Global cardiovascular disease prevention: time to get serious

Red blood cell membrane-functionalized Nanofibrous tubes for small-diameter vascular grafts

The off-the-shelf small-diameter vascular grafts (SDVGs) have inferior clinical efficacy. Red blood cell membrane (Rm) has easy availability and multiple bioactive components (such as phospholipids, proteins, and glycoproteins), which can improve the clinic's availability and patency of SDVGs. Here we developed a facile approach to preparing an Rm-functionalized poly-ε-caprolactone/poly-d-lysine (Rm@PCL/PDL) tube by co-incubation and single-step rolling. The integrity, stability, and bioactivity of Rm on Rm@PCL/PDL were evaluated. The revascularization of Rm@PCL/PDL tubes was studied by implantation in the carotid artery of rabbits. Rm@PCL/PDL can be quickly prepared and showed excellent bioactivity with good hemocompatibility and great anti-inflammatory. Rm@PCL/PDL tubes as the substitute for the carotid artery of rabbits had good patency and quick remodeling within 21 days. Rm, as a "self" biomaterial with high biosafety, provides a new and facile approach to developing personalized or universal SDVGs for the clinic, which is of great significance in cardiovascular regenerative medicine and organ chip.

Vinegar: A functional ingredient for human health

Vinegar is a well-known natural food product derived from alcoholic and subsequently acetous fermentation of carbohydrate-rich foods. Vinegar is widely used in the food industry; domestically for pickling vegetables and fruits, and as an ingredient in condiments like salad dressings, ketchups, and mayonnaise; and traditionally as a food seasoning and preservative. Historically, vinegar has been used for medicinal purposes such as a cure for stomach aches, wounds, burns, rashes, and oedema conditions. Different types of vinegar are found worldwide such as rice, black, balsamic, grain, and fruit vinegars. These are produced from different raw materials, and using different fermentation methods to give unique tastes and flavours. Vinegar, while enhancing physiological functions such as lipid metabolism, blood glucose level control, and body weight management, also possesses anticancer, antibacterial, antioxidant, and anti-infection properties. It is considered as a good source material for many bioactive compounds including organic acids, melanoidins, polyphenols, ligustrazine, and tryptophol. The pharmacological and metabolic benefits of vinegar are believed to be due to these bioactive compounds present in vinegar. Acetic acid (CH3COOH) is the essential component of vinegar; it is slightly volatile and has a strong and sour aroma and flavour. Regular consumption of vinegar-containing foods is considered important for keeping many life-style related diseases like diabetes, hypertension, hyperlipidaemia, cancers, and obesity in check. Therefore, the present review aims at highlighting the health benefits associated with vinegar consumption for the physiological well-being of an individual.

Evidence-based oral antiplatelet therapy among hospitalized Chinese patients with acute myocardial infarction: results from the Chinese acute myocardial infarction registry

Background

Oral antiplatelet therapy is the cornerstone of treatment for acute myocardial infaction (AMI). However, detailed usage data on oral antiplatelet therapy are lacking.

Methods

Using data from a nationally representative sample of patients with AMI, the detailed usage of oral antiplatelet therapy was analyzed in 40,202 consecutive eligible patients.

Results

The proportions of patients with AMI taking loading doses of aspirin and P2Y12 inhibitors were relatively low (62.2% and 63.6%, respectively), whereas approximately 90% of patients received maintenance doses of aspirin, P2Y12 inhibitors, and dual antiplatelet therapy. The proportions of patients taking loading doses of aspirin and P2Y12 inhibitors gradually decreased with age. Male sex, an educational level of at least college, an interval from onset to treatment of < 24 h, and primary PCI use were associated with a higher proportion of patients taking a loading dose of antiplatelet therapy, whereas those receiving conservative treatment had a lower rate of antiplatelet use (all P < 0.05). The proportion of patients taking loading doses of aspirin was highest in the western region, and that of patients taking loading doses of P2Y12 inhibitors was highest in the eastern region (P < 0.05). In addition, 76.7% of patients with ST-elevation MI and 91% of patients with non-ST-elevation MI received 300-mg loading dose of clopidogrel.

Conclusions

The proportion of patients with AMI receiving loading doses of aspirin and P2Y12 inhibitors during hospitalization was relatively low, and this rate was affected by many factors, such as age, sex, educational level, region of residence, and the interval from onset to treatment. The underutilization of guideline-based P2Y12 inhibitors was also problematic. Hence, quality improvement initiatives are needed to enhance adherence to guidelines to improve consistent use of oral antiplatelet therapy.

Trial registration The Chinese Acute Myocardial Infarction Registry; Trial registration number: ChiCTR-ONC-12002636; Registered 31 October 2012; http://www.chictr.org.cn/showproj.aspx?proj=6916

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02115-1.

Population attributable fraction estimates of cardiovascular diseases in different levels of plasma total cholesterol in a large-scale cross-sectional study: a focus on prevention strategies and treatment coverage

PURPOSE

Cardiovascular diseases (CVDs) are the main cause of deaths among non-communicable diseases. Arguments about the best prevention strategy to control CVDs' risk factors continue. We evaluated the population attributable fraction (PAF) of CVDs in different levels of plasma cholesterol.

METHODS

Patients' data were obtained from Iran STEPs 2016 study. In phase 0 we estimated PAF regardless of cholesterol levels and clinical factors. In phase 1 we calculated PAF based on three levels of cholesterol (<200, 200-240, ≥240 mg/dl). In phase 2 we estimated PAF in 3 groups considering lipid-lowering drugs. In phase 3 all treated participants and not treated hypercholesterolemic people were included, to evaluate the impact of treatment. Estimations were done for Ischemic heart disease (IHD) and ischemic stroke (IS), and for two sex.

RESULTS

In phase 0, the highest PAF for IHD and IS were 0.35 (95% confidence interval 0.29-0.41) and 0.22 (0.18-0.27) for females and 0.27 (0.22-0.32) and 0.18 (0.14-0.22) for males. In phase 1, the highest PAF belonged to population with cholesterol ≥240 mg/dl and IHD, as 0.90 (0.85-0.94) for females, and 0.90 (0.85-0.96) for males. In phase 2, the pre-hypercholesterolemic group had higher PAFs than the hypercholesteremic group in most of the population. Phase 3 showed treatment coverage significantly lowered fractions in all age groups, for both causes.

