Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: the Singapore Cardiovascular Cohort Study

Cardiovascular risk profile in two cohorts of young apparently healthy South Asian descendants in the Netherlands: still a long way to go!

BACKGROUND

Cardiovascular disease (CVD) imposes a major healthcare burden on young descendants of South Asian migrants living in the western world. In comparison to the native population, the prevalence is significantly higher and the prevalence of CVD risk factors is increasing rapidly. The cardiovascular risk profile and 10-year risk scores of South Asian descendants were evaluated in two cohorts with a 10-year time difference.

METHODS

Two cross-sectional studies, conducted in 2004 and 2014, focused on asymptomatic South Asian descendants aged 18-59 years were performed. A short questionnaire, BMI, waist circumference, blood pressure, and nonfasting blood tests were obtained. The cohort of 2014 was matched with the cohort of 2004, based on age, gender, and family history of CVD.

RESULTS

In 2014, 674 South Asians (44% men, age 38.2 ± 12.0 years) were matched with 674 South Asians (44% men, age 38.3 ± 12.1 years) included in 2004. Notably, hypertension prevalence decreased significantly in 2014 (10.6% vs 23.1% in 2004, P  < 0.001), while mean BMI increased (26.1 vs 24.9, P  < 0.001). The mean Framingham risk score was lower in 2014 (5.31 ± 6.19%) than in 2004 (6.45 ± 8.02%, P  < 0.05).

CONCLUSION

This study demonstrates that South Asian descendants in 2014 have a lower but still high absolute risk for coronary events compared to 2004. Important differences in cardiovascular risk profile exist. Despite improvements, South Asian descendants in 2014 still face a high absolute risk for coronary events compared to 2004, indicating the necessity for continued primary prevention and lifestyle interventions.

Risk estimation for the primary prevention of cardiovascular disease: considerations for appropriate risk prediction model selection

Cardiovascular diseases remain the number one cause of death globally. Cardiovascular disease risk scores are an integral tool in primary prevention, being used to identify individuals at the highest risk and guide the assignment of preventive interventions. Available risk scores differ substantially in terms of the population sample data sources used for their derivation and, consequently, in the absolute risks they assign to individuals. Differences in cardiovascular disease epidemiology between the populations contributing to the development of risk scores, and the target populations in which they are applied, can result in overestimation or underestimation of cardiovascular disease risks for individuals, and poorly informed clinical decisions. Given the wide plethora of cardiovascular disease risk scores available, identification of an appropriate risk score for a target population can be challenging. This Review provides an up-to-date overview of guideline-recommended cardiovascular disease risk scores from global, regional, and national contexts, evaluates their comparative characteristics and qualities, and provides guidance on selection of an appropriate risk score.

Diabetes in South Asians: Uncovering Novel Risk Factors With Longitudinal Epidemiologic Data: Kelly West Award Lecture 2023

South Asian populations have a higher prevalence and earlier age of onset of type 2 diabetes and atherosclerotic cardiovascular diseases than other race and ethnic groups. To better understand the pathophysiology and multilevel risk factors for diabetes and cardiovascular disease, we established the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study in 2010. The original MASALA study cohort (n = 1,164) included 83% Asian Indian immigrants, with an ongoing expansion of the study to include individuals of Bangladeshi and Pakistani origin. We have found that South Asian Americans in the MASALA study had higher type 2 diabetes prevalence, lower insulin secretion, more insulin resistance, and an adverse body composition with higher liver and intermuscular fat and lower lean muscle mass compared with four other U.S. race and ethnic groups. MASALA study participants with diabetes were more likely to have the severe hyperglycemia subtype, characterized by β-cell dysfunction and lower body weight, and this subtype was associated with a higher incidence of subclinical atherosclerosis. We have found several modifiable factors for cardiometabolic disease among South Asians including diet and physical activity that can be influenced using specific social network members and with cultural adaptations to the U.S. context. Longitudinal data with repeat cardiometabolic measures that are supplemented with qualitative and mixed-method approaches enable a deeper understanding of disease risk and resilience factors. Studying and contrasting Asian American subgroups can uncover the causes for cardiometabolic disease heterogeneity and reveal novel methods for prevention and treatment.

Incidence and risk factors of cardiovascular disease among population aged 40-70 years: a population-based cohort study in the South of Iran

BACKGROUND

Cardiovascular diseases are the main cause of mortality in the world. This study aimed to estimate the incidence and identify the risk factors of these diseases.

METHODS

This prospective cohort study was performed on 9442 individuals aged 40-70 years in Kharameh, a city in the South of Iran, in 2015-2022. The subjects were followed up for 4 years. The demographic information, behavioral habits, biological parameters, and history of some diseases were examined. The density incidence of cardiovascular disease was calculated. The log-rank test was calculated to assess the cardiovascular incidence difference between men and women. Simple and multiple Cox regression with Firth's bias reduction method were used to identify the predictors of cardiovascular disease.

RESULTS

The mean ± SD age of the participants was 51.4 ± 8.04 years, and the density incidence was estimated at 1.9 cases per 100,000 person-day. The log-rank test showed that men had a higher risk of cardiovascular disease than women. The Fisher's exact test showed a statistically significant difference between the incidence of cardiovascular diseases in different age groups, education levels, diabetes, and hypertension in men and women. The results of multiple Cox regression revealed that with increasing age, the risk of developing CVDs increased. In addition, the risk of cardiovascular disease is higher in people with kidney disease (HR_adj = 3.4, 95% CI 1.3 to 8.7), men (HR_adj = 2.3, 95% CI 1.7 to 3.2), individuals with hypertension (HR_adj = 1.6, 95% CI 1.3 to 2.1), diabetics (HR_adj = 2.3, 95%c CI 1.8 to 2.9), and alcohol consumption (HR_adj = 1.5, 95% CI 1.09 to 2.2).

CONCLUSIONS

In the present study, diabetes, hypertension, age, male gender, and alcohol consumption were identified as the risk factors for cardiovascular diseases; three variables of diabetes, hypertension and alcohol consumption were among the modifiable risk factors, so if they were removed, the incidence of cardiovascular disease could greatly reduce. Therefore, it is necessary to develop strategies for appropriate interventions to remove these risk factors.

Factors Associated with RANTES, EMMPIRIN, MMP2 and MMP9, and the Association of These Biomarkers with Cardiovascular Disease in a Multi-Ethnic Population

BACKGROUND

The growing cardiovascular disease (CVD) epidemic calls for further research to identify novel biomarkers for earlier detection and as potential therapeutic targets. Biomarkers Regulated on Activation, Normal T Cell Expressed and Secreted (RANTES), extracellular matrix metalloproteinase inducer (EMMPRIN), and matrix metalloproteinases (MMP-2, and MMP-9) are linked to proatherogenic and proinflammatory pathways of CVD development, the majority of which are coronary artery disease (CAD) and stroke. We evaluated potential factors affecting these four biomarkers and established their association with CVD.

METHODS

This is a cross-sectional analysis using a nested case-control design involving 580 participants aged 21-75 years from the prospective multi-ethnic cohort study. A total of 290 CVD cases and 290 age-and sex-matched controls were identified. All participants underwent interviews, health screenings, and provided blood samples, including biomarkers RANTES, EMMPRIN, and MMPs. CVD was defined based on previous medical history.

RESULTS

The average age of the participants was 55.7(SD = 10.3) years of age, and 34.6% were female. Arrhythmia history and low-density lipoprotein (LDL) levels were significant factors of logEMMPRIN (β = -0.124 [-0.245, -0.003] and β = 0.111 [0.0, 0.191], respectively). Only female sex (β = 0.189 [0.078, 0.300]) for logRANTES and age (β = 0.033 [0.010, 0.055]) for logMMP-2 and logMMP-9 were significant. The Indian ethnicity (β = 0.192 [0.048, 0.335]) and highly sensitive C-reactive protein (hs-CRP) levels (β = 0.063 [0.011, 0.116]) were statistically significant for logMMP-9. No association was detected between biomarkers and CVD.

CONCLUSIONS

In this multi-ethnic study cohort, RANTES was associated with sex, EMMPRIN was associated with a history of arrhythmia and LDL levels, MMP-2 with age, and MMP-9 with ethnicity and hs-CRP levels. The biomarker serum levels were not associated with CVD.

