Constructing a point-based prediction model for the risk of coronary artery disease in a Chinese community: a report from a cohort study in Taiwan

Economic evaluation of new blood pressure target for hypertensive patients in Taiwan according to the 2022 hypertension clinical practice guidelines of the Taiwan society of cardiology: a simulation modeling study

With the promising cardiovascular benefits in the STEP and SPRINT trials, the 2022 Taiwan's hypertension guidelines redefined the hypertension threshold as 130/80 mmHg and a universal blood-pressure target of <130/80 mmHg. This study's objective was to examine the cost-effectiveness of the intensive blood-pressure target for hypertensive patients using estimated lifetime medical costs and quality-adjusted life years (QALY) from the Taiwan national payer's perspective. We developed a lifetime Markov model comparing the intensive and conservative blood-pressure targets. Incremental cost-effectiveness ratio (ICER) against the willing-to-pay thresholds at the one-time [US$34,000(NT$1,020,000)] and three-time [US$100,000(NT$3,000,000)] gross domestic product per capita were defined as very cost-effect and only cost-effective. The cost-effectiveness in different age stratifications and cardiovascular risks treated with a more intensive target (120 mmHg) were examined in the subgroup analyses. The new blood-pressure treatment target produced more lifetime medical costs [US$31,589(NT$947,670) versus US$26,788(NT$803,640)] and QALYs (12.54 versus 12.25), and the ICER was US$16,589(NT$497,670), which was 99.1% and 100% probability of a very cost-effective and cost-effective strategy. The ICERs in all age stratifications had more than a 90% probability of being very cost-effective, and ICERs decreased with age. More intensive control in patients with high cardiovascular risks produced a lower ICER [US$14,547(NT$436,410)]. In conclusion, Taiwan's new blood-pressure treatment target can prevent more cardiovascular events with acceptable costs per QALY below the willing-to-pay thresholds. The cost-effectiveness of intensive control is consistent across different ages and more pronounced with the increase in age and cardiovascular risk.

2022 Taiwan lipid guidelines for primary prevention

Elevated circulating low-density lipoprotein cholesterol (LDL-C) is a major risk factor of atherosclerotic cardiovascular disease (ASCVD). Early control of LDL-C to prevent ASCVD later in life is important. The Taiwan Society of Lipids and Atherosclerosis in association with the other seven societies developed this new lipid guideline focusing on subjects without clinically significant ASCVD. In this guideline for primary prevention, the recommended LDL-C target is based on risk stratification. A healthy lifestyle with recommendations for foods, dietary supplements and alcohol drinking are described. The pharmacological therapies for LDL-C reduction are recommended. The aim of this guideline is to decrease the risk of ASCVD through adequate control of dyslipidemia in Taiwan.

Generalizability of Cardiovascular Disease Clinical Prediction Models: 158 Independent External Validations of 104 Unique Models

Background:

While clinical prediction models (CPMs) are used increasingly commonly to guide patient care, the performance and clinical utility of these CPMs in new patient cohorts is poorly understood.

Methods:

We performed 158 external validations of 104 unique CPMs across 3 domains of cardiovascular disease (primary prevention, acute coronary syndrome, and heart failure). Validations were performed in publicly available clinical trial cohorts and model performance was assessed using measures of discrimination, calibration, and net benefit. To explore potential reasons for poor model performance, CPM-clinical trial cohort pairs were stratified based on relatedness, a domain-specific set of characteristics to qualitatively grade the similarity of derivation and validation patient populations. We also examined the model-based C-statistic to assess whether changes in discrimination were because of differences in case-mix between the derivation and validation samples. The impact of model updating on model performance was also assessed.

Results:

Discrimination decreased significantly between model derivation (0.76 [interquartile range 0.73–0.78]) and validation (0.64 [interquartile range 0.60–0.67], P<0.001), but approximately half of this decrease was because of narrower case-mix in the validation samples. CPMs had better discrimination when tested in related compared with distantly related trial cohorts. Calibration slope was also significantly higher in related trial cohorts (0.77 [interquartile range, 0.59–0.90]) than distantly related cohorts (0.59 [interquartile range 0.43–0.73], P=0.001). When considering the full range of possible decision thresholds between half and twice the outcome incidence, 91% of models had a risk of harm (net benefit below default strategy) at some threshold; this risk could be reduced substantially via updating model intercept, calibration slope, or complete re-estimation.

