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Birhanu MM, Zaman SB, Thrift AG, Evans RG, Zengin A. Risk factors for incident cardiovascular events among adults in low- and middle-income countries: A systematic review and meta-analysis of prospective cohort studies. Prev Med 2022; 158:107036. [PMID: 35358600 DOI: 10.1016/j.ypmed.2022.107036] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 03/03/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
The relative contributions of risk factors for cardiovascular events at a population level has received little attention in low- and middle-income countries (LMICs). We estimated the population attributable fraction (PAF) of risk factors associated with incident cardiovascular events in LMICs. We searched six databases for relevant articles, supplemented with a manual search of reference lists. Articles included in the meta-analyses were those based on prospective community-based cohorts and incorporating adjusted hazard ratios (HR) or relative risks with 95% confidence intervals (95% CI) for associations between risk factors and a composite cardiovascular and/or stroke endpoint. Pooled HRs and 95% CI were calculated using the random effects model. We assessed heterogeneity using the I2 test and study quality using the Newcastle-Ottawa Scale. We calculated the PAF of each associated risk factor. The protocol was registered in PROSPERO (CRD42019122741). We identified 18 cohorts from LMICs with 1,125,846 participants, 77,045 composite cardiovascular events and 42,216 strokes. Substantial proportions of incident cardiovascular events were attributable to hypertension (HR [95% CI], 2.23 [2.01-2.48], PAF = 28%); current smoking (1.44 [1.31-1.58], PAF = 10%); and diabetes mellitus (1.93 [1.67-2.23], PAF = 8%). Other risk factors identified included number of children, depression, bone mineral density, and air pollution. A substantial proportion of incident cardiovascular events were linked to traditional metabolic and behavioural modifiable risk factors. However, other novel risk factors also appear to contribute. Targeting of these established and novel risk factors has the potential to reduce the burden of CVD in LMICs.
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Affiliation(s)
- Mulugeta Molla Birhanu
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Sojib Bin Zaman
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia; Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Ayse Zengin
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.
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Motamed N, Ajdarkosh H, Karbalaie Niya MH, Panahi M, Farahani B, Rezaie N, Nikkhah M, Faraji AH, Hemmasi G, Perumal D, Ashrafi GH, Safarnezhad Tameshkel F, Gholizadeh E, Khoonsari M, Zamani F. Scoring systems of metabolic syndrome and prediction of cardiovascular events: A population based cohort study. Clin Cardiol 2022; 45:641-649. [PMID: 35419856 PMCID: PMC9175260 DOI: 10.1002/clc.23827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aims Continuous scoring systems were developed versus traditional dichotomous approaches to define metabolic syndrome. The current study was carried out to evaluate the ability of scoring systems to predict fatal and nonfatal cardiovascular events. Materials and Methods The data of 5147 individuals aged 18 years or more obtained from a population‐based cohort study were analyzed. The occurrence of atherosclerotic cardiovascular disease (ASCVD) in the period of 7 years follow‐up was considered as the associated outcome. Joint Interim Statement (JIS) definition, as a traditional definition of metabolic syndrome (MetS), and two versions of MetS scoring systems, based on standardized regression weights from structural equation modeling (SEM) and simple method for quantifying metabolic syndrome (siMS) were considered as potential predictors. Results The scoring systems, particularly, based on SEM, were observed to have a significant association with composite cardiovascular events (HR = 1.388 [95% CI = 1.153–1.670], p = .001 in men and HR = 1.307 [0.95% CI = 1.120–1.526] in women) in multiple Cox proportional hazard regression analyses, whereas the traditional definition of MetS did not show any significant association. While both two scoring systems showed acceptable predictive abilities for cardiovascular events in women (MetS score based on SEM: area of under curve [AUC] = 0.7438 [95% CI = 0.6195–0.7903] and siMS: AUC = 0.7207 [95% CI = 0.6676–0.7738]), the two systems were not acceptable for identifying risk in men. Conclusion Unlike the dichotomous definition of MetS, the scoring systems showed an independent association with cardiovascular events. Scoring systems, particularly those based on SEM, may be useful for the prediction of cardiovascular events in women.