Signature pattern of gene expression and signaling pathway in premature diabetic patients uncover their correlation to early age coronary heart disease

BACKGROUND

Coronary Heart Disease (CHD) is the leading cause of death in industrialized countries. There is currently no direct relation between CHD and type 2 diabetes mellitus (T2D), one of the major modifiable risk factors for CHD. This study was carried out for genes expression profiling of T2D associated genes to identify related biological processes/es and modulated signaling pathway/s of male subjects with CHD.

METHOD

the subjects were divided into four groups based on their disease, including control, type 2 diabetes mellitus (T2D), CHD, and CHD + T2D groups. The RNA was extracted from their blood, and RT2 Profiler™ PCR Array was utilized to determine gene profiling between groups. Finally, the PCR Array results were validated by using Q-RT-PCR in a more extensive and independent population.

RESULT

PCR Array results revealed that the T2D and T2D + CHD groups shared 11 genes significantly up-regulated in both groups. Further analysis showed that the mRNA levels of AKT2, IL12B, IL6, IRS1, IRS2, MAPK14, and NFKB1 increased. Consequently, the mRNA levels of AQP2, FOXP3, G6PD, and PIK3R1 declined in the T2D + CHD group compared to the T2D group. Furthermore, in silico analysis indicated 36 Gene Ontology terms and 59 signaling pathways were significantly enriched in both groups, which may be a culprit in susceptibility of diabetic patients to CHD development.

CONCLUSION

Finally, the results revealed six genes as a hub gene in altering various biological processes and signaling pathways. The expression trend of these identified genes might be used as potential markers and diagnostic tools for the early identification of the vulnerability of T2D patients to develop premature CHD.

Prognostic Outcomes in Acute Myocardial Infarction Patients Without Standard Modifiable Risk Factors: A Multiethnic Study of 8,680 Asian Patients

Background

An increasing proportion of patients with acute myocardial infarction (AMI) are presenting without standard modifiable risk factors (SMuRFs) of hypertension, hypercholesterolemia, diabetes, and smoking, but with an unexpectedly increased mortality. This study examined the SMuRF-less patients presenting with AMI in a multiethnic Asian population.

Methods

We recruited patients presenting with AMI from 2011 to 2021 and compared the prevalence, clinical characteristics, and outcomes of SMuRF-less and SMuRF patients. Multivariable analysis was used to compare the outcomes of 30-day cardiovascular mortality, all-cause mortality, readmission, cardiogenic shock, stroke, and heart failure. Kaplan-Meier curves were constructed for 30-day cardiovascular mortality, with stratification by ethnicity, gender and AMI type, and 10-year all-cause mortality.

Results

Standard modifiable risk factor-less patients, who made up 8.6% of 8,680 patients, were significantly younger with fewer comorbidities that include stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI: 1.09-1.86, p = 0.048), cardiogenic shock (RR: 1.31, 95% CI: 1.09-1.52, p = 0.015), and stroke (RR: 2.51, 95% CI: 1.67-3.34, p = 0.030) among SMuRF-less patients. A 30-day cardiovascular mortality was raised in the SMuRF-less group, with similar trends in men, patients with ST-segment elevation myocardial infarction (STEMI), and the three Asian ethnicities. All-cause mortality remains increased in the SMuRF-less group for up to 5 years.

Conclusion

There is a significant proportion of patients with AMI without standard risk factors in Asia, who have worse short-term mortality. This calls for greater focus on the management of this unexpectedly high-risk subgroup of patients.

Quantifying and Understanding the Higher Risk of Atherosclerotic Cardiovascular Disease Among South Asian Individuals: Results From the UK Biobank Prospective Cohort Study

BACKGROUND

Individuals of South Asian ancestry represent 23% of the global population, corresponding to 1.8 billion people, and have substantially higher risk of atherosclerotic cardiovascular disease compared with most other ethnicities. US practice guidelines now recognize South Asian ancestry as an important risk-enhancing factor. The magnitude of enhanced risk within the context of contemporary clinical care, the extent to which it is captured by existing risk estimators, and its potential mechanisms warrant additional study.

METHODS

Within the UK Biobank prospective cohort study, 8124 middle-aged participants of South Asian ancestry and 449 349 participants of European ancestry who were free of atherosclerotic cardiovascular disease at the time of enrollment were examined. The relationship of ancestry to risk of incident atherosclerotic cardiovascular disease-defined as myocardial infarction, coronary revascularization, or ischemic stroke-was assessed with Cox proportional hazards regression, along with examination of a broad range of clinical, anthropometric, and lifestyle mediators.

RESULTS

The mean age at study enrollment was 57 years, and 202 405 (44%) were male. Over a median follow-up of 11 years, 554 of 8124 (6.8%) individuals of South Asian ancestry experienced an atherosclerotic cardiovascular disease event compared with 19 756 of 449 349 (4.4%) individuals of European ancestry, corresponding to an adjusted hazard ratio of 2.03 (95% CI, 1.86-2.22; P<0.001). This higher relative risk was largely consistent across a range of age, sex, and clinical subgroups. Despite the >2-fold higher observed risk, the predicted 10-year risk of cardiovascular disease according to the American Heart Association/American College of Cardiology Pooled Cohort equations and QRISK3 equations was nearly identical for individuals of South Asian and European ancestry. Adjustment for a broad range of clinical, anthropometric, and lifestyle risk factors led to only modest attenuation of the observed hazard ratio to 1.45 (95% CI, 1.28-1.65, P<0.001). Assessment of variance explained by 18 candidate risk factors suggested greater importance of hypertension, diabetes, and central adiposity in South Asian individuals.

CONCLUSIONS

Within a large prospective study, South Asian individuals had substantially higher risk of atherosclerotic cardiovascular disease compared with individuals of European ancestry, and this risk was not captured by the Pooled Cohort Equations.

Regional differences in office and self-measured home heart rates in Asian hypertensive patients: AsiaBP@Home study

Increased heart rate is a predictor of cardiovascular disease, heart failure, and all‐cause mortality. In those with high heart rates, interventions for heart rate reduction have been associated with reductions in coronary events. Asia is a diverse continent, and the prevalences of hypertension and cardiovascular disease differ among its countries. The present analysis of AsiaBP@Home study data investigated differences among resting heart rates (RHRs) in 1443 hypertensive patients from three Asian regions: East Asia (N = 595), Southeast Asia (N = 680), and South Asia (N = 168). This is the first study to investigate self‐measured RHR values in different Asian countries/regions using the same validated home BP monitoring device (Omron HEM‐7130‐AP/HEM‐7131‐E). Subjects in South Asia had higher RHR values compared with the other two regions, and the regional tendency found in RHR values was different from that found in BP values. Even after adjusting for age, sex, BMI, habitual alcohol consumption, current smoking habit, shift worker, hyperlipidemia, diabetes, chronic kidney disease, history of heart failure, and beta‐blocker use, both office and home RHR values in South Asia were the highest among Asia (mean values ± SE of office: East Asia [E] 75.2 ± 1.5 bpm, Southeast Asia [Se] 76.7 ± 1.5 bpm, South Asia [S] 81.9 ± 1.4 bpm; home morning: [E] 69.0 ± 1.2 bpm, [Se] 72.9 ± 1.2 bpm, [S] 74.9 ± 1.1 bpm; home evening: [E] 74.6 ± 1.2 bpm, [Se] 78.3 ± 1.2 bpm, [S] 83.8 ± 1.1 bpm). Given what is known about the impact of RHR on heart disease, our findings suggest the possible benefit of regionally tailored clinical strategies for cardiovascular disease prevention.

Public Awareness of and Action towards Heart Attack Symptoms: An Exploratory Study

Background: Cardiovascular disease (CVD) is still the leading cause of mortality worldwide, and Malaysia is not an exception in this regard. The current research is an attempt to explore symptom awareness of and necessary actions in response to heart attack (HA) among lay public. Methods: This is a cross-sectional study design, and a survey was conducted from May to July 2018 among general public in Kuantan, Pahang state, Malaysia. Results: A total of 393 respondents recruited. Slightly more than one-fourth of the respondents (26.35%) were aware of HA symptoms like pain and/or discomfort in the jaw, neck, or back, while 71.65% showed awareness only of chest pain or discomfort as symptoms. Only 35.6% reported to call an ambulance if they experience someone suffering from HA symptoms, while 82% recognized ≥1 symptom, and only 11.5% recognized all five HA symptoms. Very few respondents, i.e., 1.3% reported awareness about correct recognition of all five HA symptoms. Respondents who had diabetes and hypercholesteremia were more likely to recognize all five HA symptoms. For those who had excellent awareness of all five HA symptoms, the odds ratio (OR) were significantly higher among single respondents (OR 0.023; 95% CI 0.001–0.594), Malay (OR 0.376; 95% CI 0.193–0.733), and those who received information associated with HA (OR 7.540; 95% CI 2.037–27.914). However, those who were aware that HA requires quick treatment had significantly low odds ratio (OR 0.176; 95% CI 0.044–0.710). Conclusions: The awareness of and action towards the signs and symptoms of HA among the public were poor.