CONCLUSION

An urgent action plan and a change in preventive programs of health guidelines are needed to stop the vast burden of hypercholesterolemia in the pre-hypercholesterolemic population. Population-based prevention strategies need to be more considered to control further CVDs.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-020-00673-3.

The rise in the number of long-term survivors from different diseases can slow the increase in life expectancy of the total population

Background

Recent improvements in life expectancy in many countries stem from reduced mortality from cardiovascular disease and cancer above the age of 60. This is the combined result of decreased incidence and improved survival among those with disease. The latter has led to a higher proportion in the population of people with a past history of disease. This is a group with higher mortality than the general population. How growing shares of persons with past history of disease and improved survival with disease have affected changes in life expectancy of the total population is the objective of this paper.

Methods

Using register data for the total Swedish population, we stratified the population based on whether individuals have been diagnosed with myocardial infarction, stroke, hip fracture, colon cancer, or breast cancer. Using a novel decomposition approach, we decomposed the changes in life expectancy at age 60 between 1994 and 2016 into contributions from improved survival with disease and from changes in proportion of people with past history of disease.

Results

Improvements in survival from disease resulted in gains of life expectancy for the total population. However, while the contributions to life expectancy improvements from myocardial infarction, stroke and breast cancer were substantial, the contributions from the other diseases were minor. These gains were counteracted, to various degrees, by the increasing proportion of people with raised mortality due to a past history of disease. For instance, the impact on life expectancy by improved survival from breast cancer was almost halved by the increasing share of females with a past history of breast cancer.

Conclusion

Rising numbers of survivors of different diseases can slow the increase in life expectancy. This dynamic may represent the costs associated with successful treatment of diseases, and thus, a potential “failure of success.” This dynamic should be considered when assessing mortality and life expectancy trends. As populations are aging and disease survival continues to improve, this issue is likely to become even more important in the future.

Differences between Slovak and Dutch patients scheduled for coronary artery bypass graft surgery regarding clinical and psychosocial predictors of physical and mental health-related quality of life

BACKGROUND

Differences in health-related quality of life in coronary artery disease patients and associated factors between patients of central and western European descent are rarely investigated. We aim to test differences between Dutch and Slovak health-related quality of life, whether nationality predicted health-related quality of life and if standardised beta weights of health-related quality of life determinants differ across countries.

DESIGN

An observational multicentre study at university cardiac centres in the Netherlands and Slovakia.

METHODS

In 226 coronary artery disease patients, health-related quality of life was measured by the Short Form Health Survey 36, anxiety and depression were measured using the Hospital Anxiety and Depression Scale, and type D personality was assessed with the 14-item Type D Scale. Multivariate analysis was used to explore the effect of patient characteristics on the physical and mental component summaries. Estimates of each predictor's beta value of the physical and mental component summaries in the Slovak and Dutch patient sample were separately calculated using the Cummings criterion for comparison of two independent betas.

RESULTS

Stronger predictors of physical health-related quality of life in Slovak patients were educational level, current smoking, poor functional status, history of diabetes and amount of social support. In Dutch patients, only more symptoms of depression was a stronger predictor ( P<0.05). Regarding Slovak mental health-related quality of life, stronger predictors were educational level, current smoking and amount of social support. Female gender, history of myocardial infarction and more symptoms of depression were stronger predictors in Dutch patients ( P<0.05).

CONCLUSION

Descent and differences between both populations in determinants of health-related quality of life should be considered while planning care, follow-up, health education and rehabilitation.

Ontology-based systematical representation and drug class effect analysis of package insert-reported adverse events associated with cardiovascular drugs used in China

With increased usage of cardiovascular drugs (CVDs) for treating cardiovascular diseases, it is important to analyze CVD-associated adverse events (AEs). In this study, we systematically collected package insert-reported AEs associated with CVDs used in China, and developed and analyzed an Ontology of Cardiovascular Drug AEs (OCVDAE). Extending the Ontology of AEs (OAE) and NDF-RT, OCVDAE includes 194 CVDs, CVD ingredients, mechanisms of actions (MoAs), and CVD-associated 736 AEs. An AE-specific drug class effect is defined to exist when all the drugs (drug chemical ingredients or drug products) in a drug class are associated with an AE, which is formulated as a new proportional class level ratio (“PCR”) = 1. Our PCR-based heatmap analysis identified many class level drug effects on different AE classes such as behavioral and neurological AE and digestive system AE. Additional drug-AE correlation tests (i.e., class-level PRR, Chi-squared, and minimal case reports) were also modified and applied to further detect statistically significant drug class effects. Two drug ingredient classes and three CVD MoA classes were found to have statistically significant class effects on 13 AEs. For example, the CVD Active Transporter Interactions class (including reserpine, indapamide, digoxin, and deslanoside) has statistically significant class effect on anorexia and diarrhea AEs.

The Neutrophil-Lymphocyte Ratio Is Associated with Coronary Artery Calcification in Asymptomatic Korean Males: A Cross-Sectional Study

Introduction. The neutrophil-lymphocyte ratio (NLR) is a significant systemic predictor of cardiovascular disease (CVD). The coronary artery calcium score (CACS) reflects coronary artery calcification and is an independent risk factor for coronary artery stenosis. In the present study, we explored the relationship between the NLR and CACS in terms of subclinical inflammation and coronary artery calcification. Materials and Methods. We evaluated males and females who did not have CVD, diabetes, high blood pressure, or high fasting blood sugar levels. We measured white blood cell, neutrophil, lymphocyte counts, fasting blood sugar, total cholesterol, high-density lipoprotein cholesterol, triglycerides (TG), and high-sensitivity C-reactive protein levels in blood samples. We also obtained CACSs using coronary multidetector computed tomography. Results. Multivariate logistic regression showed that older age was significantly associated with a higher CACS (P < 0.001); males had higher CACSs than females (P < 0.001); and the higher the TG level, the higher the CACS (P = 0.019). The NLR of males, but not females, was significantly associated with the CACS. Conclusion. An independent association between the NLR and CACS was thus evident in healthy adult males after adjusting for other CVD risk factors. Therefore, the NLR is a significant predictor of potential CVD in male subjects with subclinical atherosclerosis.