Conclusions:

There are significant decreases in model performance when applying cardiovascular disease CPMs to new patient populations, resulting in substantial risk of harm. Model updating can mitigate these risks. Care should be taken when using CPMs to guide clinical decision-making.

Developing and Validating Risk Scores for Predicting Major Cardiovascular Events Using Population Surveys Linked with Electronic Health Insurance Records

A risk prediction model for major cardiovascular events was developed using population survey data linked to National Health Insurance (NHI) claim data and the death registry. Another set of population survey data were used to validate the model. The model was built using the Nutrition and Health Survey in Taiwan (NAHSIT) collected from 1993–1996 and linked with 10 years of events from NHI data. Major adverse cardiovascular events (MACEs) were identified based on hospital admission or death from coronary heart disease or stroke. The Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH), conducted in 2002 was used for external validation. The NAHSIT data consisted of 1658 men and 1652 women aged 35–70 years. The incidence rates for MACE per 1000 person-years were 13.77 for men and 7.76 for women. These incidence rates for the TwSHHH were 7.27 for men and 3.58 for women. The model had reasonable discrimination (C-indexes: 0.76 for men; 0.75 for women), thus can be used to predict MACE risks in the general population. NHI data can be used to identify disease statuses if the definition and algorithm are clearly defined. Precise preventive health services in Taiwan can be based on this model.

Validation and comparison of 28 risk prediction models for coronary artery disease

AIMS

Risk prediction models (RPMs) for coronary artery disease (CAD), using variables to calculate CAD risk, are potentially valuable tools in prevention strategies. However, their use in the clinical practice is limited by a lack of poor model description, external validation, and head-to-head comparisons.

METHODS AND RESULTS

CAD RPMs were identified through Tufts PACE CPM Registry and a systematic PubMed search. Every RPM was externally validated in the three cohorts (the UK Biobank, LifeLines, and PREVEND studies) for the primary endpoint myocardial infarction (MI) and secondary endpoint CAD, consisting of MI, percutaneous coronary intervention, and coronary artery bypass grafting. Model discrimination (C-index), calibration (intercept and regression slope), and accuracy (Brier score) were assessed and compared head-to-head between RPMs. Linear regression analysis was performed to evaluate predictive factors to estimate calibration ability of an RPM. Eleven articles containing 28 CAD RPMs were included. No single best-performing RPM could be identified across all cohorts and outcomes. Most RPMs yielded fair discrimination ability: mean C-index of RPMs was 0.706 ± 0.049, 0.778 ± 0.097, and 0.729 ± 0.074 (P < 0.01) for prediction of MI in UK Biobank, LifeLines, and PREVEND, respectively. Endpoint incidence in the original development cohorts was identified as a significant predictor for external validation performance.

CONCLUSION

Performance of CAD RPMs was comparable upon validation in three large cohorts, based on which no specific RPM can be recommended for predicting CAD risk.

A systematic review of the status and methodological considerations for estimating risk of first ever stroke in the general population

AIMS

The methodological quality of development, validation, and modification of those models have not been evaluated via a thoroughly literature review. This study aims to describe the overall status and evaluate the methodological quality of risk prediction models for stroke incidence in the general population.

METHODS

We searched the database of EMBASE and MEDLINE by the combination of subject words and key words to collect the research on stroke risk prediction model in the general population. The retrieval time was from the establishment of the database to September 2019. It should be mentioned that risk of bias for each model was assessed, and data on population characteristics and model performance was also extracted.

