six previously reported LDLR gene mutations (C107Y, D69N, R385W, W462X, G170X, V408M), two novel LDLR gene mutations (FsG631 and splice junction mutation of intron 10), and one known mutation (R3500W) and one novel missense mutation (T3540M) in the APOB gene that were present in 55 members from 18 ADH families (60%). R3500W, rather than R3500Q, could be the principle mutation responsible for familial defective apolipoprotein B in Taiwanese.

CONCLUSION

The results of our study reveal a characteristic mutation pattern of ADH in Taiwan, mainly in the LDLR and APOB genes. However, PCSK9 gene mutation may not be a major cause of ADH in our study population.

Chronic kidney disease as a risk factor for coronary artery disease in Chinese with type 2 diabetes

BACKGROUND

Chronic kidney disease (CKD) is associated with cardiovascular disease (CVD) in the general population. We investigated the effects of renal function on coronary artery disease (CAD) in Chinese with type 2 diabetes who have a high risk of developing diabetic nephropathy but who may have a low risk of developing CAD.

METHODS

We recruited a total of 2,434 Chinese with type 2 diabetes (1,078 men and 1,356 women) and diagnosed CAD by history or with an abnormal electrocardiogram (coronary probable or possible by Minnesota codes). Renal function was evaluated by serum creatinine (SCr) levels, estimated glomerular filtration rate (eGFR) (calculated by the abbreviated Modification of Diet in Renal Disease Study Croup formula) and urinary albumin/creatinine ratio (ACR).

RESULTS

We found that patients with CAD were older, had higher SCr levels and body mass index (BMI), and had lower serum high-density lipoprotein cholesterol (HDL-c) levels. After adjusting for age, BMI, blood pressure, glycosylated hemoglobin, cholesterol, LDL-c, HDL-c, and triglycerides, we found that SCr levels >1.5 mg/dl, eGFR <60 ml/min, and urinary ACR >30 mg/g were independent risk factors for CAD in diabetic men, and that SCr levels >1.4 mg/dl and eGFR <60 ml/min were independently associated with CAD in women.

CONCLUSION

Our findings indicate that Chinese with type 2 diabetes and CKD are likely to have had CAD previously and CKD is 'CVD risk state' in diabetic Chinese.

Distinct lipid/lipoprotein profiles and hormonal responsiveness in nine ethnic groups of postmenopausal Asian women: the Pan-Asia Menopause (PAM) study

BACKGROUND

Lipid/lipoprotein profiles, among other factors, are associated with risk of cardiovascular disease. Because cardiovascular disease varies in Asian countries, we hypothesized that lipid profiles differ in ethnic groups of postmenopausal Asian women. To add to the limited body of information currently available, we also investigated the effects of estrogen/progestin therapy on lipid/lipoprotein profiles in postmenopausal Asian women.

METHODS

The Pan-Asia Menopause (PAM) study was a prospective, randomized, double-blind clinical trial evaluating 1028 postmenopausal women at 22 investigational centers in 11 Asian countries/territories. Subjects were randomly assigned to one of three doses of continuous combined conjugated estrogens (CE)/medroxyprogesterone acetate (MPA): CE/MPA (in mg/day) = 0.625/2.5, 0.45/1.5 or 0.3/1.5. The treatment period, following baseline evaluations, consisted of six continuous 28-day cycles. Analysis of lipid profiles was a secondary objective of the PAM study. Total cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), very low density cholesterol (VLDC-C), triglycerides and lipoprotein(a) were analyzed at a central laboratory by state-of-the-art methods.

RESULTS

Mean concentrations of total cholesterol, LDL-C, VLDL-C and triglycerides differed significantly among the nine ethnic groups of postmenopausal women. This difference was independent of body mass index and age, two factors that also influenced lipid/lipoprotein profiles. Mean HDL-C concentrations also differed, but this difference was influenced by body mass index in a weak interaction. All three doses of CE/MPA significantly lowered total cholesterol. Treatment with the high and middle doses significantly lowered LDL-C, and increased HDL-C, VLDL-C and triglycerides. The high dose produced a significant decrease in lipoprotein(a).