The prevalence, awareness, treatment and control of dyslipidemia among adults in China

OBJECTIVES

To analyze the prevalence, awareness, treatment, control and epidemiological characteristics of dyslipidemia in Chinese adults.

METHODS

In this cross-sectional study, we adopted a multi-stage, stratified sampling method to obtain representative samples of the general population aged >18 years from different urban and rural regions in China. All subjects completed a lifestyle and medical history questionnaire and were examined for risk factors. Dyslipidemia was defined according to criteria of the 2007 Chinese Guidelines on Prevention and Treatment of Dyslipidemia in Adults. Continuous variables were compared using variance analysis. Multivariate logistic regression analysis was performed to explore the risk factors of dyslipidemia.

RESULTS

The prevalence of dyslipidemia was 34.0% overall, and 35.1%, and 26.3% in urban and rural areas, respectively. The prevalence of dyslipidemia was significantly higher in men than women (41.9% vs 32.5%; P < 0.001). Rates of awareness, treatment, and control were 31.0%, 19.5%, and 8.9%, respectively. Increasing age (OR = 1.012; 95% CI:1.010, 1.014), male sex (OR = 1.411; 95% CI:1.318, 1.510), obesity (OR = 1.424; 95% CI:1.345, 1.507), cardiovascular disease (OR = 1.343; 95% CI:1.125, 1.603), diabetes (OR = 1.955; 95% CI:1.751, 2.182), hypertension (OR = 1.481; 95% CI:1.391, 1.577) and hyperuricemia (OR = 2.223; 95% CI:2.060, 2.399) were independent risk factors of dyslipidemia.

CONCLUSION

The prevalence of dyslipidemia among Chinese adults was high but awareness, treatment, and control of dyslipidemia were low. Urban high income earners and rural medium income earners show higher prevalence. Low income earners in urban and rural population have the worst awareness treatment, and control rate. There is an increased need for closely monitoring and controlling high risk factors in the populations including postmenopausal women, unhealthy lifestyle peoples and patients with chronic non-communicable diseases.

Dietary Changes over 25 Years in Tianjin Residents: Findings from the 1986-1988, 2000-2004, and 2008-2011 Nutrition Surveys

In China, the rates of chronic diseases characteristic of countries in nutritional transition have been increasing. However, few studies have examined diet changes in recent decades. We analyzed dietary changes in Tianjin, China. The data in this descriptive, population-based study in ≥18-year-old adults were collected from three surveys from 1986 to 2011. Food consumption and nutrient intake were compared among the three surveys separately for urban and rural areas. Differences in food consumption between urban and rural areas in different periods were also shown. The consumption of cereals, vegetables, and oils decreased, and that of fruits and beans increased in both urban and rural areas. Moreover, the total consumption of animal foods, especially milk, increased (0.01% in 1986–1988; 1.72% in 2008–2011) in rural areas. Although milk consumption also increased in urban areas, consumption of other animal foods decreased (19.33% in 1986–1988; 13.74% in 2008–2011). Meanwhile, cereals consumption rebounded from 22.63% in 2000–2004 to 29.75% in 2008–2011. Moreover, the lack of dairy products and some nutrients, e.g., retinol, calcium, and dietary fiber (<80% of recommended nutrient intake), in the diet persisted in both urban and rural areas. In conclusion, differences in diet between urban and rural areas decreased over time.

Secular trends in the prevalence of low risk factor burden for cardiovascular disease according to obesity status among Chinese adults, 1993-2009

Background

Cardiovascular disease (CVD) and obesity are now common among Chinese. We aimed to examine secular trends in the prevalence of low risk profile and to examine whether comparable changes in the prevalence of low risk profile across waist circumference (WC) groups and body mass index (BMI) categories have occurred.

Methods

We used data from the nationwide China Health and Nutrition Survey conducted in 1993, 1997, 2000, 2004, 2006, and 2009. There were 7274, 8368, 9369, 8948, 8786, and 9278 participants included in the analyses across the six study periods. We created an index of low risk factor burden from the following variables: not currently smoking, BMI < 25 kg/m², WC < 90/80 cm in men/women, untreated systolic/diastolic blood pressure < 120/80 mmHg, and not having been previously diagnosed with diabetes.

Results

During the period of 1993–2009, the age-adjusted prevalence of low risk profile decreased from 16.2 to 11.5% among men and from 46.3 to 34.6% among women (both P < 0.001); Similar significant trends were observed in all age groups, rural/urban settings, education groups, WC status and BMI categories. The change in the prevalence of low risk profile was more striking among obese persons (P for interaction terms cohort *BMI were < 0.001). In 2009, 2.0 and 25.6% among central obese men and women had a low risk profile; Of note, was that 0.1 and 0.3% general obese men and women had a low risk profile.

Conclusions

The prevalence of low risk profile declined considerably over the past 17 years in all demographic groups, WC status, and BMI categories. Public health prevention strategies are urgently needed.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-961) contains supplementary material, which is available to authorized users.

Sense of coherence as a predictor of health-related behaviours among patients with coronary heart disease

AIMS

A high sense of coherence (SOC) has been found to be associated with favourable health-related behaviours. However, evidence is for the most part lacking on the influence of SOC on health-related behaviours among coronary heart disease patients. The aim of this study was to explore the association between SOC at baseline and smoking status, nutrition behaviour, physical exercise and alcohol consumption of coronary heart disease patients 12-28 months after they had undergone different cardiac treatments.

METHODS

A total of 179 coronary heart disease patients (mean age 58.32±6.54 years, 19% female) were interviewed before coronary angiography and 12-28 months after. Self-report data about health-related behaviours were obtained via a structured interview. SOC was measured using the 13-item Orientation to Life Questionnaire. The relationship between SOC and health-related behaviours was examined using regression and cross-lagged path analyses.

