Trends in hypercholesterolemia, treatment and control among United States adults

Recaticimab Monotherapy for Nonfamilial Hypercholesterolemia and Mixed Hyperlipemia: The Phase 3 REMAIN-1 Randomized Trial

BACKGROUND

Monoclonal antibodies against proprotein convertase subtilisin/kexin type 9 (PCSK9) have been used to reduce the level of low-density lipoprotein cholesterol (LDL-C), but require either biweekly or monthly dosing frequency. Recaticimab is a new humanized monoclonal antibody selectively targeting PCSK9, with long-acting characteristic.

OBJECTIVES

The purpose of this study was to assess the efficacy and safety of recaticimab monotherapy in patients with nonfamilial hypercholesterolemia and mixed hyperlipemia at low-to-moderate atherosclerotic cardiovascular disease (ASCVD) risk, and to explore different dosing strategies to provide patients with flexible administration options.

METHODS

This was a randomized, double-blind, placebo-controlled, phase 3 study conducted at 59 sites in China. Patients with fasting LDL-C ≥2.6 to <4.9 mmol/L, fasting triglyceride ≤5.6 mmol/L, and 10-year ASCVD risk score <10% were randomly assigned (2:2:2:1:1:1) to receive subcutaneous injections of recaticimab at 150 mg every 4 weeks (Q4W), 300 mg every 8 weeks (Q8W), or 450 mg every 12 weeks (Q12W), or matching placebo, on background lipid-lowering diet. Primary endpoint was percentage change in LDL-C from baseline to week 12 for 150 mg Q4W and 450 mg Q12W and to week 16 for 300 mg Q8W.

RESULTS

A total of 703 patients underwent randomization and received recaticimab (n = 157, 156, and 155 for 150 mg Q4W, 300 mg Q8W, and 450 mg Q12W, respectively) or placebo (n = 78, 79, and 78, respectively). Compared with placebo, recaticimab further reduced LDL-C by 49.6% (95% CI: 44.2%-54.9%) at 150 mg Q4W, 52.8% (95% CI: 48.3%-57.2%) at 300 mg Q8W, and 45.0% (95% CI: 41.0%-49.0%) at 450 mg Q12W (P < 0.0001 for all comparisons). Safety with recaticimab was comparable to placebo. After 12 or 16 weeks of treatment, patients who received recaticimab continued treatment until week 24, whereas those allocated to placebo were switched to recaticimab treatment with the same dosing strategy. Both 24-week recaticimab and 12- or 8-week recaticimab switched from placebo were effective. With 24 weeks of recaticimab treatment, the most common treatment-related adverse event was injection site reaction (n = 23 [4.9%]).

CONCLUSIONS

Recaticimab monotherapy yielded significant LDL-C reductions and showed comparable safety vs placebo in patients with nonfamilial hypercholesterolemia and mixed hyperlipemia at low-to-moderate ASCVD risk, even with an infrequent dosing interval up to Q12W.

A historical, evidence-based, and narrative review on commonly used dietary supplements in lipid-lowering

Dietary supplements augment the nutritional value of everyday food intake and originate from the historical practices of ancient Egyptian (Ebers papyrus), Chinese (Pen Ts'ao by Shen Nung), Indian (Ayurveda), Greek (Hippocrates), and Arabic herbalists. In modern-day medicine, the use of dietary supplements continues to increase in popularity with greater than 50% of the US population reporting taking supplements. To further compound this trend, many patients believe that dietary supplements are equally or more effective than evidence-based therapies for lipoprotein and lipid-lowering. Supplements such as red yeast rice, omega-3 fatty acids, garlic, cinnamon, plant sterols, and turmeric are marketed to and believed by consumers to promote "cholesterol health." However, these supplements are not subjected to the same manufacturing scrutiny by the Food and Drug Administration as pharmaceutical drugs and as such, the exact contents and level of ingredients in each of these may vary. Furthermore, supplements do not have to demonstrate efficacy or safety before being marketed. The holistic approach to lowering atherosclerotic cardiovascular disease risk makes dietary supplements an attractive option to many patients; however, their use should not come at the expense of established therapies with proven benefits. In this narrative review, we provide a historical and evidence-based approach to the use of some dietary supplements in lipoprotein and lipid-lowering and provide a framework for managing patient expectations.

Trends in total cholesterol control among American adults with hypercholesterolemia, 1988-2018

BACKGROUND AND AIMS

Cholesterol control and management in patients with hypercholesterolemia are significant for the primary and secondary prevention of atherosclerotic cardiovascular disease. This study analyzed the trend of serum total cholesterol (TC) control (<240 mg/dL and <200 mg/dL) in American adults with hypercholesterolemia and thereby make some effective recommendations for the public health measures.

METHODS AND RESULTS

Basing on the National Health and Nutrition Examination Survey (NHANES) data from 1988 to 2018 (12 cycles), we calculated the weighted and representative rate of patients with hypercholesterolemia who had controlled TC, and then described the trend. Among the adults with hypercholesterolemia, the age-adjusted rate of those whose TC was less than 240 mg/dL increased from 7.67% (95%CI: 5.94%-9.40%) in 1988-1991 to 58.52% (95%CI: 55.89%-61.15%) in 2013-2014 and then remained stable; and the age-adjusted rate of those whose TC was less than 200 mg/dL increased from 2.49% (95%CI: 1.48%-3.50%) in 1988-1991 to 44.58% (95%CI: 40.00%-49.16%) in 2017-2018.

CONCLUSION

We concluded that the rate of controlling TC below 200 mg/dL among all patients had shown an increasing trend from 1988 to 2018 in America, while the rate of controlling TC below 240 mg/dL remained stable in recent years after an increasing.

Prevalence, awareness, treatment, and control of dyslipidemia in Chinese adults: a systematic review and meta-analysis

Background

Researchers have conducted a considerable number of epidemiological studies on dyslipidemia in China over recent years. Nevertheless, a representative study to comprehensively appraise for the epidemiological status of dyslipidemia is still lacked. This meta-analysis is intended to explore the pooled prevalence, rates of awareness, treatment, and control of dyslipidemia among adults in Chinese Mainland.

Materials and methods

A systematic review was performed on relevant cross-sectional studies published since January 2012 by searching six authoritative literature databases. Meta-analyses were conducted in included studies based on a random-effect model to summarize the epidemiological status of dyslipidemia in China. A potential source of heterogeneity was detected by subgroup analysis and meta-regression. Publication bias was assessed by Egger's test and funnel plots. A sensitivity analysis was conducted to examine the study quality's influence on the pooled estimate of prevalence and rates of awareness, treatment, and control.

Results

Forty-one original researches with a total of 1,310,402 Chinese participants were finally included in the meta-analysis. The prevalence, rates of awareness, treatment, and control of dyslipidemia were 42.1%, 18.2%, 11.6%, and 5.4%, respectively. With a pooled prevalence estimate at 24.5%, low HDL-C was the most prevalent among various dyslipidemia types, followed by hypertriglyceridemia (TG) (15.4%), hypercholesterolemia (TC) (8.3%), and high LDL-C (7.1%). The pooled prevalence of elevated serum lipoprotein(a) [Lp(a)] was 19.4%. By gender, the prevalence of dyslipidemia was 47.3% in males and 38.8% in females. Subgroup analyses revealed that the prevalence in southern and urban areas were higher than their counterparts. Females and population in urban areas tended to possess higher rates of awareness, treatment, and control. Meta-regression analyses suggested that the year of screening influenced prevalence estimates for dyslipidemia. The impact of the study's quality on the pooled estimates is insignificant.

