Periodontitis and hypertension are linked through systemic inflammation: A 5-year longitudinal study

AIM

To investigate the associations between periodontitis and hypertension and potential mediation via systemic inflammation through a 5-year longitudinal study.

MATERIALS AND METHODS

The severity and extent of periodontitis were determined using probing depth (PD). Oral hygiene was assessed using plaque scores. The associations between periodontal variables and 5-year blood pressure changes or incident hypertension were analysed using linear or Poisson regression, adjusting for potential confounders. Mediation analysis of two systemic inflammatory biomarkers, namely white blood cell count (WBC) and C-reactive protein (CRP) levels, was performed.

RESULTS

The study population included 901 hypertension-free participants, aged 50-73 years. Greater mean PD, higher percentage of sites with PD ≥ 6 mm and poor oral hygiene were associated with elevated systolic blood pressure and increased hypertension risk (relative risks = 1.17 [95% confidence interval [CI]: 1.02-1.34], 1.13 [95% CI: 1.02-1.26] and 1.08 [95% CI: 1.03-1.13], respectively). Periodontitis and poor oral hygiene were associated with higher WBC and CRP levels (p < .05), which, in turn, were associated with increased hypertension risk (p < .05). WBC and CRP jointly mediated 14.1%-26.9% of the associations between periodontal variables and incident hypertension.

CONCLUSIONS

Periodontitis and poor oral hygiene were associated with increased hypertension risk, and systemic inflammation was, in part, a mediator of these associations.

An Increase in Vascular Stiffness is Positively Associated with Mitochondrial Bioenergetics Impairment of Peripheral Blood Mononuclear Cells in the Elderly Population

The cardio-ankle vascular index (CAVI) is a non-invasive parameter reflecting vascular stiffness. CAVI correlates with the burden of atherosclerosis and future cardiovascular events. Mitochondria of peripheral blood mononuclear cells (PBMCs) have been identified as a non-invasive source for assessing systemic mitochondrial bioenergetics. This study aimed to investigate the relationship between CAVI values and mitochondrial bioenergetics of PBMCs in the elderly population. This cross-sectional study enrolled participants from the Electricity Generating Authority of Thailand (EGAT) between 2017 and 2018. 1640 participants with an ankle-brachial index greater than 0.9 were included in this study. All participants were stratified into three groups based on their CAVI values as high (CAVI ≥9), moderate (9 >CAVI ≥8), and low (CAVI <8), in which each group comprised 702, 507 and 431 participants, respectively. The extracellular flux analyzer was used to measure mitochondrial respiration of isolated PBMCs. The mean age of the participants was 67.9 years, and 69.6% of them were male. After adjusted with potential confounders including age, sex, smoking status, body mass index, diabetes, dyslipidemia, hypertension, and creatinine clearance, participants with high CAVI values were independently associated with impaired mitochondrial bioenergetics, including decreased basal respiration, maximal respiration, and spare respiratory capacity, as well as increased mitochondrial reactive oxygen species. This study demonstrated that CAVI measurement reflects the underlying impairment of cellular mitochondrial bioenergetics in PBMCs. Further longitudinal studies are necessary to establish both a causal relationship between CAVI measurement and underlying cellular dysfunction.

Biological age as estimated by baseline circulating metabolites is associated with incident diabetes and mortality

OBJECTIVES

It is unclear how metabolomic assessment of biological aging performs in non-White populations and whether such an approach can predict future mortality. We aimed to evaluate the application of serum metabolomics combined with machine learning methodologies to predict incident diabetes and mortality in a Thai population.

DESIGN, SETTING AND PARTICIPANTS

We analyzed serum samples and mortality data over 11 years from among 454 participants with no previous history of diabetes and with a fasting plasma glucose ≥85th percentile (5.4 mmol/L) but <7 mmol/L.

MEASUREMENTS

Untargeted serum metabolomics were assessed using liquid chromatography/mass spectrometry. A deep artificial neural network was used to predict biological age based on serum metabolite profiles and chronological age.

RESULTS

The mean age of participants was 40.5 ± 6.4 years, and 70.8% were men. We found a significant positive correlation between metabolomic age and chronological age (r = 0.71, P < 0.001). After 5 years, 61 of 404 participants with available glycated hemoglobin status (15.1%) progressed to diabetes. Chronological age was associated with incident diabetes but was not significant (P = 0.08), after adjusting for BMI and sex. Metabolomic age was significantly related to incident diabetes after controlling for BMI and sex (P < 0.05). Over the 11-year follow-up, 10 participants died owing to non-accidental causes. When metabolomic age and chronological age were included together in the model, metabolomic age (but not chronological age) was associated with mortality, independent of age, sex, and BMI. Among all identifiable metabolites, beta-D-mannosylphosphodecaprenyl and phosphatidylserines were the five leading metabolites associated with mortality.

CONCLUSION

We concluded that serum metabolomic profile was associated with incident diabetes as well as mortality over our 11-year study period, which may render it potentially useful in assessing biological aging in humans.

Development of Risk Prediction Models for Severe Periodontitis in a Thai Population: Statistical and Machine Learning Approaches

BACKGROUND

Severe periodontitis affects 26% of Thai adults and 11.2% of adults globally and is characterized by the loss of alveolar bone height. Full-mouth examination by periodontal probing is the gold standard for diagnosis but is time- and resource-intensive. A screening model to identify those at high risk of severe periodontitis would offer a targeted approach and aid in reducing the workload for dentists. While statistical modelling by a logistic regression is commonly applied, optimal performance depends on feature selections and engineering. Machine learning has been recently gaining favor given its potential discriminatory power and ability to deal with multiway interactions without the requirements of linear assumptions.

OBJECTIVE

We aim to compare the performance of screening models developed using statistical and machine learning approaches for the risk prediction of severe periodontitis.

METHODS

This study used data from the prospective Electricity Generating Authority of Thailand cohort. Dental examinations were performed for the 2008 and 2013 surveys. Oral examinations (ie, number of teeth and oral hygiene index and plaque scores), periodontal pocket depth, and gingival recession were performed by dentists. The outcome of interest was severe periodontitis diagnosed by the Centre for Disease Control-American Academy of Periodontology, defined as 2 or more interproximal sites with a clinical attachment level ≥6 mm (on different teeth) and 1 or more interproximal sites with a periodontal pocket depth ≥5 mm. Risk prediction models were developed using mixed-effects logistic regression (MELR), recurrent neural network, mixed-effects support vector machine, and mixed-effects decision tree models. A total of 21 features were considered as predictive features, including 4 demographic characteristics, 2 physical examinations, 4 underlying diseases, 1 medication, 2 risk behaviors, 2 oral features, and 6 laboratory features.

RESULTS

A total of 3883 observations from 2086 participants were split into development (n=3112, 80.1%) and validation (n=771, 19.9%) sets with prevalences of periodontitis of 34.4% (n=1070) and 34.1% (n=263), respectively. The final MELR model contained 6 features (gender, education, smoking, diabetes mellitus, number of teeth, and plaque score) with an area under the curve (AUC) of 0.983 (95% CI 0.977-0.989) and positive likelihood ratio (LR+) of 11.9 (95% CI 8.8-16.3). Machine learning yielded lower performance than the MELR model, with AUC (95% CI) and LR+ (95% CI) values of 0.712 (0.669-0.754) and 2.1 (1.8-2.6), respectively, for the recurrent neural network model; 0.698 (0.681-0.734) and 2.1 (1.7-2.6), respectively, for the mixed-effects support vector machine model; and 0.662 (0.621-0.702) and 2.4 (1.9-3.0), respectively, for the mixed-effects decision tree model.

CONCLUSIONS

The MELR model might be more useful than machine learning for large-scale screening to identify those at high risk of severe periodontitis for periodontal evaluation. External validation using data from other centers is required to evaluate the generalizability of the model.

Associations between residential greenness and air pollution and the incident metabolic syndrome in a Thai worker cohort

Increasing air pollution and decreasing exposure to greenness may contribute to the metabolic syndrome (MetS). We examined associations between long-term exposure to residential greenness and air pollution and MetS incidence in the Bangkok Metropolitan Region, Thailand. Data from 1369 employees (aged 52-71 years) from the Electricity Generating Authority of Thailand cohort from 2002 to 2017 were analyzed. The greenness level within 500 m of each participant's residence was measured using the satellite-derived Normalized Difference Vegetation Index (NDVI) and Enhanced Vegetation Index (EVI). The kriging approach was used to generate the average concentration of each air pollutant (PM10, CO, SO2, NO2, and O3) at the sub-district level. The average long-term exposure to air pollution and greenness for each participant was calculated over the same period of person-time. Cox proportional hazards models were used to analyze the greenness-air pollution-MetS associations. The adjusted hazard ratio of MetS was 1.42 (95% confidence interval (CI): 1.32, 1.53), 1.22 (95% CI: 1.15, 1.30), and 2.0 (95% CI: 1.82, 2.20), per interquartile range increase in PM10 (9.5 μg/m3), SO2 (0.9 ppb), and CO (0.3 ppm), respectively. We found no clear association between NDVI or EVI and the incidence of MetS. On the contrary, the incident MetS was positively associated with NDVI and EVI for participants exposed to PM10 at concentrations more than 50 μg/m3. In summary, the incidence of MetS was positively associated with long-term exposure to air pollution. In areas with high levels of air pollution, green spaces may not benefit health outcomes.