Elevated Lipoprotein A in South Asians and the Associated Risk of Cardiovascular Disease: A Systematic Review

BACKGROUND

South Asians have a premature risk of cardiovascular disease and increased lipoprotein A which enhances their risk.

METHODS

This systematic review evaluates the role of elevated lipoprotein A in cardiovascular disease risk for South Asians. It discusses the pathophysiology, clinical studies, and treatment of elevated lipoprotein A using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

RESULTS

A total of 72 articles was incorporated which consisted of clinical studies, case-control and cohort studies, meta-analysis, reviews, and editorials. Cardiovascular disease and myocardial infarction occurs prematurely in South Asians, which is further enhanced with an elevated lipoprotein A.

CONCLUSIONS

South Asians with an elevated lipoprotein A have an increased risk of coronary artery disease so they should have early enactment of lifestyle modification and aggressive medical management.

Incidence and Progression of Coronary Artery Calcium in South Asians Compared With 4 Race/Ethnic Groups

Background

South Asians have a relatively high prevalence of coronary artery calcium (CAC) compared with other race/ethnic groups. We determined CAC incidence and progression among South Asians, and compared them with 4 race/ethnic groups.

Methods and Results

Data from the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study were used to calculate CAC incidence and progression rates and any CAC change. Data from the MESA (Multi‐Ethnic Study of Atherosclerosis) were used to compare the CAC incidence and progression rates. A total of 698 South Asians had repeat CAC measurements after 4.8±0.8 years. Among those with no CAC at baseline, the age‐adjusted CAC incidence was 8.8% (95% CI, 6.8–10.8%) in men and 3.6% (2.5–4.8%) in women. The median annual CAC progression was 26 (interquartile range, 11–62) for men and 13 (interquartile range, 4–34) for women. Compared with MESA, age‐adjusted CAC incidence was similar in South Asian men compared with white, black, and Latino men, but significantly higher than Chinese men (11.1% versus 5.7%, P=0.008). After adjusting for age, diabetes mellitus, hypertension, and statin medication use, Chinese, black, and Latino men had significantly less CAC change compared with South Asian men, but there were no differences between South Asian and white men. There was no difference in CAC incidence or progression between South Asian women and women in MESA.

Conclusions

South Asian men had greater CAC change than Chinese, black, and Latino men but similar change to that of whites after adjusting for traditional risk factors.

Exploratory analysis of traditional risk factors of ischemic heart disease (IHD) among predominantly Malay Malaysian women

Background

The risk factors of ischemic heart disease (IHD) specific for women are less well studied. However, knowing the risk factors of IHD for women will empower women themselves to be better informed and thus can help them in decision making concerning their health condition. The objective of this study is to explore the commonly studied risk factors of ischemic heart disease (IHD) among a group of Malaysian women.

Methods

A case control study was conducted among 142 newly diagnosed IHD women patients registered in government hospitals in Terengganu, Malaysia and their 1:1 frequency matched population controls. Data on sociodemographic and socioeconomic profile, co-morbidities, lifestyle factors related to physical activities, dietary fat intake, stress, passive smoking history, anthropometric measurements and biochemical markers were obtained.

Results

Middle aged women were recruited with women diagnosed with diabetes (aOR = 1.92, 95% CI: 1.11–3.31), having low HDL-C (aOR = 3.30, 95% CI: 1.28–8.27), those with positive family history of IHD (aOR = 1.92, 95% CI:1.13–3.26) and passive smokers (aOR = 2.99, 95% CI:1.81–4.94) were at higher odds of IHD.

Conclusions

The findings are useful for public health interventions and policy making focusing on specific women population.

Discordance between 10-year cardiovascular risk estimates using the ACC/AHA 2013 estimator and coronary artery calcium in individuals from 5 racial/ethnic groups: Comparing MASALA and MESA

BACKGROUND AND AIMS

South Asian (SA) individuals are thought to represent a group that is at high-risk for atherosclerotic cardiovascular disease (ASCVD). However, the performance of the Pooled Cohort Equations (PCE) remains uncertain in SAs living in the US. We aimed to study the interplay between predicted 10-year ASCVD risk and coronary artery calcium (CAC) in SAs compared to other racial/ethnic groups.

METHODS

We studied 536 SAs from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, and 2073 Non-Hispanic Whites (NHWs), 1514 African Americans (AAs), 1254 Hispanics, and 671 Chinese Americans (CAs) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were not currently on statins. We used logistic regression models to assess the association between race/ethnicity and CAC within each ASCVD risk stratum.

RESULTS

SAs at low and at intermediate estimated ASCVD risk were more likely to have CAC = 0 compared to NHWs, while SAs at high risk had a similar CAC burden to NHWs. For example, intermediate-risk SAs had a 73% higher odds of CAC = 0 compared to NHWs (95% 1.00-2.99), while high-risk SAs were equally likely to have CAC = 0 (OR 0.95, 95% CI 0.65-1.38) and CAC >100 (OR 0.86, 95% CI 0.61-1.22).

CONCLUSIONS

Our results suggest that the extent of ASCVD risk overestimation using the PCEs may be even greater among SAs considered at low and intermediate risk than among NHWs. Studies with incident ASCVD events are required to validate and/or recalibrate current ASCVD risk prediction tools in this group.

South Asians: why are they at a higher risk for cardiovascular disease?

PURPOSE OF REVIEW

We comment on the high prevalence of cardiovascular disease (CVD) in South Asians (SA). The effect of various risk factors, for example biochemical, genetic, lifestyle, socioeconomic factors and psychosocial stress on CVD risk is discussed.

RECENT FINDINGS

'Prediabetes' is common in SA, but its relationship with coronary artery disease (CAD) is not significant unlike for the white population. At the same time, 'prediabetes' in SA is associated with an increased risk for cerebrovascular disease (CeVD). The differentiating factor could be the high lipids in Europeans and their relationship to CAD. Likewise, higher diastolic blood pressure in SA may explain the risk of CeVD. Small, dense, low-density lipoprotein (LDL), low high-density lipoprotein-cholesterol (HDL-C) concentration and high triglycerides may contribute to atherosclerosis. Thrombotic factors such as increased levels of plasminogen activator inhibitor, fibrinogen, lipoprotein (a) and homocysteine have been shown to be associated with increased CVD. Impaired cerebrovascular autoregulation and sympathovagal activity, increased arterial stiffness and endothelial dysfunction may increase CVD risk further. In addition, environmental and dietary factors may exaggerate the unfavourable cardiovascular profile through genetic factors.

SUMMARY

The implications of the findings suggest comprehensive screening of SA for CVD. Cultural differences should be considered while designing prevention strategies specifically targeting barriers for uptake of preventive service.

A dose-response study of aerobic training for oxygen uptake, oxidative stress and cardiac autonomic function in type 2 diabetes mellitus: study protocol for a randomized controlled trial

Background

Cardiac autonomic neuropathy is a commonly overlooked complication of type 2 diabetes mellitus (T2DM) characterized by an imbalance between sympathetic and parasympathetic supply to the heart, which contributes to cardiovascular morbidity and mortality. T2DM has also been shown to negatively influence oxygen kinetics and increase oxidative stress, which may be linked to the development of various chronic complications. Aerobic training has been reported to improve oxygen uptake, antioxidant defense, and cardiac autonomic function in T2DM; however, the effects of varying doses of exercise on these variables are not known. Therefore, the aim of the present study is to explore the effects of manipulating training variables (volume and intensity) on the regulation of oxygen uptake response, oxidative stress, and cardiac autonomic function in patients with T2DM.

