Large-scale cohort study on the relationship between serum lipid concentrations and risk of cerebrovascular disease under low-dose simvastatin in Japanese patients with hypercholesterolemia: sub-analysis of the Japan Lipid Intervention Trial (J-LIT)

Efficacy, safety and clinical outcome associated with statin use for primary prevention in Korean patients with low-density lipoprotein cholesterol level ≥ 190 mg/dL: A retrospective cohort study

BACKGROUND

Although the current guideline recommends the use of high-intensity statin to reduce the low-density lipoprotein cholesterol (LDL-C) level by 50% in patients with baseline value of ≥ 190 mg/dL, direct application of this recommendation to Asian populations is still questionable. This study was performed to investigate the statin response of LDL-C in Korean patients with LDL-C ≥ 190 mg/dL.

METHODS

A total of 1,075 Korean patients (age 60.7 ± 12.2 years, women 68%) with baseline LDL-C ≥ 190 mg/dL without cardiovascular disease was retrospectively reviewed. Lipid profiles at 6 months, side effects and clinical outcomes during the follow-up period after statin treatment were assessed according to statin intensity.

RESULTS

Most of the patients (76.3%) were treated with moderate-intensity statins, 11.4% with high-intensity statins, and 12.3% with a statin + ezetimibe. The reductions in LDL-C percentage at 6 months were 48.0%, 56.0% and 53.3% in patients treated with moderate-intensity statins, high-intensity statins and statin + ezetimibe, respectively (P < 0.001). Side effects requiring dose reduction, medication switch or drug interruption were observed in 1.3%, 4.9% and 2.3% of patients treated with moderate-intensity statin, high-intensity statin and statin + ezetimibe, respectively (P = 0.024). During the median follow-duration of 815 days (interquartile range, 408-1,361 days), the incidences of cardiovascular events were not different among the 3 groups (log-rank P = 0.823).

CONCLUSIONS

Compared to high-intensity statin, moderate-intensity statin was effective enough in reaching target goal of LDL-C without increase in cardiovascular risk and with fewer side effects in Korean patients with LDL-C ≥ 190 mg/dL.

Deep, spontaneous intracerebral hemorrhages: Clinical differences and risk factors associated with anterior versus posterior circulation

BACKGROUND

spontaneous intracerebral hemorrhages (ICH) in different anatomical locations are considered different clinical entities, associated with different vascular etiologies. However, such a distinction between deep ICH in the posterior vs. the anterior circulation is not well documented.

OBJECTIVE

to look for different demographic, clinical, laboratory and radiological variables in order to clarify any distinction between deep ICH of the posterior versus the anterior circulations.

MATERIAL AND METHODS

Retrospective study on patients diagnosed with deep, spontaneous ICH at a single tertiary center. Patients were divided into two groups: posterior circulation (group 1) and anterior circulation (group 2). Computerized medical records were extracted for multiple variables.

RESULTS

A total of 142 patients with deep ICH were included in the study; 54.9 % (n = 78) with posterior (group 1) and 45.1 % (n = 64) with anterior circulation hemorrhages (group 2). In group 1, 67.9 % (n = 53) of hemorrhages were in the cerebellum and 28.2 % (n = 22) in the thalamus. Patients in group 1 were older at time of hemorrhage (68.69 ± 11.66 vs. 64.95 ± 13.34, p = 0.073) and had nearly threefold increased rate of BMI≥ 35 (22.0 % vs. 8.6 %, p = 0.071). In multivariate analysis, use of anti-aggregates (OR=2.391; 95 % CI 1.082-5.285, p = 0.031) and past medical history of HTN (OR=2.904; 95 % CI 1.102-7.654, p = 0.031) were significantly associated with ICH of the posterior circulation. When excluding patients with thalamic hemorrhages, BMI ≥ 35 was also associated with significant risk of having a deep hemorrhage in the posterior circulation vs. the anterior circulation (OR=3.420; 95 % CI 1.011-11.574, p = 0.048). No significant differences were found between the two groups in terms of functional and survival outcomes.

CONCLUSION

HTN, use of anti-aggregates and morbid obesity are associated with deep ICHs of the posterior circulation and should be considered significant risk factors for this major clinical event. The growing data on pathophysiology of distinct subgroups of ICH will provide useful tools that will aid in preventing and treating these neurological emergencies. Future epidemiological and clinical studies should use the distinction between ICH subgroups based on their anatomical location and vascular territories as accurately as possible in order to reach solid conclusions.