Longitudinal study of vitamin D status among Thai individuals in a sun-abundant country

Background

Vitamin D deficiency is a major public health problem worldwide, even in countries with abundant sunshine. Understanding the risk factors for vitamin D deficiency is important to inform public health recommendations. We conducted a longitudinal analysis of vitamin D status in Thai individuals to assess changes in vitamin D status over time and identify potential determinants.

Study design

This study is a long term prospective cohort study.

Methods

Of the 1239 participants who were employees of the Electricity Generating Authority of Thailand, serum 25-hydroxyvitamin D (25(OH)D) levels were measured by liquid chromatography/tandem mass spectrometry from samples collected in 2009 and 2019.

Results

There was a significant 14.8% increase in serum total 25(OH)D (P < 0.001) from 2009 to 2019, which resulted from significant increases in both 25(OH)D3 and 25(OH)D2. The epimeric form of 25(OH)D2 also increased significantly, while there was no increase in the epimeric form of 25(OH)D3. A univariate analysis showed significant associations between increased total 25(OH)D and increasing age, male sex, and lower body mass index. After controlling for baseline vitamin D status, multivariate regression analyses found that the direction of association and significance from univariate analyses persisted for total 25(OH)D and 25(OH)D3. However, a univariate association found between female sex and an increase in 25(OH)D2 was not significant in multivariate regression analysis.

Conclusions

A long-term trend of improved vitamin D status was found among Thai adult individuals over a 10-year period; however, improvements were less noticeable in women.

Gaps in the Care of Subjects with Familial Hypercholesterolemia: Insights from the Thai Familial Hypercholesterolemia Registry

AIMS

Familial hypercholesterolemia (FH) is currently underdiagnosed and undertreated. The establishment of a FH registry could facilitate a deeper understanding of this disease. We described the clinical characteristics of subjects with FH from the Thai FH Registry, compared our data with the regional and global data, and identified gaps in the care of these subjects.

METHODS

A multicenter, nationwide prospective FH registry was established in Thailand. Our data were compared with those of the European Atherosclerosis Society-FH Studies Collaboration. Multiple logistic regression analyses were performed for variables associated with lipid-lowering medication (LLM) use and the attainment of low-density lipoprotein-cholesterol (LDL-C) goal.

RESULTS

The study includes 472 subjects with FH (mean age at FH diagnosis: 46±12 years, 61.4% women). A history of premature coronary artery disease was found in 12%. The percentage of LLM use in subjects with a Dutch Lipid Clinic Network score of ≥ 6 (probable or definite FH) in our registry (64%) was slightly lower than the regional data but higher than the global data. Among those who received statins, 25.2% and 6.4% achieved LDL-C levels of ＜100 mg/dL and ＜70 mg/dL, respectively. Women with FH were less likely to achieve LDL-C ＜70 mg/dL (adjusted odds ratio: 0.22, 95% confidence interval: 0.06-0.71, p=0.012).

CONCLUSIONS

FH in Thailand was diagnosed late, and treatment was inadequate for the majority of subjects. Women with FH were less likely to achieve LDL-C goals. Our insights could potentially help raise awareness and narrow the gap in patient care.

Residential greenness and kidney function: A cohort study of Thai employees

Higher residential greenness is associated with a lower risk of chronic kidney disease, but evidence on the association between greenness exposure and kidney function has not been conducted. Using cohort data from Electricity Generating Authority of Thailand (EGAT) employees, we investigated the association between long-term exposure to greenness and kidney function using estimated glomerular filtration rate (eGFR) in Bangkok Metropolitan Region (BMR), Thailand. We analyzed data from 2022 EGAT workers (aged 25-55 years at baseline) from 2009 to 2019. The level of greenness was calculated using the satellite-derived Enhanced Vegetation Index (EVI) and Normalized Difference Vegetation Index (NDVI). From 2008 to 2019, the average concentration of each air pollutant (PM₁₀, O₃, NO₂, SO₂, and CO) at the sub-district level in BMR was generated using the Kriging method. Long-term exposure for each participant was defined as the 1-year average concentrations before the date of the physical examination in 2009, 2014, and 2019. We employed linear mixed effects models to evaluate associations of NDVI and EVI with eGFR. The robustness of the results was also tested by including air pollutants in the models. After relevant confounders were controlled, the interquartile range increase in NDVI was associated with higher eGFR [1.03% (95%CI: 0.33, 1.74)]. After PM₁₀ and SO₂ were included in the models, the associations between NDVI and eGFR became weaker. The additions of O₃, NO₂, and CO strengthened the associations between them. In contrast, we did not find any association between EVI and eGFR. In conclusion, there was a positive association between NDVI and eGFR, but not for EVI. Air pollutants had a significant impact on the relationship between NDVI and eGFR. Additional research is needed to duplicate this result in various settings and populations to confirm our findings.

Increased Efficiency of Mitochondrial Coupling With a Reduction in Other Mitochondrial Respiratory Parameters in Peripheral Blood Mononuclear Cells Is Observed in Older Adults

Mitochondrial dysfunction is a factor potentially contributing to the Aging process. However, evidence surrounding changes in mitochondrial function and aging is still limited; therefore, this study aimed to investigate further the association between them. Possible confounding factors were included in the statistical analysis to explore the possibility of any independent associations. One thousand seven hundred and sixty-nine participants (619 middle-aged adults [age < 65] and 1,150 older adults [age ≥ 65]) from the Electricity Generating Authority of Thailand were enrolled in the study. The clinical characteristics and medical history were collected. Peripheral blood mononuclear cells (PBMCs) were isolated from venous blood and used for analysis of mitochondrial function. Several parameters pertinent to mitochondrial respiration including non-mitochondrial respiration, basal respiration, maximal respiration, proton leak, and spare respiratory capacity were found to be two to three times lower in the mitochondria isolated from the cells of older adults. Interestingly, the mitochondrial ATP production was only slightly reduced, and the percentage of coupling efficiency of PBMC mitochondria was significantly higher in the older adult group. The mitochondrial mass and oxidative stress were significantly reduced in older adult participants; however, the ratio of oxidative stress to mass was significantly increased. The association of these parameters with age was still shown to be the same from the outcome of the multivariate analyses. The mitochondrial functions and mitochondrial mass in PBMCs were shown to decline in association with age. However, the upregulation of mitochondrial oxidative stress production and mitochondrial coupling efficiency might indicate a compensatory response in mitochondria during aging.

Association of body mass index and dietary intake with mild cognitive impairment and dementia: a retrospective cohort study

BACKGROUND

The prevalence of cognitive impairment in older adults is gradually increasing, and this is leading to many adverse outcomes. Common causes of cognitive impairment in advancing age are mild cognitive impairment (MCI) and dementia. However, how the nutritional status and nutrient intake are related to MCI and dementia is controversial. Therefore, we aimed to evaluate the association of body mass index (BMI) and dietary intake with the risk of MCI and dementia.

METHODS

This retrospective cohort study involved 821 participants aged ≥ 50 years from a previous population-based cohort study: the Electricity Generating Authority of Thailand (EGAT) study in 2013-2014 (baseline) and 2018-2019 (follow-up). Dietary intake was recorded using a 12-month self-reported food frequency questionnaire. MCI and dementia were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria using the Montreal Cognitive Assessment with ADL and the Kessler Psychological Distress Scale (K10) at study entry and at the 5-year follow-up.

RESULTS

Among the 821 participants, the mean age was 60.0 ± 4.3 years, and the incidence rate of MCI and dementia was 42.5 and 11.2 per 1,000 person-years, respectively. The rate of MCI and dementia was higher in participants aged ≥ 60 years and with an education level of < 7 years. The rate of MCI was also higher in those with a BMI of ≥ 25 kg/m² and type 2 diabetes. Compared to BMI 18.5-22.9 kg/m², BMI of ≥ 25 kg/m² (odds ratio 1.91 [95% confidence interval, 1.12-3.26], p < 0.001) was associated with an increased risk of MCI after adjusted for age, education level, and type 2 diabetes. Regarding dietary intake, fresh red meat consumption was inversely associated with the risk of MCI (p = 0.037) and dementia (p = 0.011) after adjusting for age, education level, type 2 diabetes, and BMI.