Methods

We will recruit 60 patients with T2DM, who will be randomly allocated into one of the three aerobic training groups: low-intensity, low-volume training; low-intensity, high volume-training; high-intensity, high-volume training; or to the control group receiving no supervised exercise. All participants will be assessed for the rate of oxygen uptake, levels of antioxidant enzymes and cardiac autonomic function at baseline and after 12 weeks of training. Secondary outcome measures will include cardiometabolic risk factors and body composition.

Discussion

Despite a large body of evidence on the efficacy of aerobic training in the prevention and treatment of T2DM, there is no unequivocal exercise prescription for the same. Oxygen kinetics and oxidative stress are highly sensitive to the magnitude of physical activity. It would therefore, be interesting to study their interaction with chronic exposure to various doses of exercises and explore the optimal volume and intensity to bring about improvements in these parameters.

Trial registration

Clinical Trials Registry – India, CTRI2017/08/009459. Registered on 23 August 2017. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2671-y) contains supplementary material, which is available to authorized users.

Chronic exposure to arsenic and high fat diet additively induced cardiotoxicity in male mice

Diet is one of the important risk factors that could potentially affect arsenic-induced cardiotoxicity. The present study was undertaken to investigate the effect of high fat diet on arsenic-induced cardiotoxicity in mice. Mice were divided into six different groups (n = 12), two control groups received either low fat diet (LFD) or high fat diet (HFD) along with deionized drinking water and four test groups given LFD + 25 ppm arsenic, LFD + 50 ppm arsenic, HFD + 25 ppm arsenic, and HFD + 50 ppm arsenic in drinking water for 5 months. The body weight, heart weight to body weight ratio, cardiac biochemical markers, lipid profile, and histological examination of heart were evaluated. The results demonstrated that arsenic exposure led to a significant decrease in heart glutathione level, catalase enzyme activity, and a significant increase in reactive oxygen species (ROS), malondialdehyde levels, and biochemical enzymes. The administration of HFD resulted in above-mentioned changes as well as an alteration in lipid profile; however, arsenic exposure alone or along with HFD caused a reduction in lipid profile factors, except HDL level. Our results revealed that HFD increased arsenic-induced heart injury in the mice. This effect may be because of reduction in antioxidant activities and/or increase in oxidative stress and ROS in mice heart tissues. These findings could be important for clinical intervention to protect against or prevent arsenic-induced cardiotoxicity in humans.

Asian-Indians: a review of coronary artery disease in this understudied cohort in the United States

Coronary artery disease (CAD) is a major cause of cardiovascular death worldwide. Prevalence of CAD is highly variable among different races. Asian Indians have been noted to have the highest CAD rates and the conventional risk factors fail to explain this difference completely. Asian Indians constitute a fifth of the global population, and the higher rates of CAD in this population constitute a major health challenge. There have been studies in the early 2000s that investigate the risk factors in this population; however, very few studies have been done since then that explore the higher CAD rates in Asian Indians. This is a comprehensive and current review of the known risk factors for CAD in Asian Indians and strategies physicians should consider relieving this burden.

PARS risk charts: A 10-year study of risk assessment for cardiovascular diseases in Eastern Mediterranean Region

This study was designed to develop a risk assessment chart for the clinical management and prevention of the risk of cardiovascular disease (CVD) in Iranian population, which is vital for developing national prevention programs. The Isfahan Cohort Study (ICS) is a population-based prospective study of 6504 Iranian adults ≥35 years old, followed-up for ten years, from 2001 to 2010. Behavioral and cardiometabolic risk factors were examined every five years, while biennial follow-ups for the occurrence of the events was performed by phone calls or by verbal autopsy. Among these participants, 5432 (2784 women, 51.3%) were CVD free at baseline examination and had at least one follow-up. Cox proportional hazard regression was used to predict the risk of ischemic CVD events, including sudden cardiac death due to unstable angina, myocardial infarction, and stroke. The model fit statistics such as area under the receiver-operating characteristic (AUROC), calibration chi-square and the overall bias were used to assess the model performance. We also tested the Framingham model for comparison. Seven hundred and five CVD events occurred during 49452.8 person-years of follow-up. The event probabilities were calculated and presented color-coded on each gender-specific PARS chart. The AUROC and Harrell's C indices were 0.74 (95% CI, 0.72-0.76) and 0.73, respectively. In the calibration, the Nam-D'Agostino χ2 was 10.82 (p = 0.29). The overall bias of the proposed model was 95.60%. PARS model was also internally validated using cross-validation. The Android app and the Web-based risk assessment tool were also developed as to have an impact on public health. In comparison, the refitted and recalibrated Framingham models, estimated the CVD incidence with the overall bias of 149.60% and 128.23% for men, and 222.70% and 176.07% for women, respectively. In conclusion, the PARS risk assessment chart is a simple, accurate, and well-calibrated tool for predicting a 10-year risk of CVD occurrence in Iranian population and can be used in an attempt to develop national guidelines for the CVD management.

Lipidomic profiling of plasma in a healthy Singaporean population to identify ethnic specific differences in lipid levels and associations with disease risk factors

Background

Plasma lipids (i.e., cholesterol, low density lipoprotein (LDL-C), high density lipoprotein (HDL-C) and triglycerides) are linked to a range of metabolic diseases, including heart disease and diabetes. Plasma lipid species have similarly been associated with the same diseases. However, neither abundance profiling of plasma lipid species in healthy populations, nor differences between ethnic groups has not been reported.

Methods

In this study, we have profiled over 280 lipid species using liquid chromatography-tandem mass spectrometry, independently across two sites, in 359 healthy Singaporean individuals of Chinese (n = 122), Indian (n = 120) and Malay (n = 117) ethnicity.

Results

We found variations in abundance (defined as % coefficient of variation) of plasma lipid species that fluctuated between 13 and 120%. Analysis of covariance (ANCOVA) identified differences between ethnic groups, particularly among alkyl and alkenylphosphatidylethanolamine species, as well as in two species of sphingosine-1-phosphate (i.e., d18:0 and d18:1), which were elevated in the Chinese group. Regression analysis identified ethnic-specific differences in the association of plasma lipids and lipid species with age, gender and body mass index (BMI). Chinese and Malay groups showed a positive association of glycerolipids (i.e., diglycerides (DG), triglycerides (TG)) and cholesteryl esters (CE) with BMI, but this was not seen in the Indian group. Furthermore, Indian and Malay groups showed a positive association between the abundance of sphingolipids and age, which was absent in the Chinese group.

Conclusions

This study provides baseline characterisation of the natural biological variation of plasma lipid species in three healthy ethnic groups, and identifies important differences in plasma lipid levels and their association with known disease risk factors.

A cross-sectional study of gender differences in lifestyle behavior and usage of medications among community-dwelling Asians towards achieving their LDL-Cholesterol treatment goals

Background:

Men differ from women in their cardiovascular mortality and morbidity globally, possibly due to their varying dietary and lifestyle behavior and usage of medications in dyslipidemia control.

Objectives:

The study aimed to compare the gender differences among community-dwelling Asians in their dietary habits, physical activity, their perception and use of lipid-lowering medications towards achieving their LDL-Cholesterol goals.

Methods:

A cross-sectional study was conducted, which included patients with physician-diagnosed dyslipidemia, aged 31–80 years in two public primary care clinics in Singapore. They were administered a questionnaire survey on their diet, exercise and lipid-lowering medication. Their latest laboratory fasting lipid tests, retrieved from their electronic health records, defined their treatment goals based on adapted Framingham risk scores.

Results:

Amongst 1093 patients, 61.9% were female. Fewer men (65.9%) achieved LDL-C treatment goals compared with women (75.2%). Comparing with their counterpart, more women were willing to change their diet (75.8% vs. 46.2%) and exercise (78.4% vs. 70.9%) to achieve their LDL treatment goals. However, men who were treated with lipid medication were more likely to reach LDL-C treatment goals.

Conclusion:

Fewer Asian men in Singapore attained their LDL-C treatment goals than women, which appeared to be associated with greater reluctance to embark on dietary and lifestyle changes. Gender-specific interventions should be considered to address these differences.

Coronary atherosclerotic plaque burden and composition by CT angiography in Caucasian and South Asian patients with stable chest pain

AIMS

South Asian (SA) patients are known to have an increased incidence of acute cardiovascular events compared with Caucasians. The aim of this observational study was to compare the prevalence of coronary stenoses, the amount and composition of coronary atherosclerosis in a cohort of Caucasian and SA patients with stable chest pain, in non-acute settings.

