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Abdullah N, Blin JA, Kamalul Arifin AS, Abd Jalal N, Ismail N, Mohd Yusof NA, Abdullah MS, Husin NF, Dauni A, Kamaruddin MA, Mohammed Nawi A, Ahmad N, Hassan MR, Jamal R. Cardiovascular risk prediction with cardio-ankle vascular index in the malaysian cohort study. Curr Probl Cardiol 2024; 49:102192. [PMID: 37952789 DOI: 10.1016/j.cpcardiol.2023.102192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
The cardio-ankle vascular index (CAVI) is an important parameter assessing arterial function. It reflects arterial stiffness from the origin of the aorta to the ankle, and the algorithm is blood pressure independent. Recent data have suggested that a high CAVI score can predict future cardiovascular disease (CVD) events; however, to date, no study has been done in Malaysia. We conducted a prospective study on 2,168 The Malaysian Cohort (TMC) CVD-free participants (971 men and 1,197 women; mean age 51.64 ± 8.38 years old) recruited from November 2011 to March 2012. This participants were followed-up until the emergence of CVD incidence and mortality (endpoint between May to September 2019; duration of 7.5 years). Eligible participants were assessed based on CAVI baseline measurement which categorised them into low (CAVI <9.0) and high (CAVI ≥ 9.0) scores. The CVD events in the group with high CAVI (6.5 %) were significantly higher than in the low CAVI (2.6 %) group (p < 0.05). CAVI with cut-off point ≥ 9.0 was a significant independent predictor for CVD event even after adjustment for male, ethnicity, age, and intermediate atherogenic index of plasma (AIP). Those who have higher CAVI have 78 % significantly higher risk of developing CVD compared to those with the low CAVI (adjusted OR [95 % CI] = 1.78 [1.04 - 3.05], p =0.035). In addition, the participants with higher CAVI have significantly lower survival probability than those who have lower CAVI values. Thus, this study indicated that the CAVI can predict CVD event independently among the TMC participants.
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Affiliation(s)
| | - Joan Anak Blin
- UKM Medical Molecular Biology Institute (UMBI), Kuala Lumpur 56000, Malaysia.
| | | | - Nazihah Abd Jalal
- UKM Medical Molecular Biology Institute (UMBI), Kuala Lumpur 56000, Malaysia.
| | - Norliza Ismail
- UKM Medical Molecular Biology Institute (UMBI), Kuala Lumpur 56000, Malaysia.
| | | | | | - Nurul Faeizah Husin
- UKM Medical Molecular Biology Institute (UMBI), Kuala Lumpur 56000, Malaysia.
| | - Andri Dauni
- UKM Medical Molecular Biology Institute (UMBI), Kuala Lumpur 56000, Malaysia.
| | | | - Azmawati Mohammed Nawi
- Department of Public Health Medicine, Faculty of Medicine, UKM, Kuala Lumpur 56000, Malaysia.
| | - Norfazilah Ahmad
- Department of Public Health Medicine, Faculty of Medicine, UKM, Kuala Lumpur 56000, Malaysia.
| | - Mohd Rohaizat Hassan
- Department of Public Health Medicine, Faculty of Medicine, UKM, Kuala Lumpur 56000, Malaysia.
| | - Rahman Jamal
- UKM Medical Molecular Biology Institute (UMBI), Kuala Lumpur 56000, Malaysia.
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Suanrueang P. A comparison of the disease occurrence of cerebrovascular diseases, diabetes mellitus, hypertensive diseases, and ischaemic heart diseases among hospitalized older adults in Thailand. Sci Rep 2024; 14:123. [PMID: 38168490 PMCID: PMC10761676 DOI: 10.1038/s41598-023-49274-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
This observational research analyzed public hospital data from the Thailand Ministry of Public Health website to investigate gender differences in four categories of non-communicable diseases (NCDs) affecting hospitalized senior Thai populations for 12 years. This study aimed to determine the cumulative effects and analyze the odds ratio (OR) according to ICD-10 cause categories for the data from 2010 to 2021, accounting for 1,327,093 cases in 2010 and 2,275,936 cases in 2021. The findings revealed statistically significant gender differences in four categories of NCDs. Men were found to be more likely than women to have two types of NCDs, as measured by the OR (95%CI): cerebrovascular diseases (OR 1.34-1.47, 95%CI 1.32-1.48), and ischaemic heart disease (OR 1.24-1.63, 95%CI 1.23-1.64). Conversely, diabetes mellitus (OR 0.64-0.84, 95%CI 0.63-0.85) and hypertensive disorders (OR 0.82-0.95, 95%CI 0.81-0.97) were discovered to have a lower likelihood of ratios related in men compared to women. However, the trend of all four NCDs in men has significantly increased every year: cerebrovascular diseases = 0.0093 year(s) + 1.3391, (R2 0.82, p-value 0.001); diabetes mellitus = 0.0171 year(s) + 0.6143, (R2 0.97, p-value 0.001); hypertension = 0.0125 year(s) + 0.8091, (R2 0.96, p-value 0.001); and ischaemic heart disease = 0.0345 year(s) + 1.1884, (R2 0.99, p-value 0.001).Gender, a crucial biological factor, contributes to variations in the prevalence of illness. As such, it is essential to prioritize the disease risk occurrence and preventive care for men and women separately, with a focus on implementing more detailed screening and detection strategies, as well as tailored interventions.