RESULTS

SOC at baseline predicted non-smoking and quitting smoking: odds ratio (OR) (95% confidence interval (CI)) per unit increase (over range 38-91) was 1.11 (1.03-1.19) and 1.09 (1.01-1.17), respectively. Moreover, baseline SOC predicted healthy nutrition behaviour among percutaneous coronary intervention patients: the OR per unit increase was 1.08 (95% CI: 1.01-1.15). Lastly, SOC at baseline predicted improvement in alcohol consumption at follow-up among coronary artery bypass grafting patients (standard score result: -0.15, p<0.05).

CONCLUSION

Coronary heart disease patients with a low SOC before treatment are less likely to improve health behaviours after cardiac treatment and should thus get additional attention in health promotion.

Perceptions of coronary heart disease: the development and psychometric testing of a measurement scale

Individuals' perceptions of coronary heart disease (CHD) have implications for the ways in which they respond to the disease, process risks, make decisions, and take action to reduce CHD risks. This study aimed to develop and evaluate the psychometric properties of the perceptions of coronary heart disease scale (PCS) among a Hong Kong Chinese population. A cross-sectional study was conducted using a convenient sample (n = 232) of participants recruited from a variety of catchments including public domains, a cardiac unit, and a cardiac rehabilitation and prevention center. Exploratory factor analysis identified a nine-item, two-factor model that accounted for 52.5% of the total explained variance. The two factors were the perceived risk (five items) and perceived seriousness (four items) of CHD. The PCS demonstrated good content validity; acceptable total, and subscale internal consistency (.73, .61 - .81); and significant contrast-group differences with higher levels of CHD perceptions among males (p = .002), younger participants (p < .001), and those with higher educational levels (p < .001), suggesting excellent construct validity. The newly developed PCS demonstrates acceptable psychometric properties as a short measurement scale, which supports its use in future research. Future validation of this scale is warranted.

Coronary artery atherosclerosis and risk stratification in young adults with an intermediate pretest likelihood detected by multidetector computed tomography

RATIONALE AND OBJECTIVES

To document the prevalence of coronary artery disease (CAD) and major adverse cardiac events (MACE) in patients younger than 45 years of age with intermediate pretest likelihood of CAD, and to determine whether coronary computed tomography angiography (cCTA) is useful for risk stratification of this cohort.

MATERIALS AND METHODS

We followed 452 intermediate pretest likelihood (according to Diamond and Forrester) outpatients who were suspected of CAD and underwent cCTA. They were all younger than 45 years old. The endpoint was MACE, defined as composite cardiac death, nonfatal myocardial infarction, or coronary revascularization.

RESULTS

Follow-up was completed in 427 patients (94.5%) with a median follow-up period of 1081 days. No plaque was noted in 357 (83.6%) patients. Nonsignificant CAD was noted in 33 (7.7%) individuals and 37 (8.7%) patients with significant CAD. At the end of the follow-up period, 12 (2.8%) patients experienced MACE. The annualized event rate was 0.2% in patients with no plaque, 2.0% in patients with nonsignificant CAD, and 7.3% in patients with significant CAD. Hypertension, smoking, and significant CAD in cCTA were significant predictors of MACE in univariate analysis. Moreover, cCTA remained a predictor (P < .001) of events after multivariate correction (hazard ratio: 8.345, 95% CI: 3.438-17.823, P < .001).

CONCLUSION

The prevalence of CAD and MACE in young adults with an intermediate pretest likelihood of CAD was considerable. cCTA is effective in restratifying patients into either a low or high posttest risk group. These results further emphasize the usefulness of cCTA in this cohort.

Adherence to antihypertensive agents after ischemic stroke and risk of cardiovascular outcomes

OBJECTIVE

To evaluate the relationship between antihypertensive (AH) drug adherence and cardiovascular (CV) outcomes among patients with a recent ischemic stroke and assess the validity of our approach.

METHODS

A cohort of 14,227 patients diagnosed with an ischemic stroke was assembled from individuals 65 years and older who were treated with AH agents from 1999 to 2007 in Quebec, Canada. A nested case-control design was used to evaluate the occurrence of nonfatal major CV outcomes and mortality. Each case was matched to 15 controls by age and cohort entry time. Medication possession ratio was used for AH agent adherence level. Adjusted conditional logistic regression models were used to estimate the rate ratio of CV events. The validity of the approach was assessed by evaluating the adherence level of CV-protective and non-CV-protective drugs.

RESULTS

Mean age was 75 years, 54% were male, 38% had coronary artery disease, 23% had diabetes, 47% dyslipidemia, and 14% atrial fibrillation or flutter. High adherence to AH therapy was mirrored by similar adherence to statins and antiplatelet agents and was associated with a lower risk of nonfatal vascular events compared with lower adherence (rate ratio 0.77 [0.70-0.86]). We observed a paradoxic link between adherence to several drugs and all-cause mortality.

CONCLUSION

Adherence to AH agents is associated with adherence to other secondary preventive therapies and a risk reduction for nonfatal vascular events after an ischemic stroke. Overestimation of all-cause mortality reduction may be related to frailty and comorbidities, which may confound the apparent benefit of different drugs.

Differences in perceptions of coronary disease among Hong Kong Chinese: implications for the societal readiness in disease prevention

Perceptions of coronary heart disease (CHD) influence individual health behavior, which is central to preventing the disease. Not enough is known about the demographic differences in perceptions of CHD among Chinese communities. This study examined these differences in the perceived seriousness and risk of CHD among Hong Kong Chinese. A self-developed questionnaire was administered to a convenient sample (n = 236). Significant differences were identified in the perceived seriousness and risk of CHD between younger and older age groups (p < 0.001) and groups with lower and higher education levels (p < 0.001), but not between genders (p > 0.05). Over 50% of participants expressed greater concern about infectious disease than about CHD, while two-thirds to over half of female, older, and less educated participants were more concerned about stroke. This study highlighted populations with lower levels of CHD perception that need increased public education. The findings have implications for the societal readiness to establishing ongoing public healthcare strategies to increase awareness of CHD.