Conclusion

Our study suggested a severe epidemic situation of dyslipidemia among adults in Chinese Mainland. More importantly, the awareness, treatment, and control rates were extremely low, revealing that dyslipidemia is a grave health issue. Consequently, we should attach more importance to the management of dyslipidemia, especially in economically underdeveloped areas.

Systematic review registration

PROSPERO [CRD42022366456].

Temporal trends in atherosclerotic cardiovascular disease risk among U.S. adults. Analysis of the National Health and Nutrition Examination Survey, 1999-2018

BACKGROUND

Atherosclerotic cardiovascular diseases are a significant cause of disability and mortality. Study of trends in cardiovascular risk at a population level helps understand the overall cardiovascular health and the impact of primary prevention efforts.

AIMS

To assess trends in the estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among U.S. adults from 1999-2000 to 2017-18 with no established cardiovascular disease (CVD).

METHODS AND RESULTS

Serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 (10 cycles), including 24 022 US adults aged 40-79 years with no reported ASCVD. ASCVD risk was assessed using the pooled cohort equations (PCEs). There was a significant temporal decline in the mean 10-year ASCVD risk from 13.5% (95% CI, 12.5-14.4) in 1999-2000 to 11.1% (10.5-11.7) in 2011-12 (Ptrend < 0.001) and to 12.0% (11.3-12.7) in 2017-2018 (overall Ptrend = 0.001), with the mean ASCVD risk score remaining stable from 2013-14 through 2017-2018 (Ptrend = 0.056). A declining trend in ASCVD risk was noted in females, non-Hispanic Blacks and those with income <3 times the poverty threshold with Ptrend of <0.001, 0.002, and 0.007, respectively. Mean total cholesterol and prevalence of smokers showed a downward trend (Ptrend <0.001 for both), whereas type 2 diabetes and mean BMI showed an upward trend (Ptrend < 0.001 for both).

CONCLUSIONS

The 20-year trend of ASCVD risk among NHANES participants 40-79 years, as assessed by the use of PCE, showed a non-linear downward trend from 1999-2000 to 2017-18. The initial and significant decline in estimated ASCVD risk from 1999-2000 to 2011-12 subsequently stabilized, with no significant change from 2013-14 to 2017-18. Mean BMI and prevalence of diabetes mellitus increased while mean serum cholesterol levels and prevalence of smoking declined during the study period. Our findings support invigoration of efforts aimed at prevention of CVD, including primordial prevention of CVD risk factors.

Health equity in the implementation of genomics and precision medicine: A public health imperative

Recent reviews have emphasized the need for a health equity agenda in genomics research. To ensure that genomic discoveries can lead to improved health outcomes for all segments of the population, a health equity agenda needs to go beyond research studies. Advances in genomics and precision medicine have led to an increasing number of evidence-based applications that can reduce morbidity and mortality for millions of people (tier 1). Studies have shown lower implementation rates for selected diseases with tier 1 applications (familial hypercholesterolemia, Lynch syndrome, hereditary breast and ovarian cancer) among racial and ethnic minority groups, rural communities, uninsured or underinsured people, and those with lower education and income. We make the case that a public health agenda is needed to address disparities in implementation of genomics and precision medicine. Public health actions can be centered on population-specific needs and outcomes assessment, policy and evidence development, and assurance of delivery of effective and ethical interventions. Crucial public health activities also include engaging communities, building coalitions, improving genetic health literacy, and building a diverse workforce. Without concerted public health action, further advances in genomics with potentially broad applications could lead to further widening of health disparities in the next decade.

Level and trend of total plasma cholesterol in national and subnational of Iran: a systematic review and age-spatio-temporal analysis from 1990 to 2016

Purpose

We aimed to estimate the level and trend of plasma cholesterol and raised total cholesterol (TC > 200 mg/dl) prevalence at national and subnational level of Iran.

Methods

Nine national surveys and 27 studies, encompassing 3,505 unique points on over 500,000 adults, aged > 25 years with a report of laboratory measurement of TC were found. Age-spatio-temporal model and Gaussian Process Regression were used to estimate mean TC for each sex, 5-year age groups, and 31 provinces from 1990 to 2016.

Results

At national level, age-standardized prevalence of TC > 200 mg/dL has decreased from 57·2%(53·3-61·1) to 22·4%(20·5-24·3) in women and 53·2%(49·1-57·3) to 18·0%(16·4-19·6) in men. TC distribution presented a condensation between 170-200 mg/dL. At subnational level, decreasing and converging patterns of raised TC prevalence were detected.

Conclusion

The decrease in raised TC is likely the result of statin widespread use, food industry improvements, and the expanded primary health care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01052-w.

Cardiovascular risks before myocardial infarction differences between men and women

Background

Prodromal cardiac symptoms are warning signals preceding cardiac disease. Previous studies have shown some gender differences in prodromal symptoms as well as established risk factors for MI. This study aims to map possible gender differences in social factors and established risk factors preceding myocardial infarction (MI).

Methods

The study includes data of N = 213 middle-aged men and women, all diagnosed with myocardial infarction (ICD-10 I21.9) from the region of south-east Sweden. They answered a questionnaire at discharge from the cardiologic clinic and additional clinical data from medical records were merged from the National Swedeheart Register.

Results

The dominant prodromal symptom for both sexes were experience of chest pain at the onset of MI. The major gender differences were that significantly more females (p = 0.015) had a hyperlipidemia diagnose. Females also reported to have experienced higher stress load the year preceding myocardial infarction with serious life events (p = 0.019), strained economy (p = 0.003), and reports of sadness/depression (p < 0.001). Females reported higher perceived stress load than men (p = 0.006). Men had higher systolic blood pressure than women at hospital admission and a higher systolic- and diastolic blood pressure at discharge.

Conclusions

Influences of the social environment, such as serious life events, strained economy, depression, stress, and sleep deprivation were stronger as potential risk factors for myocardial infarction in women than among men. Of the traditional risk factors only, hyperlipidemia was more frequent among women. These findings could contribute to a deeper understanding of diagnostic differences between gender, as well as a more gender-oriented cardiovascular preventive work.

PCSK9 inhibitor recaticimab for hypercholesterolemia on stable statin dose: a randomized, double-blind, placebo-controlled phase 1b/2 study

BACKGROUND

Recaticimab (SHR-1209, a humanized monoclonal antibody against PCSK9) showed robust LDL-C reduction in healthy volunteers. This study aimed to further assess the efficacy and safety of recaticimab in patients with hypercholesterolemia.

