Explanation for the Japanese paradox: prevention of increase in coronary heart disease and reduction in stroke

Primary Prevention of Coronary and Other Cardiovascular Diseases: A Focused Review

In 2022, the Japan Atherosclerosis Society (JAS) updated its prevention guidelines, the "Japan Atherosclerosis Society (JAS) Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases 2022" (JAS2022GL), expanding its scope from coronary artery disease (CAD) to atherosclerotic cardiovascular diseases (ASCVDs), including atherothrombotic stroke. The following year, the Japanese Circulation Society (JCS) updated its guidelines for primary prevention entitled "JCS 2023 Guideline on the Primary Prevention of Coronary Artery Disease" (JCS2023GL). Since those publications, scientific advancements in relevant fields have continued. This review article outlines the current recommendations provided by the guidelines, provides background information supporting these recommendations, introduces scientific findings subsequent to prior publications, and discusses future directions on select topics for the primary prevention of CVD. The topics covered in this review are traditional risk factors, including dyslipidemia and hypertension, the application of comprehensive risk stratification or risk scoring systems, patient-specific topics, salt and alcohol, and environmental factors. These topics were deliberate and selected by the authors, who were involved in the compilation of either or both JAS2022GL and JCS2023GL. This review not only emphasizes the pivotal role of continuously updated guidelines in shaping clinical practice but also stresses the urgent need for ongoing research to bridge existing knowledge and practice gaps.

Association between Sudden Sensorineural Hearing Loss and the Risk of Cardio Cerebrovascular Disease

OBJECTIVES

This study investigated the association between sudden sensorineural hearing loss (SSNHL) and the risk of cardio-cerebrovascular disease (CCVD) among older adults in South Korea.

METHODS

Data from 38,426 patients in the Korean National Health Insurance Service-Senior Cohort from 2002 to 2019 were collected. The risk of CCVD includes both stroke and acute myocardial infarction. Propensity score matching (1:1) was used to identify pairs of individuals with and without SSNHL (n = 19,213 for cases and controls). Cox proportional hazards regression models were used to analyze the associations between variables.

RESULTS

Patients with SSNHL had a higher risk of CCVD (hazard ratio [HR] = 1.17, 95% confidence interval [CI] = 1.11-1.24) compared to those without. The risk of CCVD was higher among those who experienced a stroke than those who did not (HR = 1.17 95% CI = 1.10-1.25). Compared to their matched controls, patients with SSNHL were 1.69 times (HR = 1.69 CI = 1.46-1.94) more likely to have CCVD during the first 12 months of the follow-up period.

CONCLUSION

Older patients with SSNHL are at an increased risk of CCVD. Hence, a more attentive approach featuring aggressive monitoring of patients with SSNHL is required to lessen their risk of CCVD.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2372-2376, 2024.

Coronary Artery Calcium in Assessment of Atherosclerotic Cardiovascular Disease Risk and its Role in Primary Prevention

Coronary artery calcium (CAC), which is detected using computed tomography scanning, is a well-established indicator of subclinical atherosclerosis. The CAC score is independently associated with atherosclerotic cardiovascular disease (ASCVD) outcomes and provides improved predictive values for estimating the risk of ASCVD beyond traditional risk factors. Thus, CAC is considered to have important implications for reclassification as a decision aid among individuals in the preclinical phase and as the primary prevention of ASCVD. This review is focused on epidemiological evidence on CAC in asymptomatic population-based samples from Western countries and Japan. We also discuss the usability of CAC as a tool for assessing ASCVD risk and its role in the primary prevention of ASCVD. A lack of evidence for the CAC score in ASCVD risk assessment beyond traditional risk factors in populations other than those in Western countries (including Japan) warrants further investigation. Clinical trials are also necessary to demonstrate the usefulness and safety of CAC screening in the primary prevention of ASCVD.

History of cardiovascular epidemiology in Japan

There are several patterns of epidemiological study in Japan. One is the international collaborative studies, such as Seven Countries Study, NI-HON-SAN Study, International Study of Salt and Blood Pressure (INTERSALT), International Study of Macro-and Micro-nutrients and Blood Pressure (INTERMAP), and Monitoring of Cardiovascular Disease (MONICA). The next one is the several cohort studies in Japanese unique surveys, such as Hisayama Study, Osaka-Akita Study, Tanno-Sobetsu Study, Suita Study, Ohazama Study, National Integrated Project for Prospective Observation of Noncommunicable Disease and Its Trends in the Aged (NIPPON DATA), Japan Collaborative Cohort (JACC), and Japan Public Health Center-Based Study (JPHC). Finally, some recent special meta-analysis in Japan are Japan Arteriosclerosis Longitudinal Study (JALS) and Evidence for Cardio-vascular Prevention from Observational Cohorts in Japan (EPOCH-JAPAN). The aim of this review is to introduce the history of epidemiologcal study, especially, cardiovascular epidemiology from the mid-20th century to in the early 21st century by dividing three patterns.

Nephrons, podocytes and chronic kidney disease: Strategic antihypertensive therapy for renoprotection

Chronic kidney disease (CKD) is one of the strongest risk factors for hypertension, and hypertension can exacerbate the progression of CKD. Thus, the management of CKD and antihypertensive therapy are inextricably linked. Research over the past decades has shown that the human kidney is more diverse than initially thought. Subjects with low nephron endowment are at increased risk of developing CKD and hypertension, which is consistent with the theory of the developmental origins of health and disease. Combined with other lifetime risks of CKD, hypertension may lead to a vicious cycle consisting of podocyte injury, glomerulosclerosis and further loss of nephrons. Of note, recent studies have shown that the number of nephrons correlates well with the number of podocytes, suggesting that these two components are intrinsically linked and may influence each other. Both nephrons and podocytes have no or very limited regenerative capacity and are destined to decrease throughout life. Therefore, one of the best strategies to slow the progression of CKD is to maintain the "numbers" of these essential components necessary to preserve renal function. To this end, both the achievement of an optimal blood pressure and a maximum reduction in urinary protein excretion are essential. Lifestyle modifications and antihypertensive drug therapy must be carefully individualized to address the potential diversity of the kidneys.

Short-term associations of ambient air pollution with hospital admissions for ischemic stroke in 97 Japanese cities

The short-term association between ambient air pollution and hospital admissions for ischemic stroke is not fully understood. We examined the association between four regularly measured major ambient air pollutants, i.e., sulfur dioxide (SO₂), nitrogen dioxide (NO₂), photochemical oxidants (O_x), and particulate matter with aerodynamic diameters ≤ 2.5 μm (PM_2.5), and hospital admissions for ischemic stroke by analyzing 3 years of nationwide claims data from 97 cities in Japan. We first estimated city-specific results by using generalized additive models with a quasi-Poisson regression, and we obtained the national average by combining city-specific results with the use of random-effect models. We identified a total of 335,248 hospital admissions for ischemic stroke during the 3-year period. Our analysis results demonstrated that interquartile range increases in the following four ambient air pollutants were significantly associated with hospital admissions for ischemic stroke on the same day: SO₂ (1.05 ppb), 1.05% (95% CI: 0.59-1.50%); NO₂ (6.40 ppb), 1.10% (95% CI: 0.61-1.59%); O_x (18.32 ppb), 1.43% (95% CI: 0.81-2.06%); and PM_2.5 (7.86 μg/m³), 0.90% (95% CI: 0.35-1.45%). When the data were stratified by the hospital admittees' medication use, we observed stronger associations with SO₂, NO₂, and PM_2.5 among the patients who were taking antihypertensive drugs and weaker associations with SO₂, NO₂, and O_x among those taking antiplatelet drugs. Short-term exposure to ambient air pollution was associated with increased hospital admissions for ischemic stroke, and medication use and season may modify the association.