Coronary artery disease in asymptomatic young adults: its prevalence according to coronary artery disease risk stratification and the CT characteristics

Objective

We aimed at evaluating the prevalence and CT characteristics of occult coronary artery disease (CAD) in young Korean adults under 40 years of age by performing coronary CT angiography (CCTA).

Materials and Methods

We retrospectively enrolled 112 consecutive asymptomatic subjects (90 men, mean age: 35.6 ± 3.7 years) who underwent CCTA as part of a general health evaluation. We classified the subjects into three National Cholesterol Education Program risk categories and we assessed the plaque characteristics on CCTA according to the number of involved vessels, the location and type of plaques and vascular remodeling.

Results

Twelve individuals had CAD (11%, 11 men). The prevalence of CAD was significantly higher in the subgroups with moderate (22%) or high (25%) risk than that in the low risk subgroup (5%) (p < 0.05). Nine patients had single-vessel disease and three patients had two-vessel disease. The most common location for plaque was the proximal left anterior descending coronary artery (60%). All the patients had non-significant stenosis and plaque, including the non-calcified (27%), mixed (47%) and calcified (27%) types. Positive vascular remodeling was identified in all the patients with non-calcified or mixed plaques.

Conclusion

The prevalence of occult CAD was not negligible in the asymptomatic young adults with moderate to high risk, and this suggests the importance of management and risk factor modification in this population. All the patients had non-significant stenosis, and one fourth of the plaques did not show calcification.

A Survey of Coronary Heart Disease Knowledge in a Sample of Hong Kong Chinese

Using a self-developed questionnaire, this study examined the knowledge of coronary heart disease (CHD) in 467 Hong Kong Chinese, comprising participants with a low risk (LR) of CHD and high risk (HR) of CHD, and those who had had a myocardial infarction (MI). The results showed that the LR and HR respondents were less likely to respond correctly to items regarding knowledge of typical symptoms and certain risk factors for CHD. The MI group had the highest level of CHD knowledge. Significant differences were found across the 3 target populations in most of the domains of CHD knowledge. Women and older respondents of the LR population were found to have better CHD knowledge than their counterparts. The study highlighted that CHD prevention in Hong Kong should not focus on secondary prevention at the expense of primary prevention. Promotion of knowledge should be targeted to primary education, in particular among the male population and younger Chinese.

Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization: results from the Clinical Pathways for Acute Coronary Syndromes in China (CPACS) study

BACKGROUND

Coronary heart disease has emerged as a leading cause of death in China. Although there is strong evidence for the use of antiplatelet, blood pressure-lowering, and lipid-lowering therapy in patients with acute coronary syndromes, the extent to which these medications are used in China remains uncertain.

METHODS

We conducted a multicenter prospective study using data from consecutive patients diagnosed with suspected acute myocardial infarction or unstable angina pectoris admitted to the inpatient wards during the recruitment period. Medication adherence and reasons for nonadherence were reported using standardized questionnaires. Logistic regression was used to identify important patient and hospital characteristics associated with use of medication at 6 and 12 months after hospital discharge.

RESULTS

The use of drug therapy was high (above 90% for aspirin, 70% for beta-blockers and angiotensin-converting enzyme inhibitors, 80% for statin) at the time of hospital discharge but decreased during follow-up. However, fewer than half (48%) of patients were discharged on 4-drug combination therapy (antiplatelet, beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statin), and the proportion remaining on this treatment 1 year after discharge was even lower (41%). In adjusted logistic regression analyses, medical insurance, dyslipidemia, hypertension, and administration of invasive therapy (percutaneous coronary intervention or coronary artery bypass graft) were important in determining use of treatment at discharge and during follow-up. In a substantial proportion of patients, medication was considered "not indicated" by the treating physician.

CONCLUSIONS

The findings highlight opportunities to improve the use and maintenance of appropriate combinations of evidence-based treatment among patients with acute coronary syndromes presenting to hospitals in China.

The impact of demographic and risk factor changes on coronary heart disease deaths in Beijing, 1999-2010

Background

Recent, dramatic increases in coronary heart disease (CHD) mortality in China can be mostly explained by adverse changes in major cardiovascular risk factors. Our study aimed to assess the potential impact of subsequent changes in risk factors and population ageing on CHD deaths in Beijing between 1999 and 2010.

Methods

The previously validated IMPACT model was used to estimate the CHD deaths expected in 2010, with treatment uptakes being held constant at levels measured in 1999, comparing three scenarios: a) taking into account the ageing of the population but assuming no further changes in major risk factor levels from 1999 or, b) if recent risk factor trends continued until 2010 or, c) if there was a 0.5% annual reduction in each risk factor.

Results

Population ageing alone would result in approximately 1990 additional deaths in 2010 compared with 1999, representing an increase of 27%. Continuation of current risk factor trends would result in approximately 3,015 extra deaths in 2010, [a 40% increase]; three quarters of this increase would be attributable to rises in total cholesterol levels. Thus, demographic changes and worsening risk factors would together result in a 67% increase in CHD deaths. Conversely, assumed 0.5% annual reductions in risk factors (a mean population level decline of 0.3 mmol/L for total cholesterol in both genders, and smoking prevalence declining by 3.0% for men and 4.1% for women, body mass index by 1.3 kg/m² for men and 1.4 kg/m² for women, diabetes prevalence by 0.4% in both genders, and diastolic blood pressure by 4.7 mmHg for men and 4.4 mmHg for women) would result in some 3,730 fewer deaths, representing a 23% decrease overall. These findings remained consistent in sensitivity analyses.

Conclusion

CHD death rates are continuing to rise in Beijing. This reflects worsening risk factor levels, compounded by demographic trends. However, the adverse impact of population ageing on CHD burden could be completely offset by eminently feasible improvements in diet and smoking.

Will China's nutrition transition overwhelm its health care system and slow economic growth?

Rapid social and economic change is transforming China, with enormous implications for its population and economy. More than a fifth of China's adult population is overweight, related to changing dietary and physical activity patterns. Overweight and poor diets are becoming a greater burden for the poor than for the rich, with subsequent large increases in hypertension, stroke, and adult-onset diabetes. The related economic costs represent 4-8 percent of the economy. Public investments are needed to head off a huge increase in the morbidity, disability, absenteeism, and medical care costs linked with this nutritional shift.