RESULTS

The search screened 11,386 peer-reviewed publications and 57 citation searching, of which 48 were included in the review, describing the development of 51 prediction models, 47 external validation models, and 12 modification models. Among 51 development models, the predicted outcome concentrated on fatal or non-fatal stroke (n = 37, 73%). Thirty-nine development models (76%) were without internal validation. C-statistic or AUC was adopted for discrimination in 80% models, and Hosmer-Lemeshow test (n = 25, 49%) was also performed for calibration. Twenty-six development models (53%) were externally validated, among which only 2 (8%) were validated by independent researchers. Risk prediction performance was improved when models were modified by adding novel risk factors, such as the internal carotid artery plaque and intima-media thickness.

CONCLUSION

Models for predicting stroke occurrence need further external validation, recalibration, or modification in different populations, to help interpret those models in the practice of stroke prevention.

New findings in the roles of Cyclin-dependent Kinase inhibitors 2B Antisense RNA 1 (CDKN2B-AS1) rs1333049 G/C and rs4977574 A/G variants on the risk to coronary heart disease

The relationship between Cyclin-Dependent Kinase Inhibitors 2B Antisense RNA 1 (CDKN2B-AS1) variants rs1333049 G/C and rs4977574 A/G and the risk of coronary heart disease is unclear. We conducted an update analysis incorporating odds ratios and 95% confidence intervals to assess the correlation. Furthermore, we used in silico analysis to investigate the genes and proteins that interact with CDKN2B. Fifty case-control studies with a sample size of 35,915 cases and 48,873 controls were involved. We revealed that the rs1333049 C allele could increase the risk of coronary heart disease in the overall analysis (allele comparison, OR = 1.13, 95%CI = 1.05–1.21, P = 0.001; homozygous contrast, OR = 1.29, 95%CI = 1.11–1.49, P = 0.001; dominant comparison, OR = 1.14, 95%CI = 1.03–1.27, P = 0.011; recessive comparison, OR = 1.21, 95%CI = 1.10–1.34, P < 0.001). In subgroup analysis, positive correlations were detected in studies involving West and East Asians and in population-based control studies. The rs4977574 G allele was also a risk factor for coronary heart disease (allelic comparison, P = 0.001; heterozygous comparison, P = 0.003; homozygous comparison, P < 0.001; dominant comparison, P = 0.001). These results indicate correlation of CDKN2B-AS1 rs1333049 G/C and rs4977574 A/G variants may be correlated with the risk of coronary heart disease.

Abbreviations CDK: Cyclin Dependent Kinase; CCND: G1/S-specific cyclin-D; CDKN: Cyclin Dependent Kinase Inhibitor; GWAS: Genome-wide association study; CDKN2B-AS1: Cyclin-Dependent Kinase Inhibitors 2B Antisense RNA 1; CHD: Coronary heart disease; MAF: minor allele frequencies; HWE: Hardy-Weinberg equilibrium of controls; CI: confidence interval; COL8A2: Collagen type VIII alpha 2 chain; HB: Hospital-based; ORs: odds ratios; ITGA11: Integrin subunit alpha 11; LTBP: Latent transforming factor beta binding protein; PB: Population-based; IBC: Itmat Broad Care; NA: Not applicable; PCR-RFLP: polymerase chain reaction-restriction fragment length polymorphism; MI: Myocardial Infarction; SNP: single nucleotide polymorphism; SMAD: Mothers against decapentaplegic homolog; RT-PCR: Real-time polymerase chain reaction; UK: United Kingdom

Cardiometabolic risk prediction algorithms for young people with psychosis: a systematic review and exploratory analysis

OBJECTIVE

Cardiometabolic risk prediction algorithms are common in clinical practice. Young people with psychosis are at high risk for developing cardiometabolic disorders. We aimed to examine whether existing cardiometabolic risk prediction algorithms are suitable for young people with psychosis.

METHODS

We conducted a systematic review and narrative synthesis of studies reporting the development and validation of cardiometabolic risk prediction algorithms for general or psychiatric populations. Furthermore, we used data from 505 participants with or at risk of psychosis at age 18 years in the ALSPAC birth cohort, to explore the performance of three algorithms (QDiabetes, QRISK3 and PRIMROSE) highlighted as potentially suitable. We repeated analyses after artificially increasing participant age to the mean age of the original algorithm studies to examine the impact of age on predictive performance.

