Mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world: an update. ACTA ACUST UNITED AC. 2009;16:333-350. [PMID: 19369880 DOI: 10.1097/hjr.0b013e328325d67d]

Elevated triglycerides and low triiodothyronine: Key risk factors for coronary artery calcification in patients with schizophrenia

OBJECTIVE

Coronary artery calcification (CAC) is a well-established independent predictor of coronary heart disease, and patients with schizophrenia have significantly higher rates compared to the general population. We performed this study to examine the population-specific risk factors associated with CAC in patients with schizophrenia.

METHODS

In this cross-sectional study, patients with schizophrenia who underwent low-dose chest CT scans between January 2020 and December 2021 were analyzed. Ordinary CAC scores and results of routine blood tests were obtained. Logistic regression was used to calculate the odds ratio (OR) for potential risk factors in patients with and without CAC, while the negative binomial additive model was used to explore the dose-response relationship between risk factors and CAC score.

RESULTS

Of the 916 patients, 233 (25.4 %) had CAC, while 683 (74.6 %) did not. After adjusting for confounding factors, higher triglyceride levels (OR = 1.20, 95 % confidence interval (CI): 1.04 to 1.38, p = 0.013) and low triiodothyronine levels (OR = 0.50, 95 % CI: 0.29 to 0.84; p = 0.010) were identified as risk factors for CAC. Both triglycerides (p = 0.021) and triiodothyronine (p = 0.010) were also found to have significant dose-response relationships with CAC scores according to the negative binomial additive model in the exploratory analysis.

CONCLUSIONS

This study highlights elevated serum triglycerides and decreased triiodothyronine levels as population-specific risk factors for CAC in patients with schizophrenia, suggest the need for close monitoring of CAC in patients with schizophrenia and further prospective trials to provide additional evidence on this topic.

Is there a change in the appropriateness of admission after patients were admitted? Evidence from four county hospitals in rural China

Objective

This study aims to investigate the changes in admission appropriateness after patients were admitted and provide a reference for physicians to make admission decisions and for the supervision of medical service behavior by the medical insurance regulatory department.

Methods

Medical records of 4,343 inpatients were obtained based on the largest and most capable public comprehensive hospital in four counties in central and western China for this retrospective study. The binary logistic regression model was employed to examine the determinants of changes in admission appropriateness.

Results

Nearly two-in-thirds (65.39%) of the 3,401 inappropriate admissions changed to appropriate at discharge. Age, type of medical insurance, medical service type, severity of the patient upon admission, and disease category were found to be associated with the changes in the appropriateness of admission. Older patients (OR = 3.658, 95% CI [2.462-5.435]; P < 0.001) were more likely to go from "inappropriate" to "appropriate" than younger counterparts. Compared with circulatory diseases, the case evaluated as "appropriate" at discharge was more frequent in the urinary diseases (OR = 1.709, 95% CI [1.019-2.865]; P = 0.042) and genital diseases (OR = 2.998, 95% CI [1.737-5.174]; P < 0.001), whereas the opposite finding was observed for patients with respiratory diseases (OR = 0.347, 95% CI [0.268-0.451]; P < 0.001) and skeletal and muscular diseases (OR = 0.556, 95% CI [0.355-0.873]; P = 0.011).

Conclusions

Many disease characteristics gradually emerged after the patient was admitted, thus the appropriateness of admission changed. Physicians and regulators need to take a dynamic view of disease progression and inappropriate admission. Aside from referring to the appropriateness evaluation protocol (AEP), they both should pay attention to individual and disease characteristics to make a comprehensive judgment, and strict control and attention should be paid to the admission of respiratory, skeletal, and muscular diseases.

Trend of Mortality Rate and Years of Life Lost due to Cerebrovascular Diseases in Fars Province, Iran (2004-2019)

BACKGROUND

According to the Global Burden of Disease Study (GBD), cerebrovascular diseases are the second leading cause of death in the world. This is a cross-sectional study on deaths due to cerebrovascular diseases in southern Iran.

METHODS

In this cross-sectional study, data on all deaths caused by cerebrovascular diseases in the Fars province between 2004 and 2019 was extracted from the Electronic Death Registry System (EDRS). To eliminate or minimize the influence of age composition, standardized mortality rate was used based on the 2013 Segi standard populations of low- and middle-income countries. In order to measure the years of life lost (YLL) from cerebrovascular diseases, the standardized life table was considered. The Joinpoint Regression method was used to examine the trend of the crude and standardized mortality rate and the YLL rate.

RESULTS

Over the study period, 24,051 deaths occurred due to cerebrovascular diseases in Fars with 12,586 cases in men (52.3%). The trend of standardized mortality rate in males and females was decreasing (P value=0.001 and<0.001 for males and females, respectively). All YLL due to premature mortality from cerebrovascular disease during the 16-year study period were 119,436 (3.8 per 1000 persons) in men, and 111,172 (3.6 per 1000 persons) in women. Based on the joinpoint regression, the 16-year trend of YLL rate due to premature death was decreasing: annual percent change (APC) was -1.6% (95% CI -3.4 to 0.3, P=0.098) for males, and -2.0% (95% CI -3.6 to -0.4, P=0.017) for females.

CONCLUSION

The trend of mortality rate and YLL caused by cerebrovascular diseases has decreased in our study. Necessary measures, mainly primary and secondary prevention, should be taken to continue the diminishing trend of cerebrovascular diseases.

Effects of 2-Year-Long Maintenance Training and Detraining on 558 Subacute Ischemic Stroke Patients' Clinical-Motor Symptoms

PURPOSE

This study aimed to determine the effects of a 2-yr-long maintenance training (MT) exergaming and detraining (DT) on clinical-motor symptoms in subacute ischemic patients with stroke (PwST). The hypothesis was that MT motor rehabilitation program would further increase the effects of the initial rehabilitation.

METHODS

After high-intensity and high-frequency exergaming twice or once a day, 5 times per week for 5 wk (EX2: 50 sessions; EX1: 25 sessions, results reported previously), 558 PwST were randomized to EX2-MT, EX2-DT, EX1-MT, and EX1-DT. MT exergaming consisted of once a day, 3 times per week for 2 yr, and DT did not train. Outcomes were measured at 6, 12, 18, and 24 months. The data were analyzed using longitudinal linear mixed-effects models and general linear hypotheses testing.

RESULTS

Modified Rankin Score (primary outcome), body mass, Mini-Mental State Examination score, Beck Depression Inventory, measures of quality of life, Berg Balance Scale, 6-min walk test, and four measures of center of pressure path tended to retain the initial rehabilitation-induced gains in the MT patients in selected outcomes (especially walking capacity). The scores tended to mildly worsen after DT, partially supporting the hypothesis.

CONCLUSIONS

MT successfully maintained, but only in selected variables did it further increase the initial exergaming rehabilitation-induced robust improvements. DT modestly reduced the initial exergaming rehabilitation-induced improvements. MT programs might be needed after initial stroke rehabilitation to reduce subsequent losses of quality of life and further improve clinical-motor symptoms.

Risk Assessment of Cardiovascular Disease Among Adults Attending Primary Healthcare Centers in Riyadh City 2015

BACKGROUND

The prevalence of cardiovascular disease (CVD) risk factors is expected to rise in Saudi Arabia as the prevalence of CVD risk factors rises. Effective primary CVD prevention necessitates risk assessment to categorize patients and select the most appropriate intervention for each category.

OBJECTIVES

To estimate the prevalence of CVD at primary healthcare (PHC) in Riyadh city and to categorize the at-risk population as a slow, intermediate, or high risk of CVD.