METHODS

In this randomized, double-blind, placebo-controlled phase 1b/2 trial, patients receiving stable dose of atorvastatin with an LDL-C level of 2.6 mmol/L or higher were randomized in a ratio of 5:1 to subcutaneous injections of recaticimab or placebo at different doses and schedules. Patients were recruited in the order of 75 mg every 4 weeks (75Q4W), 150Q8W, 300Q12W, 150Q4W, 300Q8W, and 450Q12W. The primary endpoint was percentage change in LDL-C from the baseline to end of treatment (i.e., at week 16 for Q4W and Q8W schedule and at week 24 for Q12W schedule).

RESULTS

A total of 91 patients were enrolled and received recaticimab and 19 received placebo. The dose of background atorvastatin in all 110 patients was 10 or 20 mg/day. The main baseline LDL-C ranged from 3.360 to 3.759 mmol/L. The least-squares mean percentage reductions in LDL-C from baseline to end of treatment relative to placebo for recaticimab groups at different doses and schedules ranged from -48.37 to -59.51%. No serious treatment-emergent adverse events (TEAEs) occurred. The most common TEAEs included upper respiratory tract infection, increased alanine aminotransferase, increased blood glucose, and increased gamma-glutamyltransferase.

CONCLUSION

Recaticimab as add-on to moderate-intensity statin therapy significantly and substantially reduced the LDL-C level with an infrequent administration schedule (even given once every 12 weeks), compared with placebo.

TRIAL REGISTRATION

ClinicalTrials.gov , number NCT03944109.

Examining Association Between Reported High Cholesterol and Risk Factors in Adults With Intellectual and Developmental Disabilities (IDD): A Five-Year Follow-Up

Adults with intellectual and developmental disabilities (IDD) are at a greater risk of developing high cholesterol and cardiovascular disease. We examined whether physical inactivity, obesity, and diabetes were predictive of reported high cholesterol and whether there were any mediating effects of diabetes on the relationship between obesity and high cholesterol in 1,618 adults with IDD across five years. Results suggest that obesity and diabetes were significantly associated with high cholesterol after adjusting for age, sex, and residence type with a partial mediator effect of diabetes in the relationship between obesity and high cholesterol across all time points. Further research is needed to explore the causal mechanisms behind the relationships between obesity, diabetes, and high cholesterol.

Joint effect of race/ethnicity or location of residence and sex on low density lipoprotein-cholesterol among veterans with type 2 diabetes: a 10-year retrospective cohort study

BACKGROUND

Cardiovascular (CV) disease is the leading cause of death among United States women. Rural residence and ethnic-minority status are individually associated with increased CV mortality. Managing dyslipidemia is important in the prevention of CV mortality. However, the impact of race/ethnicity and location of residence on sex differences in dyslipidemia management is not well understood. Therefore, we sought to understand the joint effects of race/ethnicity and location of residence on lipid management differences between veteran men and women with type 2 diabetes (T2D).

METHODS

Veterans Health Administration and Centers for Medicare and Medicaid Services data were used to perform a longitudinal cohort study of veterans with T2D (2007-2016). Mixed effects logistic regression with a random intercept was used to model the association between sex and low-density lipoprotein (LDL) > 100 mg/dL and its interaction with race/ethnicity and location of residence after adjusting for all measured covariates.

RESULTS

When female sex and rural location of residence were both present, they were associated with an antagonistic harmful effect on LDL. Similar antagonistic harmful effects on LDL were observed when the joint effect of female sex and several minority race/ethnicity groups were evaluated. After adjusting for measured covariates, the odds of LDL > 100 mg/dL were higher for urban women (OR = 2.66, 95%CI 2.48-2.85) and rural women (OR = 3.26, 95%CI 2.94-3.62), compared to urban men. The odds of LDL > 100 mg/dL was the highest among non-Hispanic Black (NHB) women (OR = 5.38, 95%CI 4.45-6.51) followed by non-Hispanic White (NHW) women (OR = 2.59, 95%CI 2.44-2.77), and Hispanic women (OR = 2.56, 95%CI 1.79-3.66).

CONCLUSION

Antagonistic harmful effects on LDL were observed when both female sex and rural location of residence were present. These antagonistic effects on LDL were also present when evaluating the joint effect of female sex and several minority race/ethnicity groups. Disparities were most pronounced in NHB and rural women, who had 5.4 and 3.3 times the odds of elevated LDL versus NHW and urban men after adjusting for important covariates. These striking effect sizes in a population at high cardiovascular risk (i.e., older with T2D) suggest interventions aimed at improving lipid management are needed for individuals falling into one or more groups known to face health disparities.

The Fate and Prognostic Implications of Hyperreflective Crystalline Deposits in Nonneovascular Age-Related Macular Degeneration

Purpose

To explore patterns of disease progression in nonneovascular age-related macular degeneration (AMD) associated with hyperreflective crystalline deposits (HCDs) in the sub-retinal pigment epithelium-basal laminar space.

Methods

Retrospective review of medical records, multimodal imaging, and longitudinal eye-tracked near-infrared reflectance (NIR) and optical coherence tomography (OCT) spanning ≥2 years. NIR/OCT images were analyzed with ImageJ software to identify HCD morphology and location. Associated macular complications were reviewed from the time of HCD detection to the most recent follow-up, using NIR/OCT.

Results

Thirty-three eyes with HCDs from 33 patients (mean age: 72 ± 7.5 years) had 46.7 months (95% confidence limits: 33.7, 59.6) of serial eye-tracked NIR/OCT follow-up. Baseline best-corrected visual acuity (BCVA) was 0.44 logMAR (Snellen equivalent 20/55). At a mean of 11.3 months (3.1, 19.6) after HCD detection, 31/33 (93.9%) eyes had developed macular complications including de novo areas of complete retinal pigment epithelium and outer retinal atrophy (cRORA) in 21/33 (64%) eyes, enlargement of preexisting cRORA in 4/33 (12%) eyes, and incident macular neovascularization in 3/33 (9%) eyes. Movement and clearance of HCDs in 9/33 (27%) eyes was associated with enlargement of preexisting cRORA (r = 0.44, P = 0.02). BCVA at the last follow-up visit had decreased to 0.72 logMAR (20/105).

Conclusions

Eyes with nonneovascular AMD demonstrating HCDs are at risk for vision loss due to macular complications, particularly when movement and clearance of these structures appear on multimodal imaging. HCD reflectivity and dynamism may be amenable to automated recognition and analysis to assess cellular activity related to drusen end-stages.

Report of Health Behavior Modification Among Latinos Diagnosed With Multiple Cardiovascular Risk Factors

INTRODUCTION

Hypertension, hypercholesterolemia, and type II diabetes are leading cardiovascular risk factors in the United States, and Latinos are disproportionately burdened by these chronic health conditions. The extent to which Latinos overall and by language spoken at home report health behavior modification following diagnosis is poorly understood.

METHODS

Our inclusion criteria included participants sampled in the 2011-2016 waves of the National Health and Nutrition Examination Survey who self-identified as Latinos, were 20 years of age or above, and reported a diagnosis of hypertension, hypercholesterolemia or diabetes (N=2027). We examined associations between the language spoken at home and report of adoption of 3 recommended health behaviors in the past year: weight loss, leisure-time physical activity (LTPA) and smoking cessation. Separate log-binomial models were fit to estimate prevalence ratios (PRs) for each health behavior.