The role of social resources and trajectories of functional health following stroke

Stroke is a major cause of disability in old age. Research has revealed that social resources available after the onset of stroke can mitigate functional prognosis. However, most studies have conceptualized resources as static rather than dynamic and have not measured changes in social resources from the pre-to post-stroke periods. To better understand the recovery process following stroke, we examined how social resources available before its onset and changes from pre-to post-stroke were associated with trajectories of functional health following stroke. Data were derived from an up to 19-year longitudinal study of a nationally representative sample of Japanese adults aged 60 years and older. We identified 389 people who experienced self- or proxy-reported first stroke during follow-up (age at stroke onset: M = 75.9, SD = 6.8; 49.1% women). The average number of observations was 4.6 (SD = 1.6, range 2-7). Functional health was measured with self- or proxy-reported basic and instrumental activities of daily living. Social resources were indexed as residential status, contact with own non-coresident children, social participation, and perceived support. Analyses were adjusted for age at stroke onset, sex, education, health condition, and cognitive function. A multiphase growth model indicated that individuals who participated more frequently in social groups prior to stroke exhibited less functional deterioration post-stroke than those who participated less frequently. Whereas contact frequency with non-coresident children typically declined following stroke, the analysis further revealed that individuals who maintained contact frequency from pre-to post-stroke showed less steep functional decline over time in the post-stroke period despite minor individual differences. We found that social resources before stroke onset and changes in the resources following stroke may play a protective role against adverse prognoses. Inclusive communities may help older adults remain independent even after serious health events.

Impact of Dietary Fructose and High Salt Diet: Are Preclinical Studies Relevant to Asian Societies?

Fructose consumption, especially in food additives and sugar-sweetened beverages, has gained increasing attention due to its potential association with obesity and metabolic syndrome. The relationship between fructose and a high-salt diet, leading to hypertension and other deleterious cardiovascular parameters, has also become more evident, especially in preclinical studies. However, these studies have been modeled primarily on Western diets. The purpose of this review is to evaluate the dietary habits of individuals from China, Japan, and Korea, in light of the existing preclinical studies, to assess the potential relevance of existing data to East Asian societies. This review is not intended to be exhaustive, but rather to highlight the similarities and differences that should be considered in future preclinical, clinical, and epidemiologic studies regarding the impact of dietary fructose and salt on blood pressure and cardiovascular health worldwide.

Indicators Predicting Inpatient Mortality in Post-Stroke Patients Admitted to a Chronic Care Hospital: A Retrospective Pilot Study

Evidence concerning the mortality of post-stroke patients admitted to a chronic-phase hospital seems to be lacking. This pilot study aimed to identify mortality-related clinical variables in the admission of post-stroke patients from a retrospective perspective. A group of 38 non-survival stroke patients and another group of 46 survival stroke patients in a chronic-phase ward of the single center were recruited. Clinical variables including age, sex, stroke type, and Barthel index (BI) score were collected. The difference in the age and BI scores on admission were statistically significant between the two groups (p < 0.01). Polytomous logistic regression analysis revealed that age (odds ratio = 1.09, p = 0.03, and 95% confidence interval: 1.01−1.07), male sex (odds ratio = 5.04, p = 0.01, and 95% confidence interval: 1.39−18.27), and BI scores on admission (odds ratio = 0.90, p = 0.01, and 95% confidence interval: 0.83−0.97) could be prognostic variables. The percentage of correct classification was 83.3%. Age, male sex, and BI scores on admission may be prognostic indicators. The result of this study could lay the groundwork for palliative care for such a clinical population.

The Morphology of Coronary Artery Disease in South Asians versus White Caucasians and its Implications

South Asians (SAs) experience a higher prevalence and earlier onset of coronary artery disease and have worse outcomes relative to White Caucasians (WCs) following invasive revascularization procedures, a mainstay of coronary artery disease (CAD) management. We sought to review the differences in the CAD pattern and risk factors between SA and WC patients and discuss their potential impact on the development of coronary disease, acute coronary syndrome and revascularization outcomes. SAs have a more diffuse pattern with multi-vessel involvement compared to WCs. However, less is known about other morphological characteristics such as calcification of atherosclerotic plaque and coronary diameter in SA populations. Despite a similar coronary calcification burden, higher non-calcified plaque composition, elevated thrombosis and inflammatory markers likely contribute to the disease pattern. While the current evidence on the role of coronary vessel size remains inconsistent, smaller coronary diameters in SAs could play a potential role in the higher disease prevalence. This is especially important given the impact of coronary artery diameter on revascularization outcomes. In conclusion, SAs have a unique CAD risk profile comprised of traditional and novel risk factors. Our findings highlight the need for additional awareness of healthcare professionals of this specific risk profile and potential therapeutic targets, as well as the need for further research in this vulnerable population.

Changes in cause-specific mortality trends across occupations in working-age Japanese women from 1980 to 2015: a cross-sectional analysis

Background

Reducing health inequalities is an important public health challenge. Many studies have examined the widening health gap by occupational class among men, but few among women. We therefore estimated variation in absolute and relative mortality by occupational category across four leading causes of mortality—cancer, ischaemic heart disease, cerebrovascular disease, and suicide—to explore how occupational class is associated with health among working women aged 25–64 in Japan.

Methods

We conducted a repeated cross-sectional study using Poisson regression analysis on each five-yearly mortality data from 1980 to 2015, obtained from the National Vital Statistics and the Japanese Population Census.

Results

There was a decreasing trend in mortality from all cancers, ischaemic heart disease, cerebrovascular disease, and suicide among women in all occupational groups from 1980 to 2015. Agriculture workers had higher risk of mortality than professional workers for all four causes of death. The absolute difference in mortality rates for all cancers and cerebrovascular disease was higher in 2000–2015 than 1980–1995. The mortality trend among clerks and sales workers decreased after 2000, except for suicide.

Conclusions

Mortality rates from all four causes are higher among agriculture workers compared to professional workers, and attention is needed to reduce this mortality gap. Continuous monitoring of ongoing mortality trends is essential to ensure better health and wellbeing in Japan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01621-4.

Difference in the prevalence of hypertension and its risk factors depending on area-level deprivation in Japan

Objectives

Area-level deprivation is an important factor related to mortality or health behaviors; however, a study investigating differences in hypertension prevalence depending on area-level deprivation has not been conducted in Japan. We investigated differences in the prevalence of hypertension and its risk factors, i.e. obesity, smoking, alcohol consumption, and heavy alcohol drinking depending on area-level deprivation using nationwide health checkups data in 2018.

