Trends in serum lipids and lipoproteins of adults, 1960-2002. JAMA. 2005;294:1773-1781. [PMID: 21834954 PMCID: PMC3199603 DOI: 10.1186/1471-2458-11-641]

Prevalence, patterns and associated risk factors for dyslipidaemia among individuals attending the diabetes clinic at a tertiary hospital in Central Malawi

BACKGROUND

Dyslipidaemia among individuals with diabetes is a significant modifiable risk factor for atherosclerotic cardiovascular diseases (ASCVDs). ASCVDs are a major cause of mortality and morbidity globally, especially in people with diabetes. In Malawi, limited data exist on the prevalence and biochemical characteristics of diabetic dyslipidaemia. This study investigated the prevalence and biochemical characteristics of dyslipidaemia in individuals attending the diabetes clinic at Kamuzu Central Hospital, the largest tertiary referral hospital in Central Malawi.

METHODS

Using a cross-sectional design, sociodemographic, medical and anthropometric data were collected from 391 adult participants who were enrolled in the study. Blood samples were analysed for glycosylated haemoglobin (HBA1c) and fasting lipid profiles. The prevalence of dyslipidaemia was calculated, and the biochemical characteristics of the dyslipidaemia were defined. The associations between dyslipidaemia and risk factors such as sociodemographic characteristics, obesity, and HBA1c levels were evaluated using logistic regression analysis.

RESULTS

Prevalence of dyslipidaemia was observed in 71% of the participants, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality among the study participants. None of the participants were receiving any lipid-lowering therapy. On bivariate analysis, dyslipidemia was positively associated with female sex [OR 1.65 (95% CI 1.05- 2.58); p = 0.09], age ≥ 30 years [OR 3.60 (95% CI 1.17-7.68); p = 0.001] and overweight and obesity [OR 2.11 (95% CI 1.33-3.34); p = 0.002]. On multivariate analysis, being overweight or obese was an independent predictor of dyslipidaemia [AOR 1.8;(95% CI 1.15- 3.37); p = 0.04].

CONCLUSION

Dyslipidaemia was highly prevalent among individuals with diabetes in this study, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality. Overweight and obesity were also highly prevalent and positively predicted dyslipidaemia. This study highlights the importance of appropriately addressing dyslipidaemia, overweight and obesity among individuals with diabetes in Malawi and other similar settings in Africa as one of the significant ways of reducing the risk of ASCVDs among this population.

The rise and fall of tobacco smoking and associated rise and fall of coronary atherosclerosis the lethal role of tobacco

In this review two new hypotheses are explored, one, that the decline in coronary heart disease is mainly due to a dramatic decline in the prevalence of underlying atherosclerosis and two, that tobacco smoking has been a much greater influence on atherosclerosis than previously estimated. The major outcome of coronary atherosclerosis is myocardial infarction. Between 1900 and 1960 the prevalence of coronary atherosclerosis dramatically rose in young male soldiers. Between 1960 and 2010 the prevalence of coronary atherosclerosis in young US soldiers equally dramatically fell. Understanding the reasons for this rise and fall offers important insights into the causes of atherosclerosis. In 1960 over 50% of US military personnel were tobacco smokers but by 1988 the rate had reduced to 30%. The increased prevalence of coronary atherosclerosis in young soldiers between 1900 and 1960 was mainly due to increased tobacco smoking. An additional influence was an increase in food and sugar consumption. The fall in atherosclerosis between 1960 and 2010 was probably due to a reduction in tobacco smoking and to a lesser extent, control of hypertension and lowering of high serum total cholesterol. In Western populations up to two thirds of the fall in deaths due to myocardial infarction has been shown to be due to declines in the incidence of heart attacks. Based on the data included in this review it is arguable that the main reason for the fall in the incidence of heart attacks is the fall in the prevalence of underlying coronary atherosclerosis. The adverse influences of tobacco have been well documented. However the enormity of these adverse influences has not been recognised. Over 50% of men continue to smoke tobacco in China, Indonesia, Russia and middle eastern countries. Based on the experience of Western countries over half of these men will die of smoking related conditions.

Clinical determinants of ischemic heart disease in Eastern Europe

Cardiovascular inequalities remain pervasive in the European countries. Disparities in disease burden is apparent among population groups based on sex, ethnicity, economic status or geography. To address this challenge, The Lancet Regional Health - Europe convened experts from a broad range of countries to assess the current state of knowledge of cardiovascular disease inequalities across Europe. This report presents the main challenges in Eastern Europe. There were pronounced variations in cardiovascular disease mortality rates across Eastern European countries with a remarkably high disease burden in the North-Eastern Europe. There were also significant differences in access and delivery to healthcare and unmet healthcare needs. Addressing the cardiovascular determinants of health and reducing health disparities in its many dimensions has long been a priority of the European Parliament's work through resolutions and by financing pilot projects. Yet, despite these efforts, few large-scale studies have been conducted to examine the feasibility of reducing cardiovascular disparities in Eastern Europe. There is an urgent need for improved data, measurements, reporting, and comparisons; and for dedicated, collaborative research. There is also a need for a broader understanding of the typology of actions needed to tackle cardiovascular inequalities and a clear political will.