CONCLUSION

Obesity was associated with a greater risk of MCI. Moreover, low consumption of fresh red meat could be a risk factor for MCI and dementia. Further studies are required to confirm and explain these findings.

Validity of Simple Self-Reported Periodontal Status Questions

OBJECTIVE

The aim of this research was to evaluate the validity of the questions developed by Thai periodontists on self-reported periodontal status and symptoms in identifying severe periodontitis amongst adults in Thailand.

METHODS

Registered Electricity Generating Authority of Thailand (EGAT) employees completed medical examinations and full-mouth periodontal examinations. They also were interviewed using a self-reported questionnaire that was developed by Thai periodontists. The questions pertained to their periodontal status and symptoms comprising swollen gums, bad breath, loose teeth, bleeding on brushing, painful gums, and pus or abscesses. The participants were categorised as having nonsevere and severe periodontitis according to the Centers for Disease Control and Prevention in partnership with the American Academy of Periodontology (CDC/AAP) case definitions. Self-reported periodontal status and symptom results were compared with actual periodontal status. The area under the receiver operating characteristic curve (AUROCC), sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.

RESULTS

A total of 1393 EGAT employees participated in this study. The questions on self-reported periodontal status and all symptoms poorly identified patients with severe periodontitis, with an AUROCC of 0.52 to 0.60. The sensitivity was 5.0% to 40.2%; however, the specificity was good, at 73.2% to 99.1%. The validity of the self-reported questions was comparable amongst the sex, education, and income subgroups.

CONCLUSIONS

This study demonstrated that self-reported periodontal status and symptoms were inadequate in identifying patients with severe periodontal disease.

Long-Term Effects of Cigarette Smoking on All-Cause Mortality and Cardiovascular Outcomes in Thai Population: Results From a 30-Year Cohort Study

Despite the overwhelming evidences on the health consequences of smoking, studies in Asian population in low-to-middle income countries are very limited. Baseline data of a prospective cohort study were collected in year 1985. Endpoints regarding all-cause mortality and major adverse cardiovascular events (MACE) were followed for 30 years. Cox proportional hazard models were used for analysis. Participants had an average age of 43 years, 23% were female, and 43% were current smokers. All-cause mortality was significantly higher in ex-smokers (hazard ratio [HR] 1.32) and current smokers (HR 1.70) when compared with never smokers. Participants with any history of smoking had significantly higher risk of developing MACE. Furthermore, all-cause death, cardiovascular death, and MACE increased with increasing pack years. Statistically significant dose-response relationships were established. Therefore, cigarette smoking increased the risk of all-cause mortality, cardiovascular mortality, and MACE in Thai population. Results emphasized the importance of tobacco control in Thailand.

Effectiveness and Safety of Direct Oral Anticoagulants in Thai Patients with Atrial Fibrillation: A Real-World Retrospective Cohort Study

Background

Direct oral anticoagulants (DOACs) are commonly used to prevent stroke and systemic embolism in patients with atrial fibrillation (AF). However, studies into their effectiveness and safety in the Thai population have so far been limited.

Objectives

To study the effectiveness and safety of warfarin and DOACs among Thai AF patients

Methods

A retrospective cohort study was conducted on AF patients at Ramathibodi Hospital from 2013 to 2018. All patients were followed for at least 1 year. Relevant clinical information was collected and compared between AF patient groups receiving warfarin, dabigatran, rivaroxaban, and apixaban. The primary outcome was a composite of major bleeding, ischemic stroke, and systemic thromboembolism. The secondary outcomes were all-cause mortality and disease-specific mortality caused by major bleeding, ischemic stroke, and systemic thromboembolism.

Results

A total of 1680 AF patients were enrolled in the study (warfarin 1193, apixaban 140, dabigatran 193, rivaroxaban 114). The estimated incidence of composite outcome was 16% [95% CI, 14−18%] and 12.4% [95% CI, 9.4−15.3%] in the warfarin and DOAC group, respectively, given a number needed to treat of 28 [95% CI, 3−52]. Compared with warfarin, DOACs were associated with both lower rate of all-cause mortality (4.9% [22/447] vs 8% [98/1193]) and lower disease-specific mortality (0.4% [2/447] and 1% [12/1193]).

Conclusions

This study suggests DOACs were associated with a lower risk of major bleeding, ischemic stroke, and systemic thromboembolism compared to warfarin in Thai patients with AF. Patients receiving DOAC also had a lower rate of all-cause mortality and disease-specific mortality.

Clinical significance of undetectable high sensitivity cardiac troponin I (hs-TnI) in Thai individuals with low cardiovascular risk

Introduction

The long term prognosis of individuals who has undetectable hs-TnI is poorly defined in low cardiovascular risk. We aim to examine whether undetectable hs-TnI individuals have better cardiovascular outcomes in low cardiovascular risk population.

Methods

Data of low cardiovascular risk population (&lt;7.5%) who has no established of atherosclerosis cardiovascular disease (ASCVD) was derived from the Electricity Generating Authority of Thailand (EGAT) study in 2007–2009 survey. High sensitivity cardiac troponin I was measured by using the Abbott ARCHITECT i2000 SR assay. We categorized level of hs-TnI into undetectable hs-TnI (&lt;1.9 ng/L), low hs-TnI, intermediate and more hsTnI by gendered specific cut-off. The low cardiovascular risk population was classified into extremely low risk (&lt;5%) and low risk (5–7.5%). Major cardiovascular event (MACE) and all-cause mortality were collected until 31st December 2019. Survival analysis and subgroup analysis were performed.

Results

A total of 3,442 participants were eligible. Mean age was 43.6 years-old, 65.5% male, hs-TnI was detected 79.8%, median hs-cTnI was 2.6 ng/L (2,3.6). During median time followed-up 10.3 years, 52 events (1.5%) of MACE and 60 events (1.7%) of all-cause mortality occurred. After adjusted for conventional risk factors, hs-cTnI significantly associated with incidence of MACE (HR 1.03 95% CI 1.02–1.04, p-value &lt;0.001). Compared with intermediate and more hs-TnI group, undetectable hs-TnI and low hs-TnI had 79% and 52% lower incidence of MACE (HR 0.21, 95% CI (0.05–0.79) and HR 0.48, 95% CI (0.23–1.0), p-value for trend 0.04. Subgroup analysis, incidence of MACE remained higher either extremely low or low CV risk compared with those undetectable hs-TnI. (P for interact 0.83)

Conclusion

Among individuals with low cardiovascular risk, hs-TnI testing can provide risk prognostication. Undetectable hs-TnI could be as a negative risk marker for adverse cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

Mendelian randomization study of the effect of coronary artery calcification on atherosclerotic cardiovascular diseases

Calcium calcification in the wall of arteries (CAC) leads to a higher risk of atherosclerosis related outcomes, especially myocardial infarction (MI). Nevertheless, the causal role of CAC on other related outcomes is unclear. In this study, we used Mendelian randomization (MR) to systematically investigate the causal role of CAC across a broad range of atherosclerotic cardiovascular diseases including coronary heart disease, angina, MI, ischemic heart disease, stroke, and peripheral vascular disease. Publicly available data from the UK biobank and other data sources were used. Using the two-sample Mendelian randomization (MR) approach, we applied 3 MR models including the inverse variance weighted, the weighted-median, and the weighted-mode methods. Eight SNPs associated with CAC were selected as instrumental variables. We observed causal evidence of CAC on MI consistently across all MR models (P_IVW = 1.0 × 10^-4, P_W-Median = 1.1 × 10^-4, P_W-Mode = 3.8 × 10^-2) and this causation is shown in an acute transmural MI of inferior wall (P_IVW = 1.5 × 10^-4, P_W-Median = 4.8 × 10^-5, P_W-Mode = 3.2 × 10^-2) but not consistently observed in an anterior wall. As each site of acute MI was suggested to have relatively specific mechanisms, our finding suggested that the causal role of CAC on MI is in an inferior wall possibly as a consequence of large calcification from a prolonged process, whereas non-calcified artery plaque or other underlying mechanisms may predominantly play role in an anterior infarction during an advanced atherosclerotic process.

Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand

BACKGROUND

Due to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown.

METHODS

Cost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed.

FINDINGS

From the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK.

INTERPRETATION

In a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase.

FUNDING

None.