Results

Area-level deprivation was derived from census data. An analysis of the data by secondary medical areas revealed that the age-standardized proportions of individuals whose systolic blood pressure was ≥ 140 mmHg, those whose diastolic blood pressure was ≥ 90 mmHg, those whose body mass index was ≥ 25 or 30 kg/m², smokers, and heavy alcohol drinkers showed an increasing trend with an increase in the deprivation level. The relative index of inequality, which can be interpreted as the ratio of the age-standardized proportion for the most deprived area compared with that for the least deprived area, was significantly greater than 1 for all proportions, except for the proportion of drinkers in women. Overall, there was a disparity in the prevalence of hypertension and its risk factors depending on area-level deprivation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-05931-6.

The 21-Year Trend of Stroke Incidence in a General Japanese Population: Results from the Takashima Stroke Registry, 1990-2010

INTRODUCTION

Since the 1960s, the stroke morality rate in Japan has declined significantly. Although several risk factors for stroke have become more evident due to increasingly Westernized lifestyle, there have been no population-based registry data on recent time trends in stroke incidence in Japan. The purpose of this study is to determine these trends in stroke incidence using a population-based registry.

METHODS

Data were obtained from the Takashima Stroke Registry, which covers approximately 50,000 residents in Takashima City, Japan. The age- and sex-standardized stroke incidence rate was estimated using the direct method. Average annual relative changes of stroke incidence were estimated using Poisson regression models.

RESULTS

We identified a total of 2,371 patients with first-ever stroke during the period 1990-2010. Crude incidence rates of total stroke (per 100,000 person-years) were 225 in the early period (1990-2001) and 187 in the late period (2002-2010), and the mean age at onset of stroke increased from 71.9 years in the early period to 74.8 years in the late period. Age- and sex-standardized incidence rates of stroke (per 100,000 person-years) decreased from 327 in the early part of this study period and 206 in the later period. During the 21-year period, age- and sex-standardized average annual relative reduction in stroke incidence was statistically significant (-3.7% per year). When stratified into early and late periods, the adjusted annual relative reduction in stroke incidence was observed during the early period (-2.1% per year), and there were no significant changes during the late period.

CONCLUSIONS

In this population-based registry, there was a significant reduction in incidence of stroke from 1990 to 2010. Although the speed of reduction in stroke incidence appears to have slowed down after 2000, continuous public health measures are required to provide further protection against stroke.

Effect of fish paste products, fish balls 'tsumire', intake in Sprague-Dawley rats

The fish paste product, fish balls ‘tsumire’, is a traditional type of Japanese food made from minced fish as well as imitation crab, kamaboko and hanpen. Although tsumire is known as a high-protein and low-fat food, there is a lack of scientific evidence on its health benefits. Hence, we aimed to investigate the effects of tsumire intake on organ weight and biomarker levels in Sprague–Dawley rats for 84 d as a preliminary study. Six-week-old male Sprague–Dawley rats were divided into two groups: group I, fed normal diets, and group II, fed normal diets with 5 % dried tsumire. Throughout the administration period, we monitored their body weight and food intake; at the end of this period, we measured their organ weight and analysed their blood biochemistry. No significant differences were observed with respect to body weight, food intake, organ weight and many biochemical parameters between the two groups. It was found that inorganic phosphorus and glucose levels were higher in group II rats than in group I rats. On the other hand, sodium, calcium, amylase and cholinesterase levels were significantly lower in group II than in group I. Interestingly, we found that the levels of aspartate aminotransferase, alanine transaminase, lactate dehydrogenase and leucine aminopeptidase in group II were significantly lower than in group I, and that other liver function parameters of group II tended to be lower than in group I. In conclusion, we consider that the Japanese traditional food, ‘tsumire,’ may be effective as a functional food for human health management worldwide.

Relationship of Ambient Temperature Parameters to Stroke Incidence in a Japanese Population - Takashima Stroke Registry, Japan, 1988-2010

BACKGROUND

Using a population-based stroke registry system, we evaluated the relationship between ambient temperature parameters and stroke incidence in a Japanese population.Methods and Results:We analyzed data from the Takashima Stroke Registry, which records all stroke occurrences in Takashima City, Japan. The study period of 8,401 days was divided into quintiles of daily weather parameters, and the middle quintile was used as the reference category. Incidence rates (IR per 100,000 person-years) were calculated across the quintiles. Poisson regression analysis was used to calculate the effect of temperature parameters on stroke incidence. There were 2,405 first-ever strokes (1,294 men), including 1,625 ischemic, 545 cerebral hemorrhages, 213 subarachnoid hemorrhages, and 22 unclassified strokes. The stroke IR was higher in the middle quintile of average temperature, 357.3 (328.4-388.8), and for other parameters. After adjustment for age and sex, for all stroke, the incidence rate ratio (IRR) in the highest (Q5: IRR 0.81, 95% confidence interval (CI) 0.71-0.92) and the second-highest (Q4: IRR 0.80, 95% CI 0.71-0.91) quintile was lower than that in the middle quintile (Q3: Reference). Analogous results were observed for the minimum, maximum, and lag-days temperatures, also in the subtypes and across ≥65 years of age, also in females.

CONCLUSIONS

Higher temperatures, irrespective of the parameter (average, minimum, or maximum), had a protective effect against stroke occurrence in Japan.

Incidence Rate of Acute Coronary Syndrome Including Acute Myocardial Infarction, Unstable Angina, and Sudden Cardiac Death in Nobeoka City for the Super-Aged Society of Japan

BACKGROUND

This study aimed to calculate incidence rates (IR) of acute coronary syndrome (ACS) including acute myocardial infarction (AMI), unstable angina (UAP), and sudden cardiac death (SCD) in Nobeoka city, Japan.Methods and Results:This was an observational study based on a city-wide comprehensive registration between 2015 and 2017 in Nobeoka city, Japan, using 2 databases: all patients with cardiogenic out-of-hospital cardiac arrest in Nobeoka city and hospitalized ACS patients from Miyazaki Prefectural Nobeoka Hospital in which all ACS patients in Nobeoka city were hospitalized except for possible rare cases of patients highly unlikely to be hospitalized elsewhere. The IRs of ACS based on the population size of Nobeoka city (125,000 persons), and their age-adjusted IRs by using the direct method and the 2015 model population of Japan were calculated. There were 260 eligible patients hospitalized with first-onset ACS (age [SD]=71.1 [12.4], 34.2% women) and 107 eligible SCD patients. Crude IRs of hospitalized ACS and SCD patients, and hospitalized AMI and SCD patients, respectively, were 130.2 (183.3 for men, 85.6 for women) and 107.5 (148.4 for men, 73.2 for women) per 100,000. Crude IRs of hospitalized ACS, AMI, and UAP patients, respectively, were 92.3 (132.8 for men, 58.1 for women), 69.6 (97.9 for men, 45.7 for women), and 22.7 (35.0 for men, 12.4 for women) per 100,000.

CONCLUSIONS

The calculated IRs can be useful in building a health strategy for treating ACS.