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Affiliation(s)
- Passakorn Suanrueang
- Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand.
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Lonardo A. The heterogeneity of metabolic syndrome presentation and challenges this causes in its pharmacological management: a narrative review focusing on principal risk modifiers. Expert Rev Clin Pharmacol 2023; 16:891-911. [PMID: 37722710 DOI: 10.1080/17512433.2023.2259306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/12/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION Metabolic syndrome (MetS), i.e. the cluster of cardiometabolic risk factors comprising visceral obesity, impaired glucose metabolism, arterial hypertension and atherogenic dyslipidemia, is prevalent globally and exacts a heavy toll on health care expenditures. AREAS COVERED The pathophenotypes of individual traits of the MetS in adults are discussed first, with strong emphasis on nonalcoholic fatty liver disease (NAFLD) and sex differences. Next, I discuss recent studies on phenotypic and outcome heterogeneity of the MetS, highlighting the role of NAFLD, sex, reproductive status, and depressive disorders. In the second half of the article, the therapeutic implications of the variable MetS types and features are analyzed, focusing on the most recent developments, and guidelines. EXPERT OPINION I have identified physiological, pathological, social and medical sources of phenotypical heterogeneity in the MetS and its constitutive traits. Improved understanding of these variables may be utilized in the setting of future precision medicine approaches in the field of metabolic disorders and target organ damage.
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Affiliation(s)
- Amedeo Lonardo
- Operating Unit of Metabolic Syndrome, Azienda Ospedaliero-Unversitaria di Modena, Ospedale Civile di Baggiovara, Baggiovara, Modena, Italy
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Suzuki Y, Kaneko H, Yano Y, Okada A, Hashimoto Y, Itoh H, Matsuoka S, Yokota I, Fujiu K, Michihata N, Jo T, Takeda N, Morita H, Kamiya K, Matsunaga A, Ako J, Node K, Yasunaga H, Komuro I. Threshold of BMI for the Development of Hypertension among Japanese Adults. J Nutr 2022; 152:2565-2571. [PMID: 36774122 DOI: 10.1093/jn/nxac192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/16/2022] [Accepted: 08/23/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The optimal value of BMI for the development of hypertension and the influence of BMI on the development of stage 1 or stage 2 hypertension remain unclear. OBJECTIVES We sought to identify the BMI threshold for the prevention of hypertension and how changes in BMI would influence the risk of developing hypertension. METHODS We analyzed 1,262,356 participants (median age: 43 y; 50.9% men) with normal blood pressure [BP; systolic BP (SBP) <120 mmHg and diastolic BP (DBP) <80 mmHg] or elevated BP (SBP: 120-129 mmHg and DBP <80 mmHg). The primary outcome was stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg) or stage 2 hypertension (SBP ≥140 mmHg or DBP ≥90 mmHg). We analyzed the relation between baseline BMI, change in BMI, and the risk of developing hypertension using generalized additive models with a smoothing spline. RESULTS During the median follow-up of 851 d, 341,212 cases of stage 1 hypertension and 70,968 cases of stage 2 hypertension were detected. The risk of developing stage 1 or stage 2 hypertension increased steeply after BMI (kg/m2) exceeded 20. The annual change in BMI was positively correlated with the risk of developing stage 1 or 2 hypertension. Contour mapping using generalized additive models demonstrated an additive increase in the risk of developing hypertension with higher baseline BMI and increases in BMI over 1 y. Body-weight gain increases the risk of developing hypertension even in underweight or normal-weight individuals based on the WHO classification. CONCLUSIONS In Japanese adults with normal or elevated BP, the risk of developing hypertension increased with BMI when baseline BMI was >20. Body-weight gain additively interacted with baseline BMI during hypertension development. Our results underscore the importance of maintaining body weight in preventing the development of hypertension.