Causal relationship of excess body weight on cardiovascular events through risk factors

Excess body weight is associated with cardiovascular events (CVEs) and premature death. This study aimed to find the causal pathways between excess body weight and CVEs through risk factors in a general adult population. A total of 7921 employees of the Electricity Generating Authority of Thailand were enrolled during 1997-2009. Baseline characteristics and blood test results were collected. A body mass index (BMI) ≥ 23 kg/m², using WHO criteria for Asians was defined as excess body weight. A mediation analysis was applied to assess potential causal pathways. BMI ≥ 23 kg/m² was considered as an independent variable, whereas diabetes mellitus (DM), hypertension (HT), and chronic kidney disease (CKD) were considered as mediators, and CVEs (i.e., fatal and non-fatal coronary artery disease or stroke) were considered as the outcomes. The prevalence of BMI ≥ 23 kg/m², DM, HT, and CKD were 62.7%, 7.8%, 28.1% and 11.8% respectively. During an average of 17.2 ± 5.5 years follow-up, subjects with BMI ≥ 23 kg/m² compared with those with lower BMIs more frequently developed CVEs (9.4 vs 6.2%, P < 0.001). The effects of BMI ≥ 23 kg/m² on CVEs were mediated indirectly through DM and HT with significant ORs of 1.61 (1.34, 2.09) and 1.57 (1.39, 1.80), respectively. The indirect effect of CKD on CVEs was significantly increased if mediated through DM → HT or HT [ORs of 1.17 (1.09, 1.32) and 1.20 (1.10, 1.32), respectively]. Subjects with excess body weight were prone to develop CVEs which were mediated indirectly through DM and HT. The effect of CKD on CVEs was small but enhanced if it occurred as a complication of DM or HT.

Long-term air pollution exposure and decreased kidney function: A longitudinal cohort study in Bangkok Metropolitan Region, Thailand from 2002 to 2012

BACKGROUND

Kidney dysfunction is considered a cardiovascular risk factor. However, few longitudinal studies have examined the effects of air pollution on kidney function. We evaluated associations between long-term air pollution exposure and estimated glomerular filtration rate (eGFR) using data from a cohort of the Electricity Generating Authority of Thailand (EGAT) study in Bangkok Metropolitan Region, Thailand.

METHODS

This longitudinal study included 1839 subjects (aged 52-71 years in 2002) from the EGAT1 cohort study during 2002-2012. eGFR, based on creatinine, was measured in 2002, 2007, and 2012. Annual mean concentrations of air pollutants (i.e., particulate matter with an aerodynamic diameter ≤10 μm (PM₁₀), ozone (O₃), nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and carbon monoxide (CO)) prior to a measurement of creatinine were assessed with the ordinary kriging method. Mixed-effect linear regression models were used to assess associations between air pollutants and eGFR, while controlling for potential covariates. eGFR values are expressed as percent change per interquartile range (IQR) increments of each pollutant.

RESULTS

Lower eGFR was associated with higher concentrations of PM₁₀ (-1.99%, 95% confidence interval (CI): -3.33, -0.63), SO₂ (-4.89%, 95%CI: -6.69, -3.07), and CO (-0.97%, 95%CI: -1.96, 0.03). However, after adjusting for temperature, relative humidity, PM₁₀, and SO₂, no significant association was observed between CO and eGFR.

CONCLUSIONS

Our findings support the hypothesis that long-term exposure to high concentrations of PM₁₀ and SO₂ is associated with the progression of kidney dysfunction in subjects of the EGAT cohort study.

Cardio-ankle vascular index as a predictor of major adverse cardiovascular events in metabolic syndrome patients

Background

Arterial stiffness, as reflected in the cardio‐ankle vascular index (CAVI), is a risk factor for major adverse cardiovascular events (MACEs).

Hypothesis

Combining CAVI and metabolic syndrome (MetS) may enhance prediction of MACEs in a general adult population.

Methods

A total of 3807 employees of the Electricity Generating Authority of Thailand were enrolled in a longitudinal health study during 2007‐2008. Baseline characteristics were collected and CAVI determined. Subjects with previous coronary artery disease or stroke were excluded from analysis. MetS was defined using the modified NCEP‐ATP III for Asians. The primary study endpoint was occurrence of a MACE (myocardial infarction, stroke, or cardiovascular death).

Results

MetS was present in 39.2% at study baseline. The prevalence of CAVI > 9 was higher in subjects with MetS compared to those without (33.7% vs. 28.5%, P = 0.001). During the 12.4 ± 0.6 years follow‐up, 227 participants developed MACEs and 350 died. MetS was more common in patients who developed a MACE (8.2% vs. 5.0%, p < 0.001) than was non‐MetS, but it was not a significant risk after adjusting covariables. Participants with CAVI > 9 had greater risk for MACEs 1.34 (95% CI: 1.01, 1.79) relative to those with CAVI < 9. Participants with both MetS and CAVI > 9 had the worst outcomes, with the highest frequency of MACEs, among the four groups.

Conclusion

Arterial stiffness assessed by CAVI may enhance prediction of future MACEs, adding to the null predictive power of MetS. This index can be used to motivate MetS patients to modify their life‐styles for prevention.

The effect of obesity on periodontitis progression: the 10-year retrospective cohort study

OBJECTIVE

Due to inconsistent findings in limited previous cohort studies, the aim of this study was to estimate the obesity effect on periodontitis progression in Thai adults.

MATERIALS AND METHODS

This 10-year retrospective cohort study comprised 2216 employees of the Electric Generation Authority of Thailand (EGAT). Their demographic, medical, and periodontal status was collected. Subjects with periodontitis progression were defined as having ≥ 2 teeth with progression. Additional proximal clinical attachment loss ≥ 3 mm or tooth loss with severe periodontitis at baseline were used to identify disease progression at the tooth level. Central obesity was classified using the waist-hip ratio. Multi-level Poisson regression was used to determine the effect of obesity on periodontitis progression by adjusting for age, sex, education, income, smoking, alcohol drinking, exercise, diabetes mellitus, and hypertension.

RESULTS

The cumulative incidence of periodontitis progression during the 10-year period was 59.6 cases per 100 persons (95% CI: 57.5, 61.6). The univariate analysis indicated that obese subjects had 15% higher risk of progression than that of healthy subjects. However, when confounders were analyzed simultaneously, the effect of obesity was not significant with a risk ratio of 0.98 (95% CI: 0.88, 1.08).

CONCLUSIONS

Despite the higher incidence of disease progression in the obese, obesity is not an independent risk factor for periodontitis progression.

CLINICAL RELEVANCE

Obesity and periodontitis progression share many common risk factors. Using the obesity as a preliminary screening for periodontitis progression may be an alternative prevention protocol.

Metabolic syndrome and severe periodontitis were associated in Thai adults: A cross-sectional study

BACKGROUND

Studies support the relationship between metabolic syndrome (MetS) and periodontitis. However, age is the major confounding factor for both conditions. Therefore, this cross-sectional study was performed to investigate the relationship between MetS and severe periodontitis in different Thai adult age groups.

METHODS

Data on the medical history, medical examination, and full mouth oral examination of 5,690 Electricity Generating Authority of Thailand employees aged 25 to 77 years were collected. The prevalence ratio (PR) between risk variables, MetS, and periodontitis was determined using Poisson regression analysis. Moreover, the subgroup analysis and effect modification by age on severe periodontitis were performed.

RESULTS

Overall, MetS was significantly associated with severe periodontitis compared with non-severe periodontitis (adjusted PR, 1.11; 95% confidence interval [CI], 1.01 to 1.13). The association was modified by age, with negative effect modification observed on the multiplicative and additive scales. The subgroup analysis revealed a significant relationship between MetS and severe periodontitis only in participants aged <45 years with an adjusted PR of 1.69 (95% CI, 1.29 to 2.21). All MetS components, except hypertension, were associated with severe periodontitis in this group.

CONCLUSIONS

There is a significant relationship between MetS and severe periodontitis in adults aged <45 years. Therefore, attempts to control the risk of MetS and periodontitis should be emphasized for early adults to reduce the incidence of these conditions and related complications when they become elderly.

Periodontitis is associated with cardiovascular diseases: A 13-year study

AIM

To prospectively evaluate the association between periodontitis and the incidence of cardiovascular diseases (CVDs) in Thai adults.

MATERIALS AND METHODS

Medical data from the questionnaires and physical examinations of 1850 participants aged 47-73 years from EGAT study were gathered. Random half-mouth periodontal examination of each participant was performed by calibrated periodontists, and periodontal status was defined. The incidence of new CVD events, including coronary heart disease (CHD) and stroke, was verified by cardiologists. The Cox proportional hazard regression model was used to estimate hazard ratios (HRs).