Complications Associated With Catheter Ablation in Patients With Atrial Fibrillation: A Report From the JROAD-DPC Study

Background Aging is one of the major concerns and determinants of the indications for catheter ablation (CA) for atrial fibrillation. This study aimed to assess the safety of CA in older patients with atrial fibrillation undergoing CA. Methods and Results The JROAD-DPC (Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination) is a nationwide claims database using data from the Japanese Diagnosis Procedure Combination/Per Diem Payment System. Among 6 632 484 records found between April 2012 and March 2018 from 1058 hospitals, 135 299 patients with atrial fibrillation (aged 65±10 years, 38 952 women) who underwent CA in 456 hospitals were studied and divided into the following age groups: <60, 60 to 64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, and ≥85 years. The overall in-hospital complication rate was 3.4% (cardiac tamponade 1.2%), and in-hospital mortality was 0.04%. Older patients had a higher prevalence of women, lower body mass index, and a higher burden of comorbidities such as hypertension, and all of those characteristics were predictors for complications in multivariate analysis. A multivariate adjusted odds ratio revealed that increased age was independently and significantly associated with overall complications (60-64 years, 1.19; 65-69 years, 1.29; 70-74 years, 1.57; 75-79 years, 1.63; 80-84 years, 1.90; and ≥85 years, 2.86; the reference was <60 years). Conclusions The nationwide JROAD-DPC database demonstrated that the frequency of complications following CA in patients with atrial fibrillation increased according to age.

Guidance on ambulatory blood pressure monitoring: A statement from the HOPE Asia Network

Hypertension is an important public health issue due to its association with a number of serious diseases, including cardiovascular disease and stroke. The importance of evaluating hypertension taking into account different blood pressure (BP) profiles and BP variability (BPV) is increasingly being recognized, and is particularly relevant in Asian populations given the specific features of hypertension in the region (including greater salt sensitivity and a high rate of nocturnal hypertension). Ambulatory BP monitoring (ABPM) is the gold standard for diagnosing hypertension and assessing 24-hour BP and provides data on several important parameters that cannot be obtained using any other form of BP measurement. In addition, ABPM parameters provide better information on cardio- and cerebrovascular risk than office BP. ABPM should be used in all patients with elevated BP, particularly those with unstable office or home BP, or who are suspected to have white-coat or masked hypertension. ABPM is also an important part of hypertension diagnosis and monitoring in high-risk patients. ABPM needs to be performed using a validated device and good practice techniques, and has a role both in hypertension diagnosis and in monitoring the response to antihypertensive therapy to ensure strict BP control throughout the 24-hour period. Use of ABPM in clinical practice may be limited by cost and accessibility, and practical education of physicians and patients is essential. The ABPM evidence and practice points in this document are based on the Hypertension Cardiovascular Outcome Prevention and Evidence (HOPE) Asia Network expert panel consensus recommendations for ABPM in Asia.

Low- and moderate-dose non-cancer effects of ionizing radiation in directly exposed individuals, especially circulatory and ocular diseases: a review of the epidemiology

PURPOSE

There are well-known correlations between high and moderate doses (>0.5 Gy) of ionizing radiation exposure and circulatory system damage, also between radiation and posterior subcapsular cataract. At lower dose correlations with circulatory disease are emerging in the Japanese atomic bomb survivors and in some occupationally exposed groups, and are still to some extent controversial. Heterogeneity in excess relative risks per unit dose in epidemiological studies at low (<0.1 Gy) and at low-moderate (>0.1 Gy, <0.5 Gy) doses may result from confounding and other types of bias, and effect modification by established risk factors. There is also accumulating evidence of excess cataract risks at lower dose and low dose rate in various cohorts. Other ocular endpoints, specifically glaucoma and macular degeneration have been little studied. In this paper, we review recent epidemiological findings, and also discuss some of the underlying radiobiology of these conditions. We briefly review some other types of mainly neurological nonmalignant disease in relation to radiation exposure.

CONCLUSIONS

We document statistically significant excess risk of the major types of circulatory disease, specifically ischemic heart disease and stroke, in moderate- or low-dose exposed groups, with some not altogether consistent evidence suggesting dose-response non-linearity, particularly for stroke. However, the patterns of risk reported are not straightforward. We also document evidence of excess risks at lower doses/dose-rates of posterior subcapsular and cortical cataract in the Chernobyl liquidators, US Radiologic Technologists and Russian Mayak nuclear workers, with fundamentally linear dose-response. Nuclear cataracts are less radiogenic. For other ocular endpoints, specifically glaucoma and macular degeneration there is very little evidence of effects at low doses; radiation-associated glaucoma has been documented only for doses >5 Gy, and so has the characteristics of a tissue reaction. There is some evidence of neurological detriment following low-moderate dose (∼0.1-0.2 Gy) radiation exposure in utero or in early childhood.

Gender differences in the risk factors associated with atherosclerosis by carotid intima-media thickness, plaque score, and pulse wave velocity

Cardiovascular disease (CVD) remains the leading cause of death, but the risk factors for CVD differ between men and women. Although carotid intima-media thickness (IMT), carotid plaque, and pulse wave velocity (PWV) are useful atherosclerotic parameters, patient backgrounds have differed in previous reports. Therefore, this study aimed to investigate gender differences in associations between these three parameters and traditional risk factors in the same population. We enrolled 3888 participants (women: 743) who underwent routine health checkups. High IMT, high carotid plaque score (PS), or high brachial-ankle PWV (baPWV) were defined by the median values for each gender. We analyzed the association between each parameter and atherosclerotic risk factors, such as obesity, smoking, blood pressure (BP) elevation, impaired fasting glucose (IFG), and dyslipidemia (DL). In both sexes, BP elevation was the only common risk factor for high IMT, high PS, and high baPWV in the multivariate logistic regression analysis adjusted for age. In men, IFG and DL were common risk factors for the three parameters. Furthermore, obesity was an additional risk factor for high IMT and smoking was an additional risk factor for high IMT and high PS. In contrast, in women, obesity, DL, or IFG was an additional risk factor for high IMT, high PS, or high baPWV, respectively. The risk factors for IMT, PS, and baPWV differ in in men and women. The management for atherosclerotic risk factors on early stage should be considered in terms of gender-specific risk factors.

Tracking Pattern of Total Cholesterol Levels from Childhood to Adolescence in Japan

Aims: This study aimed to evaluate the tracking pattern of serum total cholesterol (TC) levels among Japanese children using data collected continuously for 9 years and examine the relationship between childhood and adulthood TC levels.

Methods: TC levels of 2,608 first grade primary school children enrolled during 1981-2014 from two Japanese towns were measured during annual health check-ups. Nine-year trajectories of estimated TC levels stratified by TC quartiles in the first grade were analyzed using a mixed effects model. Adulthood TC levels were measured in participants who underwent health check-ups in the same area.