Hypocholesterolemic and antioxidant properties of 3-(4-hydroxyl)propanoic acid derivatives in high-cholesterol fed rats

The purpose of the present study was to evaluate the in vivo efficacy of two cinnamic acid synthetic derivatives (allyl 3-[4-hydroxyphenyl]propanoate; HPP304, 1-naphthyl-methyl 3-[4-hydroxyphenyl]propanoate; HPP305) in high-cholesterol fed rats and compare their actions to that of cinnamic acid. Cinnamic acid and its synthetic derivatives were supplemented with a high-cholesterol diet for 42 days at a dose of 0.135 mmol/100g of diet. The supplementation of HPP304 and HPP305 significantly lowered cholesterol and triglyceride levels in the plasma and liver with a simultaneous increase in the HDL-cholesterol concentration, whereas cinnamic acid only lowered the plasma cholesterol concentration. Cinnamic acid lowered hepatic HMG-CoA reductase activity in high-cholesterol fed rats, however, its synthetic derivatives (HPP304 and HPP305) did not affect HMG-CoA reductase activity compared to the control group. Instead, the HPP304 and HPP305 supplements significantly lowered hepatic acyl coenzyme A:cholesterol acyltransferase activity and increased the fecal bile acid. The SOD activity of the erythrocytes and liver was not different between the groups, however, the activities of CAT and GSH-Px, and the level of GSH in the erythrocytes were significantly higher in the HPP304 and HPP305 groups than in the control group. On the other hand, the activities of CAT and GSH-Px, and the level of malondialdehyde in the liver were significantly lower in the HPP304 and HPP305 groups. The antioxidant activities of these cinnamic acid synthetic derivatives were similar to the cinnamic acid in the high-cholesterol fed rats. In addition, HPP304 and HPP305 lowered amniotransferase activity in the plasma. These results suggest that two cinnamic acid synthetic derivatives (HPP304 and HPP305) exert lipid-lowering action and antioxidant properties without hepatotoxicity in high-cholesterol fed rats.

Cardiovascular Disease in Early Stages of Chronic Kidney Disease in a Chinese Population

Cardiovascular disease (CVD) is one of the most serious complications of kidney disease, yet studies of CVD in early stage of chronic kidney disease (CKD) in Asian patients are very limited. Therefore, this study determined the prevalence and the spectrum of CVD in individuals with early-stage CKD and compared them with data of individuals without CKD. Compared with individuals with estimated GFR (eGFR) >90 ml/min per 1.73 m2, the prevalence of myocardial infarction, stroke, and total CVD of individuals with eGFR 60 to 89 ml/min per 1.73 m2 was increased by 91.4, 71.7, and 67.6%, respectively. For individuals with eGFR 30 to 59 ml/min per 1.73 m2, the percentage was 105.2, 289.1, and 200.7%, respectively. For each eGFR category, stroke was more prevalent than myocardial infarction. Compared with individuals with eGFR >90 ml/min per 1.73 m2, participants with eGFR 60 to 89 and 30 to 59 ml/min per 1.73 m2 tended to have more cardiovascular risk factors, and there were strong unadjusted and adjusted associations between CVD with different stages of eGFR (eGFR >90 ml/min per 1.73 m2 as reference). This is the first report on the prevalence and the spectrum of CVD in early stages of CKD in a community-based Chinese population. The spectrum of CVD in this Chinese population is different from reports of Western countries. Individuals with subtle decreased renal function seem much more likely to have multiple cardiovascular risk factors and have higher prevalence of CVD than those without CKD.

Prevalence of cardiovascular diseases and associated risk factors in a rural black population of South Africa

BACKGROUND

To determine the prevalence and associated risk factors of cardiovascular diseases in a rural adult black population from Limpopo Province in South Africa.

DESIGN

A cross-sectional study.

METHODS

A sample of 1608 women and 498 men aged 30 years and above participated in the study. Sociodemographic data, anthropometric measures (body mass index, waist/hip ratio), blood pressure and biochemical risk factors were measured. A global cardiovascular disease (CVD) risk profile was developed.

RESULTS

There was a high prevalence of tobacco use for men (57%) and women (35.4%), with women (28.1%) predominantly using smokeless tobacco. Alcohol use was very common in men (57.2%). Women weighed a great deal more than men, and 51.7% were either overweight or obese. Diabetes was diagnosed in 8.8 and 8.5% of women and men, respectively. High-density lipoprotein-cholesterol was relatively high, whereas 42.3% of women and 28.5% of men had low-density lipoprotein-cholesterol levels of 3 mmol/l or more. Hypertension (blood pressure > or =140/90 mmHg) was found in 25.5% of women and 21.6% of men. According to the Framingham formulae, 18.9% of women and 32.1% of men had a 20% or higher chance of having a CVD event in the next 10 years.

CONCLUSIONS

There was a high prevalence of chronic disease risk factors in the rural, poor black community in Limpopo, South Africa. Consequently, the population had a higher than expected risk of developing a CVD event in the following 10 years when compared with similar studies in black Africans.

Effects of a global risk educational tool on primary coronary prevention: the Atherosclerosis Assessment Via Total Risk (AVIATOR) study

OBJECTIVE

The use of Framingham equations to determine 10-year absolute coronary risk ('global risk') represents an accepted strategy to target coronary prevention measures and enhance clinical outcomes. The aim of this study was to determine the effects of providing global risk scores to physicians on the prescription of lipid-lowering therapy for patients at increased coronary risk.

RESEARCH DESIGN AND METHODS

This prospective, randomized controlled trial enrolled 368 primary-care patients without a history of coronary heart disease and not on therapy with a hydroxymethylglutaryl coenzyme A reductase inhibitor (i.e. statin). The study was conducted in the general medical clinics of an academic US teaching hospital. In the intervention group (n = 186) patients' charts were reviewed, 10-year absolute coronary risk computed, and this information conveyed via a simple educational tool appended to charts. In the control group (n = 182), charts were accompanied by a form with general information on coronary prevention goals and strategies.