RESULTS

The prevalence of no/mild, moderate and severe periodontitis in the study participants was 11.7%, 52.7% and 35.6%, respectively. During the 13-year follow-up, CVD events occurred in 110 (5.9%) participants, with 82 (4.4%) from CHD and 28 (1.5%) from stroke. After adjusting for cardiovascular risk factors, a significant association between severe periodontitis and the incidence of CHD was found compared with the no/mild periodontitis group with an HR of 4.53 (95% confidence intervals: 1.08-19.02). However, no significant association was seen when considering total CVD events and stroke outcome.

CONCLUSIONS

This study demonstrates that severe periodontitis is associated with an increased incidence of CHD, independent of established cardiovascular risk factors.

Estimated dietary sodium intake in Thailand: A nationwide population survey with 24-hour urine collections

Thailand has committed to reducing population sodium intake by 30% by 2025. However, reliable nationally representative data are unavailable for monitoring progress toward the goal. We estimated dietary sodium consumption using 24‐hour urinary analyses in a nationally representative, cross‐sectional population‐based survey. We selected 2388 adults (aged ≥ 18 years) from the North, South, North‐east, Central Regions, and Bangkok, using multi‐stage cluster sampling. Mean sodium excretion was inflated by 10% to adjust for non‐urinary sources. Multivariate logistic regression was performed to assess factors associated with sodium consumption ≥ 2000 mg. Among 1599 (67%) who completed urine collection, mean age was 43 years, 53% were female, and 30% had hypertension. Mean dietary sodium intake (mg/day) was 3636 (±1722), highest in South (4108 ± 1677), and lowest in North‐east (3316 ± 1608). Higher sodium consumption was independently associated with younger age (Adjusted Odds Ratio (AOR) 2.81; 95% Confidence interval (CI): 1.53‐5.17; p = .001); higher education (AOR 1.79; 95% CI: 1.19‐2.67; p = .005), BMI ≥ 25 (AOR 1.55; 95% CI: 1.09‐2.21; p=.016), and hypertension (AOR 1.58; 95% CI: 1.02‐2.44; p = .038). Urine potassium excretion was 1221 mg/day with little variation across Regions. Estimated dietary sodium consumption in Thai adults is nearly twice as high as recommended levels. These data provide a benchmark for future monitoring.

Associations between alcohol consumption trajectory and deaths due to cancer, cardiovascular diseases and all-cause mortality: a 30-year follow-up cohort study in Thailand

OBJECTIVES

This study examined the association between alcohol consumption trajectory and deaths due to cancer, cardiovascular diseases (CVDs) and all-cause mortality in Thailand.

DESIGN

Data were obtained from a Thai prospective cohort study with more than 30 years of follow-up (n=1961).

SETTING

All participants resided in Bangkok and its vicinity.

PARTICIPANTS

Employees from the Electricity Generating Authority of Thailand aged between 35 and 54 years old were randomly selected.

MAIN OUTCOME MEASURES

Exposure was alcohol consumption trajectory over the study period from 1985 to 2012. The main outcomes were all-cause mortality, and deaths due to cancer and CVDs recorded in national vital registries between 2002 and 2015. Cox's proportional hazard regression was used to determine the associations between alcohol consumption trajectory and each outcome adjusting for sample characteristics, health behaviours and health conditions.

RESULTS

From a total of 59 312 person years, 276 deaths were observed. Compared with drinkers who drank occasionally or most occasional over their lifetime, consistent regular or mostly consistent-regular drinkers had higher rates of all-cause mortality (HR: 1.53; 95% CI 1.09 to 2.16) and cancer mortality (HR: 2.05; 95% CI 1.13 to 3.74). The study did not find a significant association between trajectory of alcohol consumption and deaths due to CVDs.

CONCLUSIONS

Regular drinking of alcohol increased risk for all-cause and cancer mortality. Effective interventions should be implemented to reduce number of regular drinkers in order to saves life of individuals.

Efficacy of different dietary patterns on lowering of blood pressure level: an umbrella review

BACKGROUND

Many systematic reviews and meta-analyses have assessed the efficacy of dietary patterns on blood pressure (BP) lowering but their findings are largely conflicting.

OBJECTIVE

This umbrella review aims to provide an update on the available evidence for the efficacy of different dietary patterns on BP lowering.

METHODS

PubMed and Scopus databases were searched to identify relevant studies through to June 2020. Systematic reviews with meta-analyses of randomized controlled trials (RCTs) were eligible if they measured the effect of dietary patterns on systolic (SBP) and/or diastolic blood pressure (DBP) levels. The methodological quality of included systematic reviews was assessed by A Measurement Tool to Assess Systematic Review version 2. The efficacy of each dietary pattern was summarized qualitatively. The confidence of the effect estimates for each dietary pattern was graded using the NutriGrade scoring system.

RESULTS

Fifty systematic reviews and meta-analyses of RCTs were eligible for review. Twelve dietary patterns namely the Dietary Approaches to Stop Hypertension (DASH), Mediterranean, Nordic, vegetarian, low-salt, low-carbohydrate, low-fat, high-protein, low glycemic index, portfolio, pulse, and Paleolithic diets were included in this umbrella review. Among these dietary patterns, the DASH diet was associated with the greatest overall reduction in BP with unstandardized mean differences ranging from -3.20 to -7.62 mmHg for SBP and from -2.50 to -4.22 mmHg for DBP. Adherence to Nordic, portfolio, and low-salt diets also significantly decreased SBP and DBP levels. In contrast, evidence for the efficacy of BP lowering using the Mediterranean, vegetarian, Paleolithic, low-carbohydrate, low glycemic index, high-protein, and low-fat diets was inconsistent.

CONCLUSION

Adherence to the DASH, Nordic, and portfolio diets effectively reduced BP. Low-salt diets significantly decreased BP levels in normotensive Afro-Caribbean people and in hypertensive patients of all ethnic origins. This review was registered at PROSPERO as CRD42018104733.

The severity and extent of periodontitis is associated with cardio-ankle vascular index, a novel arterial stiffness parameter

OBJECTIVES

To evaluate the association between the severity and extent of periodontitis and arterial stiffness using the cardio-ankle vascular index (CAVI).

MATERIALS AND METHODS

A cross-sectional study of 2888 Electricity Generation Authority of Thailand (EGAT) employees aged 44-78 years was conducted. The severity of periodontitis was evaluated based on mean clinical attachment level (CAL). The percentage of sites with CAL ≥ 5 mm was used to divide the extent of periodontitis into healthy (0%), localized (> 0-< 30%), and generalized (≥ 30%). The CAVI value, a novel blood pressure-independent arterial stiffness parameter, was analyzed as both continuous and categorical data (low: < 9 or high: ≥ 9). Regression analysis was used to estimate the level of association.

RESULTS

The participants demonstrated a mean CAL, % sites with CAL ≥ 5 mm, and a CAVI value of 3.2 ± 1.2 mm, 16.0 ± 20.8%, and 8.24 ± 1.12, respectively. Higher mean CAVI was observed with greater mean CAL and % sites with CAL ≥ 5 mm. The mean CAVI of the healthy, localized, and generalized periodontitis groups were 8.01 ± 1.11, 8.22 ± 1.12, and 8.51 ± 1.04, respectively (p < 0.01). Linear and logistic regression analysis demonstrated a significant relationship between CAVI and all periodontal variables with β = 0.004-0.17 and OR = 1.01-1.58, respectively.

CONCLUSIONS

There is a significant dose-dependent association between the severity and extent of periodontitis and arterial stiffness measured by CAVI in Thai adults.

CLINICAL RELEVANCE

Preventing arterial stiffness, an early sign of cardiovascular events, by controlling the emerging risk factors, such as periodontitis, might have a high impact on health promotion.

Roles of kininogen-1, basement membrane specific heparan sulfate proteoglycan core protein, and roundabout homolog 4 as potential urinary protein biomarkers in diabetic nephropathy

Diabetic nephropathy, a major complication of diabetes mellitus (DM), is increasing worldwide and the large majority of patients have type 2 DM. Microalbuminuria has been used as a diagnostic marker of diabetic nephropathy. But owing to its insufficient sensitivity and specificity, other biomarkers are being sought. In addition, the pathophysiology of diabetic nephropathy is not fully understood and declines in renal function occur even without microalbuminuria. In this study, we investigated urinary proteins from three study groups (controls, and type 2 diabetic subjects with or without microalbuminuria). Non-targeted label-free Nano-LC QTOF analysis was conducted to discover underlying mechanisms and protein networks, and targeted label-free Nano-LC QTOF with SWATH was performed to qualify discovered protein candidates. Twenty-eight proteins were identified as candidates and functionally analyzed via String DB, gene ontology and pathway analysis. Four predictive mechanisms were analyzed: i) response to stimulus, ii) platelet activation, signaling and aggregation, iii) ECM-receptor interaction, and iv) angiogenesis. These mechanisms can provoke kidney dysfunction in type 2 diabetic patients via endothelial cell damage and glomerulus structural alteration. Based on these analyses, three proteins (kininogen-1, basement membrane-specific heparan sulfate proteoglycan core protein, and roundabout homolog 4) were proposed for further study as potential biomarkers. Our findings provide insights that may improve methods for both prevention and diagnosis of diabetic nephropathy.

