Angiographic and coronary risk factor analyses of Japanese patients with ischemic heart disease before age 40--a multicenter cooperative study

Hypertension is the most important component of metabolic syndrome in the association with ischemic heart disease in Taiwanese type 2 diabetic patients

BACKGROUND

To evaluate the association between components of metabolic syndrome (MS) and ischemic heart disease (IHD) in Taiwanese patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

A total of 1,296 (604 men and 692 women) subjects with T2DM aged 62.5+/-11.7 (14-87) years were studied. MS was defined using the World Health Organization modified criteria and included more than 2 of hypertension, obesity, dyslipidemia and microalbuminuria. IHD was diagnosed through history or ischemic electrocardiogram according to the Minnesota codes. Results showed that MS was present in 76.2% and IHD in 36.3% of the patients, respectively. MS increased with age for both sexes, but there was no difference between men and women in the age groups of <45, 45-54 and 55-64 years. However, the prevalence of MS was significantly higher in women (87.7% vs 78.0%) in the age group>or=65 years. IHD prevalence was significantly higher in patients with MS, hypertension, dyslipidemia and obesity (p<0.01), and was higher with borderline significance for microalbuminuria (0.05<p<0.1). The respective age-adjusted odds ratios were 3.61 (2.57-5.08), 7.10 (5.38-9.38), 1.70 (1.32-2.18), 1.75 (1.33-2.28), and 1.11 (0.88-1.41).

CONCLUSIONS

The prevalence of MS in subjects with T2DM is high and increases with age. The impact of different risk factors on IHD is diverse, with hypertension being the most important.

Age-Period-Cohort analysis of mortality due to ischemic heart disease in Japan, 1955 to 2000

BACKGROUND

Mortality from ischemic heart disease (IHD) has been showing a marked decline in Japan. The objective of this study was to clarify the effects of age, time period, and cohort on mortality from IHD in Japan from 1955 to 2000.

METHODS AND RESULTS

IHD death data from vital statistics and national population surveys were tabulated for 11 5-year age groups (from 30-34 to 80-84) and 10 quinquennial demographic profiles (from 1955 to 2000), to yield 20 5-year birth cohorts (mid-years from 1873 to 1968). The stratified Age-Period-Cohort model with 7 age classes shows: (1) mainly linear age trends for men with IHD, but effects below the linear age trends for women in middle-aged groups (40-74 years); (2) a decline in the effect of time period on IHD for both men and women from 1970 to 1990, and a sharp increase between 1990 and 1995 along with the change of the International Classification of Diseases Code; and (3) 2 patterns for both sexes for non-linear birth cohort effects, an increase (1873-1928) and a decrease (1928-1968) for men, and an increase (1873-1923) and a decrease (1923-1968) for women, with a stronger effect for women than for men born between 1893 and 1938, but the reverse for men and women born between 1938 and 1968.

CONCLUSION

Declining effects of birth cohort on mortality rates of IHD for young and middle-aged people suggest that mortality rates are likely to continue to decrease in Japan.

Sex Difference in the Distribution of Atherosclerotic Risk Factors and Their Association With Peripheral Arterial Disease in Taiwanese Type 2 Diabetic Patients

BACKGROUND

There appear to be sex differences in the risk factors for peripheral arterial disease (PAD) in type 2 diabetic patients, but studies in Taiwanese patients have not been conducted.