How low is safe? The frontier of very low (<30 mg/dL) LDL cholesterol

Low-density lipoprotein cholesterol (LDL-C) is a proven causative factor for developing atherosclerotic cardiovascular disease. Individuals with genetic conditions associated with lifelong very low LDL-C levels can be healthy. We now possess the pharmacological armamentarium (statins, ezetimibe, PCSK9 inhibitors) to reduce LDL-C to an unprecedented extent. Increasing numbers of patients are expected to achieve very low (<30 mg/dL) LDL-C. Cardiovascular event reduction increases log linearly in association with lowering LDL-C, without reaching any clear plateau even when very low LDL-C levels are achieved. It is still controversial whether lower LDL-C levels are associated with significant clinical adverse effects (e.g. new-onset diabetes mellitus or possibly haemorrhagic stroke) and long-term data are needed to address safety concerns. This review presents the familial conditions characterized by very low LDL-C, analyses trials with lipid-lowering agents where patients attained very low LDL-C, and summarizes the benefits and potential adverse effects associated with achieving very low LDL-C. Given the potential for cardiovascular benefit and short-term safe profile of very low LDL-C, it may be advantageous to attain such low levels in specific high-risk populations. Further studies are needed to compare the net clinical benefit of non-LDL-C-lowering interventions with very low LDL-C approaches, in addition to comparing the efficacy and safety of very low LDL-C levels vs. current recommended targets.

Deep versus Superficial Spontaneous Cerebellar Hemorrhages: Separated Vascular Etiologies with Different Clinical Consequences

BACKGROUND

Spontaneous cerebellar hemorrhage (CH) is a critical neurosurgical event. It is usually categorized as a homogenous group under the general term of deep/nonlobar intracerebral hemorrhage. However, increasing evidence suggests it is composed of 2 subgroups, separated from each other by their anatomic location (deep vs. superficial), as well as by their vascular etiology (small vessel disease vs. cerebral amyloid angiopathy).

OBJECTIVE

To identify any clinically significant differences between anatomically separated subgroups of CHs: deep versus superficial.

METHODS

This is a retrospective study on patients who were diagnosed with spontaneous CHs at a single tertiary center. On the basis of the radiologic location of the hematoma, patients were divided into 2 groups: deep (group 1) and superficial (group 2). Computerized medical records were extracted for multiple variables.

RESULTS

A total of 69 patients fulfilled the inclusion criteria. Fifty-three (77%) were in group 1, and 16 (23%) were in group 2. Having any vascular risk factor was associated with the highest odds ratio for having a deep CH. Morbid obesity (body mass index ≥30) and the use of antiplatelets were also associated with increased odds ratios. Group 1 is also associated with high prevalence of intraventricular hemorrhage, acute hydrocephalus, and less favorable outcome.

CONCLUSIONS

This study supports the notion that CH is most likely a heterogenous condition, composed of 2 subgroups, separated from each other in terms of anatomic location, vascular etiologies, and clinical consequences. Further studies on large cohort of patients are needed in order to accurately define the subgroups of this life-threatening event.

Low-density lipoprotein cholesterol and risk of intracerebral hemorrhage: A prospective study

OBJECTIVE

To prospectively examine the association between low-density lipoprotein (LDL) cholesterol (LDL-C) concentrations and intracerebral hemorrhage (ICH) risk.

METHODS

The current cohort study included 96,043 participants (mean age 51.3 years) who were free of stroke, myocardial infarction, and cancer at baseline (2006). Serum LDL-C concentrations were assessed in 2006, 2008, 2010, and 2012. Cumulative average LDL-C concentrations were calculated from all available LDL-C data during that period. Incident ICH was confirmed by review of medical records.

RESULTS

We identified 753 incident ICH cases during 9 years of follow-up. The ICH risk was similar among participants with LDL concentrations of 70 to 99 mg/dL and those with LDL-C concentrations ≥100 mg/dL. In contrast, participants with LDL-C concentrations <70 mg/dL had a significantly higher risk of developing ICH than those with LDL-C concentrations of 70 to 99 mg/dL; adjusted hazard ratios were 1.65 (95% confidence interval [CI] 1.32-2.05) for LDL-C concentrations of 50 to 69 mg/dL and 2.69 (95% CI 2.03-3.57) for LDL-C concentrations <50 mg/dL.

CONCLUSIONS

We observed a significant association between lower LDL-C and higher risk of ICH when LDL-C was <70 mg/dL, and the association became nonsignificant when LDL-C ≥70 mg/dL. These data can help determination of the ideal LDL range in patients who are at increased risk of both atherosclerotic disease and hemorrhagic stroke and guide planning of future lipid-lowering studies.

Treatment patterns in hyperlipidaemia patients based on administrative claim databases in Japan

BACKGROUND AND AIMS

Real-world evidence on treatment of hyperlipidaemia (HLD) in Japan is limited. We aimed to describe treatment patterns, persistence with, and adherence to treatment in Japanese patients with HLD.

METHODS

Retrospective analyses of adult HLD patients receiving drug therapy in 2014-2015 were conducted using the Japan Medical Data Center (JMDC) and Medical Data Vision (MDV) databases. Depending on their HLD treatment history, individuals were categorised as untreated (UT) or previously treated (PT), and were followed for at least 12 months. Outcomes of interest included prescribing patterns of HLD drug classes, persistence with treatment at 12 months, and adherence to treatment.