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Affiliation(s)
- Yuta Suzuki
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan; Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Saitama, Japan
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan; Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan.
| | - Yuichiro Yano
- Department of Advanced Epidemiology, NCD Epidemiology Research Center, Shiga University of Medical Science, Shiga, Japan; Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yohei Hashimoto
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Matsuoka
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan; Department of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Isao Yokota
- Department of Biostatistics, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan; Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
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Goyal P, Chhabra ST, Jyotsna M. Hypertension in Women: The Current Understanding and Future Goals. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2022. [DOI: 10.25259/mm_ijcdw_476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hypertension is one of the major contributing risk factor of cardiovascular diseases. Despite enormous advances in the preventive cardiology, hypertension remains the leading cause of death and disability in women. The article aims to focus on the gender specific differences in hypertension, and existing gaps in the current understanding of high blood pressure (BP) in women. Apart from epidemiological differences, hypertension in men and women has distinct pathophysiological mechanisms, impact on cardiovascular system, awareness and control. Prevalence of hypertension is higher in men than women till menopause; following this the prevalence rises steeply in women, and exceeds that of men above 75 years of age. Women with their estrogenic environment are relatively protected from high BP as their hormonal/chromosomal profile govern expression of alternate renin angiotensin axis (RAS) pathway and anti-inflammatory, vasodilatory, anti-proliferative immune cells whereas in males, classical RAS driven inflammatory, pro-hypertensive and proliferative milieu confers higher risk of hypertension. Thus, immunotherapy can have a potential therapeutic role in the treatment of hypertension in future. Cardiovascular consequences of high BP are worse in women than men in majority of trials. Women are now getting more aware of hypertension but the control of BP still remains poorer than men, especially in older age group. There are some noteworthy pharmacokinetic and pharmacogenomics gender differences in response to various antihypertensive drugs, which can be taken into consideration while choosing a particular class of drugs in female population. Standard treatment guidelines recommend same BP targets and management strategies in both the genders, but the trials so far have not been designed in a way to draw women specific conclusions on optimal cut-offs for diagnosis and treatment of BP due to under representation of women in majority of trials. More women centered analysis in future hypertension research projects can provide better scientific insights in various clinical aspects of hypertension.
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Affiliation(s)
- Prerna Goyal
- Department of Medicine, RG Stone and Super-speciality Hospital, Ludhiana, Punjab, India
| | - Shibba Takkar Chhabra
- Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - M. Jyotsna
- Department of Cardiology, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India,
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Ma G, Zhong Z, Duan Y, Shen Z, Qin N, Hu D. Development and Validation of a Self-Quantification Scale for Patients With Hypertension. Front Public Health 2022; 10:849859. [PMID: 35646756 PMCID: PMC9132107 DOI: 10.3389/fpubh.2022.849859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background The self-management ability of patients with hypertension is poor, and self-quantification increases gradually with the development of electronics. Self-quantification for patients with hypertension has important implications for individual health. However, there is a lack of relevant scales at present, and we aim to develop a self-quantified scale for patients with hypertension. Methods The instrument was developed based on protection motivation theory with literature review, a qualitative interview study and focus group discussions, and pilot testing. A total of 360 patients with hypertension were investigated using the scale. The psychometric properties of the scale were evaluated concerning validity and reliability employing internal consistency reliability, split-half reliability, test-retest reliability, content validity (S-CVI/Ave and I-CVI), and construct validity (exploratory factor analysis and confirmatory factor analysis). Results The final scale had 30 items with seven sub-domains. The Cronbach's α for all domains was 0.900 with a range of 0.817–0.938. The split-half reliability coefficient for all domains was 0.743 with a range of 0.700–0.888. The test-retest reliability coefficient for all domains was 0.880 with a range of 0.849–0.943. The S-CVI/Ave for all domains was 0.922 with a range of 0.906- 0.950, and the I-CVI of each item was a range of 0.800–1.000. The result of confirmatory factor analysis of this scale showed that χ2/df was 2.499, RMSEA = 0.065, GFI=0.865, NFI=0.894, IFI=0.934, TLI=0.914, CFI=0.933, RFI=0.865. The Pearson's coefficients between the total scale and every domain were ranging from 0.347 to 0.695, and each domain ranged from 0.130 to 0.481. Conclusion The scale has good validity and reliability and can be used as a self-quantification scale for patients with hypertension.