Prevalence, patterns and associated risk factors for dyslipidaemia among individuals attending the diabetes clinic at a tertiary hospital in Central Malawi

Background

Dyslipidaemia among individuals with diabetes is a significant modifiable risk factor for atherosclerotic cardiovascular diseases (ASCVDs). ASCVDs are a major cause of mortality and morbidity globally, especially in people with diabetes. In Malawi, limited data exist on the prevalence and biochemical characteristics of diabetic dyslipidaemia. This study investigated the prevalence and biochemical characteristics of dyslipidaemia in individuals attending the diabetes clinic at Kamuzu Central Hospital, the largest tertiary referral hospital in Central Malawi.

Methods

Using a cross-sectional design, sociodemographic, medical and anthropometric data were collected from 391 adult participants who were enrolled in the study. Blood samples were analysed for glycosylated haemoglobin (HBA1c) and fasting lipid profiles. The prevalence of dyslipidaemia was calculated, and the biochemical characteristics of the dyslipidaemia were defined. The associations between dyslipidaemia and risk factors such as sociodemographic characteristics, obesity, and HBA1c levels were evaluated using logistic regression analysis.

Results

Prevalence of dyslipidaemia was observed in 71% of the participants, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality among the study participants. On bivariate analysis, dyslipidemia was positively associated with female sex [OR 1.65 (95% CI 1.05-2.58); p = 0.09], age ≥ 30 years [OR 3.60 (95% CI 1.17-7.68); p = 0.001] and overweight and obesity [OR 2.11 (95% CI 1.33-3.34); p = 0.002]. On multivariate analysis, being overweight or obese was an independent predictor of dyslipidaemia [AOR 1.8 ;( 95% CI 1.15-3.37); p = 0.04].

Conclusion

Dyslipidaemia was highly prevalent among individuals with diabetes in this study, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality. Overweight and obesity were also highly prevalent and positively predicted dyslipidaemia. This study highlights the importance of appropriately addressing dyslipidaemia, overweight and obesity among individuals with diabetes in Malawi and other similar settings in Africa as one of the significant ways of reducing the risk of ASCVDs among this population.

Behavioral and Metabolic Risk Factors for Noncommunicable Diseases among Population in the Republic of Srpska (Bosnia and Herzegovina)

Noncommunicable diseases (NCDs) are the major cause of death worldwide, and they are attributable to genetic and physiological determinants, behavioral risk factors and environmental impacts. The aim of this study is to assess behavioral risk factors for metabolic disease using demographic and social-economic aspects of the population characterized by risk factors, and to investigate relations among lifestyle risk factors (alcohol consumption, tobacco use, physical inactivity, intake of vitamins, fruits and vegetables) that are responsible for the majority of NCD deaths in the Republic of Srpska's (RS's) population. This is a cross-sectional study based on the analysis of a survey conducted among 2311 adult (≥18 years) persons (54.0% women, and 46.0% men). The statistical analysis was carried out by using Cramer's V values, clustering, logistic regression (binomial, multinomial and ordinal), a chi-square test and odds ratios. In the case of logistic regression, we provide the prediction accuracy in percentages. A significant statistical correlation between demographic characteristics (gender and age) and risk factors was observed. The highest difference according to gender was observed in alcohol consumption (odds ratio (OR) = 2.705, confidence interval (95% CI) = 2.206-3.317), particularly in frequent consumption (OR = 3.164, 95% CI = 2.664-3.758). The highest prevalence of high blood pressure was registered in the elderly (66.5%); the same holds for hypertension (44.3%). Additionally, physical inactivity was one of the most common risk factors (33.4% physically inactive respondents). A significant presence of risk factors was confirmed among the RS population, with higher involvement of metabolic risk factors among the older population, while the prevalence of behavioral factors was related to younger age groups, particularly in the case of alcohol consumption and smoking. A low level of preventive awareness was observed among the younger population. Therefore, prevention is one of the most important instruments related to decreasing NCD risk factors in the RS population.

High prevalence of dyslipidaemia among persons with diabetes mellitus and hypertension at a tertiary hospital in Blantyre, Malawi

BACKGROUND

Dyslipidaemia drives the process of atherosclerosis, and hence a significant modifiable risk factor complicating hypertension and diabetes. In Malawi, the prevalence, screening and management of dyslipidaemia among persons with diabetes mellitus have not been reported. This study aimed to investigate the prevalence, biochemical characteristics, screening and management practices for dyslipidaemia among persons with diabetes mellitus, hypertension, and diabetes mellitus and hypertension comorbidity at Queen Elizabeth Central hospital in Blantyre, Malawi.

METHODS

This was a cross-sectional study conducted in 2021. A total of 256 adult participants (diabetes mellitus = 100); hypertension = 100; both conditions = 56) were included. Medical data and anthropometric measurements were recorded. Blood samples were analysed for HbA1C and serum lipids. Associated risk factors for dyslipidaemia were also assessed.