RESULTS

We screened 7820 results, including 110 studies. All algorithms were developed in relatively older participants, and most were at high risk of bias. Three studies (QDiabetes, QRISK3 and PRIMROSE) featured psychiatric predictors. Age was more strongly weighted than other risk factors in each algorithm. In our exploratory analysis, calibration plots for all three algorithms implied a consistent systematic underprediction of cardiometabolic risk in the younger sample. After increasing participant age, calibration plots were markedly improved.

CONCLUSION

Existing cardiometabolic risk prediction algorithms cannot be recommended for young people with or at risk of psychosis. Existing algorithms may underpredict risk in young people, even in the face of other high-risk features. Recalibration of existing algorithms or a new tailored algorithm for the population is required.

Analysis on the polymorphisms of site RS4977574, and RS1333045 in region 9p21 and the susceptibility of coronary heart disease in Chinese population

Background

Rs4977574 (A > G) and Rs1333045 (C > T) are both single nucleotide polymorphisms (SNPs) related with coronary artery disease, locating on chromosome 9p21.3. The study aimed to identify the correlation between rs4977574 and rs1333045 polymorphism genotypes and coronary heart disease (CHD) in a Chinese population.

Methods

Blood samples were collected from 855 subjects. A case-control study was used in this experiment, and 598 cases in the CHD group and 257 subjects in the control group were enrolled. Genotyping was identified by the Agena MassARRAY system. Statistical analysis was conducted by SPSS (Ver 16.0) and plink (Ver. 1.07, Shaun Purcell). Haplotype analysis was performed using Haploview software.

Results

Association analysis by plink indicated a significant difference in the allele distribution for single nucleotide polymorphisms between cases and controls (rs4977574 P = 0.003, rs1333045 P = 0.035). Fisher’s exact test by plink proved that allele G may be associated with a higher risk of CHD (P = 0.003, odds ratio (OR) = 1.371) and the T allele was likely to reduce the risk of coronary events (P = 0.035, OR = 0.798). The serum levels of apolipoprotein A (ApoA) were higher in subjects with the AG + AA genotype of rs4977574 compared to those with the GG genotype (P = 0.028). In the dominant model of rs1333045, the levels of ApoA were higher and LDL levels were lower in the TC + TT genotype than in the CC genotype.

Conclusions

The present study examined the association between the 9p21 chromosome rs4977574 and rs1333045 polymorphism genotypes and CHD in a population of Chinese patients. The G allele of rs4977574 and the C allele of rs1333045 are the susceptibility sites of CHD.

Insulin glargine compared to neutral protamine Hagedorn (NPH) insulin in patients with type-2 diabetes uncontrolled with oral anti-diabetic agents alone in Hong Kong: a cost-effectiveness analysis

Background

International guidelines recommend using basal insulin in patients with type-2 diabetes mellitus if glycaemic target cannot be attained on non-insulin anti-diabetic drugs. Available choices of basal insulin include intermediate-acting neutral protamine Hagedorn (NPH) insulin and long-acting insulin analogues like insulin glargine U100. Despite clear advantages of glargine U100, the existing practice in Hong Kong still favours NPH insulin due to lower immediate drug costs.

Objectives

The objective of this study was to assess the cost-effectiveness of insulin glargine U100 compared to NPH insulin in patients with type-2 diabetes uncontrolled with non-insulin anti-diabetic agents alone in Hong Kong.

Methods

The IQVIA™ Core Diabetes Model (CDM) v9.0 was used to conduct the cost-effectiveness analysis of glargine U100 versus NPH. Baseline characteristics were collected from the Hong Kong Diabetes Registry. Efficacy rates were extracted from a published study comparing glargine U100 and NPH in Asia, utilities from published literature, and costs constructed using the Hong Kong Hospital Authority (HA) Gazette (public healthcare setting). The primary outcome was an incremental cost-effectiveness ratio (ICER).