Results: Overall, 1,322 boys and 1,286 girls in the first grade of a primary school were followed for 9 years. Trajectories of TC levels during the period stratified by TC quartiles in the first grade differed significantly and did not cross each other for both sexes. Childhood data of 242 adult participants were linked with their adulthood data; the mean of age was late 20s for both sexes. The average TC levels in adulthood increased from the first to the fourth quartile in the first grade. Additionally, trajectories of TC levels differed between boys and girls. The later the admission year, the more elevated the TC levels in girls.

Conclusion: Among Japanese children, TC levels were strongly tracked from childhood to adolescence for 9 years, and elevated TC levels in childhood were related to elevated TC levels in adulthood. Maintaining appropriate TC levels during childhood may be important to prevent future coronary artery diseases.

Association among daily fish intake, white blood cell count, and healthy lifestyle behaviors in an apparently healthy Japanese population: implication for the anti-atherosclerotic effect of fish consumption

Higher fish consumption has been reported to be associated with a lower incidence of coronary artery disease. We hypothesized that a higher frequency of fish intake may be associated with lower peripheral white blood cell (WBC) counts, a marker of chronic inflammation, which is known to be involved in the development of atherosclerotic cardiovascular disease (ASCVD), and a healthy lifestyle. This cross-sectional study was conducted between April 2018 and August 2018 at the Health Planning Center of Nihon University Hospital in a cohort of 4105 apparently healthy subjects. The average frequency of fish intake was 2.3 ± 1.3 days per week. The WBC count decreased significantly as the frequency of fish intake (0-2 days, 3-4 days, or 5-7 days per week) increased (s < 0.0001). Multivariate linear regression analysis identified higher weekly frequency of fish intake as a significant independent determinant of a lower WBC count (β =  - 0.051, p = 0.001). Furthermore, as the weekly frequency of fish intake increased, the proportion of habitual cigarette smokers decreased (p = 0.021), that of subjects engaging in habitual aerobic exercises increased (p < 0.0001), and the weekly alcohol intake frequency increased (p < 0.0001). Moreover, the above-mentioned lifestyle behaviors were also independent determinants of the WBC count. These results suggest that a high frequency of fish intake might be associated with healthier lifestyle behaviors as well as lower WBC counts, and thus may both exert beneficial anti-inflammatory effects and represent a component of healthier lifestyle behaviors associated with a lower risk of ASCVD in Japanese. This association may be partially related to the preventive effects of a higher fish intake on ASCVD events. CLINICAL TRIAL REGISTRATION: UMIN ( http://www.umin.ac.jp/ ) Study ID: UMIN000039197 retrospectively registered 1 February 2020.

Risk Factors That Most Accurately Predict Coronary Artery Disease Based on the Duration of Follow-up - NIPPON DATA80

BACKGROUND

This study assessed sex-specific time-associated changes in the impact of risk factors on coronary artery disease (CAD) mortality in a general population over long-term follow-up.Methods and Results:A prospective longitudinal cohort study was conducted on representative Japanese populations followed up for 29 years. Data from 8,396 participants (3,745 men, 4,651 women) were analyzed. The sex-specific multivariable adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of 4 risk factors (smoking, diabetes, serum total cholesterol [TC], and systolic blood pressure [SBP]) for CAD mortality were calculated at baseline and at 10, 15, 20, 25, and 29 years of follow-up. In men, smoking (HR 3.23; 95% CI 1.16-9.02) and a 1-SD increase in TC (HR 1.82; 95% CI 1.29-2.57) were strongly associated with a higher risk of CAD in the first 10 years, but this association decreased over time. Diabetes (HR 2.30; 95% CI 1.37-3.85) and a 1-SD increase in SBP (HR 1.23; 95% CI 1.00-1.50) were strongly correlated with a higher risk of CAD after 29 years). In women, diabetes was correlated with CAD after 20 years (HR 2.53; 95% CI 1.19-5.36) and this correlation persisted until after 29 years (HR 2.47; 95% CI 1.40-4.35).

CONCLUSIONS

The duration of follow-up needed for the accurate assessment of risk factors for CAD mortality varies according to risk factor and sex.

Socioeconomic Disparities in All-Cause and Cause-Specific Mortality Rates among Municipalities in Japan, 1999-2019

Differences in all-cause and cause-specific mortality rates depending on municipal socioeconomic status (SES) in Japan have not been revealed over the last 20 years. This study exposes the difference in 1999 and 2019 using the Vital Statistics. All of the municipalities were grouped into five quintiles based on their SES, and standardized mortality ratio (SMR) of each municipal quintile compared with all of Japan was calculated for all-cause mortality and representative cause of deaths. As a result, although SMR for all-cause mortality for women tended to be lower in low SES quintiles in 1999, the reverse phenomenon was observed in 2019. Additionally, although SMR for all-cause of mortality for men was the lowest in the highest SES quintiles already in 1999, the difference in the SMR for all-cause mortality rates between the lowest and highest SES quintiles increased in 2019. The improvement of the SMR in the highest SES quintile and the deterioration in the lowest was also observed in representative types of cancer, heart disease, stroke, pneumonia, liver disease, and renal failure for men and women. Therefore, this study indicates a disparity in mortality depending on municipal SES enlarged in the last 20 years.

An Age-Period-Cohort Analysis of Biomarkers of Lifestyle-Related Diseases Using the National Health and Nutrition Survey in Japan, 1973-2018

Studies of biomarkers of lifestyle-related diseases in Japanese cohorts are scarce. This study aimed to analyze trends in risk markers of lifestyle-related diseases using age-period-cohort (APC) analysis. Data on systolic blood pressure and BMI from 1973 to 2018 and serum glucose, triglyceride, and high-density lipoprotein cholesterol levels from 1989 to 2018 available from the National Health and Nutrition Survey were used. Values for each of the risk markers for each age, period, and cohort were estimated using APC analysis. For women, a decrease in all the risk markers of lifestyle-related diseases was observed in individuals born between the 1930s and approximately 1970. Therefore, female individuals born in approximately 1970 were considered to have the lowest risk of developing lifestyle-related and cardiovascular diseases. Meanwhile, the cohort effect on all the risk markers deteriorated for the younger cohorts, and changes in lifestyle behavior are needed for cohorts born more recently. For men, the trends in risk markers across the cohorts differed, and the relative risk of lifestyle-related diseases for each cohort differed according to disease. These results could help understand cohort-specific risks for lifestyle-related disease and enable identification of high-risk populations who could benefit from preventive measures.

Cardiovascular outcome and home blood pressure in relation to silent myocardial ischemia in a clinical population: The J-HOP study

Several guidelines recommend measuring home blood pressure (BP) and lowering blood pressure than ever before. But several studies reported that lowering diastolic blood pressure (DBP) increased the incidence of coronary artery disease (CAD). We analyzed 3605 individuals who underwent both home and office BP monitoring over 14 days and baseline Hs-cTnT measurement and identified follow-up data of the Japan Morning Surge-Home Blood Pressure (J-HOP) study who had a history of or risk factors for cardiovascular disease. During a mean follow-up period of 6.4 years (23 173 person-years), 114 coronary artery disease and 81 stroke events occurred. Elevated Hs-cTnT (≥0.014 ng/mL) was observed in 298 patients (8.3%). In the group with non-elevated Hs-cTnT (<0.014 ng/mL, n = 3307), an adjusted Cox hazard model showed that home systolic BP (SBP) was associated with a risk of stroke incidence (hazard ratio [HR] per 1 SD, 1.62; 95% confidence interval [CI], 1.29-2.03). This association was also observed in office SBP (HR per 1 SD, 1.43; 95%CI, 1.07-1.91). There was no association between office or home BP and CAD events in the group with non-elevated Hs-cTnT. In the group with elevated Hs-cTnT, an adjusted Cox hazard model showed that home DBP was associated with a risk of CAD incidence (HR per 1 SD, 0.54; 95%CI, 0.30-0.99). However, this association was not observed in office DBP. In patients with elevated Hs-cTnT, which is a marker of subclinical myocardial ischemia, excessive lowering of home DBP may be associated with a risk of incident CAD.