RESULTS

Dyslipidaemia was prevalent in 58%, 55%, and 70% of participants with diabetes mellitus, hypertension, and both conditions. Low-density lipoprotein cholesterol (LDL-C) dyslipidaemia was the most common in all participant groups. Participants with both diabetes and hypertension had 2.4 times (95% CI 1.2-4.6) increased risk of LDL-C dyslipidaemia than those with diabetes alone (p < 0.02). Being overweight or obese and age over 30 years were risk factors for dyslipidaemia in participants with diabetes mellitus alone (OR 1.3 (95% CI 1.1-1.6), p < 0.04, and OR 2.2 (95% CI 1.2-4.7) (p < 0.01), respectively. Overweight and obesity predicted LDL-C dyslipidaemia in hypertensive patients (OR 3.5 (95% CI 1.2-9.9) p < 0.001). Poorly controlled hypertension and the use of beta-blockers and thiazide diuretics predicted dyslipidaemia among patients with both diabetes mellitus and hypertension (OR 6.50 CI 1.45-29.19; and OR 5.20 CI 1.16-23.36 respectively). None of the participants had a lipogram performed before the study or were on lipid-lowering therapy.

CONCLUSIONS

Dyslipidaemia with LDL-C derangement was highly prevalent, especially in individuals with both diabetes mellitus and hypertension, and there was absent use of lipid-lowering therapy. Screening and managing dyslipidaemia should be reinforced to reduce the risk of cardiovascular complications in this population at increased risk.

Temporal trends in atherosclerotic cardiovascular disease risk among U.S. adults. Analysis of the National Health and Nutrition Examination Survey, 1999-2018

BACKGROUND

Atherosclerotic cardiovascular diseases are a significant cause of disability and mortality. Study of trends in cardiovascular risk at a population level helps understand the overall cardiovascular health and the impact of primary prevention efforts.

AIMS

To assess trends in the estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among U.S. adults from 1999-2000 to 2017-18 with no established cardiovascular disease (CVD).

METHODS AND RESULTS

Serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 (10 cycles), including 24 022 US adults aged 40-79 years with no reported ASCVD. ASCVD risk was assessed using the pooled cohort equations (PCEs). There was a significant temporal decline in the mean 10-year ASCVD risk from 13.5% (95% CI, 12.5-14.4) in 1999-2000 to 11.1% (10.5-11.7) in 2011-12 (Ptrend < 0.001) and to 12.0% (11.3-12.7) in 2017-2018 (overall Ptrend = 0.001), with the mean ASCVD risk score remaining stable from 2013-14 through 2017-2018 (Ptrend = 0.056). A declining trend in ASCVD risk was noted in females, non-Hispanic Blacks and those with income <3 times the poverty threshold with Ptrend of <0.001, 0.002, and 0.007, respectively. Mean total cholesterol and prevalence of smokers showed a downward trend (Ptrend <0.001 for both), whereas type 2 diabetes and mean BMI showed an upward trend (Ptrend < 0.001 for both).

CONCLUSIONS

The 20-year trend of ASCVD risk among NHANES participants 40-79 years, as assessed by the use of PCE, showed a non-linear downward trend from 1999-2000 to 2017-18. The initial and significant decline in estimated ASCVD risk from 1999-2000 to 2011-12 subsequently stabilized, with no significant change from 2013-14 to 2017-18. Mean BMI and prevalence of diabetes mellitus increased while mean serum cholesterol levels and prevalence of smoking declined during the study period. Our findings support invigoration of efforts aimed at prevention of CVD, including primordial prevention of CVD risk factors.

Ceramides improve atherosclerotic cardiovascular disease risk assessment beyond standard risk factors

Ceramides are bioactive lipids that act as secondary messengers for both intra- and inter-cellular signaling. Elevated plasma concentrations of ceramides are associated with multiple risk factors of atherosclerotic cardiovascular diseases and comorbidities including obesity, insulin resistance and diabetes mellitus. Furthermore, atherosclerotic plaques have been shown to be highly enriched with ceramides. Increases in ceramide content may accelerate atherosclerosis development by promoting LDL infiltration to the endothelium and aggregation within the intima of artery walls. Thus, ceramides appear to play a key role in the development of cardiometabolic disease due to their central location in major metabolic pathways that intersect lipid and glucose metabolism. Recently published data have shown that ceramides are not only of scientific interest but may also have diagnostic value. Their independent prognostic value for future cardiovascular outcomes over and above LDL cholesterol and other traditional risk factors have consistently been shown in numerous clinical studies. Thus, ceramide testing with a mass spectrometer offers a simple, reproducible and cost-effective blood test for risk stratification in atherosclerotic cardiovascular diseases.