Long-term effects of socioeconomic status on the incidence of decreased glomerular filtration rate in a Southeast Asian cohort

BACKGROUND

There is limited information on the role of low socioeconomic status (SES) in the development of new chronic kidney disease (CKD) in the general population, especially from developing countries. This study will test the hypothesis that low SES increases the risk of incidence of decreased glomerular filtration rate (GFR, used as an estimate for CKD) in a Thai worker cohort.

METHOD

In this prospective, longitudinal observational study, we evaluated the association of income and educational attainment on incident decreased GFR (iGFR <60 mL/min/1.73 m²) over a 27-year period in employees of Electricity Generating Authority of Thailand. In 1985, subjects participated in a health survey and were re-examined in 1997, 2002, 2007 and 2012. Education was classified into three categories: low, 0-8th grade; medium, 9-12th grade; and high, >12th grade. Income was categorised as follows: low <10 000 Thai Baht (THB)/month; medium, 10 000-20 000 THB/month; and high, >20 000 THB/month. HRs of iGFR<60 mL/min/1.73 m² were estimated using Cox interval-censored models with high income or education as the reference groups after adjustments for clinical risk factors.

RESULTS

Participants (n=3334) were followed for 23 (15, 27) years. When evaluated separately, both education and income were risk factors for iGFR<60 mL/min/1.73 m² (adjusted HR education: medium-1.26 (95% CI 1.13 to1.42) and low-1.57 (95% CI 1.36 to 1.81) and adjusted HR income: medium-1.21 (95% CI 0.97 to 1.50) and low-1.47 (95% CI 1.18 to 1.82)). When both income and education were included together, low and medium education remained independently associated with iGFR<60 mL/min/1.73 m².

CONCLUSIONS

Low education was independently associated with increased risk of decreased GFR in a Thai worker population. Strategies to identify risk factors among low SES may be useful to prevent early CKD.

Fragmented QRS in prediction of ischemic heart disease diagnosed by stress cardiovascular magnetic resonance imaging

Background

In patients with ischemic heart disease (IHD), many studies demonstrated an association between fragmented QRS complex (fQRS) on 12‐lead ECG and myocardial scar, heart failure, and increased mortality. However, data in adults without history of IHD is limited. We aimed to evaluate whether there is an association between fQRS and IHD diagnosed by stress cardiac MRI.

Method

We retrospectively reviewed demographic data, 12‐lead ECG, and stress cardiac MRI data from 604 patients. Fragmented QRS was defined as the presence of additional R wave (R’), notching in the nadir of R or S wave, or the presence of more than one R’ in any ECG leads. Both cardiac MRI and ECG were analyzed by two independent observers.

Result

Final analysis included 554 patients, 39% were male, with a mean age of 67.8 ± 11.1 years. There was positive stress cardiac MRI in 219 patients (39.5%). Older age, diabetes mellitus, and hypertension were more frequent in the positive group (p < .05). fQRS was identified in 300 patients (54.2%). Baseline characteristic did not differ significantly between patients with and without fQRS. There is an association between fQRS and IHD, OR 1.605 (95% CI 1.14–2.27), p = .007. After adjustment for age, diabetes, hypertension, renal function, and left ventricular ejection fraction, the strong association between fQRS and IHD persisted, OR 1.71 (95% CI 1.18–2.47), p = .004.

Conclusion

In patients without known history of coronary artery disease, fragmented QRS is independently associated with ischemic heart disease diagnosed by stress cardiac MRI.

P251 Fragmented QRS in prediction of ischemic heart disease diagnosed by stress cardiovascular magnetic resonance imaging

Funding Acknowledgements

None

Background

Fragmented QRS complex (fQRS) on 12-lead EKG is not uncommon in general population. Previous studies found an association between fQRS and myocardial scar, heart failure, and increased cardiac mortality. However, data in adults without history of coronary artery disease is limited. We aimed to evaluate whether there is an association between fQRS and ischemic heart disease (IHD) diagnosed by stress cardiac MRI.

Method

We retrospectively reviewed data from 604 patients who underwent stress cardiac MRI, in which 50 patients were excluded due to known history of coronary artery disease or incomplete stress test. A positive result was defined as stress-induced perfusion defect in at least 2 contiguous myocardial segments corresponding to epicardial coronary territory, or a presence of ischemic scar. The 12-lead EKG done on the same day with MRI, prior to stress testing, were analyzed. Fragmented QRS was defined as the presence of additional R wave (R’), notching in the nadir of R or S wave, or the presence of more than one R’ in any EKG leads. Both cardiac MRI and EKG were analyzed by two independent observers.

Result

 

Final analysis included 554 patients, 39% were male, with a mean age of 67.8 ± 11.1 years. There was positive stress cardiac MRI in 219 patients (39.5%). Older age, diabetes mellitus, and hypertension were more frequent in the positive group (p &lt;0.05). fQRS was identified in 300 patients (54.2%). Baseline characteristic did not differ significantly between patients with and without fQRS. There is an association between fQRS and IHD, OR 1.605 (95% CI 1.136-2.269), p = 0.007. Using linear regression, the number of leads with presence of fQRS showed an association with IHD (OR 1.204, p = 0.005). After adjustment for age, diabetes, hypertension, renal function, and left ventricular ejection fraction, the strong association between fQRS and IHD persisted, OR 1.709 (95% CI 1.182-2.470), p = 0.004.

Conclusion

In patients without known history of coronary artery disease, fragmented QRS is independently associated with ischemic heart disease diagnosed by stress cardiac MRI.

Multiple regression analysis OR 95% CI p-value Age (years) 1.013 0.992 - 1.035 0.234 Diabetes mellitus 1.532 1.032 - 2.274 0.034 Hypertension 1.194 0.737 - 1.935 0.471 GFR (ml/min/1.73m&sup2;) 0.999 0.987 - 1.011 0.904 LV ejection fraction (%) 0.972 0.950 - 0.994 0.014 fragmented QRS 1.709 1.182 - 2.470 0.004

Metformin, aspirin and statin and risk of cancer: A population-based study in Thailand

65

Background: There were the conflicted results of the association of ASA, metformin or statin and risk of cancer in the previous studies. This is a population-based study in Thai population which aims to investigate the association between these drugs and the risk of cancer. Methods: A population-based retrospective study was done in Electricity Generating Authority of Thailand (EGAT) 1 and 2 databases which have been contained the 27-year and 15-year follow-up time, respectively. This database composed of the clinical characteristics, onset of cancer, and history of interested drugs from the questionnaire, together with the laboratory result from January 2002 to December 2015. We adjusted for age, sex, BMI, smoking and alcohol consumption. The incidence rate ratio (IRR) was estimated for the association between incidence of cancer and interested drugs. Results: Among 2508 and 2731 participants in EGAT1 and 2 respectively, the incidence of cancer was 8.3% in EGAT 1 and 3.5% in EGAT 2. From univariate analysis, use of interested drugs was significant associated with increased risk of cancer with IRR 1.74 ( P< 0.001) for ASA, IRR 1.54 ( P= 0.043) for metformin and IRR 1.64 ( P= 0.001) for statin. In multivariate analysis, only ASA showed significant increasing risk of cancer with IRR 1.47 ( P= 0.021). There was a trend increasing risk of cancer for metformin and statin users but not significant. Older age, low BMI, and female significantly associated with higher risk of cancer. In sub-group analysis, age and alcohol were significantly increased risk of GI cancer, while ASA use showed a non-significant trend of increasing risk of GI cancer. HBV infection was a strongly risk factor for hepatobiliary cancer and statin use had a trend lowering risk of this cancer but it was not statistically significant. Metformin also showed a non-significant trend of increasing risk of thoracic cancer. Conclusions: ASA use significantly associated with increasing risk of cancer but metformin and statin showed a trend of higher risk of cancer. These drugs may associate with cancer metabolome pathway which maybe an important role of carcinogenesis. However, ASA, metformin or statin use and risk of cancer is needed to confirm in the longer follow-up and larger cohort.

4946The effects of climate and air pollutants on heart failure hospitalizations and mortality (CLIMATE-HF Study)

Background

The data on the effects of air pollution on acute heart failure (HF) in tropical countries is limited. Particulate matter air pollution in Thailand is comparably higher than in other countries in Southeast Asia. The existence of climate and air pollution seasonal variation in our country has never been studied before.