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Affiliation(s)
- Guiyue Ma
- Third Xiangya Hospital, Central South University, Changsha, China
- Xiangya School of Nursing, Central South University, Changsha, China
- College of Nursing, Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Zhuqing Zhong
- Third Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Medical Information Research, Central South University, College of Hunan Province, Changsha, China
- *Correspondence: Zhuqing Zhong
| | - Yinglong Duan
- Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhiying Shen
- Third Xiangya Hospital, Central South University, Changsha, China
| | - Ning Qin
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Dehua Hu
- Xiangya School of Life Science, Central South University, Changsha, China
- Dehua Hu
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Risk for Proteinuria in Newly Defined Hypertensive People Based on the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. Am J Cardiol 2022; 168:83-89. [PMID: 35063272 DOI: 10.1016/j.amjcard.2021.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022]
Abstract
Whether blood pressure (BP) classification using the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline can identify patients at high risk for proteinuria remains unknown. We examined the association of BP classification using the 2017 ACC/AHA guideline with the subsequent risk for the development of proteinuria. This is an observational cohort study using the JMDC Claims Database. We analyzed 914,786 participants with negative proteinuria assessed using urine dipstick tests at the initial health check-ups, not taking BP-lowering medications, and who underwent repeated urine dipstick tests within 4 years. Based on the 2017 ACC/AHA guideline, each participant was categorized as having normal BP (n = 487,020), elevated BP (n = 134,798), stage 1 hypertension (n = 197,618), or stage 2 hypertension (n = 95,350). The primary outcome was incident proteinuria. We investigated the association of BP based on the 2017 ACC/AHA guideline category with incident proteinuria using multivariable analyses. We used restricted cubic spline functions to identify the relation between systolic BP (SBP) and the risk for proteinuria. The median age was 45 years, and 59.4% were men. Multivariable analysis demonstrated that stage 1 hypertension (relative risk 1.14, 95% confidence interval 1.11 to 1.17), and stage 2 hypertension (relative risk 1.48, 95% confidence interval 1.43 to 1.52) were associated with a higher incidence of proteinuria than normal BP. The restricted cubic spline demonstrated that the risk for proteinuria increased linearly with SBP after SBP exceeded 120 mm Hg. Not only stage 2 hypertension but also stage 1 hypertension was associated with a greater risk for proteinuria, suggesting the importance of establishing the management strategy for stage 1 hypertension.
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Otaki Y, Watanabe T, Konta T, Watanabe M, Fujimoto S, Sato Y, Asahi K, Yamagata K, Tsuruya K, Narita I, Kasahara M, Shibagaki Y, Iseki K, Moriyama T, Kondo M, Watanabe T. One-Year Change in Diastolic Blood Pressure and Aortic Disease-Related Mortality in a Japanese General Population Aged 50-75 Years. Circ J 2021; 85:2222-2231. [PMID: 34483149 DOI: 10.1253/circj.cj-21-0514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Aortic diseases (ADs), including aortic dissection, aortic aneurysm, and aortic rupture, are fatal diseases with extremely high mortality rates. Hypertension has been reported to be associated with AD development; however, it remains unclear whether a 1-year change in diastolic blood pressure (DBP) is a risk factor for AD-related mortality in the general population.Methods and Results:This study used a nationwide database of 235,076 individuals (aged 50-75 years) who participated in the annual "Specific Health Check and Guidance in Japan" for 2 consecutive years between 2008 and 2010. There were 55 AD-related deaths during the follow-up period of 1,770 days. All subjects were divided into 4 groups based on the baseline DBP and change in DBP at 1 year: persistent high DBP, increasing DBP, decreasing DBP, and normal DBP. Kaplan-Meier analysis demonstrated that the persistent high DBP group had the greatest risk among the 4 groups. Multivariate Cox proportional hazard regression analysis demonstrated that both DBP and 1-year change in DBP were significantly associated with AD-related deaths. The prediction capacity was significantly improved by the addition of 1-year change in DBP to confounding risk factors. CONCLUSIONS This study demonstrated for the first time that a 1-year change in DBP was associated with AD-related deaths in the general population. Monitoring changes in DBP are of critical importance in the primary prevention of AD-related deaths in apparently healthy subjects aged 50-75 years.