CONCLUSIONS

The different lipid/lipoprotein profiles in the nine ethnic groups of postmenopausal Asian women evaluated here suggest a relationship to differences in the prevalence of cardiovascular disease reported for different regions in Asia. However, the reported prevalence data on cardiovascular disease morbidity and mortality in the regions corresponding to the nine ethnic groups are insufficient to allow qualitative comparisons with the lipid profiles shown in our study. The lipid/lipoprotein changes in response to estrogen/progestin therapy observed here are consistent with those reported for Western women.

Plasma lipid, lipoprotein and apolipoprotein levels in a random population sample of 2875 Hong Kong Chinese adults and their implications (NCEP ATP-III, 2001 guidelines) on cardiovascular risk assessment

The age- and sex-related levels of plasma lipids, lipoproteins and apolipoproteins in a random population sample of 2875 Hong Kong Chinese Adults (1397 men and 1478 women aged 25-74) and their implications on cardiovascular risk assessment are reported. Total cholesterol, low-density lipoprotein (LDL)-cholesterol and triglycerides increased with age in both sexes. Postmenopausal women had the worst profiles. They also showed higher triglyceride and non-high density lipoprotein (non-HDL)-cholesterol and had higher percentage of values greater than the desirable limits, compared with men of the same age groups. Overall 39% of men and 29% of women had non-HDL cholesterol of 4.2 mmol/L or greater. Apolipoproteins A-I and B followed the same trends as HDL-cholesterol and LDL-cholesterol, respectively. Apolipoprotein E (apo E) allele frequencies were: epsilon2 8.7, epsilon3 80.4 and epsilon4 10.9% with the genotype having a significant effect on plasma apo E concentration (p < 0.001). Carriers of the epsilon2 allele had higher apo E values than those homozygous for E3. Lipoprotein(a) levels were higher in women than men (geometric mean 152 versus 102 mg/L, p < 0.05) and in women with FSH above versus below 40 IU/L (185 versus 136 mg/L, p < 0.05). With respect to the NCEP ATP-III 2001 guidelines, the prevalence of hyperlipidemia in the Hong Kong population approached those in high CHD prevalence Caucasian communities. Local management guidelines and community-wide programs to reduce fat intake, increase regular moderate exercise and reduce the prevalence of overweight and obesity are urgently required, and hormone replacement therapy for postmenopausal women might be warranted.

Secular trends in coronary heart disease mortality, hospitalization rates, and major cardiovascular risk factors in Taiwan, 1971-2001

BACKGROUND

While mortality from coronary heart disease (CHD) has declined substantially in most developed countries in recent decades, discordant rising trends have been observed in many developing and newly developed countries. In this study, we examined the trends of CHD mortality and its hospitalization rate, and correlated the trends with changes in major cardiovascular risk factors in Taiwan.

METHODS

Mortality data during the period 1971-2001 were obtained from official vital statistics. Hospitalization rates were calculated using information extracted from the National Health Insurance Database, which was available from 1996 to 2001. Changes in major cardiovascular risk factors were obtained from official statistics and review of previous epidemiologic studies.

RESULTS

In 2001, the age-standardized CHD mortality in Taiwan was 28.7 per 100,000 for men and 15.5 per 100,000 for women. For both men and women, age-adjusted CHD mortality increased slowly but steadily from 1971 to 1992, but after that, a downward trend was observed. Hospitalization rates for CHD, however, increased substantially from 1996 to 2001. Levels of per-capita cigarette consumption, dietary fat intake, body mass index, and prevalence of hypertension and diabetes had all increased over the past three decades.

CONCLUSIONS

The overall cardiovascular risk profile has worsened in the general population in Taiwan. The decline in CHD mortality observed in recent years was most likely attributable to the improvement in acute cardiac care and medical treatment among patients with CHD. We anticipated that CHD incidence and prevalence would continue to rise in Taiwan.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Risk Factors for Cardiovascular Disease in the Elderly in Taiwan