RESULTS

Approximately one third (28%) of study participants had been diagnosed with diabetes and more than half reported a diagnosis of hypercholesterolemia (65%) or hypertension (60%). Most Latinos met the highest levels of smoking cessation criteria (82%), whereas less than a third met LTPA recommendations (29%) or attempted weight loss (24%) in the past year. Fully adjusted outcome specific models showed that exclusively speaking English at home was associated with a higher probability of reporting weight loss attempt and LTPA compared with Spanish only speakers, although only LTPA was statistically significant [weight loss PR: 1.23, 95% confidence interval (CI): 0.92, 1.65; LTPA PR: 1.74; 95% CI: 1.37, 2.20; smoking cessation PR: 0.93, 95% CI: 0.86, 1.01].

CONCLUSIONS

Our findings provide new evidence on patterns of behavioral modification in a population-based sample of Latinos diagnosed with chronic health conditions. Findings suggest the need to promote language and culturally relevant initiatives to increase the adoption of health-enhancing behaviors and improve chronic disease management among Spanish-speaking Latinos.

Black-White Differences in 20-year Trends in Cardiovascular Risk in the United States, 1990-2010

Objective

Improvements in the Black-White difference in life expectancy have been attributed to improved diagnosis and treatment of cardiovascular diseases and declines in cardiovascular disease mortality. However, it is unclear whether race differences in total cardiovascular risk and the prevalence of cardiovascular risk factors have improved in the United States since the 1990s.

Design

Serial cross-sectional design.

Setting

Data from the 1988-1994, 1999-2002, and 2009-2012 National Health and Nutrition Examination Survey (NHANES).

Methods

We estimated total cardiovascular risk levels, the prevalence of high-risk cardiovascular risk factors and the use of antihypertensive and lipid-lowering drugs among US Black and White men and women to determine whether differential changes occurred from 1990-2010.

Results

Total cardiovascular risk declined for all races from 1990-2010. The Black-White difference was only significant in 2000 and sex-specific analyses showed that trends seen in the total population were driven by changes among women. Black and White men did not differ in risk at any time during this period. Conversely, Black women had significantly higher risk than White women in 1990 and 2000; this difference was eliminated by 2010. Improved diagnosis and treatment of high blood pressure and high cholesterol reduced risk in the total population; improved blood pressure and lipid profiles among Black women and increasing obesity prevalence among White women specifically contributed to the narrowing of the Black-White difference in risk among women.

Conclusion

Cardiovascular risk and racial disparities in risk declined among US Whites and Blacks due to greater use and effectiveness of lipid-lowering and antihypertensive medications.

The double burden of food insecurity and obesity among Latino youth: Understanding the role of generational status

BACKGROUND

Obesity is linked to food insecurity and generational status; however, little is known about how both impact obesity risk among Latino youth.

OBJECTIVE

To investigate the joint effect of generational status and food insecurity on obesity prevalence among Latino youth.

METHODS

We pooled data from the 2011 to 2017 waves of the National Health Interview Survey to derive a sample Latino youth aged 12 to 17 (N = 7532). Four generational categories were constructed: first generation (foreign-born children); second generation (US-born child; foreign-born parent[s]); 2.5 generation (US-born child; one foreign-born parent and one US-born parent); third generation (US-born child; U.S.-born parent[s]). Food insecurity was defined by monthly instances of food scarcity over the past year. Obesity was measured using age- and sex-specific body mass index percentile cut-offs. Log-binomial multivariable regression models estimated the association between generational status and food insecurity categories on obesity.

RESULTS

Obesity percentages among food-insecure households ranged from 12.8% in the first generation, 15.8% in the second, 24.3% in the 2.5, and 19.2% in the third. In fully adjusted models, 2.5 generation food secure youth had the highest prevalence of obesity (aPR: 1.53; 95% CI, 1.09-2.16) when compared with first generation food secure youth, followed by third generation food insecure youth (aPR: 1.49; 95% CI, 1.01-2.20).

CONCLUSIONS

Food security status is associated with increased obesity prevalence among Latino youth across the generations. Given that obesity is a risk factor for top causes of mortality and morbidity, growing rates among this population is of public health and clinical importance.

Time trend of cardiometabolic risk factors over a 10-year period in the office-working population in China

OBJECTIVES

Recent dramatic increases in cardiovascular disease mortality in China can be mostly explained by adverse changes in hypertension, dyslipidaemia, diabetes and obesity, known as cardiometabolic risk factors. Our study aimed to assess the trend of these four signatures by a 10-year lag in Nanjing, China.

METHODS

8017 subjects attended the routine health examination in 2008, and 9379 subjects in 2017, from multiple work units of Nanjing, were included in the present study. The prevalence and trend of four cardiometabolic risk factors: hypertension, dyslipidaemia, diabetes and obesity were analysed.

RESULTS

From 2008 to 2017, the prevalence of hypertension declined, while the prevalence of dyslipidaemia, diabetes and obesity increased. Besides, the population in 2008 and 2017 had an average of 0.66 and 0.78 risk factors, respectively.

CONCLUSION

Cardiometabolic risk factors are common for the staff in administrative agencies and institutions of Nanjing, China. Effective screening and interventions against these risk factors should be adopted in high-risk populations such as the office-working population in China.

Frequency of dyslipidemia in migraineurs in comparison to control group

BACKGROUND

Migraine is a common disease with neurovascular nature, which is commonly prevalent in the general population. Due to the significant prevalence of migraine and its long-term complications, it is necessary to pay attention to its exacerbating factors. Therefore, the aim of this study was to evaluate the frequency distribution of dyslipidemia in patients with migraine compared with control group.

MATERIALS AND METHODS

This is a case-control study, in which 50 patients with migraine (with aura and without aura) were confirmed by the criteria of International Headache Society. Migraineurs and control group (n = 50) were selected from among patients who referred to the Neurology Clinic of Imam Hossein Hospital. The levels of total cholesterol, triglyceride, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol were measured in both the groups. SPSS software (version 21) was used to analyze the data.

RESULTS

The findings showed that among migraineurs, 21 patients (42%) revealed high levels of cholesterol and 22 revealed high levels of LDL (44%); whereas among subjects without migraine, 12 subjects (24%) exhibited high levels of cholesterol and 12 (24%) high levels of LDL, where a significant correlation between the two groups was achieved.

CONCLUSION

The present results showed that migraine is associated with higher level of cholesterol and LDL when compared with the control group, where a significant relationship was found.

Orbital atherectomy for calcified femoropopliteal lesions: a current review

The orbital atherectomy system is a novel form of atherectomy that uses orbital sanding and pulsatile forces, an effective method of treatment for peripheral atherosclerotic lesions with varying levels of occlusion. Although the devices only has a general indication from the FDA to treat atherosclerotic lesions, they are effective in treating all kinds of lesions, and can therefore mitigate effects of all severities of peripheral artery disease. This approach to endovascular therapy involves the use of differential sanding to preferentially ablate fibrous, fibrofatty and calcified lesions, while deflecting healthy intima away from the crown. The eccentrically mounted crown design allows the device to employ rhythmic pulsating forces that penetrate the medial layer, and cause cracking in the lesions in order to facilitate easier balloon inflation and intravascular drug elution. The combination of vessel modification and lumen enlargement through sanding can effectively restore blood flow to the extremities, and can eliminate risk of critical limb ischemia, as well as subsequent amputation. Extensive lab testing and clinical trials have confirmed the high success rates and low major adverse events associated with this form of treatment. The device is economically viable as well, since its cost is offset by the lower frequency of adjunctive therapy sessions when compared to other devices. Considering the results outlined in this manuscript, the Diamondback 360° is an effective form of atherectomy therapy for peripheral artery disease. In-depth understanding of the operation preparation, procedure, and best imaging techniques can help to optimize outcomes.