Results

Insulin glargine U100 resulted in an ICER of HKD 98,663 per Quality Adjusted Life Year (QALY) gained. The incremental gains in QALY and costs were 0.217 years and HKD 21,360 respectively. Results from scenario and probabilistic sensitivity analyses were consistent with that from base case analysis.

Conclusion

Insulin glargine U100 is a cost-effective treatment for patients with type 2 diabetes compared to NPH insulin in setting in Hong Kong. This was mainly driven by the significantly lower rates of hypoglycaemia of insulin glargine U100 than NPH insulin.

Electronic supplementary material

The online version of this article (10.1186/s12962-019-0180-9) contains supplementary material, which is available to authorized users.

Impacts of the New 2017 ACC/AHA Hypertension Guideline on the Prevalence of Brachial Hypertension and Its Concordance with Central Hypertension

OBJECTIVES

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline lowers the blood pressure (BP) thresholds for defining brachial hypertension. We therefore aimed to investigate how the new guideline influences the prevalence of brachial hypertension and whether it improves the identification of central hypertension in an Asian national representative population.

METHODS

A total of 2,742 adults older than 19 years participated in the 2013-2016 National Nutrition and Health Survey in Taiwan. Central and brachial BPs were simultaneously measured twice and averaged using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device). Brachial hypertension was defined by brachial systolic/diastolic BP ≥ 130 or 80 mm Hg or using antihypertensive medication, and central hypertension was defined by central systolic/diastolic BP ≥ 130 or 90 mm Hg or using antihypertensive medication.

RESULTS

The national weighted prevalence rates of brachial hypertension according to the 2017 AHA/ACC guideline were 48.7% in men and 30.7% in women. The prevalence of brachial hypertension increased by 18.8% in men and 9.4% in women, when compared with the prevalence defined by the conventional thresholds of brachial systolic/diastolic BP ≥ 140 or 90 mm Hg. In comparison with the conventional criteria, the new hypertension criteria had a higher sensitivity (93.0% vs. 77.4%) and a lower specificity (86.7% vs. 99.6%) for detecting central hypertension.

CONCLUSIONS

Adoption of the 2017 AHA/ACC BP thresholds substantially increases the prevalence of brachial hypertension, especially in men, and identifies over 90% of those with central hypertension at the expense of lesser specificity.

Comparing the Consistency and Performance of Various Coronary Heart Disease Prediction Models for Primary Prevention Using a National Representative Cohort in Taiwan

BACKGROUND

Predicting future coronary artery disease (CAD) risk by model-based approaches can facilitate identification of high-risk individuals for prevention and management. Therefore, we compared the consistency and performance of various CAD models for primary prevention using 1 external validation dataset from a national representative cohort in Taiwan.Methods and Results:The 10 CAD prediction models were assessed in a validation cohort of 3559 participants (≥35 years old, 53.5% women) from a Taiwanese national representative cohort that was followed up for a median 9.70 (interquartile range, 9.63-9.74) years; 63 cases were documented as developing CAD events. The overall κ value was 0.51 for all 10 models, with a higher value for women than for men (0.53 for women, 0.40 for men). In addition, the areas under the receiver operating characteristics curves ranged from 0.804 (95% confidence interval, 0.758-0.851) to 0.847 (95% confidence interval, 0.805-0.889). All non-significant chi-square values indicated good calibration ability.

CONCLUSIONS

Our study demonstrated these 10 CAD prediction models for primary prevention were feasible and validated for use in Taiwanese subjects. Further studies of screening and management are warranted.

Prevalence of Hypertension Defined by Central Blood Pressure Measured Using a Type II Device in a Nationally Representative Cohort

OBJECTIVES

Central blood pressure (BP) can be used to define hypertension. A central BP approach may be more sensitive than a conventional brachial BP approach in detecting hypertension. We aimed to compare the 2 approaches in estimating the prevalence hypertension in a nationally representative population.