The major objective of the present study was to identify biologic and behavioral risk factors of cardiovascular disease (CVD) in the elderly population in Taiwan. It is hypothesized that the selected risk factors are significantly associated with the prevalence of CVD. Data came from a nationwide geriatric survey in 1991. Stratified proportional sampling was used to recruit 2,600 subjects. These were evaluated by family physicians working for the Departments of Family Medicine at four medical centers in four major cities in Taiwan. Univariate and multivariate logistic regression analyses were used to examine the associations between risk factors and the prevalence of CVD. The prevalence of CVD was 38.31%. Patients with CVD consistently had higher values for each selected risk factor except high-density lipoprotein-cholesterol (HDL-C) and glucose concentrations. The findings also indicated that hypertension, hypertriglyceridemia, low HDL-C concentration, ex-drinking status, and overweight were significantly associated with the prevalence of CVD among the elderly in Taiwan. The findings not only confirm the risk factors for CVD, but also invite more attention to be given to the importance of biologic and behavioral risk factors in CVD.

Prevalence of erectile dysfunction and impacts on sexual activity and self-reported intercourse satisfaction in men older than 40 years in Taiwan

In order to assess the prevalence of erectile dysfunction (ED), and its association with chronic diseases and impact upon sexual activity and satisfaction during sexual intercourse, a reproductive survey was conducted among 1002 Taiwanese men aged over 40 y. The information collected comprised age, gender, level of education, history of chronic diseases, and self-reported data pertaining to erectile function, sexual activity, and sexual satisfaction during sexual intercourse. The prevalence of ED amongst study subjects was 17.7%, and the frequency increased with age. A history of chronic diseases were significantly associated with ED (P<0.05). A reduced incidence of sexual activity and a decreased level of satisfaction during sexual intercourse were observed among subjects suffering from ED as compared to those not suffering such a condition. In conclusion, based upon the results of a community-based survey the prevalence of ED among Taiwanese men aged 40 y or more was 17.7% and it increased with age. It was also found that ED was associated with various chronic diseases and that it exerted a negative impact upon sexual activity and the level of satisfaction associated with its conduct.

Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study

The purpose of the study was to compare nutrient intakes among Chinese, Japanese, UK, and US INTERMAP samples, and assess possible relationships of dietary patterns to differential patterns of cardiovascular diseases between East Asian and Western countries. Based on a common Protocol and Manuals of Operations, high-quality dietary data were collected by four standardized 24-h dietary recalls and two 24-h urine collections from 17 population samples in China (three samples), Japan (four samples), UK (two samples), and USA (eight samples). There were about 260 men and women aged 40-59 years per sample--total N=4680. Quality of dietary interview and data entry were monitored and enhanced by extensive systematic ongoing quality control procedures at local, country, and international level. Four databases on nutrient composition of foods from the four countries were updated and enhanced (76 nutrients for all four countries) by the Nutrition Coordinating Center, University of Minnesota, in cooperation with Country Nutritionists. The mean body mass index was much higher for Western than East Asian samples. Macronutrient intakes differed markedly across these samples, with Western diet higher in total fat, saturated and trans fatty acids, and Keys dietary lipid score, lower in total carbohydrate and starch, higher in sugars. Based on extensive published data, it is a reasonable inference that this pattern relates to higher average levels of serum total cholesterol and higher mortality from coronary heart disease in Western than East Asian populations. The rural Chinese diet was lower in protein, especially animal protein, in calcium, phosphorus, selenium, and vitamin A. Dietary sodium was higher, potassium lower, hence Na/K ratio was higher in the Asian diet, especially for Chinese samples. This pattern is known to relate to risks of adverse blood pressure level and stroke. At the end of the 20th century, East Asian and Western diets remain significantly different in macro- and micronutrient composition. Both dietary patterns have aspects that can be regarded, respectively, as adverse and protective in relation to the major adult cardiovascular diseases. In both Asian and Western countries, public efforts should be targeted at overcoming adverse aspects and maintaining protective patterns for prevention and control of cardiovascular diseases.