METHODS AND RESULTS

A total of 610 (268 men, 342 women) Taiwanese patients aged 63.3+/-10.8 years were evaluated. PAD was diagnosed by an ankle - brachial index <0.9. Risk factors included age, sex, body mass index (BMI), waist circumference (WC), smoking, menopause, diabetes duration, hypertension, insulin therapy, systolic and diastolic blood pressures, fasting glucose, total cholesterol (TC), triglyceride (TG), high- (HDL-C) and low-density lipoprotein-cholesterol (LDL-C), apolipoproteins A1 (ApoA1) and B (ApoB) and uric acid (UA). When compared with the men, the women were significantly older and had longer duration, smaller WC, higher levels of systolic blood pressure, TC, TG, HDL-C, LDL-C, ApoA1 and ApoB, lower levels of UA, fewer smokers and more insulin users. Stepwise logistic regression showed age, BMI (inverse association) and systolic blood pressure as independent risk factors for men [respective odds ratios (OR): 1.080 (1.024-1.139), 0.832 (0.713-0.971) and 1.028 (1.005-1.051)]; and for women they were age, UA and insulin therapy [respective OR: 1.113 (1.056-1.173), 1.340 (1.101-1.630) and 4.173 (1.974-8.824).

CONCLUSIONS

PAD risk factors differ significantly between the sexes.

Combined cardiovascular risk factors and outcome: NIPPON DATA80, 1980-1994

BACKGROUND

To examine the prognostic significance of the high-risk group with combined cardiovascular risk factors in the Japanese, we analyzed the relationship between the high-risk group with combined risks and coronary heart disease (CHD) and stroke mortality using the NIPPON DATA80 database.

METHODS AND RESULTS

At baseline in 1980, those of age>or=30 years were randomly selected and 4,144 men and 5,318 women without CHD and/or stroke at baseline were followed for 14 years. The cutoff values for risk components obtained heuristically by Cox analysis were hypertension (systolic>or=130, or diastolic>or=85 mmHg, or on antihypertensive drugs), hypercholesterolemia (total cholesterol>or=200 mg/dl), hyperglycemia (>or=130 mg/dl, or self-reported diabetes) and obesity (body mass index>or=27 kg/m2). Subjects were divided into 3 groups (0, 1-2 and 3-4 risks). Compared with those men in the risk 0 group, the hazard ratios in men in the risk 3-4 for CHD mortality was 8.04 (95% confidence interval: 1.03-62.6), and the stroke mortality was 5.06 (1.53-16.7). In women, no statistically significant difference was found due to a lesser number of events.

CONCLUSION

The high-risk group with combined risk factors is important risk for Japanese men.

Medium-Term Prognosis of Young Japanese Adults Having Acute Myocardial Infarction

BACKGROUND

Data on the medium- and long-term prognosis of young Japanese patients with acute myocardial infarction (AMI) are still lacking.

METHODS AND RESULTS

In the present study, 1,458 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2003. Of these, clinical characteristics and medium-term prognosis were retrospectively compared in 21 young patients < 40 years (young group), and 190 non-young patients 60-70 years old (non-young group) who could be followed after hospital discharge. The young group was all male and had higher prevalence of current smoking and greater body mass index, but previous myocardial infarction (MI) and hypertension were more prevalent in the non-young group. The young group had a higher prevalence of single-vessel disease and a lesser incidence of left circumflex coronary artery as the culprit lesion. The acquisition rates of Thrombolysis In Myocardial Infarction 3 flow after primary percutaneous coronary intervention did not differ between the 2 groups, but the data of maximal creatine kinase was significantly higher in the young group. During the follow-up period (average 2.42 years for young, 2.37 years for non-young), survival and event-free survival rates and incidence of major adverse cardiac events (MACE) did not differ between the 2 groups. The predictor of MACE during follow-up period was the presence of multivessel disease in the young group, whereas the presence of multivessel disease, history of previous MI and longer hospitalization were the predictors of MACE in the non-young group.

CONCLUSIONS

These results suggest that the medium-term prognosis in young AMI patients is comparable to that of non-young AMI patients in Japan.