METHODS

A total of 2,742 adults older than 19 years participated in the 2013-2016 National Nutrition and Health Survey in Taiwan. Central and brachial BP were simultaneously measured using a cuff-based stand-alone central BP monitor purporting to measure invasive central BP (type II device). Central hypertension was defined by central systolic (SBP)/diastolic BP (DBP) ≥130 or 90 mm Hg or using antihypertensive medications, and brachial hypertension was defined by brachial SBP/DBP ≥140 or 90 mm Hg or using antihypertensive medications.

RESULTS

The World Health Organization-standardized and national weighted prevalence rates of central hypertension were 27.95% and 32.48%, respectively, and both were significantly higher than those of brachial hypertension (20.80% and 25.43%, both P < 0.001). The national weighted prevalence rates of concordant central and brachial hypertension, concordant central and brachial nonhypertension, isolated central hypertension, and isolated brachial hypertension were 25.13%, 67.22%, 7.35%, and 0.30%, respectively. Most subjects with the isolated central hypertension (97%) were within the range of brachial prehypertension, but only 38.0% of subject with brachial prehypertension had central hypertension.

CONCLUSION

Almost one-third of a nationally representative population had hypertension detected by a central BP approach. Hypertension detection using a conventional brachial BP approach may underestimate the prevalence of hypertension and result in a less effective hypertension control.

Mini-Review of the Chin-Shan Community Cardiovascular Cohort Study in Population Health Research in Taiwan

Preventing and controlling non-communicable diseases (NCDs) is a growing global public health concern, and evidence-based data from population-based health studies are needed in order to develop appropriate public health policies for controlling NCDs. The Chin-Shan Community Cardiovascular Cohort (CCCC) study is a prospective cohort consisting of participants from one community in China in 1990-1991, and has provided substantial evidence-based data on domestic and global health issues in preventive cardiology fields. The present study is a mini-review of the CCCC study. In this review, we have described the historical background of the cardiovascular disease burden and related risk factors, especially lifestyle factors, subclinical disease markers, biomarkers and prediction models, and related international collaborative projects. In addition, this mini-review study provides a measure of insight into future plans for 21st century epidemiological research in cardiovascular diseases, suggesting possible areas of focus for future research.

Prediction models for cardiovascular disease risk in the general population: systematic review

OBJECTIVE

 To provide an overview of prediction models for risk of cardiovascular disease (CVD) in the general population.

DESIGN

 Systematic review.

DATA SOURCES

 Medline and Embase until June 2013.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Studies describing the development or external validation of a multivariable model for predicting CVD risk in the general population.

RESULTS

 9965 references were screened, of which 212 articles were included in the review, describing the development of 363 prediction models and 473 external validations. Most models were developed in Europe (n=167, 46%), predicted risk of fatal or non-fatal coronary heart disease (n=118, 33%) over a 10 year period (n=209, 58%). The most common predictors were smoking (n=325, 90%) and age (n=321, 88%), and most models were sex specific (n=250, 69%). Substantial heterogeneity in predictor and outcome definitions was observed between models, and important clinical and methodological information were often missing. The prediction horizon was not specified for 49 models (13%), and for 92 (25%) crucial information was missing to enable the model to be used for individual risk prediction. Only 132 developed models (36%) were externally validated and only 70 (19%) by independent investigators. Model performance was heterogeneous and measures such as discrimination and calibration were reported for only 65% and 58% of the external validations, respectively.

CONCLUSIONS

 There is an excess of models predicting incident CVD in the general population. The usefulness of most of the models remains unclear owing to methodological shortcomings, incomplete presentation, and lack of external validation and model impact studies. Rather than developing yet another similar CVD risk prediction model, in this era of large datasets, future research should focus on externally validating and comparing head-to-head promising CVD risk models that already exist, on tailoring or even combining these models to local settings, and investigating whether these models can be extended by addition of new predictors.

Total 25-hydroxyvitamin D concentration as a predictor for all-cause death and cardiovascular event risk among ethnic Chinese adults: a cohort study in a Taiwan community

BACKGROUND

Evidence of an inverse association between serum 25-hydoroxyvitamin D [25(OH)D] and the risk of all-cause death and cardiovascular disease from prospective studies is inconsistent. We tested the relationship between 25(OH)D and the risk among adult ethnic Chinese in Taiwan.