Worldwide burden of LDL cholesterol: Implications in cardiovascular disease

BACKGROUND AND AIM

an increased value of low-density lipoprotein cholesterol (LDL-C) is now universally considered a major cardiovascular disease (CVD) risk factor. LDL-C is included in the vast majority of worldwide cardiovascular risk prediction algorithms, as well as in the guidelines for cardiovascular risk prevention. We aimed to provide an overview of the worldwide adverse healthcare impact of low-density lipoprotein cholesterol (LDL-C).

METHODS AND RESULTS

Data on the epidemiologic burden of LDL-C >1.3 mmol/L were retrieved from Global Health Data Exchange (GHDx) registry. The current burden is 94.92 million disability-adjusted life years (DALYs), with an exponential increase occurred during the past 25 years. 4.32 million deaths can be attributed to LDL cholesterol values > 1.3 mmol/L. DALYs and deaths due to LDL-C have significantly increased in all countries except those with high socio-demographic index.

CONCLUSION

More effective structural healthcare policies shall be planned at a worldwide scale for contrasting the epidemics of LDL-C attributable heath loss.

Changes in conventional cardiovascular risk factors and the estimated 10-year risk of acute myocardial infarction or cerebral stroke in Sami and non-Sami populations in two population-based cross-sectional surveys: the SAMINOR Study

OBJECTIVE

To describe changes in cardiovascular risk factors and in the estimated 10-year risk of acute myocardial infarction (AMI) or cerebral stroke (CS) between SAMINOR 1 (2003-2004) and SAMINOR 2 (2012-2014), and explore if these changes differed between Sami and non-Sami.

DESIGN

Two cross-sectional surveys.

SETTING

Inhabitants of rural Northern Norway.

PARTICIPANTS

Participants were aged 40-79 years and participated in SAMINOR 1 (n=6417) and/or SAMINOR 2 (n=5956).

PRIMARY OUTCOME MEASURES

Generalised estimating equation regressions with an interaction term were used to estimate and compare changes in cardiovascular risk factors and 10-year risk of AMI or CS between the two surveys and by ethnicity.

RESULTS

Mean cholesterol declined by 0.50, 0.43 and 0.60 mmol/L in women, Sami men and non-Sami men, respectively (all p<0.001). Sami men had a small decline in mean high-density lipoprotein (HDL) cholesterol and an increase in mean triglycerides (both p<0.001), whereas non-Sami showed no change in these variables. Non-Sami women had an increase in mean HDL cholesterol (p<0.001) whereas Sami women had no change. Triglycerides did not change in non-Sami and Sami women. Systolic and diastolic blood pressure declined by 3.6 and 1.0 mm Hg in women, and 3.1 and 0.7 in men, respectively (all p<0.01). Mean waist circumference increased by 6.7 and 5.9 cm in women and men, respectively (both p<0.001). The odds of being a smoker declined by 35% in women and 46% in men (both p<0.001). Estimated 10-year risk of AMI or CS decreased in all strata of sex and ethnicity (p<0.001), however, Sami women had a smaller decline than non-Sami did.

CONCLUSIONS

Independent of ethnicity, there was a decline in mean cholesterol, blood pressure, smoking, hypertension (women only) and 10-year risk of AMI or CS, but waist circumference increased. Relatively minor ethnic differences were found in changes of cardiovascular risk factors.

Association between sleep duration, sleep quality and hyperlipidemia in middle-aged and older Chinese: The Dongfeng–Tongji Cohort Study

Aims

This study aimed to evaluate the relationship between sleep duration, sleep quality and hyperlipidemia in middle-aged and older Chinese.

Methods

We included 20,712 individuals at baseline from September 2008 to June 2010, and they were followed-up until October 2013. Hyperlipidemia was defined according to the Chinese guidelines on the prevention and treatment of dyslipidemia in adults. Sleep duration was self-reported and sleep quality was evaluated with a questionnaire that was designed according to the Pittsburgh Sleep Quality Index. Logistic regression and Cox proportional hazard models were conducted to explore the associations.

Results

In the cross-sectional analyses, longer sleep duration (≥10 h) was significantly associated with higher prevalence of hyperlipidemia (odds ratio (OR) = 1.17, 95% confidence interval (CI) = 1.02–1.35) after adjusting for potential confounders. The ORs of hyperlipidemia were significantly elevated among participants with impaired sleep quality (OR = 1.14, 95% CI = 1.08–1.22) and poor sleep quality (OR = 1.20, 95% CI = 1.08–1.34) when compared to those with good sleep quality. In the longitudinal analyses, compared to participants with a sleep duration of 7–<8 h, those with a sleep duration of 9–<10 h (hazard ratio (HR) = 1.19, 95% CI = 1.04–1.35) and ≥10 h (HR = 1.27, 95% CI = 1.02–1.58) showed significantly higher risk of hyperlipidemia after adjusting for potential confounders. However, no statistically significant association was found between impaired or poor sleep quality and hyperlipidemia.

Conclusions

Longer sleep duration was significantly associated with higher risk of hyperlipidemia. Impaired or poor sleep quality were associated with elevated prevalence of hyperlipidemia, but not with the incidence of hyperlipidemia.

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.