Characteristics of Metabolic and Lifestyle Risk Factors in Young Japanese Patients With Coronary Heart Disease A Comparison With Older Patients

Coronary heart disease (CHD) is recognized as a lifestyle-related disease and is the second leading cause of death in Japan. However, the cardiac risk factor profile of young patients with CHD has not been clarified in suburban areas of Japan. Our study aimed to determine metabolic and lifestyle risk factors in young patients and compare them with older patients living in suburban areas of Nagano Prefecture. A multicenter study was conducted in 86 young (aged less than 40 years) and 91 older (aged 50 years and over) patients diagnosed with CHD from 1992 to 2002. There was a strong association between obesity and the occurrence of CHD events in young patients (odds ratio = 3.61, P = 0.006). Lifestyle in the young patients was characterized by a lack of physical activity and regular physical activity was found to decrease the risk of the CHD events in these patients (odds ratio = 0.31, P = 0.030). In older patients, hypertension was identified as an independent risk factor for CHD events. The results of the present study have demonstrated that obesity and a lack of regular physical exercise are independent risk factors for CHD events in younger patients. Thus, the data may be useful for the effective screening of high-risk individuals and the development of educational programs for the prevention of CHD, especially in younger Japanese.

Acute Myocardial Infarction in Young Japanese Adults Clinical Manifestations and In-Hospital Outcome

BACKGROUND

The prevalence and clinical manifestations of acute myocardial infarction (AMI) in young patients in Japan have not been fully investigated.

METHODS AND RESULTS

In the present study, 1651 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and June 2004. Of these, the clinical background, risk factors, angiographic findings, acute results of primary percutaneous coronary intervention (PCI) and in-hospital outcomes for 27 young patients <40 (young group), and 338 non-young patients 60<or=, <70 years old (non-young group) were retrospectively compared. The young AMI patients were all male. Current smoking, hypercholesterolemia and family history were the most common risk factors in young patients, while hypertension and diabetes mellitus were more prevalent in non-young patients. Young patients had a higher prevalence of single-vessel disease and a lesser incidence of left circumflex coronary artery as a culprit lesion. The young group had high acquisition rates of Thrombolysis In Myocardial Infarction 3 flow just after primary PCI (95.8%) and no in-hospital deaths, which was not significantly different from the non-young group.

CONCLUSIONS

These results suggest that young AMI patients have different clinical characteristics from those in non-young AMI patients, and acute results of primary PCI and in-hospital prognosis in young AMI patients are comparable to those in non-young AMI patients in Japan.

Trends over the last 20 years in the clinical background of young Japanese patients with coronary artery disease

BACKGROUND

The prevalence, pathogenesis, and clinical background of coronary artery disease (CAD) in patients aged 40 years or less in Japan are not well understood.

METHODS AND RESULTS

Temporal trends in the clinical background, including growth from childhood, of young patients with CAD over the last 20 years were examined. The study group comprised 38 patients who were 40 years of age or less (7 patients in 1980-84, phase I; 10 patients in 1985-89, phase II; 10 patients in 1990-94, phase III; 11 patients in 1995-99, phase IV). Among the classic coronary risk factors, obesity significantly increased in prevalence. An increase in patients with multiple risk factors was seen (0, 10%, 20%, and 36% in phases I, II, III, and IV, respectively). There was no significant change in the prevalence of familial hypercholesterolemia, sequelae of Kawasaki disease or vasospastic angina. All phase III and IV patients with multiple risk factors had moderate to severe obesity, and 83% had been overweight since childhood.

CONCLUSIONS

These results suggest that the number of young patients with CAD because of multiple risk factors has been increasing, and most of them have been overweight since childhood. Thus, for primary prevention it is essential to control cardiovascular risk factors in overweight children.

Past history of obesity (overweight by WHO criteria) is associated with an increased risk of nonfatal acute myocardial infarction: a case-control study in Japan

BACKGROUND

Obesity is an important risk factor for the occurrence of coronary artery disease (CAD) in Western countries and furthermore, it often coexists with other CAD risk factors such as hypertension, dyslipidemia and diabetes mellitus. However, it is uncertain whether obesity is a CAD risk factor in Japan because Japanese are relatively thin on average.