RESULTS

Data for 49,582 and 53,865 patients from the JMDC and MDV databases, respectively, were analysed. First-line HLD prescriptions for UT patients were predominantly for moderate statins (JMDC: 75.9%, MDV: 77.0%). PT patients most commonly received combination therapy (JMDC: 43.9%, MDV: 52.6%). Approximately half of the UT patients discontinued treatment during observation. Within each cohort, persistence rates were lower in UT patients than in PT patients (JMDC: 45.0% vs. 77.5%; MDV: 51.9% vs. 85.3%). Adherence was ≥80% across almost all HLD drug classes, and was slightly lower in the JMDC cohort than MDV cohort.

CONCLUSIONS

Most common prescriptions were moderate statins in UT patients and combination therapy in PT patients. The high discontinuation rate of HLD therapy in UT patients warrants further investigation and identification of methods to encourage and support long-term persistence.

Association of CDKN2B-AS1 rs1333049 with Brain Diseases: A Case-control Study and a Meta-analysis

Objective

CDKN2B-AS1 polymorphisms were shown to associate with the risk of stroke in European. The goal of this study was to evaluate the contribution of CDKN2B-AS1 rs1333049 to the risk of hemorrhagic stroke (HS) and brain tumor (BT) in Han Chinese.

Methods

A total of 142 HSs, 115 BTs, and 494 controls were included in the current association study. The genotyping test was performed using the melting temperature shift method.

Results

We failed to validate the association of CDKN2B-AS1 rs1333049 with the risk of brain disease. Significantly higher levels of low-density lipoprotein cholesterol (LDL-C) (p=0.027), high-density lipoprotein cholesterol (HDL-C) (p<0.001) and total cholesterol (TC) (p<0.001) were found in HSs in the genotype GG/GC carriers, but not the genotype CC carriers (p>0.05). The meta-analysis of 10 studies among 133,993 individuals concluded that rs1333049 of CDKN2B-AS1 gene was likely to increase a 16% incidence rate of cerebrovascular disease (CD) among various populations (odds ratio 1.16, 95% confidence interval 1.08–1.25; p<0.0001, random-effect method).

Conclusion

Our case-control study identified rs1333049 genotypes showed different association with the concentration of the LDL-C, HDL-C and TC in the HS patients. Meta-analysis supported the association between rs1333049 and CD risk in various populations, although we were unable to observe association between rs1333049 and the risk of HSs in Han Chinese.

Risk Factors for Early Hemorrhagic Progression after Traumatic Brain Injury: A Focus on Lipid Profile

The purpose of this study was to identify the risk factors related to the hemorrhagic progression (HP) of brain contusion in patients after traumatic brain injury (TBI). Recently, many studies have reported abnormal lipid levels associated with hemorrhagic stroke. Unlike hemorrhage stroke, however, the lipid profiles in patients with TBI have not been examined. Therefore, we evaluated the risk factors of HP in patients with TBI and focused on lipid profiles. Fifty-six patients with TBI with mild to moderate injuries (Glasgow Coma Scale ≥9) who initially did not need surgical intervention were enrolled in this study. Patients underwent repeated computed tomography (CT) scans at 4 h and 24 h after injury. Magnetic resonance imaging (MRI) was performed 7 days after the initial injury. In each noncontrast CT scan, the hemorrhage volume was quantified using the ABC/2 technique. Clinical features, previous medical history, initial CT, and microbleeding on follow-up MRI were analyzed retrospectively. There were 31 (55%) patients in whom significant HP developed (volume >30%). Current smoking (p=0.034), higher initial systolic blood pressure (p=0.035), and lower triglyceride levels (p=0.039) were significantly associated with HP. Current smoking and a triglyceride (TG) level <150 mg/dL were the only statistically significant predictors of HP in the multivariate analysis (p=0.019, p=0.021, respectively). HP with TBI is common in patients who currently smoke and have lower TG levels (150 mg/dL). These patients should be monitored closely, and surgery may be considered before deterioration occurs.

Statin use and risk of haemorrhagic stroke in a community-based cohort of postmenopausal women: an observational study from the Women's Health Initiative

OBJECTIVES

To determine whether statin treatment is associated with increased risk of haemorrhagic stroke (HS) in older women. A secondary objective was to evaluate HS risk in users of combined statin and antiplatelet treatment.

DESIGN

Observational study: secondary data analysis from the Women's Health Initiative (WHI) clinical trials.

SETTING

Women were recruited from 40 participating sites.

PARTICIPANTS

Cohort of 68,132 women followed through 2005 (parent study) and for an additional 5 years in the extension study.

MAIN OUTCOME MEASURES

Statin use was assessed at baseline and at follow-up visits (1, 3, 6 and 9 years). Women brought medications in original containers for inventory. Strokes were ascertained semiannually and centrally adjudicated. Risk of HS by statin use (time-varying covariate, with the 'no use' category as the referent) was estimated from Cox proportional hazard regression models adjusted for age (model 1); risk factors for HS (model 2); and possible confounders by indication (model 3). Prespecified subgroup analyses were conducted by use of antiplatelet medications.