Long-Term Survival after Stroke in 1.4 Million Japanese Population: Shiga Stroke and Heart Attack Registry

Background and Purpose

Although numerous measures for stroke exist, stroke remains one of the leading causes of death in Japan. In this study, we aimed to determine the long-term survival rate after first-ever stroke using data from a large-scale population-based stroke registry study in Japan.

Methods

Part of the Shiga Stroke and Heart Attack Registry, the Shiga Stroke Registry is an ongoing population-based registry study of stroke, which covers approximately 1.4 million residents of Shiga Prefecture in Japan. A total 1,880 patients with non-fatal first-ever stroke (among 29-day survivors after stroke onset) registered in 2011 were followed up until December 2016. Five-year cumulative survival rates were estimated using the Kaplan-Meier method, according to subtype of the index stroke. Cox proportional hazards models were used to assess predictors of subsequent all-cause death.

Results

During an average 4.3-year follow-up period, 677 patients died. The 5-year cumulative survival rate after non-fatal first-ever stroke was 65.9%. Heterogeneity was present in 5-year cumulative survival according to stroke subtype: lacunar infarction, 75.1%; large-artery infarction, 61.5%; cardioembolic infarction, 44.9%; intracerebral hemorrhage, 69.1%; and subarachnoid hemorrhage, 77.9%. Age, male sex, Japan Coma Scale score on admission, and modified Rankin Scale score before stroke onset were associated with increased mortality during the chronic phase of ischemic and hemorrhagic stroke.

Conclusions

In this study conducted in a real-world setting of Japan, the 5-year survival rate after non-fatal first-ever stroke remained low, particularly among patients with cardioembolic infarction and large-artery infarction in the present population-based stroke registry.

Blood levels of microRNAs associated with ischemic heart disease differ between Austrians and Japanese: a pilot study

Mortality from ischemic heart disease (IHD) is significantly lower in Japan than in Western countries. The purpose of this study was to investigate differences in circulating microRNA (miRNA) levels related to IHD in Austrians and Japanese. Participants were middle-aged healthy male Austrians (n = 20) and Japanese (n = 20). Total miRNAs in serum from each participant were analyzed using the 3D-Gene miRNA Oligo chip. Twenty-one miRNAs, previously reported as associated with IHD, were compared between Austrians and Japanese. The expression levels of miR-106a-5p, miR-135a-3p, miR-150-3p, miR-16-5p, miR-17-5p. miR-191-5p, miR-320b, miR-451a, miR-486-5p, miR-663b, and miR-92a-3p were significantly higher, while the miR-2861 expression level was significantly lower in Austrians as compared to Japanese. Both in Austrians and Japanese, there were significant positive correlations between serum expression levels of each pair of the above miRNAs except for miR-2861. The expression level of miR-2861 showed significant positive correlations with the expression levels of miR-106a-5p, miR-150-3p, miR-17-5p, miR-486-5p, miR-663b and miR-92a-3p in Austrians but not in Japanese. In pathway analysis, proinflammatory cytokine production in foam cells and collagen synthesis in vascular smooth muscle cells were associated with differentially expressed miRNAs. Difference in miRNA levels may contribute to lower cardiovascular risk in Japan than in Western countries.

Epidemiology of hypertension in Japan: beyond the new 2019 Japanese guidelines

From the national surveys of Japan over a 55-year period (1961-2016), a steady decrease was observed in systolic blood pressure (BP) levels among all age groups of men and women, but not in diastolic BP levels-particularly among men. Hypertension prevalence remains high: over 60% of men aged ≥50 years and women aged ≥60 years had hypertension in 2016. However, the control rates of hypertension have continuously improved over a 36-year period, and were ~40% in 2016. Nonetheless, the over 50% prevalence of uncontrolled hypertension is a major risk factor for future cardiovascular diseases. Of the estimated 43 million hypertensives in Japan, most (31 million, 72%) were under poor control. According to new Japanese hypertension guidelines (JSH 2019), there will be only a small increase (2.2 million, 2.1 percentage points) in adults who are recommended for antihypertensive medication compared with 2014 guidelines. However, an additional 5.3 million (22.1 percentage points) adults taking antihypertensive medication would have a BP above the target defined by JSH 2019. The number of hypertensives with poor control was targeted to decrease by 7 million-from 31 million in 2017 to 24 million in 2028-when the followings are achieved: (1) the prevalence of hypertension decreases by 5 percentage points; (2) the treatment rate of hypertension among hypertensives increases by 10 percentage points; and (3) the control rate of hypertension, defined as BP <140/90 mmHg, among individuals taking antihypertensive medication increases by 10 percentage points. Both high-risk and population strategies to manage and prevent hypertension deserve greater priority.

Neuroprotective effect of Umbelliferone against Cerebral ischemia/Reperfusion induced neurological deficits: in-vivo and in-silico studies

Inflammatory pathway is the significant marker of neuro-inflammation and plays a significant role in the expansion of cerebral ischemia/reperfusion injury. Umbelliferone (UF), 7-hydroxy coumarin, has been already proved for its anti-inflammatory and anti-oxidative effects against ischemic brain injury in the rodent model, but its underlying pharmacological mechanism for neuro-protection remain unclear. In this study, we try to explore the neuro-protective effect of umbelliferone against ischemia/Reperfusion induced neurological deficits in rats and explore the underlying mechanism. Inserting thread into the middle cerebral artery was used to induce the ischemic stroke model. The rats were treated with the umbelliferone (5, 10 and 20 mg/kg) for 14 days prior to the ischemic stroke. At the end of the experimental study, brain infarction volume, neurological score, brain edema, pro-inflammatory cytokines, inflammatory mediator were estimated in the region of brain and serum. The mRNA expression of Toll-like receptor-4 (TLR4), myeloid differentiation factor 88 (MyD88), Fas and FasL were also estimated at the end of the study. Dose dependently treatment of umbelliferone down-regulated the neurological score, brain infarction, inflammatory mediator (TNF-α, IL-1β, IL-6, COX-2, NF-kB and PGE₂) in the serum and brain tissue as compared to I/R induced control group rats. Umbelliferone also reduced the expression of TRL4, MyD88, Fas and FasL as compared to I/R control group rats. Umbelliferone also decreased the level of nuclear factor kappa B (NF-kB) compared to MACO control group rats. Collectively, the obtained result showed that the umbelliferone protected the brain against the ischemic injury in the rats through the inhibition of inflammatory pathway.Communicated by Ramaswamy H. Sarma.