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Affiliation(s)
- Yoichiro Otaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tsuneo Konta
- Department of Public Health and Hygiene, Yamagata University School of Medicine
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | | | - Yuji Sato
- Dialysis Division, University of Miyazaki Hospital
| | - Koichi Asahi
- The Japan Specific Health Checkups study (J-SHC study) Group
| | | | | | - Ichiei Narita
- The Japan Specific Health Checkups study (J-SHC study) Group
| | - Masato Kasahara
- The Japan Specific Health Checkups study (J-SHC study) Group
| | - Yugo Shibagaki
- The Japan Specific Health Checkups study (J-SHC study) Group
| | - Kunitoshi Iseki
- The Japan Specific Health Checkups study (J-SHC study) Group
| | | | - Masahide Kondo
- The Japan Specific Health Checkups study (J-SHC study) Group
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Matsuoka S, Kaneko H, Yano Y, Itoh H, Fukui A, Morita K, Kiriyama H, Kamon T, Fujiu K, Seki H, Michihata N, Jo T, Takeda N, Morita H, Nakamura S, Yokoo T, Nishiyama A, Node K, Yasunaga H, Komuro I. Association Between Blood Pressure Classification Using the 2017 ACC/AHA Blood Pressure Guideline and Retinal Atherosclerosis. Am J Hypertens 2021; 34:1049-1056. [PMID: 34008020 DOI: 10.1093/ajh/hpab074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We aimed to explore the association between the blood pressure (BP) classification defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline and the prevalence of retinal atherosclerosis. METHODS This study was a retrospective observational cross-sectional analysis using the JMDC Claims Database. We analyzed 280,599 subjects not taking any antihypertensive medications. According to the 2017 ACC/AHA guideline, each subject was categorized as having normal BP (n = 159,524), elevated BP (n = 35,603), stage 1 hypertension (n = 54,795), or stage 2 hypertension (n = 30,677) using the BP value at the initial health checkup. Retinal photographs were assessed according to the Keith-Wagener-Barker system. RESULTS The median age was 46 years, and 50.4% subjects were men. Retinal atherosclerosis, defined as Keith-Wagener-Barker system grade ≥1, was observed in 3.2% in normal BP, 5.2% in elevated BP, 7.7% in stage 1 hypertension, and 18.7% in stage 2 hypertension. Compared with normal BP, elevated BP (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.23-1.38), stage 1 hypertension (OR, 1.71; 95% CI, 1.64-1.79), and stage 2 hypertension (OR, 4.10; 95% CI, 3.93-4.28) were associated with a higher prevalence of retinal atherosclerosis. Among 92,121 subjects without obesity, high waist circumference, diabetes mellitus, dyslipidemia, cigarette smoking, and alcohol consumption, elevated BP (OR, 1.34; 95% CI, 1.19-1.51), stage 1 hypertension (OR, 1.79; 95% CI, 1.61-1.98), and stage 2 hypertension (OR, 4.42; 95% CI, 4.00-4.92) were associated with a higher prevalence of retinal atherosclerosis. This association was observed in all subgroups stratified by age or sex. CONCLUSIONS Our investigation suggests that retinal atherosclerosis could start even in individuals with elevated BP and stage 1 hypertension.
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Affiliation(s)
- Satoshi Matsuoka
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
- The Department of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Hidehiro Kaneko
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
- The Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan
| | - Yuichiro Yano
- YCU Center for Novel and Exploratory Clinical Trials, Yokohama City University Hospital, Yokohama, Japan
- The Department of Family Medicine and Community Health, Duke University, Durham, North Carolina, USA
| | - Hidetaka Itoh
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Fukui
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Kojiro Morita
- The Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- The Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Kiriyama
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Kamon
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuhito Fujiu
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
- The Department of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Hikari Seki
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- The Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- The Department of Health Services Research, The University of Tokyo, Tokyo, Japan
| | - Norifumi Takeda
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Morita
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Sunao Nakamura
- The Department of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hideo Yasunaga
- The Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- The Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
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Yotsumoto H, Kaneko H, Itoh H, Kamon T, Kiriyama H, Fujiu K, Takeda N, Morita H, Komuro I. Promoting analysis of real-world data: Prospects for preventive cardiology in Japan. Glob Health Med 2021; 3:203-213. [PMID: 34532601 DOI: 10.35772/ghm.2020.01077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 08/03/2021] [Accepted: 08/10/2021] [Indexed: 11/08/2022]
Abstract
According to the statistics for 2018 in Japan, cardiovascular disease and cerebrovascular disease were the most common causes of death (cardiovascular disease with 208,210, cerebrovascular disease with 108,165), and these two diseases account for 23.2% of all deaths. Stroke, especially cerebral hemorrhage, was the main cause of death in Japan after World War II. Along with improved management of hypertension, the mortality rate from cerebral hemorrhage reached a high of 266.7 per 100,000 men in 1960 and 213.9 per 100,000 women in 1951, then decreased to 15.9 per 100,000 men and 6.9 per 100,000 women in 2013. However, mortality from lifestyle-related diseases such as metabolic syndrome and ischemic heart disease has been on the rise since 1990 due to the westernization of diet, urban lifestyles, and lack of exercise habits. Moreover, since aging is the greatest risk factor for heart failure, the number of patients with heart failure in Japan will inevitably increase in the future. A large amount of evidence has demonstrated that prevention and proper management of risk factors can reduce the future incidence of cardiovascular disease. Specific health checkups (metabolic syndrome checkups) have been carried out in Japan since 2008. Big data on physical examinations are valuable real-world data that can be utilized for clinical research. As the importance of preventive cardiology increases in the future, we should analyze the real-world data from health checkups in Japan in detail and disseminate these results to clinical practice, which will contribute to development of preventive cardiology and the promotion of public health.