RESULTS

Final models included 67,882 women (mean age, 63±7 years). Over a mean follow-up of 12 years, incidence rates of HS were 6.4/10,000 person-years among statin users and 5.0/10,000 person-years among non-users (p=0.11). The unadjusted risk of HS in statin users was 1.21 (CI 0.96 to 1.53); after adjusting for age and HS risk factors the HR was 0.98 (CI 0.76 to 1.26). Risk of HS was higher among women on statins and antiplatelet agents versus women on antiplatelet medications alone (HR=1.59; CI 1.03 to 2.47); p for interaction=0.011.

CONCLUSIONS

This retrospective analysis did not show an association between statin use and HS risk among older women. HS risk was higher among women taking statins with antiplatelet agents. These findings warrant further investigation, given potential implications for clinical decision-making.

Rationale and design of the EPISTEME trial: efficacy of post-stroke intensive rosuvastatin treatment for aortogenic embolic stroke

BACKGROUND

Large atheromatous aortic plaques (AAPs) are associated with stroke recurrence. Rosuvastatin is a potent lipid-lowering agent and suppresses carotid and coronary artery atherosclerosis. It is unclear whether rosuvastatin has anti-atherogenic effects against AAPs in stroke patients. We designed a clinical trial in stroke patients to analyze changes in AAPs after rosuvastatin treatment using repeated transesophageal echocardiography (TEE).

METHODS

This trial is a prospective randomized open label study. Inclusion criteria were patients were ischemic stroke with hypercholesterolemia and AAPs ≥ 4 mm in thickness. The patients are randomly assigned to either a group treated with 5 mg/day rosuvastatin or a control group. Primary endpoint is the changes in volume and composition of AAPs after 6 months using transesophageal echocardiography (TEE). Biochemical findings are analyzed. By using repeated TEE and binary image analysis, we will be able to compare the dynamic changes in plaque composition of AAPs before and after therapy in the two groups.

CONCLUSIONS

The EPISTEME trial will provide information on the changes in plaque volume and composition achieved by improvement of lipid profiles with rosuvastatin therapy in stroke patients with aortic atherosclerosis. The results of the study may provide evidence for a therapeutic strategy for aortogenic brain embolism. This study is registered with UMIN-CTR (UMIN000010548).

Total cholesterol level for assessing pancreatic insufficiency due to chronic pancreatitis

Background/Aims

To determine the nutritional markers important for assessing the degree of pancreatic insufficiency due to chronic pancreatitis in routine clinical practice.

Methods

A total of 137 patients with chronic pancreatitis were followed up for more than 1 year. They were divided into two groups: a pancreatic diabetes mellitus (DM) group, consisting of 47 patients undergoing medical treatment for DM of pancreatic origin, and a nonpancreatic DM group, consisting of 90 other patients (including 86 patients without DM). Serum albumin, prealbumin, total cholesterol, cholinesterase, magnesium, and hemoglobin were compared between the two groups.

Results

The total cholesterol was significantly lower in the pancreatic than the nonpancreatic DM group (164 mg/dL vs 183 mg/dL, respectively; p=0.0028). Cholinesterase was significantly lower in the former group (263 U/L vs 291 U/L, respectively; p=0.016). Among the 37 patients with nonalcoholic pancreatitis, there was no difference in the cholinesterase levels between the pancreatic and nonpancreatic (296 U/L vs 304 U/L, respectively; p=0.752) DM groups, although cholesterol levels remained lower in the former (165 mg/dL vs 187 mg/dL, respectively; p=0.052).

Conclusions

Cholinesterase levels are possibly affected by concomitant alcoholic liver injury. The total cholesterol level should be considered when assessing pancreatic insufficiency due to chronic pancreatitis.

HindIII polymorphism in the lipoprotein lipase gene and hypertensive intracerebral hemorrhage in the Chinese Han population

BACKGROUND

To investigate the relationship between the HindIII polymorphism and hypertensive intracerebral hemorrhage (HIH) and lipid metabolism.

METHODS

A polymerase chain reaction-restriction fragment length polymorphism assay and the chain termination DNA sequencing method were used to determine the HindIII genotypes of 267 subjects, which included 120 cerebral hemorrhagic patients and 147 controls. The fasting levels of lipids and glucose in the plasma were used to measure the effect of genotype on HIH risk factors.

RESULTS

The frequency of the T allele of the HindIII polymorphism in the HIH group was 90.8%. The frequency of the G allele was 9.2%. In the control group, the frequencies were 82.3% T and 17.7% G, which indicated that the proportion of the G allele in the HIH patient group was significantly lower than in the control group (P<.05). The frequency of GG+GT genotypes in HIH patients (P<.05) and the plasma triglyceride (TG) levels in these patients (P<.05) were also lower than in the control group. The levels of plasma TG, low-density lipoprotein cholesterol, glucose, systolic blood pressure, and diastolic blood pressure in the HIH group were higher than in the controls (P<.05). After controlling for risk factors related to HIH, the HindIII G allele was negatively correlated with the incidence of HIH (odds ratio=.417, 95% confidence interval: .193-.901).