Prevalence of the metabolic syndrome between 1999 and 2014 in the United States adult population and the impact of the 2007-2008 recession: an NHANES study

To document changes in prevalence of the metabolic syndrome (MetS) in the United States adult population between 1999 and 2014 and to explore how variations in the dietary intakes explain changes in MetS prevalence and its components over time. A total of 38 541 individuals (aged 20-85 years; National Health and Nutrition Examination Survey 1999-2014) were studied. Outcome variables were MetS, waist circumference (WC), plasma high-density lipoprotein cholesterol (HDL-c), triglycerides, fasting glucose (FG) levels, resting systolic and diastolic blood pressure, dietary intakes (total daily energy, carbohydrates, proteins, fats, sodium, and alcohol intakes), the poverty income ratio (PIR) and sociodemographic data (age, sex, ethnicity). Overall, the prevalence of the MetS significantly increased between 1999 and 2014 (27.9% to 31.5%). High plasma FG levels and high WC increased between 1999 and 2014, while the prevalence of the other components of MetS decreased or remained stable. Interestingly, a significant peak in MetS prevalence was observed in 2007-2008 compared with 1999-2006 (34.4% vs 27.6%), accompanied by a concomitant increase in WC and plasma FG levels, as well as a decrease in plasma HDL-c. Finally, significant decreases were observed for the PIR, total daily energy intake, sodium, and all macronutrient intakes in 2007-2008 compared with 1999-2006 (all P < 0.01). Results showed that the MetS prevalence significantly increased between 1999 and 2014 in the United States adult population, with a peak in 2007-2008. Interestingly, the 2007-2008 peak in MetS prevalence was accompanied by decreases in the PIR, total daily energy, and macronutrients intakes, suggesting potential impact of the 2007-2008 recession.

Cardiovascular risk factors from diagnosis in children with type 1 diabetes mellitus: a longitudinal cohort study

BACKGROUND

For childhood onset type 1 diabetes (T1D), the pathogenesis of atherosclerosis is greatly accelerated and results in early cardiovascular disease (CVD) and increased mortality. However, cardioprotective interventions in this age group are not routinely undertaken.

AIMS

To document prevalence of cardiovascular risk factors from diagnosis of childhood T1D and their relationship with disease duration and ethnicity.

METHODS

Routinely collected clinical records for 565 children with T1D were retrospectively analyzed. Data were collected from diagnosis and at routine check-ups at pediatric diabetes clinics across Barts Health National Health Service Trust. Age at diagnosis was 8.5 years (0.9-19.4). Mean follow-up 4.3 years (0-10.8). 48% were boys and 60% were non-white. Linear longitudinal mixed effects models were used to evaluate relationships between risk factors and diabetes duration.

RESULTS

CVD risk factors were present at first screening; 33.8% of children were overweight or obese, 20.5% were hypertensive (elevated diastolic blood pressure (BP)) and total cholesterol, low-density lipoprotein-cholesterol and high-density lipoprotein-cholesterol were abnormal in 63.5%, 34.2% and 22.0%, respectively. Significant associations between diabetes duration and annual increases of body mass index (0.6 kg/m²), BP (0.1 SD score) and lipids (0.02-0.06 mmol/L) were noted. Annual increases were significantly higher in black children for BP and Bangladeshi children for lipids. Bangladeshi children also had greatest baseline levels.

CONCLUSIONS

CVD risk factors are present in up to 60% of children at diagnosis of T1D and increase in prevalence during the early years of the disease. Commencing screening in younger children and prioritizing appropriate advice and attention to ethnic variation when calculating risk should be considered.

The prevalence, awareness, and treatment of lipid abnormalities in Iranian adults: Surveillance of risk factors of noncommunicable diseases in Iran 2016

BACKGROUND

Hypercholesterolemia is one of the modifiable risk factors for atherosclerosis and cardiovascular diseases. Prevention and treatment of hypercholesterolemia and other lipid abnormalities require reliable data regarding the current prevalence of these abnormalities in the country.

OBJECTIVE

This study aims to determine the current prevalence, awareness, and treatment of lipid abnormalities in Iran.

METHODS

We planned to recruit 31,050 individuals who are 18 years old and above and take blood samples from individuals who are 25 years and above as representative sample at national and provincial levels in 2016. In practice, we recruited 21,293 Iranian adult aged more than 25 years through a systematic random sampling from 30 provinces of Iran. Sociodemographic, anthropometric, and lifestyle data and history of cardiometabolic diseases were gathered. Serum total cholesterol, high-density lipoprotein-cholesterol (HDL-C), triglyceride, low-density lipoprotein-cholesterol (LDL-C), and non-HDL-C were investigated. The prevalence of lipid abnormalities, awareness, treatment, and achievement to non-HDL-C and LDL-C goals were determined based on National Cholesterol Education Program Adult Treatment Panel III criteria.

RESULTS

In this representative Iranian adult population, 80.0% had at least one lipid abnormality, 69.2% had low HDL-C, 39.5% had high non-HDL-C, 28.0% had hypertriglyceridemia, and 26.7% hypercholesterolemia. Of those with hypercholesterolemia, 74.2% were aware of their lipid abnormality. Only 22.0% and 36.5% of the study population met the desired level of non-HDL-C and LDL-C, respectively.

CONCLUSION

Low HDL-C is the main lipid abnormality in adult Iranian population. The majority of the population did not meet the desired level of non-HDL-C and LDL-C. Public health preventive policies should be made and implemented to better manage dyslipidemia.

Does Identification of Previously Undiagnosed Conditions Change Care-Seeking Behavior?

OBJECTIVE

To determine whether identification of previously undiagnosed high cholesterol, hypertension, and/or diabetes during an in-home assessment impacts care seeking among Medicare beneficiaries.

DATA SOURCES/STUDY SETTING

Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, which recruited African American and white participants across the continental United States from 2003-2007, were linked to Medicare claims.

STUDY DESIGN

We used panel data models to analyze changes in doctor visits for evaluation and management of conditions after participants were assessed, utilizing the study's rolling recruitment to control for secular trends.

DATA EXTRACTION METHODS

We extracted Medicare claims for the 24 months before through 24 months after assessment via REGARDS for 5,884 participants.

PRINCIPAL FINDINGS

Semi-annual doctor visits for previously undiagnosed conditions increased by 22 percentage points (95 percent confidence interval: 16-28) 2 years following assessment. The effect was similar by gender, race, region, and Medicaid, but it may have been lower among participants who lacked a usual health care provider.