METHODS

A cross-sectional study was carried out at seven PHC centers in Riyadh. Seven hundred participants (half of whom were males and the other half females) were selected at random from PHCs visitors, and data was collected using a structured questionnaire, as well as required measurements and laboratory investigations. The World Health Organization risk prediction charts were used to calculate CVD risk. Participants were assigned to one of three CVD risk categories (low, intermediate, high).

RESULTS

Obesity was found to be the most common risk factor found in this study (53.2%). Overweight (31.2%), with females having higher BMI levels. The study found that 83.4% of participants had low CVD risk, 12.9% had intermediate risk, and 3.7% had high CVD risk category. Age, systolic blood pressure, cholesterol level, smoking, and prior diagnosis of diabetes were all statistically significant predictors of moderate and high CVD risk.

CONCLUSION

CVD risk factors were discovered to be common among study participants. It requires healthcare decision-makers to engage in community-based interventions to decrease the risk of CVD.

Therapeutic Opportunities and Delivery Strategies for Brain Revascularization in Stroke, Neurodegeneration, and Aging

Central nervous system (CNS) diseases, especially acute ischemic events and neurodegenerative disorders, constitute a public health problem with no effective treatments to allow a persistent solution. Failed therapies targeting neuronal recovery have revealed the multifactorial and intricate pathophysiology underlying such CNS disorders as ischemic stroke, Alzheimeŕs disease, amyotrophic lateral sclerosis, vascular Parkisonism, vascular dementia, and aging, in which cerebral microvasculature impairment seems to play a key role. In fact, a reduction in vessel density and cerebral blood flow occurs in these scenarios, contributing to neuronal dysfunction and leading to loss of cognitive function. In this review, we provide an overview of healthy brain microvasculature structure and function in health and the effect of the aforementioned cerebral CNS diseases. We discuss the emerging new therapeutic opportunities, and their delivery approaches, aimed at recovering brain vascularization in this context. SIGNIFICANCE STATEMENT: The lack of effective treatments, mainly focused on neuron recovery, has prompted the search of other therapies to treat cerebral central nervous system diseases. The disruption and degeneration of cerebral microvasculature has been evidenced in neurodegenerative diseases, stroke, and aging, constituting a potential target for restoring vascularization, neuronal functioning, and cognitive capacities by the development of therapeutic pro-angiogenic strategies.

Review of cadmium exposure and smoking-independent effects on atherosclerotic cardiovascular disease in the general population

BACKGROUND

Exposure to cadmium (Cd) via food and smoking is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). Blood and urine levels of Cd are established biomarkers of exposure.

OBJECTIVES

To review (1) the smoking-independent associations between Cd exposure and ASCVD, including the possible presence of a nonlinear dose-response relationship with Cd exposure and (2) the causal effects of Cd exposure on different stages of atherosclerosis.

METHODS

Narrative review.

RESULTS

Cd confers increased risk of ASCVD and asymptomatic atherosclerosis in the carotid and coronary arteries above B-Cd >0.5 μg/L or U-Cd >0.5 μg/g creatinine, but it has not been shown below a threshold of these exposure levels. Adjustment for smoking does not exclude the possibility of residual confounding, but several studies in never-smoking cohorts have shown associations between Cd and ASCVD, and experimental studies have demonstrated pro-atherosclerotic effects of Cd. Cd accumulates in arterial walls and atherosclerotic plaques, reaching levels shown to have proatherosclerotic effects. Suggested early effects are increased subendothelial retention of atherogenic lipoproteins, which become oxidized, and endothelial dysfunction and damage with increased permeability for monocytes, which in the intima turn to macrophages and then to foam cells. Later, Cd may contribute to plaque rupture and erosion by endothelial apoptosis and degradation of the fibrous cap. Finally, by having prothrombotic and antifibrinolytic effects, the CVD risk may be further increased.

CONCLUSIONS

There is strong evidence that Cd causes ASCVD above a suggested exposure level via mechanisms in early as well as the late stages of atherosclerotic disease.

Explaining the increment in coronary heart disease mortality in Mexico between 2000 and 2012

BACKGROUND

Mexico is still in the growing phase of the epidemic of coronary heart disease (CHD), with mortality increasing by 48% since 1980. However, no studies have analyzed the drivers of these trends. We aimed to model CHD deaths between 2000 and 2012 in Mexico and to quantify the proportion of the mortality change attributable to advances in medical treatments and to changes in population-wide cardiovascular risk factors.

METHODS

We performed a retrospective analysis using the previously validated IMPACT model to explain observed changes in CHD mortality in Mexican adults. The model integrates nationwide data at two-time points (2000 and 2012) to quantify the effects on CHD mortality attributable to changes in risk factors and therapeutic trends.

RESULTS

From 2000 to 2012, CHD mortality rates increased by 33.8% in men and by 22.8% in women. The IMPACT model explained 71% of the CHD mortality increase. Most of the mortality increases could be attributed to increases in population risk factors, such as diabetes (43%), physical inactivity (28%) and total cholesterol (24%). Improvements in medical and surgical treatments together prevented or postponed 40.3% of deaths; 10% was attributable to improvements in secondary prevention treatments following MI, while 5.3% to community heart failure treatments.

CONCLUSIONS

CHD mortality in Mexico is increasing due to adverse trends in major risk factors and suboptimal use of CHD treatments. Population-level interventions to reduce CHD risk factors are urgently needed, along with increased access and equitable distribution of therapies.

Partial contributions and temporal trends of leading causes of death during the last four decades in Spain

OBJECTIVES

The study was conducted to assess time trend shifts of leading causes of death and their partial contributions over the years 1975-2016 in Spain.

STUDY DESIGN

A longitudinal ecological epidemiologic design was conducted to analyse linear trend period shifts using joinpoint regression as the annual percentage of change (APC) in the period 1975-2016. The partial contributions were illustrated as the rate ratio of a singular-cause to their major-cause shift periods.

RESULTS

HIV/AIDS shaped the increasing trend period of infectious diseases in 1989-1995 (APC = 25.3, P < 0.05) and the decreasing trend in 1995-1999 and 1999-2016. Lung cancer fell gradually from 1994 in men (-0.4, P < 0.05); however, in women, the condition continued increasing from 1990 (P < 0.05). Dementia types influenced mental and neurological disease drifts. The recent trend for circulatory periods (1980-2016) was mainly modulated by cardiac ischaemia, with increased partial contributions (25%, 32% and 30%). Traffic accidents defined the descending tendency of external causes.

CONCLUSIONS

Spain showed a Western pattern in descended rates, including non-decreasing trends in mental and neurological diseases, pancreatic cancer, drug abuse and suicide. Trend shifts and partial contributions illustrated targets for further mortality reduction.

Smoking, heavy drinking, physical inactivity, and obesity among middle-aged and older adults in China: cross-sectional findings from the baseline survey of CHARLS 2011-2012

BACKGROUND

Prevention and control of cardiometabolic conditions and cardiovascular disease (CVD) in China may contribute to sustainable CVD reduction globally, given the fact that one-fifth of the worldwide population is in China. Knowing the distribution of behavioral risk factors (e.g., smoking and physical inactivity), especially at a national level in China, would be extremely relevant to the field of public health and CVD prevention. The objectives of this study were to investigate the nationwide prevalence of obesity, smoking, heavy drinking, and physical inactivity in Chinese adults, and further explore whether cardiometabolic conditions would modify the distribution of behavioral risk factors.

METHODS

This population-based study is based on the China Health and Retirement Longitudinal Study (2011-2012), including 17,302 adults (≥45 years, mean age 59.67 years, female 51.66%) from 25 provinces in China. Data on demographics, lifestyle factors, health status and history of diseases were collected via structured interviews and laboratory tests. Smoking, heavy drinking, obesity, and physical inactivity were defined following standard guidelines. We performed descriptive analysis and logistic regressions in this study.