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Affiliation(s)
- Haruki Yotsumoto
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan.,Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Kamon
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Kiriyama
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan.,Department of Advanced Cardiology, The University of Tokyo, Tokyo, Japan
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
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11
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Cardio-ankle vascular index is associated with coronary plaque composition assessed with iMAP-intravascular ultrasound in patients with coronary artery disease. J Cardiol 2021; 78:502-508. [PMID: 34284942 DOI: 10.1016/j.jjcc.2021.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The cardio-ankle vascular index (CAVI) is an indicator of arterial stiffness and has been reported to be associated with the severity of coronary artery disease and cardiovascular events. However, whether CAVI can predict the composition of coronary plaques remains unclear. METHODS We enrolled 208 patients who underwent percutaneous coronary intervention (PCI) for culprit lesions evaluated with iMAP-intravascular ultrasound (IVUS), a radiofrequency imaging system for characterizing tissues. iMAP-IVUS classified the culprit plaque composition as fibrotic, lipidic, necrotic, or calcified, and the respective absolute volumes [fibrotic volume (FV), lipidic volume (LV), necrotic volume NV, and calcified volume] and their ratios (%) within the total plaque volume were calculated. A plaque with a median %NV of ≥ 33.2% was defined as a larger NV (LNV) plaque. We measured CAVI and divided the patients into two groups according to CAVI ≥8 (high CAVI, n = 164) or <8 (low CAVI, n = 44). RESULTS Culprit plaques had significantly greater absolute NV (p = 0.016), %NV (p = 0.01), and smaller %FV (p = 0.02) in patients with high CAVI than in those with low CAVI. Patients with high CAVI had a higher prevalence of LNV plaques in culprit lesions than those with low CAVI (54% vs. 34%, p = 0.026). CAVI correlated significantly and positively with absolute NV, LV, and negatively with %FV. In logistic regression analysis after adjustment for the classic coronary risk factors and possible variables associated with vulnerable plaques, high CAVI had an independent and significant association with the presence of LNV plaques (OR, 3.37; 95% CI, 1.45-7.79; p = 0.0032). CONCLUSIONS A high CAVI is associated with the composition of coronary culprit plaques, particularly increased amount of necrotic tissue, in patients with coronary artery disease undergoing PCI .
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12
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Pędzińska-Betiuk A, Weresa J, Schlicker E, Harasim-Symbor E, Toczek M, Kasacka I, Gajo B, Malinowska B. Chronic cannabidiol treatment reduces the carbachol-induced coronary constriction and left ventricular cardiomyocyte width of the isolated hypertensive rat heart. Toxicol Appl Pharmacol 2021; 411:115368. [PMID: 33338514 DOI: 10.1016/j.taap.2020.115368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/29/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022]
Abstract
Cannabidiol (CBD) is suggested to possess cardioprotective properties. We examined the influence of chronic (10 mg/kg once daily for 2 weeks) CBD administration on heart structure (e.g. cardiomyocyte width) and function (e.g. stimulatory and inhibitory responses induced by β-adrenoceptor (isoprenaline) and muscarinic receptor (carbachol) activation, respectively). Experiments were performed on hearts and/or left atria isolated from spontaneously (SHR) and deoxycorticosterone (DOCA-salt) hypertensive rats; Wistar-Kyoto (WKY) and sham-operated rats (SHAM) served as the respective normotensive controls. CBD diminished the width of cardiomyocytes in left ventricle and reduced the carbachol-induced vasoconstriction of coronary arteries both in DOCA-salt and SHR. However, it failed to affect left ventricular hypertrophy and even aggravated the impaired positive and negative lusitropic effects elicited by isoprenaline and carbachol, respectively. In normotensive hearts CBD led to untoward structural and functional effects, which occurred only in WKY or SHAM or, like the decrease in β1-adrenoceptor density, in either control strain. In conclusion, due to its modest beneficial effect in hypertension and its adverse effects in normotensive hearts, caution should be taken when using CBD as a drug in therapy.
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MESH Headings
- Adrenergic beta-Agonists/pharmacology
- Animals
- Antihypertensive Agents/toxicity
- Cannabidiol/toxicity
- Carbachol/pharmacology
- Cell Size/drug effects
- Coronary Vessels/drug effects
- Coronary Vessels/physiopathology
- Disease Models, Animal
- Hypertension/complications
- Hypertension/drug therapy
- Hypertension/physiopathology
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/pathology
- Hypertrophy, Left Ventricular/physiopathology
- Isolated Heart Preparation
- Isoproterenol/pharmacology
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/metabolism
- Myocytes, Cardiac/pathology
- Rats, Inbred SHR
- Rats, Inbred WKY
- Receptors, Adrenergic, beta-1/metabolism
- Receptors, Adrenergic, beta-2/metabolism
- Vasoconstriction/drug effects
- Vasoconstrictor Agents/pharmacology
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/pathology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left/drug effects
- Rats
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Affiliation(s)
- Anna Pędzińska-Betiuk
- Department of Experimental Physiology and Pathophysiology, Medical University of Białystok, Białystok, Poland.