METHODS AND RESULTS

The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. In 963 consecutive Caucasian and SA patients undergoing coronary computed tomography angiography, atherosclerotic plaques were quantified using a semi-automated algorithm. The vessel per cent diameter and area stenosis were measured. Plaque composition was examined from the measurement of calcified, non-calcified, and total plaque burden. There were 420 Caucasian (238 males) and 543 SA (297 males) patients. Caucasian patients were older than SA patients (54.39 ± 11.65 vs. 49.83 ± 11.03 years) and had lower prevalence of diabetes (13.13 vs. 32.41%) and hyperlipidaemia (56.90 vs. 68.51%) (all P-values <0.001). After adjusting for differences in cardiovascular risk factors, there were no differences in per cent diameter and area stenosis, and no difference in the proportions of patients with one-, two-, or three-vessel disease. There was no difference in total plaque burden; however, the per cent non-calcified plaque composition was lower in Caucasians compared with SA (80.95 vs. 90.42%; P-value <0.001).

CONCLUSION

This study conducted in non-acute settings showed an ethnic difference in composition of coronary atherosclerotic plaque with lower non-calcified composition in Caucasian patients compared with SA patients, which was independent of age, diabetes, hyperlipidaemia, and the other available cardiovascular risk factors.

Influence of Ethnicity, Age, and Time on Sex Disparities in Long-Term Cause-Specific Mortality After Acute Myocardial Infarction

Background

We examined the influence of sex, ethnicity, and time on competing cardiovascular and noncardiovascular causes of death following acute myocardial infarction in a multiethnic Asian cohort.

Methods and Results

For 12 years, we followed a prospective nationwide cohort of 15 151 patients (aged 22–101 years, median age 63 years; 72.3% male; 66.7% Chinese, 19.8% Malay, 13.5% Indian) who were hospitalized for acute myocardial infarction between 2000 and 2005. There were 6463 deaths (4534 cardiovascular, 1929 noncardiovascular). Compared with men, women had a higher risk of cardiovascular death (age‐adjusted hazard ratio [HR] 1.3, 95% CI 1.2–1.4) but a similar risk of noncardiovascular death (HR 0.9, 95% CI 0.8–1.0). Sex differences in cardiovascular death varied by ethnicity, age, and time. Compared with Chinese women, Malay women had the greatest increased hazard of cardiovascular death (HR 1.4, 95% CI 1.2–1.6) and a marked imbalance in death due to heart failure or cardiomyopathy (HR 3.4 [95% CI 1.9–6.0] versus HR 1.5 [95% CI 0.6–3.6] for Indian women). Compared with same‐age Malay men, Malay women aged 22 to 49 years had a 2.5‐fold (95% CI 1.6–3.8) increased hazard of cardiovascular death. Sex disparities in cardiovascular death tapered over time, least among Chinese patients and most among Indian patients; the HR comparing cardiovascular death of Indian women and men decreased from 1.9 (95% CI 1.5–2.4) at 30 days to 0.9 (95% CI 0.5–1.6) at 10 years.

Conclusion

Age, ethnicity, and time strongly influence the association between sex and specific cardiovascular causes of mortality, suggesting that health care policy to reduce sex disparities in acute myocardial infarction outcomes must consider the complex interplay of these 3 major modifying factors.

High-Throughput Diagnostic Assay for a Highly Prevalent Cardiomyopathy-Associated MYBPC3 Variant

A 25-basepair deletion variant of MYBPC3 occurs at high frequency in individuals of South Asian descent and is estimated to affect 55 million people worldwide, carrying an increased likelihood of cardiomyopathy. Since this variant is prevalent and severe in this subpopulation, quick and affordable screening to provide risk-assessment to guide treatment for these patients is critical. An RNaseH qPCR assay was developed to quickly and specifically diagnose the presence of the 25-basepair deletion variant in MYBPC3. RNAseH-blocked nucleotide primers were designed to identify the presence or absence of the wild type MYBPC3 allele or the genomic sequence containing the 25-basepair deletion. Using this assay, three blinded operators were able to accurately determine the genotype from human genomic DNA samples from blood and saliva using a qPCR thermocycler. Furthermore, positive variant subjects were examined by both electrocardiography and echocardiography for the presence of cardiomyopathy. A simple, robust assay was established, verified and validated that can be automated to detect the presence of the highly prevalent 25-basepair deletion MYBPC3 variant using both blood and saliva samples. The assay will provide quick and accurate prescreening of individuals at high risk for cardiomyopathies and allow for better clinical identification of 25-basepair deletion MYBPC3 carriers in large cohort epidemiological studies.

Prevalence and magnitude of classical risk factors for Coronary Heart Disease in a cohort of 4400 Chinese steelworkers over 13.5 years follow-up

BACKGROUND

The incidence and mortality of cardiovascular disease among Orientals are very different than among Caucasians. This study addresses the prevalence and magnitude of classic cardiovascular disease risk factors associated with coronary heart disease (CHD) in an Oriental cohort of at-risk men (blood pressure, total cholesterol, Body Mass Index [BMI] and smoking), compared to Caucasian populations. We also address which blood pressure index (SBP, DBP, mean arterial pressure [MAP] and pulse pressure [PP]) is the best predictor of CHD.

METHODS AND RESULTS

A cohort of 5092 male steelworkers (18-74 years old) recruited between 1974-1980 was followed up for an average of 13.5 years. The prevalence of risk factors was lower in Orientals than in Caucasians, except for smoking. The relative risks (RRs) of CHD associated with classic risk factors in this Oriental population were similar to Caucasians, except for blood pressure. The RRs of CHD associated with both SBP and DBP in this Oriental group were higher than in Caucasians; RR of CHD was approximately 3 for each 40 mmHg rise of SBP versus approximately 2 in Caucasians. SBP was the single best predictor for CHD, followed by MAP, and DBP. The population attributable risk (PAR%) for hypertension (140/90 mmHg) was 42.4.

CONCLUSION

Our results would indicate that the lower incidence of CHD in Orientals is at least partly due to the lower prevalence of hypertension, hypercholesterolemia, and obesity. The magnitude of the risk associated with these factors is similar to that in Caucasians, except perhaps for a greater risk associated with hypertension. The most predictive BP index for CHD is SBP. These results are based on indirect comparisons only and should be studied further in prospective multi-ethnic cohorts.

Ethnic inequalities in acute myocardial infarction and stroke rates in Norway 1994-2009: a nationwide cohort study (CVDNOR)

Background

Immigrants to Norway from South Asia and Former Yugoslavia have high levels of cardiovascular disease (CVD) risk factors. Yet, the incidence of CVD among immigrants in Norway has never been studied. Our aim was to study the burden of acute myocardial infarction (AMI) and stroke among ethnic groups in Norway.

Methods

We studied the whole Norwegian population (n = 2 637 057) aged 35–64 years during 1994–2009. The Cardiovascular Disease in Norway (CVDNOR) project provided information about all AMI and stroke hospital stays for this period, as well as deaths outside hospital through linkage to the Cause of Death Registry. The direct standardization method was used to estimate age standardized AMI and stroke event rates for immigrants and ethnic Norwegians. Rate ratios (RR) with ethnic Norwegians as reference were calculated using Poisson regression.

Results

The highest risk of AMI was seen in South Asians (men RR = 2.27; 95 % CI 2.08–2.49; women RR = 2.10; 95 % CI 1.76–2.51) while the lowest was seen in East Asians (RR = 0.38 in both men (95 % CI 0.25–0.58) and women (95 % CI 0.18–0.79)). Immigrants from Former Yugoslavia and Central Asia also had increased risk of AMI compared to ethnic Norwegians. South Asians had increased risk of stroke (men RR = 1.26; 95 % CI 1.10–1.44; women RR = 1.58; 95 % CI 1.32–1.90), as did men from Former Yugoslavia, Sub-Saharan Africa and women from Southeast Asia.

Conclusions

Preventive measures should be aimed at reducing the excess numbers of CVD among immigrants from South Asia and Former Yugoslavia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2412-z) contains supplementary material, which is available to authorized users.