METHODS AND RESULTS

The CAD risk associated with obesity (body mass index > or =25.0) 10 years before as well as at the time of the survey was assessed in a case - control study of acute myocardial infarction (AMI), which compared 660 AMI patients aged 40-79 years and 1,277 community controls, matched to each case by sex, year of birth, and residence. The prevalence of current obesity did not show any material difference between cases and controls, but compared with controls, past obesity was much more frequent in cases. Even after controlling for other CAD risk factors, past obesity was associated with a 2-fold increase in the risk of AMI. Past obesity was associated with an increased risk of AMI even without current obesity.

CONCLUSION

Past obesity is a CAD risk, even after weight reduction.

Independent association of uric acid levels with peripheral arterial disease in Taiwanese patients with Type 2 diabetes

AIMS

Hyperuricaemia may be a risk factor for atherosclerotic disease. Its association with peripheral arterial disease (PAD) has not been studied in Taiwanese patients with Type 2 diabetes.

METHODS

Uric acid (UA) levels and PAD were evaluated in 508 Taiwanese outpatients with Type 2 diabetes (210 men, 298 women; mean age +/- sd, 63.8 +/- 10.6 years). PAD was diagnosed when the ankle-brachial index was < 0.9. Patients with an ankle-brachial index of > or = 1.3 were excluded because of possible medial arterial calcification. Potential confounding variables with P < 0.10 were adjusted for in multivariate analyses.

RESULTS

In univariate analyses, UA levels were higher in patients with PAD than in those without PAD (345.0 +/- 95.2 vs. 309.3 +/- 89.2 micromol/l; P < 0.0005). Prevalences of PAD for quintiles of UA levels were 6.8, 8.9, 10.2, 13.1 and 16.5%, respectively (P-trend < 0.05). With UA level as a continuous variable, the multivariate-adjusted odds ratio (95% confidence interval) for PAD was 1.005 (1.001-1.008) (P < 0.01). The optimal cut-off point for UA as determined by the receiver operating characteristic curve was 264.7 micromol/l. The sensitivity and specificity at this cut-off point was 82.6 and 33.3%, respectively. The area under curve was 0.60 (95% confidence interval: 0.53-0.68). The multivariate-adjusted odds ratio for PAD for UA above this level was 2.736 (1.239-6.043) (P < 0.05). The results after excluding 56 cases using diuretics were similar.

CONCLUSIONS

Elevated uric acid level is a significant and independent risk factor for PAD in Taiwanese patients with Type 2 diabetes.

Coronary artery spasm discovered in thorough examination of perioperative VT in a 26-year-old Japanese male

We thoroughly examined a 26-year-old Japanese male who experienced perioperative ventricular tachycardia. After inhaling sevoflurane, his nasal cavity was soaked with 1:100,000 epinephrine and he was intubated through the nose. Junctional tachycardia occurred five minutes after intubation, changing to ventricular tachycardia. Six-time cardioversion was required to stop the ventricular tachycardia. Echocardiography immediately following the event showed diffuse hypokinesis, and an electrocardiogram showed an inversion of T waves in II, III, aVF and V4-6. Both returned to normal within a few days. Tl scintigraphy revealed a normal perfusion image. Coronary angiography showed a normal coronary, but an injection of acetylcholine induced vasospasm in the right coronary artery. Examination of left ventricular tissue yielded no specific findings. During electrophysiological tests, ventricular tachycardia could not be induced even in the presence of isoprenaline. This is a very young case to elicit vasospasm in the coronary artery with no underlying heart disease. Although the relationship between perioperative ventricular tachycardia and coronary spasm is unknown, cardiac events can occur during anesthesia in young and low-risk patients.

R353Q Polymorphism, Activated Factor VII, and Risk of Premature Myocardial Infarction in Japanese Men

BACKGROUND

The association between myocardial infarction (MI) and the R353Q polymorphism of the Factor VII (FVII) gene, which reportedly influences FVII concentrations, activated Factor VII (FVIIa), or FVII antigen (FVIIag), remains controversial.