RESULTS

The overall prevalence of heavy drinking, obesity, current smoking, and physical inactivity among middle-aged and older adults was 7.23% (95% confidence interval 6.53-7.29%), 11.53% (10.43-12.62%), 27.46% (26.30-28.62%), and 44.06% (41.19-46.92%), respectively. The prevalence varied between rural and urban areas as well as among geographic areas, with higher prevalence in the Northern and Northeastern regions. Heavy drinking and obesity were significantly associated with incident hypertension, diabetes, and high cholesterol; while current smoking was significantly associated with incident hypertension. Compared with healthy individuals, participants who self-reported a diagnosis of hypertension, high cholesterol, or diabetes were less likely to smoke currently and drink alcohol heavily, but more likely to be physically inactive and obese.

CONCLUSIONS

Among Chinese middle-aged and older adults, the prevalence of behavioral risk factors varies by geographic region. Further effort is required to improve physical activity and fitness for Chinese adults, especially those with cardiometabolic conditions.

Secular trends in cardiovascular risk factors among women aged 45-54 years in Gothenburg, Sweden, from 1980 to 2014

Background

A declining trend in mean cholesterol levels and smoking has been observed in high-income western countries during the last few decades, whereas obesity rates have increased. Simultaneously, mortality from coronary heart disease has decreased. The aim of the present study was to determine whether the trends in cardiovascular risk factors have continued in successive cohorts of middle-aged women over a period of 34 years.

Methods

Six population-based, cross-sectional samples of women (n = 2294) mean age: 49.8 years (range: 45–54), living in Gothenburg, Sweden, were investigated between 1980 and 2014.

Results

Body mass index (BMI) increased over time, with a mean BMI of 24.7 kg/m² in 1980 to 25.7 kg/m² in 2013–2014, corresponding to a weight gain of 4.5 kg, together with an increase in the proportion of obese individuals (BMI ≥ 30 kg/m²) from 10.4 to 16.6% (p = 0.0012). The proportion of smokers and women with hypertension decreased from 34.5 to 12.8% (p = 0.0006) and from 37.7 to 24.5% (p < 0.0001) respectively. Mean total serum cholesterol levels decreased from 6.23 (SD 1.09) mmol/L in 1980 to 5.43 (SD 0.98) mmol/L in 2013–2014 (p < 0.0001). Self-reported leisure time regular exercise increased from 7.8% in 1980 to 35.6% in 2013–2014 (p < 0.0001). For women born in 1963, the prevalence ratio of not having any of five major cardiovascular risk factors was 1.82 (95% confidence interval (CI) 1.38–2.41), compared with women born in 1925–1934.

Conclusion

The trend towards increasing obesity, more leisure-time physical activity and less smoking remains, while the decrease in serum cholesterol appears to have abated.

Coronary Artery Calcification and Mortality Risk in Patients With Severe Mental Illness

Background Cardiovascular mortality is the leading contributor to the shortened life expectancy in patients with severe mental illness (SMI), but efforts to predict cardiovascular outcomes in these patients have been lacking. In this study, we aimed to determine the severity of coronary artery calcification (CAC), and its effect on mortality rates in patients with SMI, compared with the general population. Methods All individuals with a registered cardiac computed tomography for calcium scoring in the Western Denmark Heart Registry, from January 1, 2008 to December 31, 2016, were included. We identified patients diagnosed with SMI ( International Classification of Diseases, Tenth Revision: F20, F30, F31), whereas the remaining individuals were used as a comparison group. Results Among 48 757 individuals, including 564 patients with SMI (1.2%), we found no difference in CAC score between patients with SMI and the comparison group. SMI patients with CAC >100 had an increased mortality rate (hazard ratio, 3.16; 95% CI, 1.41-7.06), as well as SMI patients with CAC <100 (hazard ratio, 3.95; 95% CI, 2.36-6.62), compared with the comparison group with CAC <100 as reference, adjusted for age, sex, and calendar period. Conclusions Patients with SMI have increased cardiovascular risks, but show no difference in CAC score, compared with the comparison group. Mortality rates were increased in patients with SMI, independent of CAC severity; however, the relatively large number of noncardiovascular causes of death in this sample might indicate other contributing factors to death than coronary artery disease in this sample of SMI patients.

Coronary heart disease mortality is decreasing in Argentina, and Colombia, but keeps increasing in Mexico: a time trend study

Background

Mortality rates due to coronary heart disease (CHD) have decreased in most countries, but increased in low and middle-income countries. Few studies have analyzed the trends of coronary heart disease mortality in Latin America, specifically the trends in young-adults and the effect of correcting these comparisons for nonspecific causes of death (garbage codes). The objective of this study was to describe and compare standardized, age-specific, and garbage-code corrected mortality trends for coronary heart disease from 1985 to 2015 in Argentina, Colombia, and Mexico.

Methods

Deaths from coronary heart disease were grouped by country, year of registration, sex, and 10-year age bands to calculate age-adjusted and age and sex-specific rates for adults aged ≥25. We corrected for garbage-codes using the methodology proposed by the Global Burden of Disease. Finally, we fitted Joinpoint regression models.

Results

In 1985, age-standardized mortality rates per 100,000 population were 136.6 in Argentina, 160.6 in Colombia, and 87.51 in Mexico; by 2015 rates decreased 51% in Argentina and 6.5% in Colombia, yet increased by 61% in Mexico, where an upward trend in mortality was observed in young adults. Garbage-code corrections produced increases in mortality rates, particularly in Argentina with approximately 80 additional deaths per 100,000, 14 in Colombia and 13 in Mexico.

Conclusions

Latin American countries are at different stages of the cardiovascular disease epidemic. Garbage code correction produce large changes in the mortality rates in Argentina, yet smaller in Mexico and Colombia, suggesting garbage code corrections may be needed for specific countries. While coronary heart disease (CHD) mortality is falling in Argentina, modest falls in Colombia and substantial increases in Mexico highlight the need for the region to propose and implement population-wide prevention policies.

Akt activation: A potential strategy to ameliorate insulin resistance

Insulin resistance is a hallmark of type 2 diabetes and obesity while the mechanism remains unclear. Current therapy to treat type 2 diabetes is metformin, the 5'-monophosphate-activated protein kinase (AMPK) activator, owing to the ability to augment peripheral glucose uptake. However, metformin also displays limitations, as AMPK activation remains intact and regular in most type 2 diabetes and metformin does not seem to facilitate peripheral insulin resistance. Evidence has shown that PI3K-Akt/PKB pathway could be induced via insulin and act as an important effector. Akt/PKB is capable of inducing a great number of downstream molecules, such as translocating glucose transporters GLUTs to the cell membrane thus increase glucose uptake. Hence, any defect in Akt/PKB pathway along with the downstream molecules could lead to insulin resistance. Inositol pyrophosphates, synthesized by inositol hexakisphosphate (IP₆) kinase 1 (IP6K1) and competitive with 3,4,5-bisphosphate (PIP₃) to bind the PH domain of Akt/PKB, demonstrate the ability to inhibit Akt signaling. In addition, IP6K1 knockout mice present increased insulin sensitivity and obesity resistance, indicating a novel therapeutic target in confronting insulin resistance. Taken together, we conclude that Akt activation is another potential strategy to ameliorate insulin resistance.

Plant-based diets for children as a means of improving adult cardiometabolic health

Cardiovascular disease (CVD) is the largest contributor to global mortality, and this trend is expected to continue. Although mortality rates have been falling, adverse developments in obesity and diabetes threaten to reverse this. It has been estimated that the only viable strategy to reduce the epidemic is to focus on population-wide risk factor reduction. Primordial prevention, a strategy aimed at avoiding the development of risk factors before the disease onset, has been shown to reduce the CVD epidemic substantially. Plant-based diets appear beneficial for prevention of cardiometabolic diseases, with adult vegetarians and vegans having lower CVD risk than omnivores. Atherosclerosis starts in childhood and progresses in relation to classical CVD risk factors, which, along with dietary habits, track to adulthood. Based on this evidence, it is proposed that plant-based diets in childhood could promote cardiometabolic health in adults and thereby reduce CVD and promote longevity and health. However, the need for additional research to establish the safety of predominantly or exclusively plant-based diets in children is noted.