Purposes

We sought to explore the effects of air pollution on HF hospitalizations and in-hospital mortality, including the effects of seasonal variation on HF negative outcomes and the association between air pollutants and hospitalizations of acute heart failure across geographical areas.

Methods

We undertook a retrospective analysis of longitudinal collected clinical data. The Data from 258,539 patients with primary HF admissions and daily pollutant parameters between 2011 and 2015 were collected. Data in daily pollutant parameters including respirable suspended particulates with diameter ≤10 μm (PM10), total suspended particles, ozone, carbon monoxide, nitric oxide, sulfur dioxide, air quality index were obtained. Generalized additive regression models and non-linear distributed lag functions were performed.

Results

440,988 hospital admissions occurred with strong seasonal variation and peaked in winter. Particulate matter ≤10 μm (PM10) 2 days prior to admission date was associated with relative risk (RR) (95% confidence interval (CI)) of 1.02 (1.00–1.04, p-value <0.001) for HF hospitalizations after adjusting with age, sex, respiratory tract infection, acute coronary syndrome and other HF comorbidities (diabetes, hypertension, chronic kidney disease). The association of HF hospitalizations and seasonal PM10 variations was strongest in the Northeastern part of Thailand with RR (95% CI) of 1.04 (1.01–1.05), p-value = 0.005.

Conclusion

HF hospitalizations were associated with preceding PM10 exposure, especially in the area with greater seasonal PM10 variations. Reducing exposure to particulate matter air pollution among those at risk for HF may be the potential prevention of HF hospitalizations.

Acknowledgement/Funding

Research grant from Heart Failure Foundation, Ramathibodi Hospital

P6584Prevalence of early repolarization in Thailand and long term risk of cardiac mortality

Introduction

Early repolarization syndrome is associated with long-term cardiac mortality in Western countries. However, there is no study of this association in Southeast Asian population.

Purpose

To determine the prevalence of early repolarization and long term risk of cardiac mortality in general Thai population.

Methods

A total of 2,756 consecutive individuals participating in from the electricity generating authority of Thailand (EGAT) study between 1997 and 2015 were included in this study. Early repolarization pattern (ERP) was defined either as “notching” or “slurring” and was localized into inferior leads, lateral leads, or both. Mortality endpoints included cardiovascular (CV) events and all-cause mortalities. Multivariable Cox-proportional hazard model, adjusted for all major CV risk factors, was used to determine the association between ERP and outcomes.

Results

Out of 2756 individuals,2,689 had complete data (80% male, mean age 55). ECGs and risk factor profiles were included for analysis. Mean follow up duration was 11.2±6.7 years. There were 444 (16.5%) cases with early repolarization pattern (slurr 54.3%, notching 38.3% and both 7.4%). Inferior leads were the most common localization at 49.8%, followed by lateral leads (35.6%) and both (14.6%). Five-hundred and sixty-six participants were dead during the follow-ups. Of these, 21 were sudden death. ERP was not associated with a greater likelihood of all causes of deaths, 20.5% in ERP and 21.2% in non-ERP (hazard ratio,1.04; 95% confidence interval (CI), 0.81 to 1.34; p=0.75). The death rates from coronary heart disease were 7.2% in ERP and 7.6% in non-ERP (HR,1.06; 95% CI, 0.71 to 1.56; p=0.79). The death rates from cardiovascular disease were 11.7% in ERP and 12.0% respectively (HR,1.03; 95% CI, 0.75 to 1.41; p=0.872) and sudden cardiac death was not difference between both groups 1.2 and 1.4% respectively.

Conclusion

The prevalence of early repolarization in Thai middle-aged population is relatively high. Over a long-term follow-up of 18 years, we did not find any differences in sudden cardiac death or death from any causes between an early repolarizationgroup and non-early repolarization group.

Herbal or traditional medicine consumption in a Thai worker population: pattern of use and therapeutic control in chronic diseases

Background

Herbal and traditional medicines (HTM) are widely used in Asian countries. Specific data on prevalent of HTM usage and association with chronic diseases in the Thai population is currently lacking. We examined the prevalence and factors associated with HTM use in a Thai worker population. In addition, we explored the relationship between HTM use and therapeutic control of cardiovascular risk factors and documented the most common types of HTM used in various chronic diseases.

Methods

Employees of EGAT (The Electric Generating Authority of Thailand) who had participated in a health examination were studied. Each participant documented their HTM consumption and self-reported chronic diseases in a questionnaire. Clinical disease and therapeutic control were also defined by concomitant laboratory tests.

Results

Of a total of 6592 subjects, 32.6% were HTM-users. Age < 50 years, female gender, self-reported history of diabetes, liver disease, cancer, dyslipidemia, and alcohol use were independently associated with HTM use. HTM consumption increased in proportion to the numbers of self-reported chronic diseases. There were no differences in the therapeutic control of cardiovascular risk factors between HTM users and non-users. Liver and kidney function were not different. The most commonly used HTM was turmeric.

Conclusions

HTM consumption is common in community-based Thai subjects, with higher use among those with chronic diseases. Although there were no differences in control of cardiovascular risk factors between HTM users and non-users, many of the commonly used herbs have relevant biological activities for chronic disease prevention or treatment.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2652-z) contains supplementary material, which is available to authorized users.

Effects of Non-statin Lipid-Modifying Agents on Cardiovascular Morbidity and Mortality Among Statin-Treated Patients: A Systematic Review and Network Meta-Analysis

Background: Currently, there is a lack of information on the comparative efficacy and safety of non-statin lipid-lowering agents (NST) in cardiovascular (CV) disease risk reduction when added to background statin therapy (ST). This study determine the relative treatment effects of NST on fatal and non-fatal CV events among statin-treated patients.

Methods: A network meta-analysis based on a systematic review of randomized controlled trials (RCTs) comparing non-statin lipid-modifying agents among statin-treated patients was performed. PubMed, EMBASE, CENTRAL, and Clinicaltrial.gov were searched up to April 10, 2018. The primary outcomes were CV and all-cause mortalities. Secondary CV outcomes were coronary heart disease (CHD) death, non-fatal myocardial infarction (MI), any stroke, and coronary revascularization. Risks of discontinuations were secondary safety outcomes.

Results: Sixty-seven RCTs including 259,429 participants with eight interventions were analyzed. No intervention had significant effects on the primary outcomes (CV mortality and all-cause mortality). For secondary endpoints, proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK) plus statin (PCSK/ST) significantly reduced the risk of non-fatal MI (RR 0.82, 95% CI 0.72–0.93, p = 0.003), stroke (RR 0.74, 95% CI 0.65–0.85, p < 0.001), coronary revascularization (RR 0.84, 95% CI 0.75–0.94, p = 0.003) compared to ST. Combinations of ST and all NST except PCSK and ezetimibe showed higher rate of discontinuation due to adverse events compared to ST.

Conclusions: None of NST significantly reduced CV or all-cause death when added to ST. PCSKs and to a lesser extent, ezetimibe may help reduce cardiovascular events with acceptable tolerability profile among broad range of patients.

Metformin, aspirin and statin and risk of cancer: A population-based study in Thailand

e13095

Background: : There were the conflicted results of the association of ASA, metformin or statin and risk of cancer in the previous studies. This is a population-based study in Thai population which aims to investigate the association between these drugs and the risk of cancer. Methods: A population-based retrospective study was done in Electricity Generating Authority of Thailand (EGAT) 1 and 2 databases which have been contained the 27-year and 15-year follow-up time, respectively. This database composed of the clinical characteristics, onset of cancer, and history of interested drugs from the questionnaire, together with the laboratory result from January 2002 to December 2015. We adjusted for age, sex, BMI, smoking and alcohol consumption. The incidence rate ratio (IRR) was estimated for the association between incidence of cancer and interested drugs. Results: Among 2508 and 2731 participants in EGAT1 and 2 respectively, the incidence of cancer was 8.3% in EGAT 1 and 3.5% in EGAT 2. From univariate analysis, use of interested drugs was significant associated with increased risk of cancer with IRR 1.74 ( P< 0.001) for ASA, IRR 1.54 ( P= 0.043) for metformin and IRR 1.64 ( P= 0.001) for statin. In multivariate analysis, only ASA showed significant increasing risk of cancer with IRR 1.47 ( P= 0.021). There was a trend increasing risk of cancer for metformin and statin users but not significant. Older age, low BMI, and female significantly associated with higher risk of cancer. In sub-group analysis, age and alcohol were significantly increased risk of GI cancer, while ASA use showed a non-significant trend of increasing risk of GI cancer. HBV infection was a strongly risk factor for hepatobiliary cancer and statin use had a trend lowering risk of this cancer but it was not statistically significant. Metformin also showed a non-significant trend of increasing risk of thoracic cancer. Conclusions: ASA use significantly associated with increasing risk of cancer but metformin and statin showed a trend of higher risk of cancer. These drugs may associate with cancer metabolome pathway which maybe an important role of carcinogenesis. However, ASA, metformin or statin use and risk of cancer is needed to confirm in the longer follow-up and larger cohort.