| | - Jolanta Weresa
- Department of Experimental Physiology and Pathophysiology, Medical University of Białystok, Białystok, Poland
| | - Eberhard Schlicker
- Department of Pharmacology and Toxicology, University of Bonn, Bonn, Germany
| | - Ewa Harasim-Symbor
- Department of Physiology, Medical University of Białystok, Białystok, Poland
| | - Marek Toczek
- Department of Experimental Physiology and Pathophysiology, Medical University of Białystok, Białystok, Poland
| | - Irena Kasacka
- Department of Histology and Cytophysiology, Medical University of Białystok, Białystok, Poland
| | - Bernadetta Gajo
- Department of Experimental Physiology and Pathophysiology, Medical University of Białystok, Białystok, Poland
| | - Barbara Malinowska
- Department of Experimental Physiology and Pathophysiology, Medical University of Białystok, Białystok, Poland
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13
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Kaneko H, Itoh H, Yotsumoto H, Kiriyama H, Kamon T, Fujiu K, Morita K, Michihata N, Jo T, Takeda N, Morita H, Yasunaga H, Komuro I. Association of Isolated Diastolic Hypertension Based on the Cutoff Value in the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines With Subsequent Cardiovascular Events in the General Population. J Am Heart Assoc 2020; 9:e017963. [PMID: 32993440 PMCID: PMC7792382 DOI: 10.1161/jaha.120.017963] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines lowered the threshold of blood pressure (BP) for hypertension to 130/80 mm Hg. However, the clinical significance of isolated diastolic hypertension (IDH) according to the cutoff value of the 2017 ACC/AHA guidelines was uncertain. Methods and Results We analyzed the claims database of Japan Medical Data Center (a nationwide epidemiological database). We excluded individuals who were aged <20 years, had systolic hypertension, were taking antihypertensive medication, or had prevalent cardiovascular disease, and studied 1 746 493 individuals (mean age, 42.9±10.7 years; 961 097 men [55.0%]). The average observational period was 1107±855 days. Stage 1 IDH, defined as diastolic BP 80 to 89 mm Hg, and stage 2 IDH, defined as diastolic BP ≥90 mm Hg, were found in 230 513 (13.2%) and 16 159 (0.9%) individuals, respectively. Compared with individuals with normal diastolic BP, individuals with stage 1 and stage 2 IDH were older and more likely to be men. Prevalence of classic risk factors was higher in patients with IDH. Kaplan-Meier curves showed that stage 1 and stage 2 IDH were associated with a higher incidence of cardiovascular events, defined as myocardial infarction, angina pectoris, and stroke. Multivariable analysis showed that stage 1 (hazard ratio [HR], 1.17) and stage 2 (HR, 1.28) IDH were independently associated with a higher incidence of cardiovascular events. Subgroup analyses showed that the association of IDH with cardiovascular events was seen irrespective of age and sex. Conclusions The analysis of a nationwide epidemiological database showed that IDH based on the cutoff value in the 2017 ACC/AHA BP guidelines was associated with an elevated risk of subsequent cardiovascular events.
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Affiliation(s)
- Hidehiro Kaneko
- The Department of Cardiovascular Medicine The University of Tokyo Japan.,The Department of Advanced Cardiology The University of Tokyo Japan
| | - Hidetaka Itoh
- The Department of Cardiovascular Medicine The University of Tokyo Japan
| | - Haruki Yotsumoto
- The Department of Cardiovascular Medicine The University of Tokyo Japan
| | - Hiroyuki Kiriyama
- The Department of Cardiovascular Medicine The University of Tokyo Japan
| | - Tatsuya Kamon
- The Department of Cardiovascular Medicine The University of Tokyo Japan
| | - Katsuhito Fujiu
- The Department of Cardiovascular Medicine The University of Tokyo Japan.,The Department of Advanced Cardiology The University of Tokyo Japan
| | - Kojiro Morita
- The Department of Clinical Epidemiology and Health Economics School of Public Health The University of Tokyo Japan.,The Department of Health Services Research Faculty of Medicine University of Tsukuba Japan
| | - Nobuaki Michihata
- The Department of Health Services Research The University of Tokyo Japan
| | - Taisuke Jo
- The Department of Health Services Research The University of Tokyo Japan
| | - Norifumi Takeda
- The Department of Cardiovascular Medicine The University of Tokyo Japan
| | - Hiroyuki Morita
- The Department of Cardiovascular Medicine The University of Tokyo Japan
| | - Hideo Yasunaga
- The Department of Clinical Epidemiology and Health Economics School of Public Health The University of Tokyo Japan
| | - Issei Komuro
- The Department of Cardiovascular Medicine The University of Tokyo Japan
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14