Socioeconomic gap between neighborhoods of Budapest: Striking impact on stroke and possible explanations

Introduction

Hungary has a single payer health insurance system offering free healthcare for acute cerebrovascular disorders. Within the capital, Budapest, however there are considerable microregional socioeconomic differences. We hypothesized that socioeconomic deprivation reflects in less favorable stroke characteristics despite universal access to care.

Methods

From the database of the National Health Insurance Fund, we identified 4779 patients hospitalized between 2002 and 2007 for acute cerebrovascular disease (hereafter ACV, i.e. ischemic stroke, intracerebral hemorrhage, or transient ischemia), among residents of the poorest (District 8, n = 2618) and the wealthiest (District 12, n = 2161) neighborhoods of Budapest. Follow-up was until March 2013.

Results

Mean age at onset of ACV was 70±12 and 74±12 years for District 8 and 12 (p<0.01). Age-standardized incidence was higher in District 8 than in District 12 (680/100,000/year versus 518/100,000/year for ACV and 486/100,000/year versus 259/100,000/year for ischemic stroke). Age-standardized mortality of ACV overall and of ischemic stroke specifically was 157/100,000/year versus 100/100,000/year and 122/100,000/year versus 75/100,000/year for District 8 and 12. Long-term case fatality (at 1,5, and 10 years) for ACV and for ischemic stroke was higher in younger District 8 residents (41–70 years of age at the index event) compared to D12 residents of the same age. This gap between the districts increased with the length of follow-up. Of the risk diseases the prevalence of hypertension and diabetes was higher in District 8 than in District 12 (75% versus 66%, p<0.001; and 26% versus 16%, p<0.001).

Discussion

Despite universal healthcare coverage, the disadvantaged district has higher ACV incidence and mortality than the wealthier neighborhood. This difference affects primarily the younger age groups. Long-term follow-up data suggest that inequity in institutional rehabilitation and home-care should be investigated and improved in disadvantaged neighborhoods.

Trends in cerebrovascular diseases mortality in Serbia, 1997-2016: a nationwide descriptive study

OBJECTIVES

Over the last decades, mortality from cerebrovascular diseases (CVDs) has decreased in many countries. The aim of this study was to assess the trends of CVDs mortality in Serbia.

METHODS

Descriptive epidemiological study. Age-standardised rates (ASRs) for CVDs mortality were assessed by joinpoint regression analysis to identify significant changes in trends and estimate annual per cent changes with 95% CI. The age-period-cohort analysis has been used to describe variations in mortality.

RESULTS

Over this 20-year period, there were 312 847 deaths from CVDs, with the overall average annual ASR of 148.4 per 100 000. The trend of ASRs from CVDs mortality in males in Serbia showed a significant joinpoint: rates insignificantly decreased from 1997 to 2005 by -0.8% per year (95% CI -1.7% to 0.2%) and thereafter rapidly decreased by -5.0% per year (95% CI -5.6% to -4.5%). A joinpoint for females was found in 2006: the mortality trend was first significantly decreasing by -1.0% per year (95% CI -1.9% to -0.0%) and then sharply falling down by -6.0% per year (95% CI -6.8% to -5.3%). Results of age-period-cohort analysis indicated that the relative risk for CVDs mortality showed statistically significant (p<0.05) cohort and period effects, as well as the net drift and local drifts in Serbian population. The trends in mortality for all subtypes of CVDs were similar in both sexes: trends significantly decreased for most subtypes, with the exception of a significant increase for cerebral infarction.

CONCLUSIONS

After a decade of increase, CVDs mortality rates are declining in last decade in Serbia. However, mortality rates from CVDs remain exceedingly high in Serbia. Differences in mortality trends of the stroke subtypes should be taken into account in the creation of both prevention and treatment guidelines.

Estimating the performance of three cardiovascular disease risk scores: the Estonian Biobank cohort study

BACKGROUND

We aim to investigate the predictive ability of PCE (Pooled Cohort Equations), QRISK2 and SCORE (Systematic COronary Risk Estimation) scoring systems for atherosclerotic cardiovascular disease (ASCVD) risk prediction in Estonia, a country with one of the highest ASCVD event rates in Europe.

METHODS

Seven-year risk estimates were calculated in risk score-specific subsets of the Estonian Biobank cohort. Calibration was assessed by standardised incidence ratios (SIRs) and discrimination by Harrell's C-statistics. In addition, a head-to-head comparison of the scores was performed in the intersection of the three score-specific subcohorts.

RESULTS

PCE, QRISK2 and SCORE risk estimates were calculated for 4356, 7191 and 3987 eligible individuals, respectively. During the 7-year follow-up, 220 hard ASCVD events (PCE outcome), 671 ASCVD events (QRISK2 outcome) and 94 ASCVD deaths (SCORE outcome) occurred among the score-specific subsets of the cohort. While PCE (SIR 1.03, 95% CI 0.90 to 1.18) and SCORE (SIR 0.99, 95% CI 0.81 to 1.21) were calibrated well for the cohort, QRISK2 underestimated the risk by 48% (SIR 0.52, 95% CI 0.48 to 0.56). In terms of discrimination, PCE (C-statistic 0.778) was inferior to QRISK2 (C-statistic 0.812) and SCORE (C-statistic 0.865). All three risk scores performed at similar level in the head-to-head comparison.

CONCLUSION

Of three widely used ASCVD risk scores, PCE and SCORE performed at acceptable level, while QRISK2 underestimated ASCVD risk markedly. These results highlight the need for evaluating the accuracy of ASCVD risk scores prior to use in high-risk populations.

The Impact of Risk Factors for Coronary Heart Disease on Related Disability in Older Irish Adults

OBJECTIVE

The aim of this study is to examine the prevalence of coronary heart disease (CHD)-related disability (hereafter also "disability") and the impact of CHD risk factors on disability in older adults in the Republic of Ireland (ROI) and Northern Ireland (NI).

METHOD

Population attributable fractions were calculated using risk factor relative risks and disability prevalence derived from The Irish Longitudinal Study on Ageing and the Northern Ireland Health Survey.

RESULTS

Disability was significantly lower in ROI (4.1% vs. 8.8%). Smoking and diabetes prevalence rates, and the fraction of disability that could be attributed to smoking (ROI: 6.6%; NI: 6.1%), obesity (ROI: 13.8%; NI: 11.3%), and diabetes (ROI: 6.2%; NI: 7.2%), were comparable in both countries. Physical inactivity (31.3% vs. 54.8%) and depression (10.2% vs. 17.6%) were lower in ROI. Disability attributable to depression (ROI: 16.3%; NI: 25.2%) and physical inactivity (ROI: 27.5%; NI: 39.9%) was lower in ROI.

DISCUSSION

Country-specific similarities and differences in the prevalence of disability and associated risk factors will inform public health and social care policy in both countries.

Sensitivity, specificity, and predictive value of cardiac symptoms assessed by emergency medical services providers in the diagnosis of acute myocardial infarction: a multi-center observational study

Objective

For patients with acute myocardial infarction (AMI), symptoms assessed by emergency medical services (EMS) providers have a critical role in prehospital treatment decisions. The purpose of this study was to evaluate the diagnostic accuracy of EMS provider-assessed cardiac symptoms of AMI.