Genetic analysis of a polymorphism in the human apoA-V gene: effect on plasma lipids

Recent discovery and characterization of APOAV suggests a role in metabolism of triglyceride (TG)-rich lipoproteins. Previously, variation at the APOAV locus was shown to modestly influence plasma TGs in normolipidemic samples. The aims of this study were to assess the effects of a polymorphism in APOAV (T-1131C) in terms of its frequency among three dyslipidemic populations and a control population, differences of allele frequency across available ethnic groups, and associations with specific lipoprotein TG and cholesterol compartments. We found a striking elevation in the frequency of the rare allele in a Chinese population (P = 0.0002) compared with Hispanic and European populations. The rare allele of the polymorphism was associated with elevated plasma TG (P = 0.012), VLDL cholesterol (P = 0.0007), and VLDL TG (P = 0.012), LDL TG (P = 0.003), and HDL TG (P = 0.016). Linear regression models predict that possession of the rare allele elevates plasma TG by 21 mg/dl (P = 0.009) and VLDL cholesterol by 8 mg/dl (P = 0.0001), and reduces HDL cholesterol by 2 mg/dl (P = 0.017). The association of the polymorphism with altered lipoprotein profiles was observed in combined hyperlipidemia, hypoalphalipoproteinemia, and hyperalphalipoproteinemia, and in controls. These findings indicate that APOAV is an important determinant of plasma TG and lipoprotein cholesterol, and is potentially a risk factor for cardiovascular disease.

Body composition as a risk factor for coronary artery disease in Chinese type 2 diabetic patients in Taiwan

This study aimed to clarify whether body mass index (BMI), waist/hip ratio (WHR) or percent body fat (%fat) is associated with coronary artery disease (CAD) in Chinese type 2 diabetic patients in Taiwan. A total of 463 patients were recruited. BMI and WHR were measured by standard methods and %fat by bioelectrical impedance. CAD was diagnosed as acute myocardial infarction, angina pectoris, or an electrocardiogram showing 'coronary probable or possible' according to the Minnesota codes. Age, sex, diabetes duration, hypertension, smoking, fasting plasma glucose, hemoglobin A(1c),and serum concentrations of total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol were treated as confounders. Results showed that 144 patients had CAD. Age, hypertension, HDL-C and %fat were independently associated with CAD. CAD prevalence was 25.5%, 26.8%, 31.9% and 43.0%, respectively, for the first to fourth quartile of %fat (p<0.05). Multivariate-adjusted odds ratio for CAD for every 1% increase in %fat was 1.02 (1.01-1.03); and 1.01 (0.73-1.88), 1.26 (0.69-2.32) and 2.11 (1.09-4.07) for the second to fourth quartile, respectively, compared with the first quartile. BMI and WHR were not associated with CAD in similar analyses. In conclusion, %fat was a better predictor for CAD than BMI and WHR in Chinese type 2 diabetic patients in Taiwan.

Joint effects of alcohol consumption and cigarette smoking on atherogenic lipid and lipoprotein profiles: results from a study of Chinese male population in Taiwan

BACKGROUND

The present study examines the effect of joint exposure to cigarette smoking and alcohol intake on serum levels of total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and triglyceride (TG) among Chinese male adults in Taiwan.

METHODS

A sample of 3311 men aged 20-59 years who reported having stable smoking and drinking behaviors during the period between January 1995 and December 1996 was selected from a periodic health checkup population. Serum lipids and lipoprotein cholesterol fractions were measured on fasting blood samples taken from participants. Statistical methods of analysis of variance and analysis of covariance were conducted to examine the associations of different smoking-drinking behavioral patterns with lipid and lipoprotein levels.

RESULTS

In the observed population, the percentages of men who had stable cigarette smoking and alcohol consumption behaviors were 39.5% (1,307/3,311) and 27.0% (895/3,311), respectively. Mean values of TC and TG increased significantly and monotonically with increasing levels of cigarette smoking and alcohol consumption. In addition, alcohol intake was significantly associated with increased HDL-C and reduced LDL-C levels in a dose-dependent manner. More interestingly, the effect of alcohol consumption on LDL-C (negative) and TG (positive) levels was substantially greater for heavy smoker (>20 cigarettes/day) than for light smokers (< or = 20 cigarettes/day) and non-smokers, while alcohol intake exerted a strong positive influence on HDL-C concentration regardless of levels of cigarette smoking.