CONCLUSIONS

The HindIII G allele may be a protective factor against the development of HIH among the Han Chinese population.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

LDL cholesterol goals in high-risk patients: how low do we go and how do we get there?

It is widely recognised that low-density lipoprotein cholesterol (LDL-C) is one of the most important and modifiable risk factors for cardiovascular disease (CVD). Statins (HMG-CoA reductase inhibitors) have consistently been shown to decrease both LDL-C and CVD risk in almost all patient categories, with the exception of heart and kidney failure as well as advanced aortic stenosis. As a consequence, statins have become the cornerstone in current prevention guidelines. In patients who do not reach the LDL-C target, combination therapy with additional LDL-C lowering drugs (e.g. ezetimibe, bile acid sequestrants or fibrates) should be considered. Guidelines provide different LDL-C levels to strive for, depending on the CVD risk. In this review, we describe the rationale for these LDL-C targets and how these goals might be reached by current and future therapies.

Ideal lipid profile and genes for an extended life span

PURPOSE OF REVIEW

The world population is aging and a rapid increase is being seen in the very elderly (aged >80 years). Cholesterol levels in general rise with age and high cholesterol has been associated with extreme longevity. The relationship between lipids and cardiovascular events in the extreme elderly is unclear.

RECENT FINDINGS

A number of genetic factors associated with lipid metabolism have also been described as having potential antiaging roles, including the genes encoding lipoprotein-associated factors - apolipoprotein E and cholesterol ester transfer protein; adipose tissue metabolism - adiponectin, leptin, glycaemia; and blood pressure - angiotensinogen. Clinical trials of lipid-lowering therapies have recruited subgroups of moderately elderly patients, but only the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) trial specifically recruited an elderly population. There is no direct equivalent of the Hypertension in the Very Elderly trial (HYVET) study of antihypertensive patients in the extreme elderly. No heterogeneity has been seen with the effects of statin therapy in the elderly compared with younger age groups on classical cardiovascular endpoints of coronary heart disease and stroke.

SUMMARY

The optimal cholesterol target, long-term tolerability and the specific effects of statins on other vascular-associated diseases of aging, for example arterial aneurysms, microvascular renal and cerebral disease (dementias), remain to be determined.

Serum lipid levels and the risk of intracerebral hemorrhage: the Rotterdam Study

OBJECTIVE

Low serum total cholesterol levels are associated with an increased risk of symptomatic intracerebral hemorrhage and with presence of asymptomatic cerebral microbleeds. The relative contribution of lipid fractions to these associations is unclear and requires investigation. We determined whether serum HDL-cholesterol, LDL-cholesterol, and triglycerides are associated with risk of intracerebral hemorrhage and presence of cerebral microbleeds.

METHODS AND RESULTS

Nine thousand sixty-eight stroke-free community-dwelling persons aged ≥55 were followed from baseline (1990-2001) up to January 1, 2009, of whom 85 suffered from intracerebral hemorrhage during follow-up. Brain MRI was carried out in 789 healthy participants, of whom 162 had cerebral microbleeds. Triglycerides were strongly and inversely associated with intracerebral hemorrhage, independently of HDL-cholesterol, LDL-cholesterol, and potential confounders [hazard ratio for highest versus lowest quartile: 0.20 (0.06-0.69)]. Triglycerides were also associated with deep or infratentorial microbleeds [odds ratio for highest versus lowest quartile: 0.37 (0.14-0.96)], but not with strictly lobar microbleeds. No associations were found for HDL-cholesterol or LDL-cholesterol.

CONCLUSIONS

Low serum triglyceride levels were associated with an increased risk of intracerebral hemorrhage and with the presence of deep or infratentorial cerebral microbleeds. This provides novel insights into the role of lipid fractions, particularly triglycerides, in the etiology of intracerebral hemorrhage.

Lower levels of high-density lipoprotein cholesterol on admission and a recurrence of ischemic stroke: a 12-month follow-up of the Fukuoka Stroke Registry

BACKGROUND

Despite recent progress in treatments for secondary prevention, ischemic stroke recurs in 8% to 12% of stroke survivors. We investigated the predisposing factors associated with recurrence within the first 12 months after an ischemic event to explore more effective preventive strategies.

METHODS

Between June 2007 and April 2008, acute (within 7 days of onset) ischemic stroke patients were registered in the Fukuoka Stroke Registry (FSR), a multicenter, prospective, observational database. The clinical characteristics on admission were analyzed, and the patients were followed for 12 months.

RESULTS

Two hundred sixty patients (151 males and 109 females, 71 ± 11 years of age) were registered; 25 (9.6%) had recurrence of ischemic stroke during the follow-up period. Kaplan-Meier curve analysis revealed a significant difference in recurrence-free survival between patients with high-density lipoprotein (HDL) cholesterol <40 mg/dL on admission and those with HDL cholesterol ≥ 40 mg/dL (P = .042). Adjusted multivariate logistic regression analysis showed that age (odds ratio 1.06; 95% CI, 1.00-1.11; P = .035) and HDL cholesterol <40 mg/dL (odds ratio 2.73; 95% CI, 1.01-7.38; P = .048) on admission were independently associated with a recurrence of ischemic stroke within 12 months of the initial onset.