METHODS AND RESULTS

The present case - control study in 127 Japanese men with their first MI at or before 45 years of age and 150 matched healthy controls was designed to clarify this association in premature MI. R353Q polymorphism was determined by polymerase chain reaction, and plasma concentrations of FVIIa and FVIIag were assayed. The distribution of the RR, RQ, and QQ genotypes with respect to R353Q polymorphism was 117, 10, and 0 in the patients, and 131, 17, and 2 in the controls. The Q allele was negatively associated with premature MI (odds ratio =0.41, p=0.038). The plasma concentration of FVIIa was slightly higher in patients (55.1+/-40.9 U/L) than in controls (44.8+/-20.2 U/L), but not significantly (p=0.078); the plasma concentration of FVIIag did not differ between patients (88.7+/-15.7%) and controls (87.0+/-9.0%) (p=0.557). Plasma FVIIa concentrations were influenced by R353Q polymorphism (p<0.001).

CONCLUSIONS

The Q allele may be protective against premature MI.

Body composition as a risk factor for coronary artery disease in Chinese type 2 diabetic patients in Taiwan

This study aimed to clarify whether body mass index (BMI), waist/hip ratio (WHR) or percent body fat (%fat) is associated with coronary artery disease (CAD) in Chinese type 2 diabetic patients in Taiwan. A total of 463 patients were recruited. BMI and WHR were measured by standard methods and %fat by bioelectrical impedance. CAD was diagnosed as acute myocardial infarction, angina pectoris, or an electrocardiogram showing 'coronary probable or possible' according to the Minnesota codes. Age, sex, diabetes duration, hypertension, smoking, fasting plasma glucose, hemoglobin A(1c),and serum concentrations of total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol were treated as confounders. Results showed that 144 patients had CAD. Age, hypertension, HDL-C and %fat were independently associated with CAD. CAD prevalence was 25.5%, 26.8%, 31.9% and 43.0%, respectively, for the first to fourth quartile of %fat (p<0.05). Multivariate-adjusted odds ratio for CAD for every 1% increase in %fat was 1.02 (1.01-1.03); and 1.01 (0.73-1.88), 1.26 (0.69-2.32) and 2.11 (1.09-4.07) for the second to fourth quartile, respectively, compared with the first quartile. BMI and WHR were not associated with CAD in similar analyses. In conclusion, %fat was a better predictor for CAD than BMI and WHR in Chinese type 2 diabetic patients in Taiwan.

Myocardial infarction with Moyamoya disease and pituitary gigantism in a young female patient

Myocardial infarction is very rare in young female patients with systemic vascular disorders. Moyamoya disease is a cerebrovascular disease associated with an abnormal vascular network. This report presents a 19-year-old female patient who suffered from chest pain and exertional dyspnea for 2 months prior to admission. She had a history of Moyamoya disease and pituitary gigantism since childhood. Her ejection fraction on echocardiogram was 20% and a perfusion defect with partial reversibility in the anterior wall was demonstrated on stress single photon emission computed tomography (SPECT). Diagnostic coronary angiogram revealed critical stenosis in the middle left anterior descending artery, which was treated by coronary stenting. Her subjective symptoms were relieved and the perfusion defect seen on SPECT decreased after coronary intervention.

Asymptomatic moyamoya disease associated with coronary and renal artery stenoses--a case report

Moyamoya disease is an occlusive intracranial arteriopathy with abnormal cerebral vascular collateral networks. Although this disease is known to be associated with stenosis of extracranial arteries, such as the renal artery, a case associated with stenoses of the coronary and renal arteries has not been reported. We described here a 23-year-old man who had effort angina, renovascular hypertension, and asymptomatic moyamoya disease. Arterioangiography revealed bilateral occlusion of the intracranial carotid arteries and stenoses in the left coronary artery and the left renal artery.