CONCLUSIONS

In this Chinese male population, cigarette smoking and alcohol consumption were confirmed to have similar effects on lipid and lipoprotein levels as in Caucasians. More interestingly, a significance of joint exposure to smoking and drinking in predicting lipid and lipoprotein levels was evident. These data indicate the importance of multifactorial interventions to obtain more favorable lipid and lipoprotein levels in the population.

Reducing the global burden of cardiovascular disease: the role of risk factors

During the last century, cardiovascular disease (CVD) has burgeoned from a relatively minor disease worldwide to a leading cause of morbidity and mortality. By 2020 it is projected that CVD will surpass infectious disease as the worlds leading cause of death and disability. Some of this increase in the relative importance of CVD is due to improved public health measures and medical care leading to longer life spans and reduced mortality from other causes. However, a substantial portion of the increasing global impact of CVD is attributable to economic, social, and cultural changes that have led to increases in risk factors for CVD. These changes are most pronounced in the countries comprising the developing world. Because the majority of the worlds population lives in the developing world, the increasing rate of CVD in these countries is the driving force behind the continuing dramatic worldwide increase in CVD. In order to blunt the impact of the global explosion in CVD, it will be crucial to attempt to understand and reduce the global increase in CVD risk factors. In this review, the authors describe the changes responsible for the global epidemic of CVD, with particular attention to the contributions of established risk factors and their impact on the growth of CVD among the worlds various economic sectors. The authors outline the major challenges facing countries in different economic sectors, and discuss ways to address these challenges with the goal of reducing the global burden of CVD.

Homocysteine, vitamin B(6), and lipid in cardiovascular disease

OBJECTIVES

Elevated homocysteine (Hcy) is considered an independent risk factor for cardiovascular disease (CVD). An elevated plasma Hcy level may interact with conventional CVD risk factors to further increase vascular disease risk. Therefore, we investigated the plasma levels of Hcy, vitamin B(6) status (pyridoxal phosphate and pyridoxal), and lipid profile in patients with CVD.

METHODS

Possible associations between sex, age, body mass index (BMI), and waist-to-hip ratio (WHR) to levels of plasma Hcy and plasma Hcy to vitamin B(6) status and lipid profile were examined.

RESULTS

Plasma Hcy level, body mass index, and waist-to-hip ratio were significantly higher in patients with CVD than in controls. Male CVD patients had significantly higher plasma Hcy levels than did female patients. Plasma levels of pyridoxal phosphate and total B(6) aldehyde were significantly higher in male than in female patients. Plasma Hcy levels of patients did not correlate to their plasma vitamin B(6) status or to their lipid profiles. Plasma Hcy level correlated positively with age, body mass index, and waist-to-hip ratio (P < 0.0001).

CONCLUSIONS

This suggested that patients with CVD have higher levels of plasma Hcy that are influenced by sex, age, body mass index, and waist-to-hip ratio and not by their plasma vitamin B(6) status and lipid profiles.

Rates and characteristics of lower limb amputations in Taiwan, 1997

This study aims to describe the national incidence rate and characteristics of lower limb amputations (LLA) in 1997 from an island-wide database of the national health insurance programme in Taiwan. Some 117,647 discharge records from a sampled database (1 in 20) of the National Health Insurance Research Database were analysed. This study included records (n=171) containing LLA procedures. The LLA procedure rates were obtained by multiplying the number of identified procedures by 20 as the numerator and mid-year total population of Taiwan in 1997 as the denominator. Each procedure was further analysed according to the demographic characteristics of the patients, cause and level of amputation. Summarised gender ratios of LLA procedure rates were obtained by Poisson regression analysis. The crude LLA procedure rate was 18.1 per 100,000 population per year and the crude major LLA procedure rate was 8.8 per 100,000 population per year in Taiwan in 1997. The major cause of LLA procedures was peripheral vascular disease (72%), and the toe was most frequently amputated (48%). The LLA procedure rates, which increased logarithmically with age of patients, were significantly higher in men with a summarised male to female rate ratio of 1.65. The age-standardised LLA procedure rate in Taiwan was lower than that reported in the United States, Finland, the Netherlands, the United Kingdom (Leeds, Middlesborough, and Newcastle), but higher than Spain, Italy, and Japan. The trend of an increasing proportion of PVD-related LLA procedures will prompt the health professionals to develop strategies for LLA prevention.