CONCLUSIONS

Aging and low HDL cholesterol levels are considered independent risk factors for a recurrence of ischemic stroke.

Triglycerides and risk of hemorrhagic stroke vs. ischemic vascular events: The Three-City Study

BACKGROUND

Few studies have assessed the relationship between triglycerides and the risk of hemorrhagic stroke, which contrasts the considerable number of studies about triglycerides and ischemic vascular events. We analyzed the association pattern between triglycerides and incident intracerebral hemorrhage as compared with coronary events and ischemic stroke, in a large cohort of elderly.

METHODS

Population-based, prospective cohort study among 8393 men and women participating in the Three-City Study, aged > or = 65 years at baseline. Fasting blood lipids, including triglycerides, were measured at baseline. Fatal and non-fatal strokes and coronary events were adjudicated and validated by scientific committees. Cox proportional hazards models were used to adjust for potential confounders.

RESULTS

During a mean follow-up of 5.0 years, 36 hemorrhagic strokes, 143 ischemic strokes, and 393 coronary events occurred. An increased level of triglycerides was associated with an increased risk of ischemic vascular events. Conversely, a low level of triglycerides (< or = 0.94 mmol/L) was associated with an increased risk of hemorrhagic stroke (adjusted hazard ratio 2.35; 95% confidence interval 1.18-4.70). The relationship with hemorrhagic stroke was mainly apparent in men, in individuals with high blood pressure, and in those with low levels of cholesterol.

CONCLUSIONS

In this large cohort of elderly men and women, low triglycerides levels were associated with an increased risk of hemorrhagic stroke and a decreased risk of ischemic vascular events. The association between triglycerides and hemorrhagic stroke was particularly strong in men, in subjects with high blood pressure and in those with low cholesterol levels.

Asymptomatic cerebral microbleeds seen in healthy subjects have a strong association with asymptomatic lacunar infarction

BACKGROUND

Cerebral microbleed (CMB), which is conspicuous on gradient-echo T2-weighted magnetic resonance imaging, is a risk factor of intracerebral hemorrhage (ICH). CMBs have been detected even in neurologically healthy persons, who also seem prone to be affected by stroke, not only ICH but also cerebral infarction.

METHODS AND RESULTS

The presence of CMB was investigated in brain dock participants, making reference to silent lacunar infarction (SLI). Participants comprised 377 neurologically healthy persons and 21 (5.6%) had CMB detected, which was associated with a high incidence of hypertension, other conventional risk factors having no significant correlation with CMB. In a simple correlation analysis, CMB showed a positive association with age and systolic blood pressure (SBP). Logistic regression analysis revealed that SLI was the factor most strongly associated with CMB. Moreover, individuals who had both CMB and SLI had higher SBP than other groups.

CONCLUSIONS

The etiology of CMB is similar to that of SLI.

Extracranial carotid plaque is increasing in Japanese ischemic stroke patients

OBJECTIVE

The objectives of this study were to investigate the prevalence of extracranial carotid plaque and the association between risk factors and carotid plaque in Japanese patients with ischemic stroke.

METHODS

We consecutively recruited patients with ischemic stroke admitted to our hospital from January 2000 to September 2002. Neurologic signs and a brain magnetic resonance imaging diagnosed ischemic stroke. All subjects underwent a carotid ultrasonography. Multiple logistic regression analysis was used to determine the risk factors that independently contributed to the presence of carotid plaques.

RESULTS

Carotid plaques were identified in 76.2% of the patients and bilateral plaques were found in 58.2%. These lesions were more frequent in comparison with previous Japanese reports. The risk factors that independently contributed to the presence of extracranial carotid plaques were hypertension, age, smoking and past history of ischemic stroke.

CONCLUSIONS

This study demonstrates that extracranial carotid plaque is increasing in Japanese patients with ischemic stroke.

Effects of hypertension and type 2 diabetes mellitus on the risk of total cardiovascular events in Japanese patients with hypercholesterolemia: implications from the Japan Lipid Intervention Trial (J-LIT)