Effect of fish paste products "Hanpen" intake in Sprague-Dawley rats

Fish paste product, "Hanpen," is a traditional type of Japanese food made from minced fish as well as imitation crab and kamaboko, and a marshmallow-like soft texture is characteristic of hanpen. Hanpen is known as a high-protein and low-fat food. However, there is a lack of evidence on its health benefits. The aim of this study was to investigate the effects of hanpen intake on organ weight and biomarker levels in Sprague-Dawley rats with diets consisting of hanpen for 84 days as an initial study. Male, 6-week-old Sprague-Dawley rats were divided into two groups: group I, fed normal diets, and group II, fed normal diets with 5% dried hanpen. Throughout the 84-day treatment period, we checked body weight and food intake, and after 84 days, we performed organ weight and blood biochemical analyses. No significant differences were seen in body weight, food intake, organ weight, and most biochemical parameters between group I and group II. Interestingly, total cholesterol (T-CHO) and high-density lipoprotein cholesterol (HDL-C) levels of group II were significantly higher than those of group I after administration for 84 days. Moreover, lactate dehydrogenase (LDH) level of group II was marked lower than that of group I, and other liver function parameters of group II tended to be lower than those of group I. As conclusion, "Hanpen," a Japanese traditional food, could be effective as a functional food for human health management worldwide.

Two-Year Recurrence After First-Ever Stroke in a General Population of 1.4 Million Japanese Patients - The Shiga Stroke and Heart Attack Registry Study

BACKGROUND

Despite many effective strategies for the prevention of recurrent stroke, individuals who survive an initial stroke have been shown to be at high risk of recurrent stroke. The aim of this study was to investigate the current status of stroke recurrence after first-ever stroke using a population-based stroke registry in Japan.Methods and Results:As part of the Shiga Stroke and Heart Attack Registry, the Shiga Stroke Registry is an ongoing population-based stroke registry study that covers approximately 1.4 million residents of Shiga Prefecture, Japan. A total of 1,883 first-ever stroke survivors at 28 days was registered in 2011 and followed-up until the end of 2013. Recurrence was defined as any type of stroke after 28 days from the onset of an index event. Two-year cumulative recurrence rates were estimated using cumulative incidence function methods. Over a mean 2.1-year follow-up period, 120 patients experienced recurrent stroke and 389 patients died without recurrence. The 2-year cumulative recurrence rate was higher in patients with index ischemic stroke (6.8%) than in those with index hemorrhagic stroke (3.8%).

CONCLUSIONS

Two-year cumulative recurrence rate after first-ever stroke remained high, particularly among patients with ischemic stroke, in the present population-based registry study in a real-world setting in Japan. Further intensive secondary prevention strategies are required for these high-risk individuals.

Metabolic Syndrome for Cardiovascular Disease Morbidity and Mortality Among General Japanese People: A Mini Review

Background

The importance of management of metabolic syndrome (MetS) for risk reduction of cardiovascular disease (CVD) has been recognized worldwide. Because of the comparatively unique characteristics of bodily figure/obesity and incident CVD in Japan, the relevance of MetS on CVD can be still discussed among Japanese people. The present study aimed to review briefly the relationship of MetS with CVD morbidity/mortality among general Japanese people.

Methods

Population-based prospective cohort studies evaluating the predictive value of MetS on CVD morbidity/mortality via a PubMed search up to 2019 were summarized.

Results

We identified two studies on morbidity that reported MetS to predict CVD morbidity. We identified three studies on mortality, and these studies showed an increased direction of hazard ratio (HR) of CVD mortality, while one study reported an insignificant prediction of MetS for CVD mortality. In the meta-analysis method, MetS significantly predicted CVD morbidity (HR=1.71 [95% confidence interval=1.34–2.18] in men and HR=1.89 [95% confidence interval=1.45–2.46] in women) as well as CVD mortality (HR=1.68 [95% confidence interval=1.37–2.06] in men and HR=1.73 [95% confidence interval=1.39–2.15] in women).

Conclusion

Among general Japanese people, MetS can be a positive predictor of CVD morbidity/mortality. Since the studies are limited, more research is needed to establish the findings.

Ground golf-induced changes in the blood pressure of healthy elderly people

Background

Ground golf is a popular sport among the elderly in Japan. Several types of exercise can reduce the body's mean arterial pressure (MAP), but little is known about how ground golf affects the MAP. We investigated the effects of ground golf on the MAP and the oxygen uptake (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$\end{document}V˙O2) in a healthy elderly population.

Participants and methods

Thirteen elderly Japanese people (3 males and 10 females, mean age of 66 years) participated. All participants played 8 holes of ground golf 6 times, as game (G)1 to G6. The MAP, heart rate (HR), and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$\end{document}V˙O2 were measured at rest and every 5 min during each game.

Results

A linear trend analysis revealed that participants’ MAP values progressively decreased as each game proceeded with marginal differences (p = 0.054). There were no significant differences in HR between at rest and any of the games. The \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$\end{document}V˙O2 during the games (except for G6) were significantly higher than that at-rest (p < 0.05). The resting MAP values were negatively associated with the ground golf-induced changes in MAP (r = 0.786, p = 0.001). The participants with greater changes in \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$\end{document}V˙O2 during the games showed significantly greater reductions in MAP (r = 0.276, p = 0.043).

Conclusions

Playing ground golf reduced the participants’ MAP and increased their \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \dot{\mathrm{V}}{\mathrm{O}}_2 $$\end{document}V˙O2. Participants with higher resting MAP experienced greater reductions in MAP by playing ground golf, which suggests that ground golf can be a useful recreational sport for the elderly.

"Japan Diet" and Health-The Present and Future

Japan achieved remarkable economic development after World War II, which has led remarkable changes in risk factors of atherosclerotic diseases and led to epidemiological transition in Japan. Nowadays, obesity is pandemic around world, which is same case in Japan. BMI of Japanese population, especially young adult men increased gradually since the 1960s associated with increase in intake of fat as well as decrease in intake of rice, which has been revealed by the annual report of the Ministry of Health, Labour and Welfare. Such changes suggest the change of dietary habit from Japanese style to westernized style. In recent years such changes in lifestyle has been accompanied by a gradual increase in serum cholesterol in the Japanese population, which is associated with increase in the incidence of cardiovascular diseases (CVD). Japanese guidelines recommend "The Japan diet" to prevent CVD, because there are several epidemiological data to show the cardio-preventive effect of fish, soy bean, and vegetables, which are the major component of "The Japan Diet". It is very important to recognize the diet habit is one of culture and that rice plays a pivotal role in "The Japan Diet".

Development of a Cardiovascular Disease Risk Prediction Model Using the Suita Study, a Population-Based Prospective Cohort Study in Japan

Aim: To construct a risk prediction model for cardiovascular disease (CVD) based on the Suita study, an urban Japanese cohort study, and compare its accuracy against the Framingham CVD risk score (FRS) model.