MAIN OUTCOME MEASURE

The primary endpoint was the proportion of high-risk patients receiving a new statin prescription. Secondary and tertiary endpoints included (1) the proportion of moderate-risk patients receiving a statin prescription; and (2) the proportion of patients in the whole cohort who had other coronary prevention measures recommended.

RESULTS

There was no significant difference in statin prescription to high-risk individuals in the intervention group (40.0%) compared with the control group (37.9%; p = 0.86). Moderate-risk individuals who were not eligible for treatment according to the National Cholesterol Education Program Adult Treatment Panel II guidelines were more likely to receive a statin prescription in the intervention group versus the control group (28.8% vs. 12.5%. p = 0.036)

CONCLUSIONS

Although a simple global risk educational tool did not improve the targeting of statin therapy to patients at high absolute coronary risk, it may be of benefit in targeting moderate-risk individuals who do not have markedly elevated low-density lipoprotein cholesterol (LDL-C) levels. Future research should evaluate the effects of physicians performing their own Framingham risk calculations on statin prescribing and on cholesterol goal attainment.

Derivative Ratio as a Measure of Effect: Sex over Age of Occurrence of Myocardial Infarction in Brazil

The concept of relative risk (RR) as an incidence rate ratio is extended to a ratio of derivatives of cumulative occurrences of events with respect to any continuous variable whose domain is partitioned in sub-domains of study and referent groups to be contrasted. RR, thus expressed as a function, allows the identification of key values of the independent variable through which effect, as a relation between sub-domains, is modulated. The effect of sex over age of occurrence of myocardial infarction in a sample of Brazilian patients is analysed. Male sex, as contrasted to female, is acknowledged as a risk factor for the disease but it is known that this risk wanes with aging. Derivatives of cumulative occurrences with respect to age are calculated for men and women. Given the normal distribution of these occurrences, derivatives are found to be very similar to the corresponding normal density functions, with difference not greater than 0.005. This provides an easy way of identifying the derivatives whose ratio is likewise easily calculated. Results suggest that, in the Brazilian sample of patients studied, the greatest men to women RR is 1.9 at the age of 23.5 years and that at the age of 61.2 years risks become evens.

Explaining the increase in coronary heart disease mortality in Beijing between 1984 and 1999

BACKGROUND

Coronary heart disease (CHD) mortality is rising in many developing countries. We examined how much of the increase in CHD mortality in Beijing, China, between 1984 and 1999 could be attributed to changes in major cardiovascular risk factors and assessed the impact of medical and surgical treatments.

METHODS AND RESULTS

A validated, cell-based mortality model synthesized data on (1) patient numbers, (2) uptake of specific medical and surgical treatments, (3) treatment effectiveness, and (4) population trends in major cardiovascular risk factors (smoking, total cholesterol, blood pressure, obesity, and diabetes). Main data sources were the WHO MONICA and Sino-MONICA studies, the Chinese Multi-provincial Cohort Study, routine hospital statistics, and published meta-analyses. Age-adjusted CHD mortality rates increased by approximately 50% in men and 27% in women (1608 more deaths in 1999 than expected by application of 1984 rates). Most of this increase ( approximately 77%, or 1397 additional deaths) was attributable to substantial rises in total cholesterol levels (more than 1 mmol/L), plus increases in diabetes and obesity. Blood pressure decreased slightly, whereas smoking prevalence increased in men but decreased substantially in women. In 1999, medical and surgical treatments in patients together prevented or postponed approximately 642 deaths, mainly from initial treatments for acute myocardial infarction ( approximately 41%), hypertension (24%), angina (15%), secondary prevention (11%), and heart failure (10%). Multiway sensitivity analyses did not greatly influence the results.

CONCLUSIONS

Much of the dramatic CHD mortality increases in Beijing can be explained by rises in total cholesterol, reflecting an increasingly "Western" diet. Without cardiological treatments, increases would have been even greater.

Some puzzling situations in the onset, occurrence and future of coronary heart disease in developed and developing populations, particularly such in sub-Saharan Africa

Coronary heart disease (CHD) was rare in developed populations until the early 1900s; this prevailed even among the small segments who were prosperous and who, in measure, had most of the currently recognised risk factors. However, in the 1930s, with improved circumstances from general rises in socio-economic state, there were major increases in the occurrence and mortality rate from the disease, the latter reaching a third of the total mortality in some countries, as in the United Kingdom (UK). Puzzlingly, the inter-population diversity of the increases in CHD has been such that there are as much as five fold differences in CHD mortality rates, as, for example, between Poland and Spain. Within recent years, with appropriate treatments, the mortality rate has halved in some countries, again, as in the UK. However, the incidence rate of the disease has diminished little or hardly at all. Risk factors include a familial component and, nutritionally, over-eating, a high fat intake, relatively low intakes of plant foods, especially of vegetables and fruit and, non-nutritionally, smoking, excessive alcohol consumption and a low level of everyday physical activity. On the one hand, known risk factors, broadly, are considered to be capable of explaining only about half of the variation in the occurrence of the disease. Even at present, known risk factors far from fully explain the epidemiological differences in mortality rates. Yet, on the other hand, there is abundant evidence that in population groups, among whom risk factors are low or have been reduced, CHD incidence and mortality rates are lower. Notwithstanding this knowledge, broadly, there is very little interest in the general public in taking avoiding measures. As to the situation in developing populations, in sub-Saharan Africa, in urban Africans, as in Johannesburg, South Africa, despite considerable westernisation of life style and with rises in risk factors, CHD remains of very low occurrence, the situation thereby resembling, historically, its relatively slow emergence in developed populations. In most eastern countries, mortality rates remain relatively low, as in Russia and Japan. However, in major contrast, in India, rates have risen considerably in urban dwellers. Indeed, in Indian immigrants, as in those in the UK, their rate actually exceeds that in the country's white population. In brief, much remains to be explained in the epidemiology of the disease.

If suicide is a public health problem, what are we doing to prevent it?