Need for hyperlipidemia management policy reform in China: learning from the global experience

OBJECTIVE

To evaluate the hyperlipidemia prevention programs and policies in different countries and highlight the need of reforming the hyperlipidemia prevention policies in China to lower the growing cardiovascular disease (CVD) risk.

RESEARCH DESIGN AND METHODS

PubMed, Google Scholar and Cochrane were searched for global hyperlipidemia prevention policies. Government-funded policies pertaining to lipid management were considered for this review. Only those studies that evaluated the success of prevention policies on the basis of: (i) achievement of hyperlipidemia targets; (ii) improvement in Cardiovascular (CV) risk reduction; and (iii) outcomes with reduction in hyperlipidemia after implementation of the policy, were included.

RESULTS

Several global policies and programs aimed to improve CV health by highlighting lipid profile management. Implementation of the global and national policies led to improvement in cholesterol related outcomes such as availability of diagnostic measures, awareness of the risk factors, decrease in cholesterol levels, achieving healthy lifestyle to prevent CVD and improvement in availability of hypolipidemic medications, etc. Statins have been covered under reimbursement policies in many countries to improve usage and thereby preventing incidence of stroke and CVD. We observed a need for introducing new programs in China as the ongoing hyperlipidemia management policies are inadequate. The World Bank Report 2016 recommended that prevention policies in China be modeled on the US Million Hearts program.

CONCLUSIONS

New hyperlipidemia prevention policies must set a time-bound target, and need to be patient and clinician centric in terms of applications, and revised periodically for long-term benefits.

Historical trends in modifiable indicators of cardiovascular health and self-rated health among older adults: Cohort differences over 20 years between the Berlin Aging Study (BASE) and the Berlin Aging Study II (BASE-II)

Background

The last decades have seen great advances in the understanding, treatment, and prevention of cardiovascular disease (CVD). Although mortality rates due to CVD have declined significantly in the last decades, the burden of CVD is still high, particularly in older adults. This raises the question whether contemporary populations of older adults are experiencing better or worse objective as well as subjective health than earlier-born cohorts. The aim of this study was to examine differences in modifiable indicators of cardiovascular health (CVH), comparing data obtained 20 years apart in the Berlin Aging Study (BASE, 1990–93) and the Berlin Aging Study II (BASE-II, 2009–2014).

Methods

Serial cross-sectional analysis of 242 propensity-score-matched participants of BASE (born 1907–1922) and BASE-II (born 1925–1942). Body mass index (BMI), blood pressure, total cholesterol, glycated hemoglobin (HbA1c), diet, smoking and physical activity were operationalized according to the “Life’s simple 7“(LS7) criteria of the American Heart Association.

Results

121 matched pairs were identified based on age, sex, and education. In the later-born BASE-II sample, the mean LS7 score was significantly higher than in the earlier-born sample (7.8±1.8 vs. 6.4±2.1, p<0.001), indicating better CVH. In detail, diet, physical activity, smoking, cholesterol, and HbA1c were more favorable, whereas blood pressure was significantly higher in individuals from the later-born cohort. BMI did not differ significantly between the two matched samples. Notably, despite better CVH, later-born individuals (BASE-II) reported lower self-rated health, presumably because of higher health expectations.

Conclusions

Overall, cardiovascular health was significantly better in the later-born cohort, but several notable exceptions exist.

Explaining the decline in coronary heart disease mortality rates in the Slovak Republic between 1993-2008

Objective

Between the years 1993 and 2008, mortality rates from coronary heart disease (CHD) in the Slovak Republic have decreased by almost one quarter. However, this was a smaller decline than in neighbouring countries. The aim of this modelling study was therefore to quantify the contributions of risk factor changes and the use of evidence-based medical therapies to the CHD mortality decline between 1993 and 2008.

Methods

We identified, obtained and scrutinised the data required for the model. These data detailed trends in the major population cardiovascular risk factors (smoking, blood pressure, total cholesterol, diabetes prevalence, body mass index (BMI) and physical activity levels), and also the uptake of all standard CHD treatments. The main data sources were official statistics (National Health Information Centre and Statistical Office of the Slovak Republic) and national representative studies (AUDIT, SLOVAKS, SLOVASeZ, CINDI, EHES, EHIS). The previously validated IMPACT policy model was then used to combine and integrate these data with effect sizes from published meta-analyses quantifying the effectiveness of specific evidence-based treatments, and population-wide changes in cardiovascular risk factors. Results were expressed as deaths prevented or postponed (DPPs) attributable to risk factor changes or treatments. Uncertainties were explored using sensitivity analyses.

Results

Between 1993 and 2008 age-adjusted CHD mortality rates in the Slovak Republic (SR) decreased by 23% in men and 26% in women aged 25–74 years. This represented some 1820 fewer CHD deaths in 2008 than expected if mortality rates had not fallen. The IMPACT model explained 91% of this mortality decline. Approximately 50% of the decline was attributable to changes in acute phase and secondary prevention treatments, particularly acute and chronic treatments for heart failure (≈12%), acute coronary syndrome treatments (≈9%) and secondary prevention following AMI and revascularisation (≈8%). Changes in CHD risk factors explained approximately 41% of the total mortality decrease, mainly reflecting reductions in total serum cholesterol. However, other risk factors demonstrated adverse trends and thus generated approximately 740 additional deaths.