Methods

Patients transported by EMS to 4 study hospitals from 2008 to 2012 were included. Using EMS and administrative emergency department databases, patients were stratified according to the presence of EMS-assessed cardiac symptoms and emergency department diagnosis of AMI. Cardiac symptoms were defined as chest pain, dyspnea, palpitations, and syncope. Disproportionate stratified sampling was used, and medical records of sampled patients were reviewed to identify an actual diagnosis of AMI. Using inverse probability weighting, verification bias-corrected diagnostic performance was estimated.

Results

Overall, 92,353 patients were enrolled in the study. Of these, 13,971 (15.1%) complained of cardiac symptoms to EMS providers. A total of 775 patients were sampled for hospital record review. The sensitivity, specificity, positive predictive value, and negative predictive value of EMS provider-assessed cardiac symptoms for the final diagnosis of AMI was 73.3% (95% confidence interval [CI], 70.8 to 75.7), 85.3% (95% CI, 85.3 to 85.4), 3.9% (95% CI, 3.6 to 4.2), and 99.7% (95% CI, 99.7 to 99.8), respectively.

Conclusion

We found that EMS provider-assessed cardiac symptoms had moderate sensitivity and high specificity for diagnosis of AMI. EMS policymakers can use these data to evaluate the pertinence of specific prehospital treatment of AMI.

Temporal trends in cardiovascular risk factors and performance of the Framingham Risk Score and the Pooled Cohort Equations

Background

The Framingham Risk Score (FRS) and the Pooled Cohort Equations (PCE) are established tools for the prediction of cardiovascular disease (CVD) risk. In the Western world, decreases in incidence rates of CVD were observed over the last 30 years. Thus, we hypothesise that there are also temporal trends in the risk prediction performance of the FRS and PCE from 1990 to 2000.

Methods

We used data from n=7789 men and women aged 40–74 years from three prospective population-based cohort studies enrolled in Southern Germany in 1989/1990, 1994/1995 and 1999/2000. 10-year CVD risk was calculated by recalibrated equations of the FRS or PCE. Calibration was evaluated by percentage of overestimation and Hosmer-Lemeshow tests. Discrimination performance was assessed by receiver operating characteristic (ROC) curves and corresponding area under the curve (AUC).

Results

Across the three studies, we found significant temporal trends in risk factor distributions and predicted risks by both risk scores (men: 18.0%, 15.4%, 14.9%; women: 8.7%, 11.2%, 10.8%). Furthermore, also the discrimination performance evolved differently for men (AUC PCE: 76.4, 76.1, 72.8) and women (AUC PCE: 75.9, 79.5, 80.5). Both risk scores overestimated actual CVD risk.

Conclusion

There are temporal trends in the performance of the FRS and PCE. Although the overall performance remains adequate, sex-specific trends have to be taken into account for further refinement of risk prediction models.

Comparison of the rates of stroke and acute coronary events in northern France

Background Although stroke and acute coronary events share several risk factors, few studies have compared population-level epidemiological surveillance indicators of the two diseases in the same age range and in the same geographical area. Design The objective of the present study was to compare the rate of acute coronary events with that of stroke among inhabitants aged from 35-74 years in Northern France (Lille). Methods All incident and recurrent acute coronary events and stroke events occurring in men and women over 2008-2014 were recorded using two population-based registries with several overlapping sources of case ascertainment for hospitalised/non-hospitalised and fatal/non-fatal events. Log-linear Poisson regression models were used to compare the event and mortality rates. Results The results showed that the incident rates of acute coronary event and stroke were similar except under 60 years. In this group (35-59 years), the incident rate of acute coronary events was 1.6-fold higher than that of stroke. In contrast, the attack (incident and recurrent) rates were higher for acute coronary events than for stroke (1.5-fold; p < 0.0001) - especially in men (1.8-fold; p < 0.0001). The mortality rate was 2.2-fold higher for acute coronary events than for stroke, independent of sex and age group ( p < 0.0001), as was the case-fatality rate (1.5-fold, p < 0.0001). Conclusion In Lille, the overall acute coronary event rate was higher than the stroke rate - especially among men, due to a higher risk of incident acute coronary event under the age of 65 and a higher risk of recurrent acute coronary event in the 65-74 year-old age range. Further efforts should be devoted to primary and secondary prevention strategies after acute coronary events.

Relation between mortality trends of cardiovascular diseases and selected cancers in the European Union, in 1970-2017. Focus on cohort and period effects

AIM

To characterise mortality trends from major non-communicable diseases in the European Union (EU) analysing data from the World Health Organization (WHO) Mortality Database.

METHODS

We obtained EU population and death certification data for major non-communicable diseases, i.e. seven cancer sites (stomach, intestine, pancreas, lung, breast, prostate and haematopoietic), total cancers, coronary heart diseases (CHDs) and cerebrovascular diseases (CVDs) from the WHO Mortality Database over the 1970 and 2012 period. We computed age-standardised rates (world standard population) and applied joinpoint regression models to identify temporal trends and age period cohort (APC) models to disentangle the effects of age, period of death and cohort of birth on mortality.

RESULTS

In 2012, 2.4 million deaths were recorded in the EU (1.3 million from cancers and 1.1 million from CHD and CVD combined). Over the last decade, mortality from cancer fell by 14% in men and 8% in women, resulting in age-standardised rates of 144 and 88/100,000 persons, respectively, in 2012. The only exceptions to the general downward trends were pancreatic cancer and female lung cancer. Both cardiovascular diseases mortality fell over 35% in both sexes with rates of 60 and 28/100,000 for CHD, and of 30 and 23/100,000 for CVD, in men and women, respectively, in 2012.

CONCLUSIONS

Overall trends in mortality rates from non-communicable diseases in the EU were favourable, and the joinpoint and APC models indicated these trends are likely to continue in the near future. Lack of progress in tobacco-related mortality in women underlines the importance of female-specific anti-tobacco policies.

Effects of a nutraceutical multicompound including bergamot (Citrus Bergamia Risso) juice on metabolic syndrome: A pilot study

BACKGROUND: The role of lipid-lowering and hypoglycemic nutraceuticals in cardiovascular disease prevention is the focus in recent years. The most studied compounds and plants are sterols, soy, red fermented rice, policosanols, artichoke, berberine. Epidemiological and experimental evidences suggest that dietary polyphenols, especially flavonoids, might play a role in preventing atherosclerosis, owing to their pleiotropic metabolic, anti-inflammatory and antioxidant effects. Recent studies have shown that bergamot juice and albedo (Citrus Bergamia Risso et Poiteau), an endemic plant growing in a limited part of the Ionian coast of Calabria (Italy) has a unique content of flavonoids and glycosides, such as neoeriocytrine, neoesperidine, naringenine, routine, neodesmine, polyphenol and poncirine. OBJECTIVE: The aim of this study was to investigate the effects of a phytocomplex from bergamot fruit (EP3116520A1) as dietary supplement to a Mediterranean diet on body weight, body mass index (BMI), waist circumference, plasmatic lipid fractions, glucose and C – reactive protein (CRP) in subjects with the metabolic syndrome (MetS; according to NCEP-ATP III criteria) without pharmacological treatment, exept for basic treatment. METHODS: 80 overweight adults (54% females, 46% males) with the diagnosis of Metabolic Syndrome (MetS), aged 45 ± 5 years, were enrolled and randomized to 2 groups: group A) followed a personalized low calorie Mediterranean diet (control group) and group B) enriched the same diet therapy with 1 tablet of a phytocomplex from bergamot fruit per day for 6 months (intervention group). RESULTS: After 6 months patients in the intervention group showed a significant reduction of total cholesterol (–15% ), LDL-Cholesterol (–22% ), triglycerides (–23% ), blood glucose (–15% ), CRP (–40% ) and a significant increase in the HDL-Cholesterol (+ 14% ) levels compared to the control group (diet alone) where the changes were not significant, with not much significance in reduced body weight. CONCLUSION: Our findings suggest that bergamot supplementation improves significantly all aspects of metabolic profile in patients with MetS and is superior to diet alone.