Although not a disease, suicide is a tragic endpoint of complex etiology and a leading cause of death worldwide. Just as preventing heart disease once meant that specialists treated myocardial infarctions in emergency care settings, in the past decade, suicide prevention has been viewed as the responsibility of mental health professionals within clinical settings. By contrast, over the past 50 years, population-based risk reduction approaches have been used with varying levels of effectiveness to prevent morbidity and mortality associated with heart disease. We examined whether the current urgency to develop effective interventions for suicide prevention can benefit from an understanding of the evolution of population-based strategies to prevent heart disease.

Measuring the health of nations: analysis of mortality amenable to health care

OBJECTIVE

To assess whether and how the rankings of the world's health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance.

DESIGN

Analysis of mortality amenable to health care (including and excluding ischaemic heart disease).

MAIN OUTCOME MEASURE

Age standardised mortality from causes amenable to health care

SETTING

19 countries belonging to the Organisation for Economic Cooperation and Development.

RESULTS

Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care.

CONCLUSION

The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.

Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults

The growing global burden of non-communicable diseases in poor countries and poor populations has been neglected by policy makers, major multilateral and bilateral aid donors, and academics. Despite strong evidence for the magnitude of this burden, the preventability of its causes, and the threat it poses to already strained health care systems, national and global actions have been inadequate. Globalisation is an important determinant of non-communicable disease epidemics since it has direct effects on risks to populations and indirect effects on national economies and health systems. The globalisation of the production and marketing campaigns of the tobacco and alcohol industries exemplify the challenges to policy makers and public health practitioners. A full range of policy responses is required from government and non-governmental agencies; unfortunately the capacity and resources for this response are insufficient, and governments need to respond appropriately. The progress made in controlling the tobacco industry is a modest cause for optimism.

Cardiovascular risk factor levels in a lower middle-class community in Ankara, Turkey

STUDY OBJECTIVE

To assess the prevalence of risk factors for coronary heart disease (CHD) in a lower middle-class urban community of Turkey.

DESIGN

Cross-sectional study in an age- and sex-stratified random community sample with equal sample size per stratum. Direct age-standardization using the standard world population to allow international comparison of findings. Logistic regression modelling to identify risk factors for obesity.

SETTING

Gülveren, a residential area in Ankara, total population 23,000 persons.

PARTICIPANTS

A total of 1672 adults aged 25-64 years and resident in the study community were interviewed, 1272 (76.1%) of those came for physical examination.

MAIN RESULTS

The age-standardized prevalence of hypertension according to WHO MONICA criteria was 18.6% (95% confidence interval: 16.1-21.1%) among women and 12.3% (9.7-14.9%) among men; of obesity (body mass index, BMI > or =30 kg/m2) 51.0% (47.6-54.3%) among women and 15.1% (12.0-18.2%) among men; of current smoking 20.1% (17.5-22.6%) among women and 64.8% (61.4-68.2%) among men; of hypercholesterolaemia 20.1% (17.4-22.9%) among women and 13.8% (10.8-16.8%) among men; and of low high density lipoprotein (HDL) 48.4% (44.8-52.1%) among women and 40.6% (36.0-45.2%) among men. In the regression model, age, female sex, non- and ex-smoking were associated with obesity.

CONCLUSIONS

The prevalence of smoking, obesity and low HDL is high in this urban, lower middle-class population, even in comparison with industrialized countries. Unexpectedly, women have less favourable CHD risk profiles than men, except for smoking. Preventive action should be community-wide and address the common risk factors simultaneously to avoid replacement effects such as becoming obese after quitting smoking.

A "natural experiment" in cardiovascular epidemiology in the early 21st century

Despite similar traditional risk factors, morbidity and mortality rates from coronary heart disease in western and non-western cohorts remain substantially different. Careful study of such cohorts may help identify novel risk factors for CHD, and contribute to the formulation of new preventive strategies

Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century

This overview of population-based studies of incidence, prevalence, mortality, and case-fatality of stroke was based on studies from 1990. Incidence (first stroke in an individual's lifetime) and prevalence were computed by age, sex, and stroke type. Age-standardised incidence and prevalence with the corresponding 95% CI were plotted for each study to facilitate comparisons. The review shows that the burden of stroke is high and is likely to increase in future decades as a result of demographic and epidemiological transitions in populations. The main features of stroke epidemiology include modest geographical variation in incidence, prevalence, and case-fatality among the--predominantly white--populations studied so far, and a stabilisation or reversal in the declining secular trends in the pre-1990s rates, especially in older people. However, further research that uses the best possible methods to study the incidence, risk factors, and outcome of stroke are urgently needed in other populations of the world, especially in less developed countries where the risk of stroke is high, lifestyles are changing rapidly, and population restructuring is occurring.

The search for new risk factors for coronary heart disease: occupational therapy for epidemiologists?

The identification of the proximal causes of coronary heart disease (CHD) during the second half of the 20th century contributed to the prevention of premature CHD and the extension of life expectancy in middle-aged and older people in many wealthy countries. These major CHD risk factors-high blood cholesterol, high blood pressure, cigarette smoking and physical inactivity-satisfy public health criteria of causality. Strong epidemiological evidence suggests that they explain at least 75% of new cases of CHD. However, the search for 'new' or 'emerging' CHD risk factors continues, partly justified by a myth that minimizes the contribution of the major risk factors. The public health criteria of causality were applied to the following proposed new risk factors: thrombotic factors and serum homocysteine levels; infectious agents; early life exposures including prenatal factors; genetic influences; oestrogen deficiency; and the role of the psychosocial environment. None of these factors are as important as the established risk factors for epidemic CHD and their potential contribution for improving population health is limited or unclear. Research into unexplained variations in the occurrence of CHD and into life course influences and socioeconomic inequalities may provide extra leads to effective public health action. Especially important is research on the upstream social and economic determinants of CHD and its major risk factors, on the spread of the CHD epidemic to poorer populations, and into prevention policy and programme effectiveness. Available evidence supports the feasibility and effectiveness of population-wide prevention directed towards increasing the proportion of people at low risk of CHD. The vast majority of the public health effort should be directed to this approach rather than to the high risk individual approach. There is still a major gap between knowledge and action in preventing the CHD epidemics.