Conclusion

Our analysis suggests that approximately half the CHD mortality fall recently observed in the SR may be attributable to the increased use of evidence-based treatments. However, the adverse trends observed in all the major cardiovascular risk factors (apart from total cholesterol) are deeply worrying. They highlight the need for more energetic population-wide prevention policies such as tobacco control, reducing salt and industrial trans fats content in processed food, clearer food labelling and regulated marketing of processed foods and sugary drinks.

Trends in Determinants of Hypercholesterolemia among Chinese Adults between 2002 and 2012: Results from theNational Nutrition Survey

Hypercholesterolemia is a known risk factor for cardiovascular diseases and affects a high proportion of the population. This study aimed to assess and compare the determinants of hypercholesterolemia among Chinese adults aged 18 years and above, from 2002 to 2012. The study used a stratified multistage cluster sampling method to select participants. Sociodemographic and lifestyle information was collected during face-to-face interviews. Dietary intake was calculated by 3-day, 24-h dietary records in combination with weighted edible oil and condiments. Hypercholesterolemia was defined as total cholesterol above 6.22 mmol/L (240 mg/dL) from fasting blood samples. The study included 47,701 (mean age 43.0 years) and 39,870 (mean age 51.0 years) participants in 2002 and 2010–2012 surveys respectively. The weighted prevalence of hypercholesterolemia increased from 1.6% (2.1% urban, 1.0% rural) in 2002 to 6.0% (6.4% urban, 5.1% rural) in 2012. The intake of plant-based food decreased but the intake of pork increased over the 10 years. A high intake of protein and pork, alcohol drinking and overweight/obesity were positively associated with hypercholesterolemia. Neither education nor fruit and vegetable intake were associated with hypercholesterolemia. In conclusion, the burden of hypercholesterolemia increased substantially between 2002 and 2012 in China. Unhealthy lifestyle factors and change in traditional dietary pattern were positively associated with hypercholesterolemia. Further research on the role of diet in the development and prevention of hypercholesterolemia is needed.

Greater decreases in cholesterol levels among individuals with high cardiovascular risk than among the general population: the northern Sweden MONICA study 1994 to 2014

AIM

Decreasing cholesterol levels in Western populations is the main reason for decreasing mortality due to coronary heart disease. Our aim was to analyze trends in cholesterol levels in the population during a period of 20 years in relation to previous cardiovascular disease (CVD), other cardiovascular risk factors, and socioeconomic status.

METHODS AND RESULTS

A total of 4546 women and 4349 men aged 25-74 years participated in five population-based surveys in the Northern Sweden MONICA Study between 1994 and 2014 (participation rate 76.8-62.5%). Total cholesterol levels decreased from 6.2 mmol/L (95% confidence interval, CI, 6.1-6.2) in 1994 to 5.5 mmol/L (CI 5.4-5.5) in 2014. The decrease was more pronounced in elderly vs. younger participants (1.0 vs. 0.5 mmol/L). In 2014, participants with previous CVD, diabetes, or hypertension had lower cholesterol levels than the general population, whereas their levels were higher or similar to the general population in 1994. The use of lipid-lowering drugs increased markedly and was used by 14.3% in 2014. Previously described differences in cholesterol levels between participants with obesity and normal weight, and between those with and without university education, diminished, or vanished over time.

CONCLUSION

Cholesterol levels decreased by 0.7 mmol/L over 20 years with no sign of abating. The improvement occurred in all age and gender groups but more prominently among those at high risk of ischaemic heart disease.

Modelling Future Coronary Heart Disease Mortality to 2030 in the British Isles

Objective

Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland.

Methods

CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted.

Results

Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25–84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8–7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1–3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2–5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8–9.0%. These projections remained stable under a wide range of sensitivity analyses.

Conclusions

Feasible reductions in four cardiovascular risk factors (already achieved elsewhere) could substantially reduce future coronary deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity.

Contributions of risk factors and medical care to cardiovascular mortality trends

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

Quantifying the contribution of statins to the decline in population mean cholesterol by socioeconomic group in England 1991 - 2012: a modelling study

Background

Serum total cholesterol is one of the major targets for cardiovascular disease prevention. Statins are effective for cholesterol control in individual patients. At the population level, however, their contribution to total cholesterol decline remains unclear. The aim of this study was to quantify the contribution of statins to the observed fall in population mean cholesterol levels in England over the past two decades, and explore any differences between socioeconomic groups.