METHODS

We conducted a community-based cohort study of 1816 participants (age 60.2±10.2 yrs, 45.0% women) in the Chin-Shan Community Cardiovascular Cohort Study who were free of cardiovascular diseases at baseline and provided 25(OH)D measurements.

RESULTS

During a median 9.6 (interquartile range, 8.8- 10.5) years' follow-up period, totally 263 cases developed cardiovascular death events and 559 participants were documented to death from any cause. As 25(OH)D concentration increased, the incidence rates of cardiovascular events and all-cause death decreased progressively. 25(OH)D was inversely associated with all-cause death: the adjusted hazard ratio was 0.49 (95% confidence interval [CI], 0.25-0.97) for the third quartile and a significant J-shape relationship was found. The performance measures by integrated discriminative improvement showed significant improvement after adding 25(OH)D information (0.14%, 95% CI, 0.03-0.31, P=0.050, for all-cause death and 0.32%, 95% CI, 0.02-0.62, P=0.018 for cardiovascular events).

CONCLUSION

These findings suggested a modest inverse association between 25(OH)D and the risk of all-cause death among diabetic participants and a good predictive factor in the community. Further studies to investigate the mechanism of vitamin D role on health effect are warranted.

Association of CDKN2BAS polymorphism rs4977574 with coronary heart disease: a case-control study and a meta-analysis

The goal of our study was to explore the significant association between a non-protein coding single nucleotide polymorphism (SNP) rs4977574 of CDKN2BAS gene and coronary heart disease (CHD). A total of 590 CHD cases and 482 non-CHD controls were involved in the present association study. A strong association of rs4977574 with CHD was observed in females (genotype: p=0.002; allele: p=0.002, odd ratio (OR)=1.57, 95% confidential interval (CI)=1.18-2.08). Moreover, rs4977574 was more likely to be a risk variant of CHD under the recessive model in females (χ2=10.29, p=0.003, OR=2.14, 95% CI=1.31-2.77). A breakdown analysis by age had shown that there was an 87% increased risk of CHD for females younger than 65 years (genotype: χ2=14.64, degrees of freedom (df)=2, p=0.0002; allele: χ2=11.31, df=1, p=0.0008, OR=1.87, 95% CI=1.30-2.70). Similar observation was also found in males younger than 65 years (genotype: χ2=8.63, df=2, p=0.04; allele: χ2=7.55, df=1, p=0.006, OR=1.45, 95% CI=1.11-1.90). p values were adjusted by age, sex, smoking, high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C). Meta-analysis of 23 studies among 36,452 cases and 39,781 controls showed a strong association between rs4977574 and the risk of CHD (p<0.0001, OR=1.27, 95% CI=1.22-1.31).

Comparison of four cardiovascular risk prediction functions among Chinese patients with diabetes mellitus in the primary care setting

AIMS/INTRODUCTION

To assess the feasibility, convergent validity and sensitivity of four cardiovascular risk prediction functions in Chinese diabetic patients in the primary care setting.

MATERIALS AND METHODS

A cross-sectional study of 1,140 diabetic patients was carried out to compare four cardiovascular risk functions, which were respectively developed from the Framingham heart study, the USA-People's Republic of China Collaborative Study of Cardiovascular and Cardiopulmonary Epidemiology cohort (PRC), the United Kingdom Prospective Diabetes Study (UKPDS) and the Joint Asia Diabetes Evaluation program (JADE). Feasibility was assessed by the percentage of patients with complete data for risk prediction. Convergent validity was measured by Spearman's rank correlation, paired Wilcoxon signed-rank sum test and Bland-Altman plots. Effect size differences between clinical risk groups were used to assess the sensitivity.