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Affiliation(s)
- Nima Motamed
- Department of Social Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Hossein Ajdarkosh
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mahshid Panahi
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behzad Farahani
- Department of Cardiology, Iran University of Medical Sciences, Tehran, Iran
| | - Nader Rezaie
- Department of Pulmonology, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Nikkhah
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amir H Faraji
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Hemmasi
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Dhayaneethie Perumal
- Faculty of Science, Engineering and Computing, Kingston University, Kingston, UK
| | | | | | - Esmaeel Gholizadeh
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmoodreza Khoonsari
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Zamani
- Gastrointestinal and Liver Diseases Research Center, Iran University of Medical Sciences, Tehran, Iran
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Lee EY, Han K, Kim DH, Park YM, Kwon HS, Yoon KH, Kim MK, Lee SH. Exposure-weighted scoring for metabolic syndrome and the risk of myocardial infarction and stroke: a nationwide population-based study. Cardiovasc Diabetol 2020; 19:153. [PMID: 32993664 PMCID: PMC7525999 DOI: 10.1186/s12933-020-01129-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/18/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) status changes over time, but few studies have investigated the relationship between the extent or duration of exposure to MetS and the risk of cardiovascular disease (CVD). We investigated the cumulative effects of MetS and its components on the risk of myocardial infarction (MI) and stroke. METHODS From the Korean National Health Insurance database, 2,644,851 people who received annual health examinations from 2010 to 2013 were recruited. Exposure-weighted scores for MetS during this 4-year period were calculated in two ways: cumulative number of MetS diagnoses (MetS exposure score, range: 0-4) and the composite of its five components (MetS component exposure score, range: 0-20). The multivariable Cox proportional-hazards model was used to assess CVD risk according to the exposure-weighted scores for MetS. RESULTS MetS was identified at least once in 37.6% and persistent MetS in 8.2% of subjects. During the follow-up (median, 4.4 years), 10,522 cases of MI (0.4%) and 10,524 cases of stoke (0.4%) occurred. The risk of MI and stroke increased gradually with increasing exposure scores of MetS and its components (each P for trend < 0.0001). The hazard ratio [(HR) (95% CI)] of MI and stroke were 5.27 (4.20-6.62) and 3.90 (3.09-4.93), respectively, in those with a score of 20 compared with those with a MetS component exposure score of 0. People fulfilling only two MetS components out of 20 already had 22% increased risk of MI, and those with three MetS components had 24% increased risk of stroke. These associations were consistent in the subgroup and sensitivity analyses. CONCLUSIONS A dose-response relationship between the cumulative exposure to metabolic disturbances and incident MI or stroke was evident. Even minimal exposure to MetS components was sufficient to increase the risk of CVD significantly, highlighting the importance of intensive risk management for the prevention of CVD.
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Affiliation(s)
- Eun Young Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #222 Banpo-daero, Seocho-gu, Seoul, 06591, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, 06978, South Korea
| | - Da Hye Kim
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, 06591, South Korea
| | - Yong-Moon Park
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, 27709, USA
| | - Hyuk-Sang Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #10 63-ro, Yeongdeungpo-gu, Seoul, 07345, South Korea
| | - Kun-Ho Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #222 Banpo-daero, Seocho-gu, Seoul, 06591, South Korea
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, 06591, South Korea
| | - Mee Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #10 63-ro, Yeongdeungpo-gu, Seoul, 07345, South Korea.
| | - Seung-Hwan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #222 Banpo-daero, Seocho-gu, Seoul, 06591, South Korea.
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, 06591, South Korea.