Methods and Findings

This is a modelling study based on data from the Health Survey for England. We analysed changes in observed mean total cholesterol levels in the adult England population between 1991-92 (baseline) and 2011-12. We then compared the observed changes with a counterfactual ‘no statins’ scenario, where the impact of statins on population total cholesterol was estimated and removed. We estimated uncertainty intervals (UI) using Monte Carlo simulation, where confidence intervals (CI) were impractical. In 2011-12, 13.2% (95% CI: 12.5-14.0%) of the English adult population used statins at least once per week, compared with 1991-92 when the proportion was just 0.5% (95% CI: 0.3-1.0%). Between 1991-92 and 2011-12, mean total cholesterol declined from 5.86 mmol/L (95% CI: 5.82-5.90) to 5.17 mmol/L (95% CI: 5.14-5.20). For 2011-12, mean total cholesterol was lower in more deprived groups. In our ‘no statins’ scenario we predicted a mean total cholesterol of 5.36 mmol/L (95% CI: 5.33-5.40) for 2011-12. Statins were responsible for approximately 33.7% (95% UI: 28.9-38.8%) of the total cholesterol reduction since 1991-92. The statin contribution to cholesterol reduction was greater among the more deprived groups of women, while showing little socio-economic gradient among men.

Conclusions

Our model suggests that statins explained around a third of the substantial falls in total cholesterol observed in England since 1991. Approximately two thirds of the cholesterol decrease can reasonably be attributed non-pharmacological determinants.

Reasons for (non)compliance with intervention following identification of 'high-risk' status in the NHS Health Check programme

Background

The Department of Health introduced a risk assessment, management and reduction programme, NHS Health Checks, which aimed to reduce premature morbidity and mortality from cardiovascular diseases for those aged 40–74. Those identified as at increased risk of CVD are offered prophylactic medication and lifestyle advice to reduce their risk. Health gains will only be achieved if patients are compliant with advice/intervention however. This study sought to understand factors that influenced adherence to medication and advice in ‘high-risk’ patients.

Methods

Qualitative data were collected through 29 semi-structured interviews with a purposive sample of individuals who had been identified as at high-risk of CVD. Participants had been offered lifestyle advice, lipid lowering medications and attended at least one annual review.

Results

Findings explore the challenges and experiences confronting ‘high-risk’ individuals when making decisions about engaging with intervention. Key findings explore: statin adherence, as well as adherence to advice about diet, physical activity, alcohol consumption and smoking cessation.

Conclusions

Attention needs to be paid to the way prophylactic medications are prescribed and explained to high-risk patients. Consistent provision of tailored lifestyle advice and access to appropriate services could facilitate sustained changes to factors that increase CVD risk.

Effect of secular trends on age-related trajectories of cardiovascular risk factors: the Whitehall II longitudinal study 1985-2009

BACKGROUND

Secular trends in cardiovascular risk factors have been described, but few studies have examined simultaneously the effects of both ageing and secular trends within the same cohort.

METHODS

Development of cardiovascular risk factors over the past three decades was analysed using serial measurements from 10 308 participants aged from 35 to 80 years over 25 years of follow-up from five clinical examination phases of the Whitehall II study. Changes of body mass index, waist circumference, blood pressure and total and high-density lipoprotein cholesterol distribution characteristics were analysed with quantile regression models in the 57-61 age group. Age-related trajectories of risk factors were assessed by fitting mixed-effects models with adjustment for year of birth to reveal secular trends.

RESULTS

Average body mass index and waist circumference increased faster with age in women than in men, but the unfavourable secular trend was more marked in men. Distributions showed a fattening of the right tail in each consecutive phase, meaning a stronger increase in higher percentiles. Despite the higher obesity levels in younger birth cohorts, total cholesterol decreased markedly in the 57-61 age group along the entire distribution rather than in higher extremes only.

CONCLUSION

The past three decades brought strong and heterogeneous changes in cardiovascular risk factor distributions. Secular trends appear to modify age-related trajectories of cardiovascular risk factors, which may be a source of bias in longitudinal analyses.

Trend in prevalence of uncontrolled total serum cholesterol for cardio-cerebro-vascular disease in a mediterranean area, 1988/89-2008/09

AIM: To examine trends of uncontrolled total serum cholesterol, treatment and control in a Mediterranean region (Campania).

METHODS: We considered and compared the data collected as part of “Montecorvino Rovella Project” 1988-1989 and cross-sectional data from the two phases of the “VIP Project-Valle dell’Irno Prevenzione”: 1998-1999 (1^st phase) and 2008-2009 (2^nd phase), in the 35-74-year-old-population.

RESULTS: Data show a reduction of mean cholesterolemia in the last twenty years of 7.3 mg/dL for men and unchanged values for women. In the three surveys the mean values for serum cholesterol are in men: 205.2 ± 47.1 mg/dL (1988/89), 200 ± 38.9 mg/dL (1998/99) and 197.9 ± 40.2 mg/dL (2008/09); in the women: 203.1 ± 42.5 mg/dL (1988/89), 198.9 ± 37.9 mg/dL (1998/99) and 203.3 ± 39.3 mg/dL (2008/09). Prevalence of uncontrolled high cholesterol ≥ 240 mg/dL for men decreased from 20.8% (1988/89) to 14.3% (1998/99) and 13.9% (2008/9), P = 0.002; for women the values decreased from 19.9% (1988/89), to 18.2% (1998/99) and 18.1% (2008/09), P = 0.007. Is statistically increased the number of patients treated and those treated to target.