Hyperlipidemia, hypertension, and diabetes mellitus (DM) are well-established risk factors for cardiovascular disease. We analyzed the cardiovascular events in hyperlipidemic patients with or without DM who were administered open-labeled simvastatin in groups stratified by blood pressure level using data from the Japan Lipid Intervention Trial (J-LIT). Hyperlipidemic patients with DM (n=6,288) had significantly more cardiovascular events than those without DM (n=33,933). The incidence rates of total cardiovascular events in the Non-DM and DM groups were 15.40 and 25.76 per 1,000 patients for the 6-year period, respectively. The relative risk of total cardiovascular events in the DM vs. the Non-DM group was 1.68, and the relative risk was significantly higher in the DM than in the Non-DM group. The relative risks of total cardiovascular events were significantly higher in DM and Non-DM patients whose systolic blood pressure (SBP) was greater than or equal to 130 mmHg compared to that of Non-DM patients whose SBP was less than 130 mmHg, and in DM and Non-DM patients whose diastolic blood pressure (DBP) was greater than or equal to 80 mmHg compared to that of Non-DM patients whose DBP was less than 80 mmHg. In all groups stratified by SBP and DBP, relative risks of total cardiovascular events were higher in DM patients than in Non-DM patients. For patients with hypercholesterolemia and DM, blood pressure should be strictly controlled in order to prevent both coronary events and stroke. These results are in good agreement with the JNC 7 and the ESH/ESC guidelines for DM patients, which recommended that the SBP and DBP be less than 130 and 80 mmHg, respectively.

Risk factors for primary intracerebral hemorrhage in patients in Izumo City, Japan

The annual incidence rate of primary intracerebral hemorrhage (ICH) in Izumo City, Japan, appears to be the highest rate among those reported. Despite improvement of management and surgical therapy, the overall morbidity and mortality after ICH are still high. The author investigated the risk factors for ICH in patients in Izumo. A case-control study of 242 patients (137 men and 105 women with ages ranging from 34 to 97 years) with primary ICH was conducted in Izumo between 1991 and 1998. Hypertension, diabetes mellitus, heart disease, liver disease, alcohol consumption, cigarette smoking, and serum levels of total cholesterol, aspartate aminotransferase, and alanine aminotransferase were assessed as possible risk factors for ICH by using conditional logistic regression. The prevalence of hypertension among ICH patients was 77% and the odds ratio (OR) for hypertension was 17.07 (95% CI: 8.30-35.09), which are much higher than figures reported from Western countries. The OR for hypertension was higher in individuals < or = 69 years of age than in those > or = 70 years of age and lower for lobar hemorrhage than for hemorrhages at other sites. High serum total cholesterol (> or = 220 mg/dl) was the second most important risk factor for ICH (OR: 2.52; 95% CI: 1.23-5.14), and low total cholesterol (< 160 mg/dl) decreased the risk of ICH (OR: 0.47; 95% CI: 0.27-0.82). In contrast, heart disease decreased the risk of ICH, and there was no observed association between alcohol consumption, cigarette smoking, or diabetes mellitus and ICH. This study conducted in Izumo suggests that hypertension is the most important risk factor for ICH and contrary to most previous studies indicates that serum total cholesterol concentration is also positively associated with the risk of ICH. In contrast, heart disease may decrease the risk of ICH.

Rationale and design for a study using intravascular ultrasound to evaluate effects of rosuvastatin on coronary artery atheroma in Japanese subjects: COSMOS study (Coronary Atherosclerosis Study Measuring Effects of Rosuvastatin Using Intravascular Ultrasound in Japanese Subjects)

BACKGROUND

There have been few multicenter studies using intravascular ultrasound (IVUS) to assess the process of atherosclerosis in a Japanese population with hypercholesterolemia that is being treated with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors for control of low-density lipoprotein-cholesterol.

METHODS AND RESULTS

An open-label multicenter study is planned to evaluate with IVUS whether treatment with rosuvastatin for 76 weeks results in regression of coronary artery atheroma volume in patients who have coronary heart disease (CHD) and hypercholesterolemia. Sample size is 200 subjects with CHD who are to undergo percutaneous coronary intervention. The planned duration is between October 2005 and October 2008.

CONCLUSIONS

The COSMOS study will be the first multicenter cardiovascular study in a Japanese population and may provide new evidence on the effects of rosuvastatin on the progression of coronary atherosclerotic lesions.

Gender difference in coronary events in relation to risk factors in Japanese hypercholesterolemic patients treated with low-dose simvastatin

BACKGROUND

Gender differences between the risk factors for coronary heart disease and coronary events were examined in the Japan Lipid Intervention Trial, a 6-year observational study.

METHODS AND RESULTS

Men (12,575) and women (27,013) were analyzed for risk of coronary events (acute myocardial infarction and sudden cardiac death). Simvastatin reduced serum low-density lipoprotein cholesterol (LDL-C) by 27% in both genders, and increased serum high-density lipoprotein cholesterol (HDL-C) in men (5%) and women (4%). The incidence of coronary events was lower in women (0.64/1,000 patient-years) than in men (1.57/1,000 patient-years). The risk of coronary events increased by 18% in men and 21% in women with each 10 mg/dl elevation of LDL-C, and decreased by 39% in men and 33% in women with each 10 mg/dl elevation of HDL-C. The risk increased proportionally with aging in women, but not in men. Diabetes mellitus (DM) was more strongly related to the risk of coronary events for women (relative risk 3.07) than for men (relative risk 1.58).

CONCLUSIONS

The incidence of coronary events is lower in women. Serum LDL-C is related to an increased risk of coronary events to the same extent in both genders. DM seems to be a more important risk factor in women, trading off the lower risk of coronary events among them.