CONCLUSIONS

In-home assessment of cholesterol, blood pressure, and blood glucose can increase doctor visits for individuals with previously undiagnosed conditions. However, biomarker assessment may have more limited impact among individuals with low access to care.

Racial/ethnic differences in the prognostic utility of left ventricular mass index for incident cardiovascular disease

BACKGROUND

Evidence exists for racial/ethnic differences in left ventricular mass index (LVMI). How this translates to future cardiovascular disease (CVD) events is unknown.

HYPOTHESIS

The impact of racial/ethnic differences in LVMI on incident cardiovascular outcomes could have potential implications for the optimization of risk stratification strategies.

METHODS

Using the prospectively collected database of the Multi-Ethnic Study of Atherosclerosis (MESA) involving 4 racial/ethnic groups (non-Hispanic Whites, Chinese, Blacks, and Hispanics) free of CVD at baseline, we assessed for racial/ethnic differences in the relationship between LVMI and incident CVD using a Cox model.

RESULTS

5004 participants (mean age, 62 ± 10 years; 48% male) were included in this study. After an average follow-up of 10.2 years, 369 (7.4%) CVD events occurred. Significant racial/ethnic differences existed in the relationship between LVMI and incident CVD (P for interaction = 0.04). Notably, the relationship was strongest for Chinese (HR per 10-unit increase in LVMI: 1.7, 95% CI: 1.1-2.8) and Hispanics (HR per 10-unit increase in LVMI: 1.9, 95% CI: 1.5-2.2). Non-Hispanic Whites demonstrated the lowest relationship (HR: 1.3, 95% CI: 1.1-1.5). LVMI values of 36.9 g/m^2.7 , 31.8 g/m^2.7 , 39.9 g/m^2.7 , and 41.7 g/m^2.7 were identified as optimal cutpoints for defining left ventricular hypertrophy (LVH) for non-Hispanic Whites, Chinese, Blacks, and Hispanics, respectively. In secondary analysis of LVH (vs no LVH) using these optimal cutpoints, we found a similar pattern of association as above (P for interaction = 0.04). For example, compared with those without LVH, Chinese with LVH had HR: 5.3, 95% CI: 1.6-17, whereas non-Hispanic Whites with LVH had HR: 1.6, 95% CI: 1.2-2.1 for CVD events.

CONCLUSIONS

Among 4 races/ethnicities studied, LVMI has more prognostic utility predicting future CVD events for Chinese and Hispanics and is least significant for non-Hispanic Whites.

External Validation of a Tool Predicting 7-Year Risk of Developing Cardiovascular Disease, Type 2 Diabetes or Chronic Kidney Disease

BACKGROUND

Chronic cardiometabolic diseases, including cardiovascular disease (CVD), type 2 diabetes (T2D) and chronic kidney disease (CKD), share many modifiable risk factors and can be prevented using combined prevention programs. Valid risk prediction tools are needed to accurately identify individuals at risk.

OBJECTIVE

We aimed to validate a previously developed non-invasive risk prediction tool for predicting the combined 7-year-risk for chronic cardiometabolic diseases.

DESIGN

The previously developed tool is stratified for sex and contains the predictors age, BMI, waist circumference, use of antihypertensives, smoking, family history of myocardial infarction/stroke, and family history of diabetes. This tool was externally validated, evaluating model performance using area under the receiver operating characteristic curve (AUC)-assessing discrimination-and Hosmer-Lemeshow goodness-of-fit (HL) statistics-assessing calibration. The intercept was recalibrated to improve calibration performance.

PARTICIPANTS

The risk prediction tool was validated in 3544 participants from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab).

KEY RESULTS

Discrimination was acceptable, with an AUC of 0.78 (95% CI 0.75-0.81) in men and 0.78 (95% CI 0.74-0.81) in women. Calibration was poor (HL statistic: p < 0.001), but improved considerably after intercept recalibration. Examination of individual outcomes showed that in men, AUC was highest for CKD (0.85 [95% CI 0.78-0.91]) and lowest for T2D (0.69 [95% CI 0.65-0.74]). In women, AUC was highest for CVD (0.88 [95% CI 0.83-0.94)]) and lowest for T2D (0.71 [95% CI 0.66-0.75]).

CONCLUSIONS

Validation of our previously developed tool showed robust discriminative performance across populations. Model recalibration is recommended to account for different disease rates. Our risk prediction tool can be useful in large-scale prevention programs for identifying those in need of further risk profiling because of their increased risk for chronic cardiometabolic diseases.

Prevalence of Type 2 Diabetes Mellitus Among Urban Bihari Communities in Dhaka, Bangladesh: A Cross-sectional Study in a Minor Ethnic Group

Introduction

The prevalence, disease progression, and treatment outcomes for patients with type 2 diabetes vary significantly between ethnic groups. The Bihari community constitutes one of the most vulnerable populations in Bangladesh on the basis of access to health services and other fundamental rights. Our study aimed at finding out the prevalence and risk factors of type 2 diabetes among the Bihari adults in Dhaka city.

Methods

This cross-sectional community-based study was carried out among stranded Pakistanis (known as Bihari) living in camps in the Mirpur area from July 2014 to June 2015. Laboratory-based oral glucose tolerance test (OGTT) was the basis for the diagnosis of type 2 diabetes mellitus (DM). Anthropometric measurements, blood pressure, biochemical tests, family history, and socioeconomic information were obtained to determine the risk factors.

Results

The prevalence of diabetes mellitus (DM), impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) were estimated at 10.11%, 8.74%, and 4.55%, respectively. Increased diastolic blood pressure, serum triglyceride, and cholesterol level were observed to be significantly (p < 0.05) associated with diabetes. Also, the presence of diabetes, high blood pressure, and obesity among relatives significantly increased the probability of diabetes.

Conclusions

To the best of our knowledge, this is the first study on diabetes prevalence among the Bihari community in Bangladesh. The prevalence of type 2 diabetes mellitus was found to be higher among the Bihari community compared to the general population in Bangladesh. Health planners and policymakers should realize the alarming situation and identified risk factors and consider the minor ethnic groups during decision-making regarding prevention and control of diabetes and other noncommunicable diseases.

Lipid-lowering nutraceuticals in clinical practice: position paper from an International Lipid Expert Panel

In recent years, there has been growing interest in the possible use of nutraceuticals to improve and optimize dyslipidemia control and therapy. Based on the data from available studies, nutraceuticals might help patients obtain theraputic lipid goals and reduce cardiovascular residual risk. Some nutraceuticals have essential lipid-lowering properties confirmed in studies; some might also have possible positive effects on nonlipid cardiovascular risk factors and have been shown to improve early markers of vascular health such as endothelial function and pulse wave velocity. However, the clinical evidence supporting the use of a single lipid-lowering nutraceutical or a combination of them is largely variable and, for many of the nutraceuticals, the evidence is very limited and, therefore, often debatable. The purpose of this position paper is to provide consensus-based recommendations for the optimal use of lipid-lowering nutraceuticals to manage dyslipidemia in patients who are still not on statin therapy, patients who are on statin or combination therapy but have not achieved lipid goals, and patients with statin intolerance. This statement is intended for physicians and other healthcare professionals engaged in the diagnosis and management of patients with lipid disorders, especially in the primary care setting.