Cardiovascular risk assessment: a global perspective

An important strategy in primary prevention of cardiovascular diseases (CVD) is the early identification of high-risk individuals. Effective implementation of a strategy to identify these individuals in a clinical setting is reliant on the availability of appropriate CVD risk-assessment models and guideline recommendations. Several well-known models for CVD risk assessment have been developed and utilized in the USA and Europe, but might not be suitable for use in other regions or countries. Very few reports have discussed the development of risk-assessment models and recommendations from a global perspective. In this Review, we discuss why risk-assessment methods developed from studies in one geographical region or ethnic population might not be suitable for other regions or populations, and examine the availability and characteristics of predictive models in areas beyond the USA or Europe. In addition, we compare the differences in risk-assessment recommendations outlined in CVD clinical guidelines from developed and developing countries, and consider their potential effect on clinical practice. This overview of cardiovascular risk assessment from a global perspective can potentially guide low-to-middle-income countries in the development or validation of their own CVD risk-assessment models, and the formulation of recommendations in their own clinical guidelines according to local requirements.

Cardiovascular Risk Factors among Bangladeshi Ready-Made Garment Workers

To estimate the prevalence and identify correlates of anthropometry and clinical risk factors for cardiovascular diseases (CVDs) among ready-made garment (RMG) of workers, majority are females, come from low-socioeconomics conditions. Population-based cross-sectional study with 614 individuals aged ≥18 years were recruited from six different RMG factories. In total, of 313 male (46%) and 301 of female (56%) workers had body mass index (BMI) in the overweight and obese range as per Asian cut off values with corresponding reflection in waist hip ratio (WHR). High proportion of male 84% (95% confidence interval 81-87) had smoking habits. The prevalence of hypertension (HTN), dyslipidemia were 24% vs 15%; 56% vs 43% among males and females respectively. Prevalence of diabetes was 7.3% (5.3-9.4) and pre-diabetes was 10.6% (8.2-13) and it showed female preponderance (4.5% male vs 10.3% female). In multivariable logistic regression HTN showed significant association with age, gender, BMI; glycemic status with age, genderand WHR; dyslipidemia with BMI and WHR. A substantial proportion of RMG workers are at an increased risk of CVDs which need focused attention to reduce smoking (among males) and body-weight and central obesity, particularly in females.

Attribution of risk for coronary heart disease in a vulnerable immigrant population: a survey study

BACKGROUND

Coronary heart disease (CHD) is a common and costly condition and is increasing at a higher rate among Asian Indians than among other ethnic groups. An understanding of how Asian Indians perceive their risk is important for health providers to develop culturally appropriate programs to raise awareness of the risk of CHD.

OBJECTIVE

The aim of this survey was to investigate the attribution of risk factors for CHD among the Asian Indian community in Australia.

METHODS

Asian Indian community leaders were recruited to provide their views of how their community perceived the risk of CHD. An online survey collected demographic data and information from the Illness Perception Questionnaire-Revised, which measures 6 domains of illness perception: timeline acute/chronic, consequences, emotional impact, personal control, treatment efficacy, and illness comprehension.

RESULTS

An 84% response rate (n = 49) was achieved from Asian Indian community leaders. Heart disease and cancer were considered to be the illnesses of major concern. Participants indicated that people in their community perceived hereditary factors (90%), hypertension, stress or worry (84%), and aging (86%) as the major cause of their illnesses. Smoking, high blood pressure, and cholesterol were identified as being major risk factors for CHD.

CONCLUSIONS

These data suggest that as well as strategies to address risk factors such as diet and exercise, stress management is an important issue to consider in developing community-based programs.

Ultrasonography-diagnosed non-alcoholic fatty liver disease is not associated with prevalent ischemic heart disease among diabetics in a multiracial Asian hospital clinic population

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and cardiovascular diseases are both common among patients with diabetes mellitus.

OBJECTIVE

The aim of this study is to determine if ultrasonography-diagnosed NAFLD is associated with prevalent ischemic heart disease (IHD) among patients with diabetes mellitus.

METHODS

This is a cross-sectional study on consecutive patients seen at the Diabetic Clinic, University of Malaya Medical Centre. The medical record for each patient was reviewed for documented IHD. Patients without documented IHD but had symptoms and/or electrocardiographic changes suggestive of IHD were referred for cardiac evaluation.

RESULTS

Data for 399 patients were analyzed. Mean age was 62.8±10.5 years with 43.1% male. NAFLD and IHD were present in 49.6 and 26.6%, respectively. The prevalence of IHD among patients with and without NAFLD was 24.7 and 28.4%, respectively (P=0.414). The prevalence of IHD was highest among the Indians (34.1%) followed by the Malays (29.2%) and the Chinese (20.1%). No association was found between NAFLD and IHD when analyzed according to ethnicity. On multivariate analysis, independent factors associated with IHD were older age, lower levels of physical activity, greater waist circumference and higher serum glycated hemoglobin level.

CONCLUSIONS

Ultrasonography-diagnosed NAFLD was not associated with prevalent IHD among patients with diabetes mellitus in a multiracial Asian hospital clinic population.

Protective effects of onion extract on cadmium-induced oxidative stress, histological damage, and apoptosis in rat heart

To date, there is no available information on the protective effect of onion (Allium cepa) extract (AcE) on cadmium (Cd)-induced cardiotoxicity. The present study was performed to assess the possible antioxidant and anti-apoptotic roles of AcE in Cd-induced cardiotoxicity in rats. A Cd group was injected subcutaneously with CdCl2 dissolved in saline at a dose of 2 ml/kg/day for 30 days, resulting in a dosage of 1 mg/kg Cd. The rats in the AcE-treated group were given 1 ml of AcE via intragastric intubation for 30 days. The rats intoxicated with Cd for 30 days showed increased tissue malondialdehyde (MDA) levels and decreased levels of the enzymatic antioxidants superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) in cardiac tissue. AcE attenuated these adverse effects of Cd. After Cd exposure, histological abnormalities were observed, including myofibrillar loss, vacuolization of cytoplasm and irregularity of myofibrils. These histological alterations were effectively attenuated by the treatment with AcE. Furthermore, our data indicate a significant reduction of apoptosis in the cardiomyocytes of the Cd group treated with AcE therapy. Animal studies show antioxidant effects of AcE. But to date, no study reported the effect of AcE on biochemical and histopathological changes due to Cd induced on rat heart. Our study showed that AcE therapy reduced Cd-induced oxidative stress and apoptosis, possibly through its antioxidant and anti-apoptotic activity.

Ethnic variation in interleukin-6 -174 (g/c) polymorphism in the malaysian population

Interleukin-6 (IL-6) is one of the cytokines that has been well studied and implicated in many diseases including cancers. The frequency of the IL-6 –174 (G/C) polymorphism had been proven to differ in various populations. Malaysia is a country with three major ethnic populations, Malays, Chinese and Indians. In this study, we proposed to determine the G or C allele frequency of the IL-6 –174 polymorphism in these three populations. A total of 348 blood samples were available for analysis. The median age for the subjects was 31 years. There were a total of 245 males and 103 females. A total of 86 Malays (25.0%), 122 Chinese (33.0%) and 140 Indians (40.0%) were genotyped. The result showed a significant difference in the G or C allele frequency of the –174 polymorphism. The total frequencies for the G and C alleles were 91.0 and 9.0%, respectively. In the Malays, the allele frequency of the C allele was 4.0% compared with 19.0% in the Indians. The C allele was not detected in the Chinese population. This finding is the first reported on the Malaysian population and may be important in determining risk of diseases associated with the IL-6 polymorphism in these three populations.

Non-alcoholic fatty liver disease in a young multiracial Asian population: a worrying ethnic predilection in Malay and Indian males

PURPOSE

Previous studies on multiracial Malaysian populations found inordinately high prevalence of NAFLD among Malays and Indians. Whether the prevalence of NAFLD is different among young adults of different ethnic origins is not known. We aimed to determine racial differences in NAFLD in a young multiracial Malaysian population and associated factors.

METHODS

This was a cross-sectional study on medical students from the University of Malaya. Diagnosis of NAFLD was by transabdominal ultrasonography and following exclusion of significant alcohol intake and other causes of chronic liver disease.