Antithrombotic Regimens in Patients With Percutaneous Coronary Intervention Whom an Anticoagulant Is Indicated: A Systematic Review and Network Meta-Analysis

Background: Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy are at increased risk of bleeding. The optimal regimen for these patients is uncertain. This study aimed to compare safety and efficacy of antithrombotic regimens used in patients undergoing PCI with concomitant anticoagulant therapy. Methods: A systematic review and network meta-analysis was performed among studies comparing antithrombotic regimens for anticoagulated patients undergoing PCI. The primary outcome of interest was major bleeding. The secondary outcomes were coronary events. The reference intervention was classic triple therapy (aspirin plus clopidogrel plus VKA). Cluster rank incorporating risk (major bleeding) and benefit (all-cause death) was performed to identify the most appropriate regimen(s). Results: There were 3 RCTs (6 interventions) and 29 non-RCTs (8 interventions) that met the inclusion criteria with 22,179 patients. Network meta-analysis of RCTs indicated that dual therapy (DT), either with vitamin K antagonist (VKA) or direct anticoagulant (DOAC) plus an antiplatelet, significantly reduced the risk of major bleeding compared to triple therapy (TT) [pooled RR of 0.51 (0.30-0.87) and 0.68 (0.49-0.94), respectively]. In addition, VKA-DT significantly reduced the risk of all-cause death compared to TT [pooled RR of 0.40 (0.17-0.93)]. Results from network meta-analysis of non-RCT paralleled that of RCTs. No significant differences of coronary events were found. Conclusions: In conclusion, for anticoagulated patients undergoing PCI, dual therapy, either with warfarin or DOAC plus an antiplatelet, should be considered due to its optimal balance on efficacy and safety.

Cost-effectiveness analysis of patient self-testing therapy of oral anticoagulation

Patient Self-testing (PST) could be an option for present anticoagulation therapy monitoring, but current evidence on its cost-effectiveness is limited. This study aims to estimate the cost-effectiveness of PST to other different care approaches for anticoagulation therapy in Thailand, a low-to-middle income country (LMIC). A Markov model was used to compare lifetime costs and quality-adjusted life years (QALYs) accrued to patients receiving warfarin through PST or either anticoagulation clinic (AC) or usual care (UC). The model was populated with relevant information from literature, network meta-analysis, and database analyses. Incremental cost-effectiveness ratios (ICERs) were presented as the year 2015 values. A base-case analysis was performed for patients at age 45-year-old. Sensitivity analyses including one-way and probabilistic sensitivity analyses (PSA) were constructed to determine the robustness of the findings. From societal perspective, PST increased QALY by 0.87 and costs by 112,461 THB compared with UC. Compared with AC, PST increased QALY by 0.161 and costs by 21,019 THB. The ICER with PST was 128,697 (3625 USD) and 130,493 THB (3676 USD) per QALY gained compared with UC and AC, respectively. The probability of PST being cost-effective is 74.1% and 51.9%, compared to UC and AC, respectively, in Thai context. Results were sensitive to the efficacy of PST, age and frequency of hospital visit or self-testing. This analysis suggested that PST is highly cost-effective compared with usual care and less cost-effective against anticoagulation clinic. Patient self-testing strategy appears to be economically valuable to include into healthcare system within the LMIC context.

Risk scores to predict decreased glomerular filtration rate at 10 years in an Asian general population

Background

Asians have among the highest prevalence of chronic kidney disease (CKD) or end-stage renal disease in the world. A risk score capable of identifying high risk individuals at the primary care level could allow targeted therapy to prevent future development of CKD. Risk scores for new CKD have been developed in US general populations, but the impact of various risks factors for development of CKD may differ in Asian subjects. In this study, we aimed to develop risk models and simplified risk scores to predict the development of decreased glomerular filtration rate (GFR) at 10 years in an Asian general population using readily obtainable clinical and laboratory parameters.

Methods

Employees of EGAT (The Electric Generating Authority of Thailand) were studied prospectively. Multivariable logistic regression models were used to assess risk factors and used to derive risk models and risk scores for developing decreased GFR at 10 years: Model 1 (Clinical only), Model 2 (Clinical + Limited laboratory tests), and Model 3 (Clinical + Full laboratory tests). The performance of the risk models or risk scores to predict incident cases with decreased GFR were evaluated by tests of calibration and discrimination.

Results

Of 3186 subjects with preserved GFR (eGFR ≥60) at baseline, 271 (8.5%) developed decreased GFR (eGFR < 60) at 10 years. Model 1 (Age, sex, systolic blood pressure, history of diabetes, and waist circumference) had good performance (χ² = 9.02; AUC = 0.72). Model 2 (Age, Sex, systolic blood pressure, diabetes, glomerular filtration rate) had better discrimination (χ² = 10.87, AUC = 0.79) than Model 1. Model 3 (Model 2+ Uric acid, Hemoglobin) did not provide significant improvement over Model 2. Based on these findings, simplified categorical risk scores were developed for Models 1 and 2.

Conclusions

Clinical or combined clinical and laboratory risk models or risk scores using tests readily available in a resource-limited setting had good accuracy and discrimination power to estimate the 10-year probability of developing decreased GFR in a Thai general population. The benefits of the risk scores in identifying high risk individuals in the Thai or other Asian communities for special intervention requires further studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0653-z) contains supplementary material, which is available to authorized users.

Age-Adjusted Dual X-ray Absorptiometry-Derived Trabecular Bone Score Curve for the Lumbar Spine in Thai Females and Males

Trabecular bone score (TBS), which has been shown to discriminate patients with fractures from healthy individuals, decreases with age. This study was conducted to derive an age-adjusted normative TBS curve for each gender aged 30-80 + years to serve as reference data for Thai males and females. A cross-sectional study was conducted among employees from the Electricity Generating Authority of Thailand cohorts, after excluding those with conditions potentially affecting bone metabolism and analysis. The values of TBS at L1-L4 vertebrae were analyzed using a commercial software. Age-adjusted TBS curves were constructed using segmental linear regression analysis for each gender. Additional analysis was also performed on TBS with age, body mass index, and body mineral density (BMD) at L1-L4 vertebrae as covariates. A database of 848 healthy subjects (341 females and 507 males) aged 30-80+ years was created. The BMDs of both male and female subjects in the youngest decade were not statistically different from previous reports (p = 0.31 and 0.22 for females and males, respectively). In this age group, the mean TBS was higher in females, albeit not statistically significant (p = 0.12). Between the ages of 30-80+ years, female and male TBS dropped by 19.8% (0.40% per year) and 10.1% (0.20% per year), respectively. The association with TBS was weak for body mass index and moderate for BMD (coefficients of about -0.01 and 0.4-0.5, respectively). The age-adjusted reference curves for healthy Thai females and males aged 30-80+ years have been established.

Effects of glomerular filtration rate estimating equations derived from different reference methods on staging and long term mortality risks of chronic kidney disease in a Southeast Asian cohort

AIM

There are limited data on the risks of chronic kidney disease (CKD) in Southeast Asian populations. Several GFR estimating equations have been developed in diverse Asian populations, but they produce markedly discrepant results. We investigated the impact of Asian equations on the mortality risk of CKD in a Thai cohort during long term follow-up, and explored the differences between equations grouped according to the reference GFR methods used to develop them.

METHODS

Employees of the Electricity Generating Authority of Thailand (n = 3430) were enrolled in a health survey and followed up for 22 years. The risks for all-cause mortality for each GFR stage classified by CKD-EPI or different Asian equations were assessed by using Cox proportional hazard models.

RESULTS

Equations derived from DTPA clearance (Chinese MDRD, Thai GFR, Singapore CKD-EPI) produced higher GFR, whereas equations from inulin clearance (Japanese CKD-EPI, Taiwan MDRD or Taiwan CKD-EPI) produced lower GFR compared to CKD-EPI. (Average ΔGFR: inulin, -14.9 vs. DTPA +5.80 mL/min per 1.73 m(2) , P < 0.001). CKD prevalence varied widely (0.7 to 24 %) with inulin-based equations being higher than DTPA-based. GFR stage concordance was over 80% for equations using similar reference method compared to less than 40% between inulin and DTPA-based equations. Low GFR (<45) was an independent mortality risk factor when DTPA-based equations were used, but not when inulin-based equations were used.

CONCLUSION

Chronic kidney disease prevalence and prognosis in Thais varied widely depending on the equation used. Differences in the reference GFR methods could be an important cause for the discrepancies between Asian equations.