Methods: After excluding participants with missing data or those who lost to follow-up, this study consisted of 3,080 men and 3,470 women participants aged 30–79 years without CVD at baseline in 1989–1999. The main outcome of this study was incidence of CVD, defined as the incidence of stroke or coronary heart disease. Multivariable Cox proportional hazards models with stepwise selection were used to develop the prediction model. To assess model performance, concordance statistics (C-statistics) and their 95% confidence intervals (CIs) were calculated using a bootstrap procedure. A calibration test was also conducted.

Results: During a median follow-up period of 16.9 years, 351 men and 241 women developed CVD. We formulated risk models with and without electrocardiogram (ECG) data that included age, sex, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, lowdensity lipoprotein cholesterol, diabetes mellitus, smoking, and urinary protein as risk factors. The C-statistics of the Suita CVD risk models with ECG data (0.782; 95% CI, 0.766–0.799) and without ECG data (0.781; 95% CI, 0.765–0.797) were significantly higher than that of the FRS model (0.768; 95% CI, 0.750–0.785).

Conclusions: The Suita CVD risk model is feasible to use and improves predictability of the incidence of CVD relative to the FRS model in Japan.

Precision Medicine and Cardiovascular Health: Insights from Mendelian Randomization Analyses

Cardiovascular disease (CVD) is considered a primary driver of global mortality and is estimated to be responsible for approximately 17.9 million deaths annually. Consequently, a substantial body of research related to CVD has developed, with an emphasis on identifying strategies for the prevention and effective treatment of CVD. In this review, we critically examine the existing CVD literature, and specifically highlight the contribution of Mendelian randomization analyses in CVD research. Throughout this review, we assess the extent to which research findings agree across a range of studies of differing design within a triangulation framework. If differing study designs are subject to non-overlapping sources of bias, consistent findings limit the extent to which results are merely an artefact of study design. Consequently, broad agreement across differing studies can be viewed as providing more robust causal evidence in contrast to limiting the scope of the review to a single specific study design. Utilising the triangulation approach, we highlight emerging patterns in research findings, and explore the potential of identified risk factors as targets for precision medicine and novel interventions.

Health Functions and Related Molecular Mechanisms of Tea Components: An Update Review

Tea is widely consumed all over the world. Generally, tea is divided into six categories: White, green, yellow, oolong, black, and dark teas, based on the fermentation degree. Tea contains abundant phytochemicals, such as polyphenols, pigments, polysaccharides, alkaloids, free amino acids, and saponins. However, the bioavailability of tea phytochemicals is relatively low. Thus, some novel technologies like nanotechnology have been developed to improve the bioavailability of tea bioactive components and consequently enhance the bioactivity. So far, many studies have demonstrated that tea shows various health functions, such as antioxidant, anti-inflammatory, immuno-regulatory, anticancer, cardiovascular-protective, anti-diabetic, anti-obesity, and hepato-protective effects. Moreover, it is also considered that drinking tea is safe to humans, since reports about the severe adverse effects of tea consumption are rare. In order to provide a better understanding of tea and its health potential, this review summarizes and discusses recent literature on the bioactive components, bioavailability, health functions, and safety issues of tea, with special attention paid to the related molecular mechanisms of tea health functions.

Key Points of the 2019 Japanese Society of Hypertension Guidelines for the Management of Hypertension

The new 2019 Japanese Society of Hypertension (JSH) guidelines for the management of hypertension are now available; these update the previous guidelines published in 2014. The primary objective of the guideline is to provide all healthcare professionals with a standard management strategy and appropriate antihypertensive treatments to prevent hypertension-related target organ damage and cardiovascular events. The major changes in the new guideline relate to the definition of normal blood pressure (BP) and target BP. The terms 'normal BP' and 'high normal BP' used in the JSH 2014 guidelines are replaced with terms 'high normal BP' and 'elevated BP,' respectively. There was no change to the office BP diagnostic threshold for hypertension (140/90 mmHg). Recommended target office and home BP values for patients with hypertension aged <75 years and/or high-risk patients are <130/80 mmHg and <125/75 mmHg, respectively. Corresponding targets for elderly patients with hypertension (age≥75 years) are 140/90 and 135/85 mmHg, respectively. The goal is that these changes will contribute to reducing cardiovascular events, especially stroke and heart failure, in Japan. The dissemination of the JSH 2019 guidelines and implementation of a home BP-based approach by all general practitioners in Japan might be facilitated by digital hypertension management using health information technology.

Household dietary salt consumption and mortality from cardiovascular diseases: an ecological panel analysis in Japan

Background

Epidemiological evidence has shown that lower salt intake reduces hypertension-related disease mortality. Japan has experienced a drastic decrease in cardiovascular mortality, although this varies across regions. This regional variation does not necessarily match the local patterns of reported average salt intake. In this study, we examined population-level risk factors for hypertension-related disease mortality, focussing on the average household dietary consumption of salt intake sources.

Methods

We prepared an ecological panel dataset, with prefecture as the unit of analysis, by referring to public statistics and market research data from 2012 to 2015. We collected prefectural averages of household dietary consumption related to salt intake and other nutrients that may affect hypertension control. We used demographic characteristics, medical care availability and local economy indices as covariates. Panel data analysis with fixed-effects modelling was performed, regressing prefectural-level mortality from ischaemic heart diseases, subarachnoid and intracerebral haemorrhage and cerebral infarction on dietary consumption and the selected covariates.

Results

We confirmed the average household consumption of salt equivalents of discretional salt intake sources to be positively but only weakly associated with mortality from ischaemic heart diseases and cerebral infarction. Household expenditure on processed foods was positively associated with ischaemic heart disease mortality.

Conclusions

These findings may suggest that the reduction of salt in processed foods, in addition to individual behavioural change, could be useful for decreasing mortality from ischaemic heart diseases in the Japanese population. Ecological factors related to decreasing cerebrovascular disease mortality in the context of the ageing Japanese population require further investigation.

Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: The HOPE Asia Network

Hypertension is an important public health issue because of its association with a number of significant diseases and adverse outcomes. However, there are important ethnic differences in the pathogenesis and cardio-/cerebrovascular consequences of hypertension. Given the large populations and rapidly aging demographic in Asian regions, optimal strategies to diagnose and manage hypertension are of high importance. Ambulatory blood pressure monitoring (ABPM) is an important out-of-office blood pressure (BP) measurement tool that should play a central role in hypertension detection and management. The use of ABPM is particularly important in Asia due to the specific features of hypertension in Asian patients, including a high prevalence of masked hypertension, disrupted BP variability with marked morning BP surge, and nocturnal hypertension. This HOPE Asia Network document summarizes region-specific literature on the relationship between ABPM parameters and cardiovascular risk and target organ damage, providing a rationale for consensus-based recommendations on the use of ABPM in Asia. The aim of these recommendations is to guide and improve clinical practice to facilitate optimal BP monitoring with the goal of optimizing patient management and expediting the efficient allocation of treatment and health care resources. This should contribute to the HOPE Asia Network mission of improving the management of hypertension and organ protection toward achieving "zero" cardiovascular events in Asia.