Apolipoprotein A-I and B and stroke events in a community-based cohort in Taiwan: report of the Chin-Shan Community Cardiovascular Study

BACKGROUND AND PURPOSE

There are limited prospective cohort studies of the well-known association between stroke events and serum lipids for the Taiwanese population, in whom stroke is the second most common cause of death.

METHODS

This report describes the effect of dyslipidemia on the risk of stroke in a community-based cohort consisting of 3602 adults aged > or =35 years, established in 1990 in the Chin-Shan community in Taipei County, Taiwan.

RESULTS

As of the end of 1998, 97 stroke incidence cases were identified from medical records and death certificates (53 in men and 44 in women). The female-to-male stroke event rates increased from 0.42 in the youngest group (aged 35 to 44 years) to 1.38 in the oldest (aged > or =75 years). Multiple Cox proportional hazard regression models controlling for age and sex revealed that individuals with serum apolipoprotein A-I (apoA-I) at the highest quartile were more likely to have a stroke event than those at the lowest quartile level (relative risk [RR]=2.02, P for trend=0.010). The corresponding risk of stroke predicted by apolipoprotein B (apoB) was also significant (RR=1.88, P for trend=0.020). After adjustment for age, sex, hypertension, and diabetes status, the interaction between hypertension and apoA-I level remained significant in predicting stroke events in men but not in women (RR=1.71, P=0.033 in men; RR=2.29, P=0.071 in women).

CONCLUSIONS

We conclude that apoA-I but not apoB levels may serve as an effect modifier of hypertension for the risk of stroke events.

Efficacy of cholesterol levels and ratios in predicting future coronary heart disease in a Chinese population

In this study, we assessed the efficacy of various lipid and lipoprotein measurements at baseline for predicting the risk for coronary heart disease (CHD) and determined the associated risk of CHD in subgroups stratified by different lipid and lipoprotein screening strategies to evaluate the adequacy of current total and low-density lipoprotein (LDL) cholesterol-based approaches in lipid management. We analyzed data from the Chin-Shan Community Cardiovascular Cohort study, a Chinese population-based prospective cohort study that began in 1990. During an 8-year follow-up period, 213 of 3,159 participants (6.7%) without CHD (aged > or =35 years) developed CHD. The total cholesterol/high-density lipoprotein (HDL) cholesterol ratio was the most powerful lipoprotein predictor of future CHD (hazard ratio 1.21 for a 1.0 increment in ratio; p <0.001). Subjects with "high-risk" LDL cholesterol levels (>160 mg/dl) and low total cholesterol/HDL cholesterol ratios (< or =5) had an incidence of CHD similar to those with low levels of both LDL cholesterol (< or =130 mg/dl) and total cholesterol/HDL cholesterol ratios (4.9% vs 4.6%). In contrast, subjects with "low-risk" LDL cholesterol levels (< or =130 mg/dl) and high total cholesterol/HDL cholesterol ratios (>5) had a 2.5-fold higher incidence of CHD than those with similar LDL cholesterol levels but low total cholesterol/HDL cholesterol ratios (p <0.001). Compared with using an LDL cholesterol level of 130 mg/dl as the cut-off point, using a total cholesterol/HDL cholesterol ratio of 5 was associated with superior specificity (73% vs 59%, p <0.001) and accuracy (72% vs 58%, p <0.001), and similar sensitivity (50% vs 53%). Our data indicate that current guidelines for lipid management may misclassify subjects with high levels of HDL and LDL cholesterol as well as those with low levels of HDL and LDL cholesterol. Using the ratio of total to HDL cholesterol as the initial screening tool can obviate this discrepancy.

Moyamoya syndrome in a patient with congenital human immunodeficiency virus infection

A 10-year-old boy with congenital human immunodeficiency virus (HIV) infection developed recurrent episodes of left hemiparesis at age 7 years. The progression of his disease was followed by computed tomography, magnetic resonance imaging, magnetic resonance angiography, and cerebral angiography. The series of images showed progressive stenosis of both carotid arteries at the suprasellar origin with involvement of his anterior and middle cerebral arteries, while prominent collateral vessels developed from his external carotid supply through ophthalmic and middle meningeal arteries. The pattern of cerebrovascular disease is consistent with moyamoya syndrome. We suggest that further studies on the pathophysiology of cerebrovascular disease in patients with HIV could be helpful in understanding the cause of moyamoya disease as well. Also, with the various advances in treatment of HIV, neurovascular complications could be seen more frequently as the long-term survival in these patients improves.