Laboratory-Confirmed Respiratory Infections as Predictors of Hospital Admission for Myocardial Infarction and Stroke: Time-Series Analysis of English Data for 2004-2015

Background

Acute respiratory infections are associated with increased risk of myocardial infarction (MI) and stroke; however, the role of different organisms is poorly characterized.

Methods

Time-series analysis of English hospital admissions for MI and stroke (age-stratified: 45-64, 65-74, ≥75 years), laboratory-confirmed viral respiratory infections, and environmental data for 2004-2015. Weekly counts of admissions were modeled using multivariable Poisson regression with weekly counts of respiratory viruses (influenza, parainfluenza, rhinovirus, respiratory syncytial virus [RSV], adenovirus, or human metapneumovirus [HMPV]) investigated as predictors. We controlled for seasonality, long-term trends, and environmental factors.

Results

Weekly hospital admissions in adults aged ≥45 years averaged 1347 (interquartile range [IQR], 1217-1541) for MI and 1175 (IQR, 1023-1395) for stroke. Respiratory infections ranged from 11 cases per week (IQR, 5-53) for influenza to 55 (IQR, 7-127) for rhinovirus. In the adjusted models, all viruses except parainfluenza were significantly associated with MI and ischemic stroke admissions in those aged ≥75. Among 65- to 74-year-olds, adenovirus, rhinovirus, and RSV were associated with MI but not ischemic stroke admissions. Respiratory infections were not associated with MI or ischemic stroke in people aged 45-64 years, nor with hemorrhagic stroke in any age group. An estimated 0.4%-5.7% of MI and ischemic stroke admissions may be attributable to respiratory infection.

Conclusions

We identified small but strongly significant associations in the timing of respiratory infection (with HMPV, RSV, influenza, rhinovirus, and adenovirus) and MI or ischemic stroke hospitalizations in the elderly.

Clinical Trials Registration

NCT02984280.

Opioids in Cardiovascular Disease: Therapeutic Options

The World Health Organization suggests that the cardiovascular diseases (CVDs) are the major cause of mortality and account for two-thirds of the deaths all over the world. These diseases kill about 17 million people every year and 3 in every 10 deaths are due to these diseases. The past decade has seen considerable improvements in diagnosis as well as treatment of various heart diseases. Various new therapeutic targets are being identified through in-depth knowledge of the disease mechanisms which has favored the testing of new strategies leading to newer treatment options. Opioid peptides and G-protein-coupled opioid receptors (ORs) have been previously studied widely in terms of central nervous system actions in mitigating the pain and drug abuse. The OR agonism or antagonism induces cytoprotective states in the myocardium, rendering these receptors as an attractive target for protection of heart from the fatal heart diseases. The opioids can provide an extended window of protection of the heart from various diseases. Although the mechanisms may not be fully understood, they seem to play a crucial role in various CVDs such as hypertension, hyperlipidemia, ischemic heart disease myocardial ischemia, and congestive heart failure. Since these compounds are already being used in acute and chronic pain, soon these compounds might be approved for use as cardioprotective agents. The following review focuses on the new information acquired on the role of the ORs in various CVDs.

Evaluation of dyslipidaemia and the impact of hypolipidemic therapy on prognosis in high and very high risk patients through the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) Registry

The use of statins in the treatment of hyperlipidaemia leads to a significant decrease in cardiovascular (CV) endpoints, and therapy effects are proportional to the reduction of cholesterol levels. In Poland, information about the effects of statin therapy is scarcely available. The information gathered in the Hyperlipidaemia Therapy in the tERtiary Cardiological cEnTer (TERCET) Registry on high-risk and very high-risk patients might improve our knowledge on this issue and help to introduce suitable activities. The main aim of the TERCET Registry is to achieve the target value of low density lipoprotein cholesterol (LDL-C) during a 1-year follow-up: LDL-C <70 mg/dL in very high-risk patients and LDL-C <100 mg/dL in high-risk patients. All consecutive patients with either stable coronary artery disease (sCAD) or acute coronary syndrome (ACS) have been included in the Registry, and the information on all-cause mortality, nonfatal myocardial infarction (MI), and planned or ACS-caused revascularisation have been being gathered within 12-month follow-up. At the moment, the TERCET Registry includes 14,873 patients (66.8% male) at an average age of 64.8 ± 10.2 with a significantly higher age of women (67.5 ± 10.3 vs. 63.5 ± 9.7; p < .001). The causes of hospitalisation were as the following: sCAD (n = 9375 patients, 63% of the investigated population), ST-elevated myocardial infarction (n = 2328 [15.6%]), non-ST-elevated myocardial infarction (n = 1700 [11.4%]), and unstable coronary artery disease (n = 1466 [10%]). 62,7% (n = 9144) of the patients were diagnosed with hyperlipidaemia before hospital admission, with no significant difference between male and female patients. The TERCET registry will allow unveiling real lipid profiles of the high- and very-high risk patients treated in the tertiary hospital. The results may play an essential role in establishing the patients' future clinical outcomes and help to assess if the lipid lowering therapy modifications changed the occurrence of CV endpoints. The registry data will summarize the number of patients unable to reach their LDL-C goals, and who in the future might become candidates suitable for new hypolipidemic therapies (ID: NCT03065543).

Ischaemic heart disease mortality in Serbia, 1991-2013; a joinpoint analysis

BACKGROUND & OBJECTIVES

Ischaemic heart disease (IHD) has been one of the leading causes of mortality in the world. In many European countries the mortality rates due to IHD have been rising rapidly. This study was aimed to assess the IHD mortality trend in Serbia.

METHODS

A population-based cross-sectional study analyzing IHD mortality in Serbia in the period 1991-2013 was carried out based on official data. The age-standardized rates (ASRs, per 100,000) were calculated using the direct method, according to the European standard population. Joinpoint analysis was used to estimate the average annual percentage change (AAPC) with the corresponding 95 per cent confidence interval (CI).

RESULTS

More than 253,000 people (143,420 men and 110,276 women) died due to IHD in Serbia during the observed period, and most of them (over 160,000 people) were patients with myocardial infarction (MI). Average annual ASR for IHD was 113.6/100,000. There was no overall significant trend for mortality due to IHD (AAPC=+0.1%, 95% CI -0.8-1.0), but there was one joinpoint: the trend significantly increased by +2.3 per cent per year from 1991 to 2006 and then significantly decreased by -6.4 per cent from 2006 to onwards. Significantly decreased mortality trends for MI in both genders were observed: according to the comparability test, mortality trends in men and women were parallel (final selected model failed to reject parallelism, P=0.0567).

INTERPRETATION & CONCLUSIONS

No significant trend for mortality due to IHD was observed in Serbia during the study period. The substantial decline of mortality from IHD seen in most developed countries during the past decades was not observed in Serbia. Further efforts are required to reduce mortality from IHD in Serbian population.

Physical Activity for the Prevention of Cardiovascular Diseases

Over the last decade, the quantity and quality of scientific literature examining the relationship between physical activity (PA) and cardiovascular diseases (CVD) have significantly increased. Data from the literature now unequivocally show that physical inactivity is one of the major risk factors for CVD. It is believed that obesity, the prevalence of which has tripled over the last three decades, and physical inactivity among children are the main factors that will increase the prevalence of CVD in this century. The cardiovascular benefits of exercise are multifactorial and include important systemic effects on skeletal muscle, the peripheral vasculature, metabolism, and neurohumoral systems, as well as beneficial alterations within the myocardium itself. Thus, exercise does much more than change traditional risk factors, such as blood pressure, blood lipids, glucose tolerance and insulin resistance, metabolic syndrome, and overweight and obesity. Evidence from epidemiologic studies suggests that the preventive effects of PA may be achieved by 150 minutes of moderate PA a week, while increases in the intensity and volume of exercise lead to further health benefits. This dose–response gradient is curvilinear, with the largest gains from the first hour of weekly exercise. However, although much progress has been made in this field, existing studies performed on human subjects do not clearly show what type, intensity, and duration of exercise is most beneficial to cardiovascular fitness and metabolic optimization. Animal-based exercise studies may provide more information and help to elucidate the abilities of different training regimens to reduce the risk of CVD.