Association of Serum Lipids and Obstructive Lung Disease in Hispanic/Latino Adults of Diverse Backgrounds

Rationale

Substantial variation in the prevalences of obstructive lung disease exist between Hispanic/Latino heritage groups. Experimental studies have posited biological mechanisms linking serum lipids and lipid-lowering medications with obstructive lung disease. The aim of this study is to examine the associations of serum lipid levels with the prevalences of asthma and chronic obstructive pulmonary disease in the Hispanic Community Health Study/Study of Latinos and how these associations vary by Hispanic/Latino heritage group.

Methods

The Hispanic Community Health Study/Study of Latinos is a population-based probability sample of 16,415 self-identified Hispanic/Latino persons aged 18–74 years recruited between 2008 and 2011 from randomly selected households in four US field centers. The baseline clinical examination included comprehensive biological testing (fasting serum lipid levels), behavioral and socio-demographic assessments, medication inventory including inhalers, and respiratory data including questionnaires for asthma and standardized spirometry with post-bronchodilator measures for identification of obstructive lung disease.

Measurements and main results

Hispanic/Latinos with current asthma had lower age- and statin-use-adjusted mean serum total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels than their non-asthmatic counterparts. In analysis adjusted for age plus gender, ethnicity, cigarette smoking, alcohol intake, body mass index, lipid/cholesterol-lowering medications, age at immigration, health insurance status, and use of oral corticosteroids, increasing serum levels of total cholesterol and low-density lipoprotein cholesterol were associated with lower odds of current asthma in the estimated population. Unlike asthma, Hispanic/Latinos with chronic obstructive pulmonary disease had lower mean high-density lipoprotein than their non- chronic obstructive pulmonary disease counterparts. In the fully adjusted analysis no significant associations were found between lipid levels and prevalent chronic obstructive pulmonary disease.

Conclusions

We showed a modest inverse relationship between serum lipid levels and current asthma. These results highlight some important differences in Hispanics/Latinos and certain serum lipids may be factors or markers of obstructive lung disease.

Race-Sex Differences in Statin Use and Low-Density Lipoprotein Cholesterol Control Among People With Diabetes Mellitus in the Reasons for Geographic and Racial Differences in Stroke Study

Background

Statin therapy is a cornerstone of cardiovascular disease risk reduction for people with diabetes mellitus. Past reports have shown race‐sex differences in statin use in general populations, but statin patterns by race and sex in those with diabetes mellitus have not been thoroughly studied.

Methods and Results

Our sample of 4288 adults ≥45 years of age with diagnosed diabetes mellitus who had low‐density lipoprotein cholesterol (LDL‐C) >100 mg/dL or were taking statins recruited for the Reasons for Geographic and Racial Differences in Stroke study from 2003 to 2007. Exposures included race‐sex groups (white men [WM], black men [BM], white women [WW], black women [BW]) and factors that may influence healthcare utilization. Proportions and prevalence ratios were calculated for statin use and LDL‐C control. Statin use for WM, BM, WW, and BW was 66.0%, 57.8%, 55.0%, and 53.6%, respectively (P<0.001). After adjustment for healthcare utilization factors, statin use was lower for BM, WW, and BW compared with WM (prevalence ratios [95%CI]: 0.96 [0.89‐1.03], 0.86 [0.80‐0.92], and 0.87 [0.81‐0.93], respectively, P<0.001). LDL‐C control among those taking statins for WM, BM, WW, and BW was 75.3%, 62.7%, 69.0%, and 56.0%, respectively (P<0.001). After adjustment, LDL‐C control was lower for BM, WW, and BW compared with WM (prevalence ratios [95%CI]: 0.85 [0.79‐0.93], 0.89 [0.82‐0.96], and 0.73 [0.67‐0.80], respectively, P<0.001).

Conclusions

Race‐sex disparities in statin use and LDL‐C control were only partly explained by factors influencing health services utilization. Healthcare provider awareness of these disparities may help to close the observed race‐sex gaps in statin use and LDL‐C control among people with diabetes mellitus.

Failure to control hypercholesterolaemia in the Irish adult population: cross-sectional analysis of the baseline wave of The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Hypercholesterolaemia is an important modifiable risk factor for cardiovascular disease (CVD) which requires monitoring and management at a population level.

AIMS

This study aims to describe the distribution of serum cholesterol in a community living population of older adults in Ireland and to examine the awareness, treatment and control of hypercholesterolaemia according to CVD risk status.

METHOD

This is a cross-sectional study in a nationally representative sample of adults aged 50-79 years (n = 5287). Hypercholesterolaemia was defined as low-density lipoprotein cholesterol (LDL-C) in excess of the recommended CVD risk category target and/or on lipid-lowering medication.

RESULTS

This study reports a mean total cholesterol (TC) of 5.1 mmol/L (95% CI 5.0-5.1 mmol/L) and a mean LDL-C of 2.9 mmol/L (95% CI 2.8-2.9 mmol/L) in those aged 50-79 years. In a subgroup aged 50-64 years, 73% (95% CI 71.5-74.5%) were hypercholesterolaemic. LDL-C was controlled to the guideline target in 57% of those with CVD and 49% of those with diabetes. Lack of awareness of hypercholesterolaemia was high across the remainder of the population.

CONCLUSION

Despite a substantial reduction in population mean TC from a high of 6.0 mmol/L in the 1980s to 5.1 mmol/L, this study reports a failure to control hypercholesterolaemia to recommended risk-stratified targets in the Irish adult population. Recommendations for policy include continued monitoring of those at highest risk and CVD risk assessment in those perceived to be at low risk in order to inform shared decision making in relation to lifestyle modification and medication management.

Increasing trend of diabetes combined with hypertension or hypercholesterolemia: NHANES data analysis 1999-2012

In order to prevent cardiovascular endpoints, control of diabetes, hypertension and hypercholesterolemia is a necessity as those risk factors frequently occur in combination. Prevalence trends of concurrent diabetes, hypertension and hypercholesterolemia in 36,673 subjects were obtained from the National Health and Nutrition Examination Survey (NHANES) from 1999–2012. The prevalence of concurrent diabetes, hypertension and hypercholesterolemia increased from 3% in 1999–2000 to 6.3% in 2011–2012 (P < 0.001). The diabetes with concurrent hypertension or hypercholesterolemia incidences also increased significantly, while the occurrence of concurrent hypertension and hypercholesterolemia was stable over the study period. Overall medical drug treatments for concurrent diabetes, hypertension, hypercholesterolemia were improved from 69.8% in 1999–2006, to 82.4% in 2007–2012 (P = 0.002). Treatment cost coverage rates in any combinations with diabetes were 79–82.4% and 90.7% in the subgroup of concurrent hypertension and hypercholesterolemia. General treatment goal achievement rates were <25%, the lowest rate being 14.2% in the subject groups with three combined risk factors. The treatment goal achievement rates in two subgroups with concurrent diabetes were 20.1% (with hypertension) and 17% (with hypercholesterolemia) and 24.5% in the group without diabetes. Cost coverage improved in all combinations, but the general treatment goal achievement rates were low, especially in the groups with concurrent diabetes.