Analysis of serum lipid levels in Japanese men and women according to body mass index. Increase in risk of atherosclerosis in postmenopausal women. Research Group on Serum Lipid Survey 1990 in Japan

Relatively low serum lipid levels are thought to be an important factor contributing to the low incidence of ischemic heart diseases (IHD) in Japanese. It has been proven that obesity or overweight constitutes a basal condition for several risk factors in atherosclerosis. The purpose of this study is to obtain data on serum lipids and lipoprotein profiles in relation to body mass index (BMI), which will enable us to compare the nature and weight of metabolic risk factors in atherosclerosis between Japanese and people in Western countries. Data of total serum cholesterol, triglyceride, and HDL-cholesterol levels of Japanese men and women obtained from a large-scale survey in 1990 were analysed according to BMI for different age groups. Apolipoprotein A-I and B and Lp(a) were also measured in randomly selected samples and their contribution as a risk factor was estimated especially in postmenopausal women. The subjects in two age groups of men (20-39 and 40 59 years) and women (20 39 and 50-69 years) were graded into quintiles according to the BMI. The middle grades of BMI were 21.9-23.3 and 22.4-23.6 for younger and older men, and 20.0-21.1 and 22.2-23.6 for younger and older women, respectively. These values are much lower than those in Western populations, the border between the IVth and the top quintile almost corresponding to the average for Americans. Total cholesterol showed a tendency to shift into higher ranges in all age groups in both men and women as BMI increased, with the highest distribution remaining in the range of 160-199 mg/dl (4.2-5.2 mmol/l). The average cholesterol levels for the top quintile of BMI were still lower than most of the average values in Western populations. The distribution of cholesterol in higher ranges was much greater and the difference according to BMI was smaller in older women than in men. In both men and women, whether younger or older, about 90% of the subjects in the lower quintiles of BMI had triglyceride levels lower than 150 mg/dl. The distribution in the higher range of triglyceride was small in women, not only at younger ages but also in postmenopausal women at the top quintile of BMI. About 85% of the younger women with a middle grade of BMI had an HDL-cholesterol level higher than 50 mg/dl. The values in postmenopausal women were still higher than in men aged 40-59 years. Shift of the distribution curves of HDL-cholesterol according to BMI was similar in all groups and more remarkable than the change in triglyceride. The average HDL-cholesterol levels at the top quintile were almost comparable to the average values in Western countries; the difference in HDL-cholesterol levels between the two populations can mostly be explained by the difference in BMI. Smokers showed a slightly lower total cholesterol and significantly (3-4 mg/dl) lower HDL-cholesterol levels, although there was no difference in distribution of BMI between smokers and non-smokers. Relatively low total cholesterol levels even in smokers has probably contributed to the low incidence of IHD in spite of the high frequency of smoking in Japanese population. Mean Lp(a) levels showed a tendency to increase after age 40 in women. BMI itself did not have a correlation with serum Lp(a) levels. The distribution curve of Lp(a) shifted to higher levels as total cholesterol increased and the tendency was most remarkable in women around or after the menopause. It was remarkable in older women that as the total cholesterol or apo B level increased there was also an increased prevalence of abnormal ECG with a pattern of myocardial ischemia. Postmenopausal women seem to have a great risk of atherosclerosis regarding the lipid and lipoprotein profile even in the Japanese population.