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Kario K, Okada K, Murata M, Suzuki D, Yamagiwa K, Abe Y, Usui I, Tsuchiya N, Iwashita C, Harada N, Okawara Y, Ishibashi S, Hoshide S. Effects of luseogliflozin on arterial properties in patients with type 2 diabetes mellitus: The multicenter, exploratory LUSCAR study. J Clin Hypertens (Greenwich) 2020; 22:1585-1593. [PMID: 32810338 PMCID: PMC7590106 DOI: 10.1111/jch.13988] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/17/2020] [Indexed: 12/12/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the occurrence of cardiovascular and renal complications in patients with type 2 diabetes mellitus (T2DM) and represent guideline-recommended therapy in this indication. However, precise mechanisms underlying the beneficial cardiovascular effects of SGLT2 inhibitors are not fully understood. This study investigated the effects of the SGLT2 inhibitor, luseogliflozin, on arterial properties and home blood pressure (BP) in patients with T2DM. This multicenter, single-arm study enrolled adults with T2DM, glycosylated hemoglobin (HbA1c) 6.5%-8.9% in the previous 4 weeks, and an indication for new/additional antidiabetic therapy. Luseogliflozin 2.5 mg/d was given for 12 weeks. Primary outcome was change in cardio-ankle vascular index (CAVI) from baseline to Week 4 and Week 12. Home and office BP, BP variability, and metabolic parameters were secondary endpoints. Forty-seven patients (mean age 63.5 ± 10.7 years) treated with luseogliflozin were included in the full analysis set. CAVI did not change significantly from baseline (mean [95% confidence interval] 8.67 [8.37-8.97]) to Week 12 (8.64 [8.38-8.91]; P = .750), but there were significant reductions from baseline in morning home BP, HbA1c, body weight, body mass index, and serum uric acid levels during luseogliflozin therapy. The reduction in morning home systolic BP was ≥ 5 mm Hg and was independent of baseline BP and BP control status. In conclusion, there was no change in arterial stiffness (based on CAVI) during treatment with luseogliflozin, but changes in BP and metabolic parameters were consistent with the known beneficial effects of SGLT2 inhibitors in T2DM.
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Affiliation(s)
- Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan.,Washiya Hospital, Tochigi, Japan
| | - Kenta Okada
- Jichi Medical University School of Medicine, Tochigi, Japan
| | | | - Daisuke Suzuki
- Jichi Medical University School of Medicine, Tochigi, Japan.,Jichi Medical University Saitama Medical Center, Saitama, Japan.,Nanbu Kousei Hospital, Saitama, Japan
| | | | | | - Isao Usui
- Washiya Hospital, Tochigi, Japan.,Dokkyo Medical University, Tochigi, Japan
| | | | - Chie Iwashita
- Jichi Medical University School of Medicine, Tochigi, Japan
| | - Noriko Harada
- Jichi Medical University School of Medicine, Tochigi, Japan
| | - Yukie Okawara
- Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shun Ishibashi
- Jichi Medical University School of Medicine, Tochigi, Japan
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15
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Using the Cardio-Ankle Vascular Index (CAVI) or the Mathematical Correction Form (CAVI 0) in Clinical Practice. Int J Mol Sci 2020; 21:ijms21072410. [PMID: 32244393 PMCID: PMC7178179 DOI: 10.3390/ijms21072410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/10/2020] [Accepted: 03/19/2020] [Indexed: 12/18/2022] Open
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16
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Chronic Cannabidiol Administration Fails to Diminish Blood Pressure in Rats with Primary and Secondary Hypertension Despite Its Effects on Cardiac and Plasma Endocannabinoid System, Oxidative Stress and Lipid Metabolism. Int J Mol Sci 2020; 21:ijms21041295. [PMID: 32075117 PMCID: PMC7072941 DOI: 10.3390/ijms21041295] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
We investigated the influence of cannabidiol (CBD) on blood pressure (BP) and heart rate (HR) in spontaneously (SHR) and deoxycorticosterone (DOCA-salt) hypertensive rats. Hypertension was connected with increases in cardiac and plasma markers of lipid peroxidation in both models, whereas cardiac endocannabinoid levels decreased in SHR and increased in DOCA-salt. CBD (10 mg/kg once a day for 2 weeks) did not modify BP and HR in hypertension but counteracted pro-oxidant effects. Moreover, it decreased cardiac or plasma levels of anandamide, 2-arachidonoylglycerol and oleoyl ethanolamide in DOCA-salt and inhibited the activity of fatty acid amide hydrolase (FAAH) in both models. In the respective normotensive control rats, CBD increased lipid peroxidation, free fatty acid levels and FAAH activity. In conclusion, chronic CBD administration does not possess antihypertensive activity in a model of primary and secondary (DOCA-salt) hypertension, despite its antioxidant effect. The latter may be direct rather than based on the endocannabinoid system. The unexpected CBD-related increase in lipid peroxidation in normotensive controls may lead to untoward effects; thus, caution should be kept if CBD is used therapeutically.
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