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Li C, He J, Wei B, Zhang X, Wang X, Zhang J, Wang K, Hu Y, Mu L, Yan Y, Ma J, Song Y, Guo H, Ma R, Guo S. Effect of metabolic syndrome on coronary heart disease in rural minorities of Xinjiang: a retrospective cohort study. BMC Public Health 2020; 20:553. [PMID: 32334557 PMCID: PMC7183686 DOI: 10.1186/s12889-020-08612-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Metabolic syndrome is diagnosed by a cluster of risk factors that associated with an increased risk of coronary heart disease (CHD). We aimed to explore the impact of and interactions between individual metabolic syndrome components on the risk of CHD in Xinjiang. Methods The baseline population included 7635 participants. The degree to which the components increase the risk of CHD and the multiplicative interactions between them were assessed using hazard ratios (HRs) and 95% confidence intervals (CIs). Additive interactions were appraised by the relative excess risk due to interaction, synergy index (SI), and attributable proportion of interaction. Results A total of 304 CHD patients were enrolled from rural residents of Xinjiang. Elevated blood pressure (HR 1.81; 95% CI 1.35–2.44) and elevated fasting blood glucose (FBG) (HR 1.82; 95% CI 1.38–2.38) increased the risk of CHD after adjustment for confounding factors. We found a positive additive interaction (SI 1.14; 95% CI 0.51–2.51) between elevated blood pressure and elevated FBG, but none were significant. As the number of components increased, the risk of CHD increased. The combinations of [high triglycerides (TG) + low high-density lipoprotein cholesterol (HDL-C) + elevated FBG + large waistline] (HR 4.26; 95% CI 1.43–12.73) and [elevated blood pressure + elevated FBG + low HDL-C + large waistline] (HR 1.82; 95% CI 1.38–2.38) increased the risk of CHD. Conclusions We provide evidence that elevated blood pressure and elevated FBG are independent risk factors for CHD and it might be necessary to maintain the normal waistline for preventing CHD.
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Affiliation(s)
- Changjing Li
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Jia He
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Bin Wei
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Xianghui Zhang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Xinping Wang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Jingyu Zhang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Kui Wang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Yunhua Hu
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Lati Mu
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Yizhong Yan
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Jiaolong Ma
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Yanpeng Song
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Heng Guo
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Rulin Ma
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China
| | - Shuxia Guo
- Department of Public Health, Shihezi University School of Medicine, Shihezi, China.
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Comparison Between Metabolic Syndrome and the Framingham Risk Score as Predictors of Cardiovascular Diseases Among Kazakhs in Xinjiang. Sci Rep 2018; 8:16474. [PMID: 30405180 PMCID: PMC6220288 DOI: 10.1038/s41598-018-34587-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 10/19/2018] [Indexed: 12/29/2022] Open
Abstract
Metabolic syndrome (MS) and Framingham risk score (FRS) can be used for predicting the risk of developing cardiovascular diseases (CVD). Previous studies that compared FRS and MS have focused on high-income urban areas. This study focused on the comparison between FRS and MS when used in nomadic minorities in mountain areas. Moreover, an applicable tool for predicting the risk of developing CVD was identified. 2,286 participants who were recruited from the far west of China were followed-up for a median of 5.49 years. MS and FRS were compared in terms of their ability in predicting development of CVD using Cox regression and receiver operating characteristic curve. After each component of MS was appraised, its area under the curve (AUC) was 0.647. When age was included, the AUC of MS risk score increased from 0.647 to 0.758 (P < 0.001). After adjusting for age, the AUC of FRS decreased from 0.732 to 0.582 (P < 0.001). The association between CVD and each quintile of MS risk score that included age was more significant than that between FRS and CVD under the same exposed condition. In conclusion, MS risk score that included age may be a better predictor of CVD among Kazakhs.
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Yang W, Gao X, Zhang X, Hu Y, Guo H, Wang K, Yan Y, He J, Zhang J, Ma J, Mao L, Mu L, Liu J, Li S, Ding Y, Zhang M, Ma R, Guo S. Impact of interactions among metabolic syndrome components on the development of cardiovascular disease among Kazakhs in Xinjiang. PLoS One 2018; 13:e0205703. [PMID: 30325976 PMCID: PMC6191126 DOI: 10.1371/journal.pone.0205703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022] Open
Abstract
Background Few prospective studies have explored the effect of interactions among metabolic syndrome (MS) components on the development of cardiovascular disease (CVD) in the Kazakh population in Xinjiang Province of China. Method As of December 2016, 2,644 participants who completed a baseline survey over a period of 5 years or more were included in the study. The multiplicative interactions among MS components were evaluated by incorporation of the product terms into a logistic regression model. The additive interactions among MS components were evaluated by calculating the additive interaction index. Logistic regression was used to construct a predictive model, and CVD risk level was divided according to the risk probability of the population that did not eventually have CVD. Results When we analyzed the independent risk of MS and its components on developing CVD, only blood pressure(BP) and waist circumference(WC) were associated with CVD. A linear association was found between the risk of CVD, BP/WC, and the number of other components (trend, P<0.001). The risk of developing CVD increased when BP and WC coexisted, or when combined BP/WC with MS (≥3 components except for BP and WC) was present; however, there were no significant interactions among MS components. After the CVD hazards were divided into four levels, it was showed that over 19.92% of the incidence probability was in the population under mediate-risk while over 35.24% of them was in the high-risk group, respectively. Conclusions BP and WC were independent risk factors for CVD in the Kazakh population. The risk of CVD was greatly increased when BP and WC coexisted or when combined BP/WC with MS (≥3 components except for BP and WC) was present, but no significant interactions were found among MS components.