Association of apolipoprotein E polymorphism and concentration with serum lipids and apolipoprotein level in the Chinese from Shanghai

The influence of apolipoprotein E polymorphism and apoE level on serum lipids and apolipoproteins was investigated in 71 healthy people and 43 patients with coronary artery disease from Shanghai. The frequency of apoE alleles was 0.06 for epsilon2, 0.86 for epsilon3, and 0.07 for epsilon4 in the healthy group, and 0.14 for epsilon2, 0.77 for epsilon3, and 0.09 for epsilon4 in the coronary artery disease group. There was no significant difference in the frequency of apoE alleles between these two groups. Serum levels of triglyceride and apo AI did not differ according to apoE genotypes, whereas serum level of apoB was significantly different according to apoE genotypes (p<0.05) both in healthy and coronary artery disease groups. However, in the healthy group, apo epsilon2 allele carriers had significantly higher level of apoE than apo epsilon3 and epsilon4 allele carriers (p<0.001) and apo epsilon4 allele carriers had significantly higher level of total cholesterol than apo epsilon3 and epsilon2 allele carriers. These were not observed in the coronary artery disease group. ApoE concentration was positively correlated with cholesterol, apoAI, and apoB levels in the control subjects and no significant correlation was observed with triglyceride level. In contrast, apoE level was positively related only to triglyceride level in the coronary artery disease group. In the control group, apoE genotypes and apoE level explained together 19.3% and 26.6% of the variability of apoB and cholesterol level, respectively, apoE polymorphism explained 23% of the variability of apoE level and apoE level explained 13.2% of the variability of apoAI level. In the coronary artery disease group, only apoE level explained 41.7% of triglyceride variability. Finally we compared our results with those previously obtained in a French healthy population, the Stanislas cohort. Results suggested that there were some difference between the Chinese control and the French subjects.

Epidemiology of cardiovascular risk factors in Hong Kong

1. To facilitate the development of appropriate population-wide coronary heart disease prevention strategies and to monitor their long-term impact, a comprehensive baseline Hong Kong Cardiovascular Risk Factor Prevalence Study was conducted in 1995-96. 2. The data obtained from 2875 men and women aged 25-74 years showed a high prevalence of diabetes mellitus and impaired glucose tolerance, particularly in those aged 65 years and over. Other risk factors, such as hypercholesterolaemia and hypertension as well as being overweight, were particularly prominent in older women.

The prevalence of insulin resistance and other cardiovascular disease risk factors in healthy elderly southwestern Nigerians

We assessed the prevalence of coronary heart disease (CHD) risk factors including insulin resistance in 500 (205 males, 295 females) healthy elderly (age > 55 years) indigenous, low socioeconomic group Yorubas residents in either an urban slum (n = 240) or a rural town (n = 260) in southwestern Nigeria. Anthropometric indices, blood pressure and fasting plasma levels of glucose, lipids, insulin and insulin resistance were measured. The results indicated that: (i) gross obesity (4.4%), diabetes (1.6%), hyperlipidaemia (0.2%) and cigarette smoking (4.8%) were relatively uncommon in the population, although the prevalence of hypertension (30%) was higher than previously reported from this population; (ii). the subjects had a relatively high prevalence of multiple CHD risk factors (about 20% had > 4 risk factors), an observation considered paradoxical in view of the reportedly low CHD prevalence in this population; (iii) these CHD risk factors (increased body mass and blood pressure (BP), hyperinsulinaemia and insulin resistance) were more prevalent in the women and in urban residents; (iv) hyperinsulinaemia (20%) and insulin resistance (35%) were common in the population, and were associated, on regression analyses, to such other CHD risk factors as BP and body mass, particularly in women, suggesting, as in Caucasians, that insulin resistance could be an important index of CHD risk; and (v) the excess of multiple CHD risk factors in the women, is due at least in part, to their increased tendency to obesity (8%) and reduced physical activity (83%). This study concludes that: (i) despite the high prevalence of multiple risk factors in this population, CHD prevalence is low, indicating the supremacy of such major risk factors as diabetes and hyperlipidaemia (relatively uncommon here) in the development of CHD; and (ii) potentially the greatest CHD risk is in the elderly women especially if relatively overweight, physically inactive and resident in an urban centre. While further confirmatory studies are necessary in younger subjects and across societal socioeconomic strata, our results nonetheless suggest that attempts to maintain the CHD prevalence at low levels in this population should include efforts directed at reducing excess body weight particularly in women, and advice on maintenance of a traditional diet to keep lipid levels and diabetes prevalence low.