RESULTS

Data of 469 subjects were analyzed (mean age 23.2 ± 2.4 years, 40.3 % male). The racial distribution was: Chinese 53.9 %, Malay 30.5 % and Indian 15.6 %. The overall prevalence of NAFLD was 7.9 %. Subjects with NAFLD were older, had greater BMI and WC, higher SBP and DBP, higher FBS, serum TG and LDL levels, and lower serum HDL level. The prevalence of NAFLD was higher among males compared to females (17.9 % vs. 3.3 %, p < 0.001). The highest prevalence of NAFLD was seen among Indian and Malay males at 33.3 and 25.5 %, respectively, compared to Chinese males at 6.8 % (p < 0.001). No significant difference was seen among females of different races. Independent factors associated with NAFLD were male gender, obesity and hypertriglyceridemia.

CONCLUSIONS

The difference in prevalence of NAFLD among the different ethnic groups can be observed as early as young adulthood. An inordinately high prevalence of NAFLD was observed among Malay and Indian males consistent with the higher prevalence of obesity in these groups.

Comparison of relative waist circumference between Asian Indian and US adults

BACKGROUND

Relative to Europeans, Asian Indians have higher rates of type 2 diabetes and cardiovascular disease. Whether differences in body composition may underlie these population differences remains unclear.

METHODS

We compared directly measured anthropometric data from the Chennai Urban Rural Epidemiology Study (CURES) survey of southern Indians (I) with those from three US ethnic groups (C: Caucasians, A: African Americans, and M: Mexican Americans) from NHANES III (Third National Health and Nutrition Examination Survey). A total of 15,733 subjects from CURES and 5,975 from NHANES III met inclusion criteria (age 20-39, no known diabetes).

RESULTS

Asian Indian men and women had substantially lower body mass index, waist circumference, hip circumference, waist-to-hip ratio, and body surface area relative to US groups (P values <0.0001). In contrast, the mean (±se) waist-weight ratio was significantly higher (P < 0.001) in I (men 1.35 ± 0.002 and women 1.45 ± 0.002) than in all the US groups (1.09, 1.21, and 1.14 in A, M, and C men; 1.23, 1.33, and 1.26 in A, M, and C women (se ranged from 0.005 to 0.006)).

CONCLUSIONS

Compared to the US, the waist-weight ratio is significantly higher in men and women from Chennai, India. These results support the hypothesis that Southeast Asian Indians are particularly predisposed toward central adiposity.

Proactive multifactorial intervention strategy reduces the risk of cardiovascular disease estimated with region-specific risk assessment models in Pacific Asian patients participating in the CRUCIAL trial

Despite race, ethnic, and regional differences in cardiovascular disease risk, many worldwide hypertension management guidelines recommend the use of the Framingham coronary heart disease (CHD) risk equation to guide treatment decisions. This subanalysis of the recently published CRUCIAL trial compared the treatment-related reductions in calculated CHD and stroke risk among Pacific Asian (PA) patients using a variety of region-specific risk assessment models. As a result, greater reductions in systolic and diastolic blood pressure, low-density lipoprotein cholesterol, and triglycerides were observed in the proactive multifactorial intervention (PMI) arm compared with the usual care arm at Week 52 for PA patients. The relative percentage change in 10-yr CHD risk between baseline and Week 52 in the PMI versus usual care arms was greatest using the NIPPON DATA80 fatal CHD model (LS [least square] mean difference -42.6%), and similar in the SCORE fatal CHD and Framingham total CHD models (LS mean difference -29.4% and -30.8%, respectively). The single-pill based PMI approach is consistently effective in reducing cardiovascular disease risk, evaluated using a variety of risk assessment models. (ClinicalTrials.gov registration number: NCT00407537).

Ethnic differences in the occurrence of acute coronary syndrome: results of the Malaysian National Cardiovascular Disease (NCVD) Database Registry (March 2006 - February 2010)

BACKGROUND

The National Cardiovascular Disease (NCVD) Database Registry represents one of the first prospective, multi-center registries to treat and prevent coronary artery disease (CAD) in Malaysia. Since ethnicity is an important consideration in the occurrence of acute coronary syndrome (ACS) globally, therefore, we aimed to identify the role of ethnicity in the occurrence of ACS among high-risk groups in the Malaysian population.

METHODS

The NCVD involves more than 15 Ministry of Health (MOH) hospitals nationwide, universities and the National Heart Institute and enrolls patients presenting with ACS [ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA)]. We analyzed ethnic differences across socio-demographic characteristics, hospital medications and invasive therapeutic procedures, treatment of STEMI and in-hospital clinical outcomes.

RESULTS

We enrolled 13,591 patients. The distribution of the NCVD population was as follows: 49.0% Malays, 22.5% Chinese, 23.1% Indians and 5.3% Others (representing other indigenous groups and non-Malaysian nationals). The mean age (SD) of ACS patients at presentation was 59.1 (12.0) years. More than 70% were males. A higher proportion of patients within each ethnic group had more than two coronary risk factors. Malays had higher body mass index (BMI). Chinese had highest rate of hypertension and hyperlipidemia. Indians had higher rate of diabetes mellitus (DM) and family history of premature CAD. Overall, more patients had STEMI than NSTEMI or UA among all ethnic groups. The use of aspirin was more than 94% among all ethnic groups. Utilization rates for elective and emergency percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) were low among all ethnic groups. In STEMI, fibrinolysis (streptokinase) appeared to be the dominant treatment options (>70%) for all ethnic groups. In-hospital mortality rates for STEMI across ethnicity ranges from 8.1% to 10.1% (p = 0.35). Among NSTEMI/UA patients, the rate of in-hospital mortality ranges from 3.7% to 6.5% and Malays recorded the highest in-hospital mortality rate compared to other ethnic groups (p = 0.000). In binary multiple logistic regression analysis, differences across ethnicity in the age and sex-adjusted ORs for in-hospital mortality among STEMI patients was not significant; for NSTEMI/UA patients, Chinese [OR 0.71 (95% CI 0.55, 0.91)] and Indians [OR 0.57 (95% CI 0.43, 0.76)] showed significantly lower risk of in-hospital mortality compared to Malays (reference group).

CONCLUSIONS

Risk factor profiles and ACS stratum were significantly different across ethnicity. Despite disparities in risk factors, clinical presentation, medical treatment and invasive management, ethnic differences in the risk of in-hospital mortality was not significant among STEMI patients. However, Chinese and Indians showed significantly lower risk of in-hospital mortality compared to Malays among NSTEMI and UA patients.

Mediators of Atherosclerosis in South Asians Living in America (MASALA) study: objectives, methods, and cohort description

BACKGROUND

South Asians (individuals from India, Pakistan, Bangladesh, Nepal, and Sri Lanka) have high rates of cardiovascular disease (CVD) that cannot be explained by traditional risk factors. There are few prospective cohort studies investigating antecedents of CVD in South Asians.

OBJECTIVES

The Mediators of Atherosclerosis in South Asians Living in America (MASALA) study is investigating the prevalence, correlates, and outcomes associated with subclinical CVD in a population-based sample of South Asian men and women age 40-79 years at 2 US clinical field centers.

POPULATION AND METHODOLOGY

This cohort is similar in methods and measures to the Multi-Ethnic Study of Atherosclerosis (MESA) to allow for efficient cross-ethnic comparisons. Measurements obtained at the baseline examination include sociodemographic information, lifestyle and psychosocial factors, standard CVD risk factors, oral glucose tolerance testing, electrocardiography, assessment of microalbuminuria, ankle and brachial blood pressures, carotid intima-media wall thickness using ultrasonography, coronary artery calcium measurement, and abdominal visceral fat measurement using computed tomography. Blood samples will be assayed for biochemical risk factors. Between October 2010 and March 2013, we enrolled 906 South Asians with mean age of 55 ± 9 years (46% women; 98% immigrants who have lived 27 ± 11 years in the United States). The sociodemographic characteristics of this cohort are representative of US South Asians. Participants are being followed with annual telephone calls for identification of CVD events including acute myocardial infarction and other coronary heart disease, stroke, peripheral vascular disease, congestive heart failure, therapeutic interventions for CVD, and mortality.

CONCLUSIONS

The MASALA study will provide novel data on the prevalence and associations of cardiovascular risk factors and subclinical atherosclerosis in South Asians living in the United States.