CONCLUSION: Encouraging increases in awareness, treatment, and control of hypercholesterolemia occurred from 1988 through 2008. Nevertheless, control of hypercholesterolemia remains poor.

Stroke and coronary heart disease: predictive power of standard risk factors into old age--long-term cumulative risk study among men in Gothenburg, Sweden

Aims

The aim of this study was to examine the short-term and long-term cumulative risk of coronary heart disease (CHD) and stroke separately based on age, sex, smoking status, systolic blood pressure, and total serum cholesterol.

Methods and results

The Primary Prevention Study comprising 7174 men aged between 47 and 55 free from a previous history of CHD, stroke, and diabetes at baseline examination (1970–73) was followed up for 35 years. To estimate the cumulative effect of CHD and stroke, all participants were stratified into one of five risk groups, defined by their number of risk factors. The estimated 10-year risk for high-risk individuals when adjusted for age and competing risk was 18.1% for CHD and 3.2% for stroke which increased to 47.8 and 19.6%, respectively, after 35 years. The estimates based on risk factors performed well throughout the period for CHD but less well for stroke.

Conclusion

The prediction of traditional risk factors (systolic blood pressure, total serum cholesterol, and smoking status) on short-term risk (0–10 years) and long-term risk (0–35 years) of CHD of stroke differs substantially. This indicates that the cumulative risk in middle-aged men based on these traditional risk factors can effectively be used to predict CHD but not stroke to the same extent.

NHS health checks through general practice: randomised trial of population cardiovascular risk reduction

BACKGROUND

The global burden of the major vascular diseases is projected to rise and to remain the dominant non-communicable disease cluster well into the twenty first century. The Department of Health in England has developed the NHS Health Check service as a policy initiative to reduce population vascular disease risk. The aims of this study were to monitor population changes in cardiovascular disease (CVD) risk factors over the first year of the new service and to assess the value of tailored lifestyle support, including motivational interview with ongoing support and referral to other services.

METHODS

Randomised trial comparing NHS Health Check service only with NHS Health Check service plus additional lifestyle support in Stoke on Trent, England. Thirty eight general practices and 601 (365 usual care, 236 additional lifestyle support) patients were recruited and randomised independently between September 2009 and February 2010. Changes in population CVD risk between baseline and one year follow-up were compared, using intention-to-treat analysis. The primary outcome was the Framingham 10 year CVD risk score. Secondary outcomes included individual modifiable risk measures and prevalence of individual risk categories. Additional lifestyle support included referral to a lifestyle coach and free sessions as needed for: weight management, physical activity, cook and eat and positive thinking.

RESULTS

Average population CVD risk decreased from 32.9% to 29.4% (p <0.001) in the NHS Health Check only group and from 31.9% to 29.2% (p <0.001) in the NHS Health Check plus additional lifestyle support group. There was no significant difference between the two groups at either measurement point. Prevalence of high blood pressure, high cholesterol and smoking were reduced significantly (p <0.01) in both groups. Prevalence of central obesity was reduced significantly (p <0.01) in the group receiving additional lifestyle support but not in the NHS Health Check only group.

CONCLUSIONS

The NHS Health Check service in Stoke on Trent resulted in significant reduction in estimated population CVD risk. There was no evidence of further benefit of the additional lifestyle support services in terms of absolute CVD risk reduction.

A high-fat diet associated with acute schistosomiasis mansoni causes disorganization in splenic architecture in mice

To date, the effect of the changes promoted by hypercholesterolemia and experimental schistosomiasis infection on splenic architecture has remained elusive. In this paper, we compared spleen from control and infected mice fed either high-fat (29% lipids) or standard diet (12% lipids), assessing spleen volume by liquid displacement and splenic disorganization by histopathology, morphometry and stereology. Infected mice showed higher spleen volume than in corresponding uninfected mice (P<0.05). The white pulp compartment was reduced, red pulp and germinal center were enhanced (P<0.01). Microscopic examination showed cellular infiltrates characterized by polymorfonuclear cells, with intensive lymphocytic mitosis and Mott cells. Hemosiderin deposits tended to be in less extent in infected mice compared with uninfected controls. The red pulp compartment showed a significantly (P<0.05) increased average number of megakaryocytes compared with uninfected mice, which may be associated with hematopoietic reconstitution. High-fat fed mice showed larger white pulp than controls (P<0.05). Standard fed mice showed exudative-productive granuloma distributed only sparsely in the red pulp, whereas a tissue reaction characterized by a cell infiltration in high-fat fed mice was found. The results of the present study suggest that there is a significant relationship between high-fat diet intake and splenic disorganization such as a decrease in the numerical density of white pulp and, red pulp and germinal center hyperplasia. Such structural disorganization due to co-morbidites (schistosomiasis and dyslipidemia) may affect the microenvironments of the spleen that are necessary for the generation of immune responses to antigens.