Fasting triglyceride is a significant risk factor for coronary artery disease in middle-aged Japanese men

BACKGROUND

It has been well established that dyslipidemia is a significant risk factor for coronary artery disease (CAD), however, the association between fasting triglyceride (TG) and the occurrence of CAD is controversial. The objective of this study was to elucidate the relationship between fasting TG and CAD in middle-aged Japanese men.

METHODS AND RESULTS

A cohort study of 6,966 middle-aged Japanese men (mean +/- SD: 46.6+/-5.2 years) with a 10-year follow-up period was conducted to identify risk factors for the occurrence of CAD. One hundred and eleven cases of CAD were identified during the follow up. The Cox proportional hazard model was used to identify the independent risk factors for CAD. Adjustment was made for variables including age, body mass index, smoking habit, alcohol intake, duration of sleeping, systolic blood pressure, uric acid, total cholesterol, high-density lipoprotein cholesterol, fasting plasma glucose, and TG. Fasting TG was identified as an independent risk factor for CAD. The adjusted hazard ratio of TG for CAD was 3.07 (95% confidence interval: 1.01-9.35, p<0.05). Additionally, a serum TG concentration level greater than 78 mg/dl was a significant risk for CAD.

CONCLUSIONS

By using the long term follow-up data of the study of middle-aged Japanese men, fasting TG was identified to be a significant risk factor for CAD.

Treatment of Hyperlipidemia from Japanese Evidence

The treatment of hyperlipidemia is aimed at preventing cardiovascular disease (CVD) and coronary heart disease (CHD). As the incidence of CHD in Japan is about one-third lower and that of stroke is two-fold higher compared to Western countries, and the doses of lipid-lowering drugs used in foreign randomized controlled clinical trials (RCTs) are much higher than in general use in Japan, it remains unclear whether the results of RCTs conducted in Western countries could be extrapolated to Japanese patients. Recently, two major large-scale, prospective, RCTs in Japanese hypercholesterolmic patients, the Management of Elevated Cholesterol in the Primary Prevention of Adult Japanese (MEGA) study and the Japan EPA Lipid Intervention Study (JELIS), have been reported. Japanese epidemiological studies and Japanese clinical studies are reviewed. The evidence suggests that hypercholesterolemia, hypertriglyceridemia, and low HDL-cholesterol are strongly associated with increased CHD risk. Lipid-lowering medication shows beneficial effects even in low-risk populations; however, the data did not support that lower cholesterol is better. The safety and efficacy of hyperlipidemia treatment in Japanese patients are discussed.

Pharmacoeconomic Analysis of Cilostazol for the Secondary Prevention of Cerebral Infarction

BACKGROUND

The antiplatelet agent, cilostazol, is known to reduce the risk of subsequent cerebral infarction. However, the cost effectiveness of such treatment in comparison to aspirin has not been studied.

METHODS AND RESULTS

A Markov model was developed to calculate the health outcomes and associated costs for 65-year-old patients with cerebral infarction who were treated with 200 mg/day cilostazol or 81 mg/day aspirin. Cilostazol was more effective, but also more expensive than aspirin. Cilostazol would extend quality-adjusted life years (QALY) by 0.64, while increasing life-time costs by approximately Yen 1.1 million. The incremental cost-effectiveness ratio of cilostazol in comparison with aspirin was estimated to be Yen 1.8 million per QALY.

CONCLUSIONS

The use of cilostazol to prevent recurrence of cerebral infarction appears to be cost effective.

The Risk of Cardiovascular Events in Japanese Hypertensive Patients with Hypercholesterolemia: Sub-Analysis of the Japan Lipid Intervention Trial (J-LIT) Study, a Large-Scale Observational Cohort Study

Coronary events and stroke are leading causes of death in Japan. However, the effects of hypertension on the risk of coronary events and stroke have not been well established in Japanese hypercholesterolemic patients. This study aimed to determine the relationship between the risk of coronary events or stroke and blood pressure and cholesterol levels during low-dose simvastatin treatment using data from the Japan Lipid Intervention Trial (J-LIT) study (a large scale nationwide cohort study). In the present study, 47,294 hypercholesterolemic patients were treated with open-labeled simvastatin (5 to 10 mg/day) for 6 years by a large number of physicians in a clinical setting. The adjusted incidence rates of coronary events in males and females were 8.9 and 2.3 and those of stroke were 17.6 and 11.3/1000 patients during the 6-year period, respectively. The incidence rate of stroke was higher than that of coronary events in both males and females. An obvious sex difference was observed in terms of the incidence of coronary events. The risk of coronary events, stroke, and total cardiovascular events were increased, with elevations in blood pressure observed in patients treated for hypercholesterolemia. The risk of total cardiovascular events in the groups exhibiting less lipid control increased, with lower blood pressure levels than those of the well-controlled group. For patients with hypercholesterolemia and hypertension, blood pressure should be strictly controlled in order to prevent both coronary events and stroke, and the serum total cholesterol levels should be maintained at low levels as well.