Nutritional essentiality of sulfur in health and disease

Sulfur is the seventh most abundant element measurable in the human body and is supplied mainly by the intake of methionine (Met), an indispensable amino acid found in plant and animal proteins. Met controls the initiation of protein synthesis, governs major metabolic and catalytic activities, and may undergo reversible redox processes safeguarding protein integrity. Withdrawal of Met from customary diets causes the greatest downsizing of lean body mass following either unachieved replenishment (malnutrition) or excessive losses (inflammation). These physiopathologically unrelated morbidities nevertheless stimulate comparable remethylation reactions from homocysteine, indicating that Met homeostasis benefits from high metabolic priority. Inhibition of cystathionine-β-synthase activity causes the upstream sequestration of homocysteine and the downstream drop in cysteine and glutathione. Consequently, the enzymatic production of hydrogen sulfide and the nonenzymatic reduction of elemental sulfur to hydrogen sulfide are impaired. Sulfur operates as cofactor of several enzymes critically involved in the regulation of oxidative processes. A combination of malnutrition and nutritional deprivation of sulfur maximizes the risk of cardiovascular disorders and stroke, constituting a novel clinical entity that threatens plant-eating population groups.

Prevalence of coronary artery disease and coronary risk factors in Kerala, South India: a population survey - design and methods

BACKGROUND

There is paucity of reliable contemporary data on prevalence of coronary artery disease (CAD) and risk factors in Indians. Only a few studies on prevalence of CAD have been conducted in Kerala, a Southern Indian state. The main objective of the Cardiological Society of India Kerala Chapter Coronary Artery Disease and Its Risk Factors Prevalence Study (CSI Kerala CRP Study) was to determine the prevalence of CAD and risk factors of CAD in men and women aged 20-79 years in urban and rural settings of three geographical areas of Kerala.

METHODS

The design of the study was cross-sectional population survey. We estimated the sample size based on an anticipated prevalence of 7.4% of CAD for rural and 11% for urban Kerala. The derived sample sizes for rural and urban areas were 3000 and 2400, respectively. The urban areas for sampling constituted one ward each from three municipal corporations at different parts of the state. The rural sample was drawn from two panchayats each in the same districts as the urban sample. One adult from each household in the age group of 20-59 years was selected using Kish method. All subjects between 60 and 79 years were included from each household. A detailed questionnaire was administered to assess the risk factors, history of CAD, family history, educational status, socioeconomic status, dietary habits, physical activity and treatment for CAD; anthropometric measurements, blood pressure, electrocardiogram and fasting blood levels of glucose and lipids were recorded.

Cross-sectional study of sociodemographic patterning of risk factors for cardiovascular disease in three isolated-based subgroups of the Uyghur population in Xinjiang, China

OBJECTIVE

To explore the sociodemographic patterning of risk factors for cardiovascular disease (CVD) in three isolated-based subgroups of the Uyghur population in Xinjiang, China.

DESIGN

A cross-sectional study. Between 2005 and 2008, a non-probability sampling design method was used to select three specific groups of the Uyghur rural populations based on their potential socioeconomic status (ie, isolated, semi-isolated and open-environment status).

SETTING

Three communities (named Desert, Turpan and Yuli Rob) in Southern Xinjiang autonomous region, China.

PARTICIPANTS

1656 people were included in this study. The inclusion criteria were that all participants were 18 years or older, they were descendants of at least three generations living in the same region, and there was no history of intermarriage.

MAIN OUTCOME MEASURES

The prevalence of CVD risk factors (ie, tobacco use, alcohol use, obesity, dyslipidemia, hypertension, diabetes, etc) was assessed.

RESULTS

Compared with the Desert and Turpan communities, Yuli Rob had the highest levels of obesity, dyslipidemia and hypertension, and the Desert had the lowest levels of CVD risk factors. Age standardisation slightly altered the estimates, though the patterns remained unchanged. Some unique characteristics were also found. For example, the Desert group displayed significantly lower high-density lipoprotein cholesterol (HDLC) level compared with Yuli Rob and Turpan groups. The mean values were 0.63, 1.06 and 1.45 mmol/l for men and 0.64, 1.22 and 1.51 mmol/l for women (p<0.0001). The HDLC levels in the Desert group increased with increase in body mass index and fasting glucose levels, which was inconsistent with previous studies.

CONCLUSIONS

Identifying the unique CVD risk factors of the ethnic-specific populations is very important in development of tailored strategies for the prevention of CVD.

Barriers to lifestyle behavioral change in migrant South Asian populations

The purpose of this literature review is to describe and assess the cultural barriers to behavior change in migrant South Asians, given the high morbidity and mortality associated with cardiovascular disease in this population. We reviewed studies that explored the relationship between South Asian culture in the Diaspora and lifestyle behaviors. Our review produced 91 studies, of which 25 discussed the relationship between various aspects of South Asians' belief system and their approach to modifying lifestyle habits. We identify 6 specific categories of beliefs which play the largest role in the difficulties South Asians describe with behavior change: gender roles, body image, physical activity misconceptions, cultural priorities, cultural identity, and explanatory model of disease. Future research and interventions should account for these cultural factors to successfully improve dietary habits and physical activity levels in migrant South Asian populations.

Ethnic-specific differences in vitamin D status is associated with adiposity

Background

Low circulating 25 hydroxyvitamin D [25(OH)D] concentrations are common in obesity (BMI ≥30 kg/m²) and a negative relationship with body fat distribution has recently been reported. Ethnic-specific differences in body fat distribution have been described with South Asians are reported to have greater visceral adipose tissue (VAT), which could influence circulating 25(OH)D concentrations. The objective of this study is to investigate the relationship between plasma 25(OH)D, adiposity, and body fat distribution in Europeans and South Asians.

Methods/Principal Findings

187 Europeans and 192 South Asians were assessed for demographics, anthropometrics, and plasma 25(OH)D concentrations. Subcutaneous adipose tissue (SAT) and VAT were quantified by CT scan, and percent body fat by DEXA. Data were assessed by general linear models. South Asians had lower (P<0.001) plasma 25(OH)D concentrations and higher VAT (P = 0.04) than Europeans. Plasma 25(OH)D concentrations were negatively (P<0.05) associated with BMI, waist circumference, percent body fat, total adipose tissue, VAT, and SAT in unadjusted models and negatively (P<0.05) associated with VAT, SAT, and percent body fat after adjusting for BMI, ethnicity, age, and season of blood collection in males and females. When percent body fat, VAT, and SAT were included in the same model, only VAT remained negatively (P<0.05) associated with plasma 25(OH)D concentrations. Ethnicity remained significant in all models (P<0.001).

Conclusion

Compared to other adipose tissue compartments, VAT may have a distinct role in determining plasma 25(OH)D concentrations, which may account for the lower levels in South Asians.

Women's cardiovascular health: perspectives from South-East Asia

Cardiovascular disease (CVD) is an under-recognized major health problem among women in South-East Asia. The prevalence of cardiovascular risk factors such as hypertension, diabetes mellitus, dyslipidemia, physical inactivity, and being overweight or obese has shown a significantly increasing trend among women in the region, with the exception of Singapore. The problem is compounded by low awareness that CVD is a health problem for women as well as for men, by misconceptions about the disease, and by the lack of suitable, locally available health literature. Efforts have been made by the national heart associations and other organizations to increase heart health awareness and promote healthy lifestyles. Singapore initiated these prevention programs in the early 1990s and has been successful in reducing the prevalence of cardiovascular risk factors. The governments of the region, in accordance with the Noncommunicable Disease Alliance, have begun implementing appropriate preventive strategies and improving health-delivery systems. However, psychological, social, and cultural barriers to cardiovascular health awareness in women need to be addressed before these programs can be fully and successfully implemented.

Low-dose nonlinear effects of smoking on coronary heart disease risk

Some recent discussions of adverse human health effects of active and passive smoking have suggested that low levels of exposure are disproportionately dangerous, so that "The effects of even brief (minutes to hours) passive smoking are often nearly as large (averaging 80% to 90%) as chronic active smoking" (Barnoya and Glantz, 2005). Recent epidemiological evidence (Teo et al., 2006) suggests a more linear relation. This paper reexamines the empirical relation between self-reported low levels of active smoking and risk of coronary heart disease (CHD) in public-domain data from the National Health and Nutrition Examination Survey (NHANES). Consistent with biological evidence on J-shaped and U-shaped relations between smoking-associated risk factors and CHD risks, we find that low levels of active smoking do not appear to be associated with increased CHD risk. Several methodological challenges in epidemiology may explain how model-derived estimates can predict low-dose linear or concave dose-response estimates, even if the empirical (i.e., data-based) relation does not show a clear increased risk at the lowest doses.