Comorbid Medical Conditions in Friedreich Ataxia: Association With Inflammatory Bowel Disease and Growth Hormone Deficiency

Friedreich ataxia is a progressive degenerative disease with neurologic and cardiac involvement. This study characterizes comorbid medical conditions in a large cohort of patients with Friedreich ataxia. Patient diagnoses were collected in a large natural history study of 641 subjects. Prevalence of diagnoses in the cohort with Friedreich ataxia was compared with prevalence in the population without Friedreich ataxia. Ten patients (1.6%) had inflammatory bowel disease, 3.5 times more common in this cohort of individuals with Friedreich ataxia than in the general population. Four subjects were growth hormone deficient, reflecting a prevalence in Friedreich ataxia that is 28 times greater than the general population. The present study identifies specific diagnoses not traditionally associated with Friedreich ataxia that are found at higher frequency in this disease. These associations could represent coincidence, shared genetic background, or potentially interactive disease mechanisms with Friedreich ataxia.

Prevalence of Major Cardiovascular Risk Factors and Coronary Heart Disease in a Sample of Greek Adults: The Saronikos Study

Background:

Comprehensive data regarding prevalence of coronary heart disease (CHD) and associated factors in different geographical regions are very important to our understanding of global distribution and evolution of CHD. The aim of this study was to assess the current prevalence of self-reported risk factors and CHD in Greek adult population.

Methods:

A community-based cross-sectional study was conducted in May 2014, during an election day, among residents of Saronikos municipality (Attica region). Data were collected from face-to-face interviews. The study sample included 2636 subjects (men, 49.5%; mean age, 50.5; range 20-95 years), with similar age and sex distribution to the target population.

Results:

The age-standardized prevalence rates of five major risk factors were as follows: type 2 diabetes 11.1%, hypercholesterolemia (cholesterol>240 mg/dl or using cholesterol-lowering medication) 23.8%, hypertension 27.2%, current smoking 38.9% and physical inactivity 43%. Of the participants, only 21% were free of any of these factors. Clustering of two to five risk factors was more frequent among persons aged 50 years and older as compared with younger ones (60% vs 27%, P=0.000). The age-adjusted prevalence of CHD was 6.3% (in men, 8.9%; in women, 3.8%) and that of myocardial infarction was 3.6% (in men, 5.2%; in women, 2.1%). According to multivariate analysis age, gender, education level, obesity, diabetes, hypercholesterolemia, hypertension and ever smoking were strongly associated with CHD.

Conclusion:

Classic risk factors are highly prevalent and frequently clustered, especially in adults aged 50 years and older. These findings raise concerns about future trends of already increased rates of CHD. Multifactorial and integrated population-based interventions need to be applied to reduce the burden of cardiovascular conditions.

Health beliefs and desire to improve cholesterol levels among patients with hyperlipidemia

OBJECTIVE

Because hyperlipidemia is asymptomatic, many veterans affairs (VA) patients may not perceive it seriously. We assessed key Health Belief model concepts to describe patients' cholesterol-related health beliefs and examine associations between patient-level factors and desire to improve cholesterol control.

METHODS

We used baseline data from an ongoing randomized clinical trial. Eligible patients were receiving care at the Durham VA and had CVD risk-total cholesterol levels >130 mg/dL and/or <80% medication adherence in the previous 12 months. A survey assessed patients' health beliefs about high cholesterol and self-reported medication adherence. Multivariable logistic regression examined whether there was an association between desire to control cholesterol and cholesterol status.

RESULTS

Approximately 64% (n=155) of patients perceived high cholesterol as 'very serious'. In multivariable logistic regression analysis, patients who perceived high cholesterol as 'very serious' (OR 2. 26, p=0.032) and/or with high self-efficacy (OR 4.70, p<0.001) had increased odds of desiring cholesterol control.

CONCLUSION

The factors most significantly associated with desire to improve cholesterol control were perceiving hyperlipidemia as 'very serious and self-efficacy for cholesterol control.

PRACTICE IMPLICATION

Educating patients, with the goal of appropriately increasing their perceived risk of disease, is likely necessary to impact cholesterol control.

Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers: Randomized Trial

BACKGROUND

Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk.

METHODS AND RESULTS

We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90-3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up.

CONCLUSIONS

Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines.

CLINICAL TRIAL REGISTRATION

URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609.

Treatment Gap in the National Health-screening Program in Korea: Claim-based Follow-up of Statin Use for Sustained Hypercholesterolemia

Participation in a screening program by itself may not improve clinical outcomes. Treatment gaps in the program may limit its full benefit. We evaluated statin prescription rates for subjects with sustained hypercholesterolemia to assess the treatment gaps in the National Health Screening Program (NHSP) in Korea. A retrospective, random cohort was established among National Health Insurance Corporation (NHIC) members. Finally, we examined 465,499 individuals who attended the NHSP from 2003 to 2010 without any history of dyslipidemia, statin prescription, or hospitalization for cardiovascular events until the end of 2002. The subsequent statin prescription rates were identified from the NHIC medical service claim database from 2003 to 2011. Descriptive data and odds ratio from multivariate logistic analyses on statin prescription rates and the corresponding correlations were evaluated. The NHSP detected 114,085 (24.5%) cases of newly diagnosed hypercholesterolemia. However, only 8.6% of these received statin prescription within 6 months of diagnosis. For cases of sustained hypercholesterolemia determined in the next screening visit by the NHSP, the statin prescription rate increased, but only to 12.2%. Statin prescriptions were more common among females, older individuals, and hypertension or diabetes patients. Furthermore, the statin prescription rates had increased over the study period. The NHSP exhibited low statin prescription rate which has been improving. For the NHSP to be effective, it would be worthwhile to decrease the gap between the diagnosis of hypercholesterolemia and the following treatment.

Contributions of risk factors and medical care to cardiovascular mortality trends

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

The challenge of translating ischemic conditioning from animal models to humans: the role of comorbidities

Following a period of ischemia (local restriction of blood supply to a tissue), the restoration of blood supply to the affected area causes significant tissue damage. This is known as ischemia-reperfusion injury (IRI) and is a central pathological mechanism contributing to many common disease states. The medical complications caused by IRI in individuals with cerebrovascular or heart disease are a leading cause of death in developed countries. IRI is also of crucial importance in fields as diverse as solid organ transplantation, acute kidney injury and following major surgery, where post-operative organ dysfunction is a major cause of morbidity and mortality. Given its clinical impact, novel interventions are urgently needed to minimize the effects of IRI, not least to save lives but also to reduce healthcare costs. In this Review, we examine the experimental technique of ischemic conditioning, which entails exposing organs or tissues to brief sub-lethal episodes of ischemia and reperfusion, before, during or after a lethal ischemic insult. This approach has been found to confer profound tissue protection against IRI. We discuss the translation of ischemic conditioning strategies from bench to bedside, and highlight where transition into human clinical studies has been less successful than in animal models, reviewing potential reasons for this. We explore the challenges that preclude more extensive clinical translation of these strategies and emphasize the role that underlying comorbidities have in altering the efficacy of these strategies in improving patient outcomes.