Cardiovascular risk and hypertension control in Italy. Data from the 2015 World Hypertension Day

BACKGROUND

Cardiovascular diseases (CVD) are the first cause of death and disability in western countries. Despite therapeutic advances, their prevalence is constantly increasing. Detailed assessment of modifiable CV risk factors could improve CVD prevention and management.

METHODS

to assess CV risk and hypertension control in a sample of the Italian population, individuals participating to the 2015 "World Hypertension Day" were interviewed in 62sites all over Italy. Blood pressure was measured with a validated auscultatory or oscillometric device and information on demography and prevalence of CVD risk factors was collected by an anonymous questionnaire. An ad-hoc modified version of the Systematic COronary Risk Evaluation (SCORE) system was then applied.

RESULTS

8657 recruited individuals (43%women, aged 56.68±16years) were subdivided into 3 age groups (40-49y, 50-59y, 60-69y) for analysis. CV risk was low in 62.4%, 18.0% and 0%; moderate in 26.0%, 66.0% and 62.5%; high/very high in 11.6%, 16% and 37.4%, respectively. Smoking was mainly responsible for increased CV risk among those aged 40-49y (26%smokers), while hypertension was the main factor in the whole sample and in subjects over 50y (36% and 42% respectively). Overall, BP control was unsatisfactory in 36% of individuals (28%, 48% and 31% of those who declared to be normotensive, hypertensive on treatment or unaware of their BP condition, respectively).

CONCLUSIONS

In this sample of the Italian population, CV risk was alarmingly high, irrespectively of age, mostly due to presence of modifiable risk factors, including hypertension, which should thus be better addressed, especially in the youngsters.

Comparison of Trends in Mortality from Coronary Heart and Cerebrovascular Diseases in North and South America: 1980 to 2013

Until the past century, mortality trends from coronary heart disease (CHD) and cerebrovascular disease (CVD) were less favorable in Latin than in North America. We calculated age-standardized mortality rates using data from the World Health Organization database over the period 1980 to 2013. To identify significant changes in trends, we performed joinpoint analysis. Since the early 2000's, CHD mortality rates decreased by about 35% in the USA and Canada in both genders; similar decreases were observed in some Latin American countries (i.e., Ecuador, Puerto Rico, and Chile), whereas the decreases were smaller in the other countries. In 2011 to 2013, the highest rates were in Venezuela (114.4/100,000 men) and Colombia (86.1/100,000 men) and the lowest ones (apart from Ecuador) in Panama, Chile, and Argentina (from 41 to 46/100,000 men and 18 to 19/100,000 women). For CVD mortality, a decrease by about 30% was observed in Argentina, Panama, and Uruguay plus Colombia for women, in addition to the USA and Canada. Smaller declines were observed in the other Latin American countries (from 23% in Colombian men to 5% in Venezuelan men). Throughout the period, rates in Latin America remained appreciably higher than those in North America. The highest CVD rates were observed in Brazil (51.6/100,000 men) and the lowest ones in Canada (12.9/100,000 women). In conclusion, trends in CHD and CVD mortality continue to be less favorable in Latin America than in Canada and the USA. The marked excess of CVD mortality is partly or largely attributable to inadequate control of dyslipidemia and hypertension.

Is anti-platelet therapy always necessary in asymptomatic 30-40% carotid stenosis?

Asymptomatic mild carotid artery stenosis is relatively frequent and associated with an increased risk of cardiovascular events. Its recognition is clinically relevant for appropriate prevention strategies. These include a healthy lifestyle approach and a careful pharmacologic control of cardiovascular risk factors, such as hypertension, hypercholesterolemia, and diabetes. Furthermore, interventions able to reduce the risk of atherothrombotic events, such as antiplatelet drugs, should be considered. Noninvasive imaging of carotid artery plaque and stenosis severity and morphology may add relevant information for the risk stratification of these subjects.

Room for depressed and exhausted mood as a risk predictor for all-cause and cardiovascular mortality beyond the contribution of the classical somatic risk factors in men

BACKGROUND AND AIMS

Depressed mood and exhaustion (DEEX) have gained attention as a risk predictor for cardiovascular disease (CVD). Studies to estimate its ranking in prediction models are sparse.

METHODS

The study included 3428 men aged 45-74 years who participated in one of three population-based MONICA/KORA Augsburg surveys conducted between 1984 and 1995. Within a follow-up time of 10 years (31,791 person-years), 557 cases of all-cause mortality and 269 fatal CVD events were observed. Adjusted Cox proportional hazards models were used to assess mortality risks for DEEX and five classical cardiovascular risk factors. The predictive ability was evaluated by the area under the receiver-operating characteristic curve, the integrated discrimination improvement statistics and the net classification improvement.

RESULTS

The (crude) absolute mortality risk for DEEX was 23.1 cases per 1000 person-years for all-cause and 11.2 for CVD mortality. The adjusted hazard ratios of 1.52 for all-cause and 1.52 for CVD mortality (p < 0.01) were higher than those for hypercholesterolemia and obesity, but lower than for hypertension, smoking and diabetes. The improvements in risk prediction from DEEX were comparable to those of hypercholesterolemia and obesity, but substantially lower than those of hypertension, smoking and diabetes. The adjusted population-attributable risk (PAR) for DEEX accounted for about 15% for all-cause and CVD mortality, which gives DEEX a middle ranking amongst the classical risk factors.

CONCLUSIONS

DEEX is a strong predictor of mortality risk, ranking in a medium position amongst classical somatic risk factors.

The predictive relationship between baseline insulin and glucose with subclinical carotid atherosclerosis after 5 years in a multi-ethnic cohort

BACKGROUND AND AIMS

We aimed at exploring the relationship between baseline insulin and glucose and the progression of carotid atherosclerosis in a multi-ethnic cohort.

METHODS

Males and females (n = 797) of European, Chinese, South Asian and Aboriginal origin were assessed as part of the Multicultural Community Health Assessment Trial (MCHAT) study for socio-demographics, smoking status, fasting insulin and glucose at baseline. IMT, plaque area and total area were assessed after 5 years.

RESULTS

A total of 545 participants returned after 5 years for a follow-up assessment. Average age of the study participants was 47.5 (SD 8.9) years. At baseline, the median and interquartile range for insulin was 62.0 (49.5) pmol/L, and glucose was 5.2 (0.60) mmol/L. Baseline glucose and insulin predicted the 5-year progression of atherosclerosis in our models, after adjusting for covariates. We found significant insulin-ethnicity interactions in the IMT model (p = 0.044) with the slope of the relationship showing that for every percentage change in insulin the Europeans experienced 7.3% more increase in IMT at 5 years than the Aboriginals. In the plaque area and total area models, there were significant glucose-ethnicity interactions (p = 0.009 and p=0.016 respectively), with the slope showing a 101% and 121% increase for plaque area and total area, respectively, in Europeans, at 5 years per percent change in glucose at baseline. Logistic regression found a significant glucose-ethnicity interaction with the presence of plaques (OR = 0.31, p = 0.03) such that compared to the Europeans, the South Asians had a lower odds of developing plaque presence. Similarly, we found glucose-ethnicity interactions in the logistic regression when comparing the Chinese to the Europeans (OR = 0.2, p=0.005), with the Chinese being less likely to develop plaque presence.