RESULTS

Risk prediction was feasible by the Framingham, UKPDS and PRC risk functions in more than 98% patients, whereas just 74% of patients had complete data for the JADE function. The annual total coronary heart disease (CHD) risk predicted by the JADE and the UKPDS functions showed excellent agreement with no significant difference, and a correlation of 0.8048. The Framingham and the PRC functions predicted significantly lower CHD risk than those by the UKPDS and the JADE functions. The UKPDS and the Framingham functions were more sensitive in differentiating clinical risk groups.

CONCLUSIONS

The UKPDS risk engine showed good feasibility, convergent validity and sensitivity in predicting CHD risk in Chinese diabetic patients. The JADE function showed excellent agreement with the UKPDS risk engine, but it was less feasible in the primary care setting.

Low socioeconomic status increases short-term mortality of acute myocardial infarction despite universal health coverage

BACKGROUND

This nationwide population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for acute myocardial infarction (AMI) in Taiwan.

METHODS

A population-based follow-up study included 23,568 patients diagnosed with AMI from 2004 to 2008. Each patient was monitored for 2 years, or until their death, whichever came first. The individual income-related insurance payment amount was used as a proxy measure of patient's individual SES. Neighborhood SES was defined by household income, and neighborhoods were grouped as advantaged or disadvantaged. The Cox proportional hazards model was used to compare the mortality rates between the different SES groups after adjusting for possible confounding risk factors.

RESULTS

After adjusting for potential confounding factors, AMI patients with low individual SES had an increased risk of death than those with high individual SES who resided in advantaged neighborhoods. In contrast, the cumulative readmission rate from major adverse cardiovascular events did not differ significantly between the different individual and neighborhood SES groups. AMI patients with low individual SES had a lower rate of diagnostic angiography and subsequent percutaneous coronary intervention (P<0.001). The presence of congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, pneumonia, septicemia, and shock revealed an incremental increase with worse SES (P<0.001).

CONCLUSIONS

The findings indicate that AMI patients with low individual SES have the greatest risk of short-term mortality despite being under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.

Comparison of predictive performance of various fatty acids for the risk of cardiovascular disease events and all-cause deaths in a community-based cohort

BACKGROUND

The issue of whether saturated fats and trans fats are superior predictors of all-cause death and cardiovascular disease than n-3 polyunsaturated fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), remains a matter of contention. Furthermore, few studies have examined the relationship between fatty acids and the outcomes of cardiovascular disease (CVD) in Asian populations. The aim of this study was to compare the effectiveness of various plasma fatty acids as predictors for all-cause death and CVD events in an ethnic Chinese population.

METHODS

This study assembled a community-based prospective cohort, comprising 1833 participants (60.6 ± 10.5 yrs, 44.5% women) who underwent a comprehensive evaluation of fatty acids in blood using gas chromatography. None of the subjects had a history of CVD at the time of recruitment.

RESULTS

A total of 568 individuals died and 275 individuals developed CVD during the follow-up period (median of 9.6 years; interquartile range of 8.9-10.5 years). Following adjustment for established cardiovascular risk factors, the relative risk of all-cause death in the highest quartile, compared with the lowest quartile, was 1.33 for saturated fats (95% confidence interval [CI], 1.01-1.75, test for trend, P = 0.015), 1.71 for trans fats (95% CI, 1.27-2.31, test for trend, P = 0.0003), 0.77 for EPA (95% CI, 0.59-1.00, test for trend, P = 0.048), and 0.89 for DHA (95% CI, 0.68-1.18, test for trend, P = 0.354). Similar patterns were observed for CVD events. Trans fats presented the largest area under the receiver operator characteristic curve (0.740, 95% CI, 0.716-0.766) for the prediction of all-cause death. A mutually adjusted two-marker model indicated that saturated fats and trans fats were significant predictors of all-cause death and CVD; however, the other fatty acids were not. In addition, trans fats presented the greatest improvement in net reclassification for all-cause death (7.7%, P = 0.003), followed by EPA (3.8%, P = 0.033). Saturated fats presented the greatest improvement in net reclassification for CVD events (5.6%, P = 0.039).

CONCLUSIONS

Our data provides strong evidence to support that plasma saturated fats and trans fats can predict all-cause death and CVD more effectively than other fatty acid markers.