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Affiliation(s)
- Wenwen Yang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Xiang Gao
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
- Department of Nutritional Sciences, The Pennsylvania State University 109 Chandlee Lab, University Park, Pennsylvania, United States of America
| | - Xianghui Zhang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Yunhua Hu
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Heng Guo
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Kui Wang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Yizhong Yan
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Jia He
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Jingyu Zhang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Jiaolong Ma
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Lei Mao
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Lati Mu
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Jiaming Liu
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Shugang Li
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Yusong Ding
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Mei Zhang
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
| | - Rulin Ma
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
- * E-mail: (SG); (RM)
| | - Shuxia Guo
- Department of Public Health, Shihezi University School of Medicine, Shihezi, Xinjiang, China
- Departmentof Pathology and Key Laboratory of Xinjiang Endemic and Ethnic Diseases (Ministry of Education), Shihezi University School of Medicine, Shihezi, Xinjiang, China
- * E-mail: (SG); (RM)
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Differences in Prevalence and Severity of Coronary Artery Disease by Three Metabolic Syndrome Definitions. Can J Cardiol 2012; 28:208-14. [DOI: 10.1016/j.cjca.2011.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 10/25/2011] [Accepted: 10/26/2011] [Indexed: 11/20/2022] Open
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Impaired spontaneous thrombolytic activity measured by global thrombosis test in males with metabolic syndrome. Thromb Res 2011; 129:499-501. [PMID: 21752433 DOI: 10.1016/j.thromres.2011.06.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/17/2011] [Accepted: 06/21/2011] [Indexed: 11/20/2022]
Abstract
INTRODUCTION In patients with metabolic syndrome (MetS), activity of the fibrinolytic system is generally surmised to be decreased through increased plasminogen activator inhibitor-1 (PAI-1) generation. However, there have been no detailed reports describing whether the clot lysis activity is more dominant than increased clot formation activity for production of the thrombotic state in MetS. METHODS The global thrombosis test (GTT) is a novel method designed to test both clot formation and clot lysis activities under physiological conditions by using non-anticoagulated blood samples in vitro. We used the GTT to examine the thrombotic or thrombolytic states in males with MetS. RESULTS Lysis time, which reflects spontaneous clot lysis activity, was significantly longer in MetS subjects (median, 1494s; range, 865-3596s; n=30) than in control subjects (median 1246s; range, 667-2239s; n=53). There was no significant difference between the two groups in occlusion time, which reflects platelet function. The mean level of PAI-1 was significantly higher in MetS subjects than in controls (mean ± SE, 8.7 ± 1.1 and 5.0 ± 0.5 ng/mL, respectively). PAI-1 level and lysis time were significantly correlated (r=0.400, P<0.01). CONCLUSION These results suggest that male patients with MetS are more likely than controls to experience a thrombotic state through decreased fibrinolytic activity due to increased PAI-1 generation, and that the GTT is useful for evaluating fibrinolytic activity in vitro.
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Hirai Y, Geleijnse JM, Adachi H, Imaizumi T, Kromhout D. Systolic Blood Pressure Predicts Cardiovascular Mortality in a Farming but Not in a Fishing Community - A 40-Year Follow up of the Japanese Cohorts of the Seven Countries Study -. Circ J 2011; 75:1890-6. [DOI: 10.1253/circj.cj-10-0971] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuji Hirai
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine
- Division of Human Nutrition, Wageningen University
| | | | - Hisashi Adachi
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Tsutomu Imaizumi
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine
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