CONCLUSIONS

Ethnicity modifies the predictive relationship between insulin and glucose with sub-clinical indicators of carotid atherosclerosis but not consistently so.

The second myocardial infarction: Higher risk factor burden and earlier second myocardial infarction in women compared with men. The Northern Sweden MONICA study

BACKGROUND

Several studies have examined various parameters and experiences when patients suffer their first myocardial infarction (MI), but knowledge about when they suffer their second MI is limited.

AIM

To compare risk factors for MI, that is, diabetes, hypertension and smoking, for the first and second MI events in men and women affected by two MIs and to analyse the time intervals between the first and second MIs.

METHODS

A retrospective cohort study of 1017 patients aged 25-74 years with first and second MIs from 1990 through 2009 registered in the Northern Sweden MONICA registry.

RESULTS

More women than men have diabetes and hypertension and are smokers at the first MI. Similar differences between the genders remain at the time of the second MI for diabetes and hypertension, although both risk factors have increased. Smoking decreased at the second MI without any remaining difference between genders. Women suffer their second MI within a shorter time interval than men do. Within 16 months of their first MI, 50% of women had a second MI. The corresponding time interval for men was 33 months.

CONCLUSION

Patients affected by an MI should be made aware of their risk of recurrent MI and that the risk of recurrence is highest during the first few years after an MI. In patients affected by two MIs, women have a higher risk factor burden and suffer their second MI earlier than men do and thus may need more aggressive and more prompt secondary prevention.

Relation of longitudinal changes in body mass index with atherosclerotic cardiovascular disease risk scores in middle-aged black and white adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

PURPOSE

We assessed whether longitudinal changes in body mass index (BMI) are positively associated with changes in 10-year American College of Cardiology/American Heart Association atherosclerotic cardiovascular disease (ASCVD) risk scores in middle-aged blacks compared to whites.

METHODS

Data were from 1691 participants enrolled in the Coronary Artery Risk Development in Young Adults Study aged 40 years or more in 2000-2001, who had follow-up examinations 5 and 10 years later.

RESULTS

The prevalence of obesity increased from 32.3% in 2000-2001 (mean age: 42.8 years) to 41.7% in 2010-2011, higher in blacks than whites. The corresponding change in 10-year ASCVD risk was significantly higher for blacks (men: 4.5%-9.6%, women: 1.7%-5.0%) than whites (men: 2.4%-5.2%, women: 0.7%-1.6%). In 2010-2011, 57.5% of black men had ASCVD risk scores of 7.5% or more compared to white men (14.7%), black women (17.4%), and white women (1.6%). Although BMI trends were positively associated with 10-year change in ASCVD risk scores (0.07% per 1 kg/m(2) increase), it explained very little variance in risk score trends in all race-sex groups.

CONCLUSIONS

In middle-aged adults, longitudinal changes in BMI had little independent influence on changes in 10-year ASCVD risk scores as its effect may be largely mediated through ASCVD risk factors already accounted for in the risk score.

Twenty years trends in mortality rates from stroke in Klaipeda

BACKGROUND

During the past decades, mortality from stroke decreased in many western European countries; however, changes concerning long-term stroke mortality in eastern European countries are less evident.

OBJECTIVE

To assess age- and gender-specific trends in stroke mortality in Klaipeda (Lithuania) from 1994 to 2013.

DESIGN

Descriptive epidemiological study.

SETTING/SUBJECTS

Permanent population of Klaipeda.

METHODS

Data on 2509 permanent residents of Klaipeda aged 35-79 years who died from stroke between 1994 and 2013 were gathered. Directly, age-standardized (European population) stroke mortality rates were analyzed using joinpoint regression separately for specific age groups (35-64, 65-79, and 35-79 years) and by gender. Annual percentage change (APC) and 95% CIs were presented.

RESULTS

Stroke mortality in the 35- to 79-year-old age group peaked in 1994-1997, it then decreased by -9.9% (95% CI: -18.7, -0.2) yearly up until 2001 and leveled off by -0.2% (-5.1, 4.9) between 2001 and 2013. Among men aged 35-64 years, mortality decreased substantially by 12.8% (-21.5, -3.3) per year from 1994 to 2001 and turned positive by 6.3% (0.8, 12.1) between 2000 and 2013. Among women aged 35-64 years, mortality decreased significantly by 15.5% (-28.1, -0.7) from 1994 to 2000. There was evidence of recent plateauing of trends for 35- to 64-year-old women between 2000 and 2013. In the 65- to 79-year-old age group, mortality decreased from 1994 onward yearly by -5.5% (-7.9, -3.0) in women and by -3.3% (-5.6, -0.9) in men.

CONCLUSIONS

Joinpoint regression revealed steadily decreasing trend in stroke mortality between 1994 and 2001. The decline in death rates flattened out in the recent decade. Mortality rates varied among age groups and were more pronounced in adults aged 35-64 years. It is essential to monitor and manage stroke risk factors, especially among middle-aged population.

Thirty-Year Trends in Mortality from Cerebrovascular Diseases in Korea

Background and Objectives

Cerebrovascular disease is a leading cause of mortality and morbidity in Korea. Understanding of cerebrovascular disease mortality trends is important to reduce the health burden from cerebrovascular diseases. We examined the changing pattern of mortality related to cerebrovascular disease in Korea over 30 years from 1983 to 2012.

Subjects and Methods

Numbers of deaths from cerebrovascular disease, hemorrhagic stroke, and cerebral infarction were obtained from the national Cause of Death Statistics. Crude and age-adjusted mortality rates were calculated for men and women for each year. Penalized B-spline methods, which reduce bias and variability in curve fitting, were used to identify the trends of 30-year mortality and identify the year of highest mortality.

Results

During the 30 years, cerebrovascular disease mortality has markedly declined. The age-adjusted cerebrovascular disease mortality rate has decreased by 78% in men and by 68% in women. In the case of hemorrhagic stroke, crude mortality peaked in 2001 but age-adjusted mortality peaked in 1994. Between 1994 and 2012, age-adjusted mortality from hemorrhagic stroke has decreased by 68% in men and 59% in women. In the case of cerebral infarction, crude and age-adjusted mortality rates steeply increased until 2004 and 2003, respectively, and both rates decreased rapidly thereafter.

Conclusion

Cerebrovascular disease mortality rate has significantly decreased over the last 30 years in Korea, but remains a health burden. The prevalence of major cardiovascular risk factors are still highly prevalent in Korea.

Why are well-educated Muscovites more likely to survive? Understanding the biological pathways

There are large socioeconomic disparities in adult mortality in Russia, although the biological mechanisms are not well understood. With data from the study of Stress, Aging, and Health in Russia (SAHR), we use Gompertz hazard models to assess the relationship between educational attainment and mortality among older adults in Moscow and to evaluate biomarkers associated with inflammation, neuroendocrine function, heart rate variability, and clinical cardiovascular and metabolic risk as potential mediators of that relationship. We do this by assessing the extent to which the addition of biomarker variables into hazard models of mortality attenuates the association between educational attainment and mortality. We find that an additional year of education is associated with about 5% lower risk of age-specific all-cause and cardiovascular mortality. Inflammation biomarkers are best able to account for this relationship, explaining 25% of the education-all-cause mortality association, and 35% of the education-cardiovascular mortality association. Clinical markers perform next best, accounting for 13% and 23% of the relationship between education and all-cause and cardiovascular mortality, respectively. Although heart rate biomarkers are strongly associated with subsequent mortality, they explain very little of the education-mortality link. Neuroendocrine biomarkers fail to account for any portion of the link. These findings suggest that inflammation may be important for understanding mortality disparities by socioeconomic status.