Predicting the 10-Year Risks of Atherosclerotic Cardiovascular Disease in Chinese Population: The China-PAR Project (Prediction for ASCVD Risk in China)

Improvement in sudden cardiac death risk prediction by the enhanced American College of Cardiology/American Heart Association strategy in Chinese patients with hypertrophic cardiomyopathy

BACKGROUND

The lack of validated and effective sudden cardiac death (SCD) risk prediction methods is the biggest barrier to perform the lifesaving treatment with a prophylactic implantable cardioverter-defibrillator in Chinese patients with hypertrophic cardiomyopathy (HCM).

OBJECTIVE

This study aimed to evaluate the efficacy of 3 existing SCD risk prediction methods recommended by the 2011 American College of Cardiology Foundation and American Heart Association (ACCF/AHA) guideline, the 2014 European Society of Cardiology (ESC) guideline, and the 2019 enhanced American College of Cardiology (ACC)/AHA strategy in Chinese patients with HCM.

METHODS

The present study consisted of 1369 consecutive adult patients with HCM without a history of SCD events. The primary end point was a composite of SCD and equivalent events, namely, resuscitation from cardiac arrest and appropriate implantable cardioverter-defibrillator shock therapy for ventricular tachycardia or fibrillation.

RESULTS

During follow-up of 3.2 ± 2.4 years, 39 patients reached SCD end points, of whom 26 (66.7%) were correctly predicted as those at a high risk of SCD by using methods recommended by the 2019 enhanced ACC/AHA strategy, 20 (51.3%) by the 2011 ACCF/AHA guideline, but only 5 (12.8%) by the 2014 ESC guideline. The 2019 enhanced ACC/AHA strategy showed a higher C-statistic (0.647) for SCD prediction than did the 2011 ACCF/AHA guideline (0.598) and 2014 ESC guideline (0.605) and resulted in the correct reclassification of SCD risk when compared with the 2011 ACCF/AHA guideline (net reclassification index 0.113; P = .074) and 2014 ESC guideline (net reclassification index 0.245; P = .038).

CONCLUSION

The 2019 enhanced ACC/AHA strategy showed better predictive performance for SCD risk stratification in Chinese patients with HCM, with a notably high sensitivity.

Dynamic Cerebral Autoregulation in Preclinical Atherosclerotic Cardiovascular Disease

OBJECTIVE

The influence of atherosclerotic cardiovascular disease (ASCVD) on cerebral blood flow control is not well known. The aim of this study was to investigate the association between cardiovascular function and dynamic cerebral autoregulation (dCA) in patients with preclinical ASCVD.

METHODS

A total of 44 participants aged 26-76 years were divided into low- and high-risk groups according to the China assessment of ASCVD risk. The cardiac function was assessed by echocardiography. The beat-to-beat blood pressure and cerebral blood flow velocity were measured at rest. Spectral and transfer function analyses were used to calculate cerebral and systemic hemodynamic variability and to estimate dCA metrics.

RESULTS

There were no group differences in beat-to-beat heart rate, blood pressure, and cerebral blood flow velocity variability nor the ejection fraction, E/A and E'/A'. The dCA phase at very low frequency was reduced in the high-risk group (P = .03). Moreover, the dCA phase and E'/A' were negatively correlated with age, and dCA phase was positively correlated with E'/A' within the high-risk group (r² = .517, P < .01).

CONCLUSIONS

These findings suggest that advancing age, particularly in the high-risk ASCVD group, impairs cerebral blood flow control and cardiac diastolic function which are correlated with each other and may interplay under the effects of ASCVD risk factors.

Chinese ASCVD risk equations rather than pooled cohort equations are better to identify macro- and microcirculation abnormalities

BACKGROUND

We hypothesized that discriminating the early subclinical organ damage would serve as a great opportunity for prevention against atherosclerotic cardiovascular disease (ASCVD). Brachial-ankle pulse wave velocity (baPWV), low retinal vascular fractal dimension, and albuminuria are surrogates of subclinical vascular changes.

METHODS

The aim of this study was to use Pooled Cohort Equations (PCE) and ASCVD risk equations derived from "Prediction for ASCVD Risk in China project (CHINA-PAR)" to observe the prevalence of macro- and microcirculation abnormalities. A total of 2166 subjects were involved. Characteristics were investigated using questionnaire and physical examinations. We calculated the urine albumin to creatinine ratio (UACR). The baPWV was measured using a fully automatic arteriosclerosis detector. The retinal vascular fractal dimension was measured by a semiautomated computer-based program. The 10-year ASCVD risk was estimated using the PCE and CHINA-PAR model.

RESULTS

The cut-off values for the elevated baPWV were 2.82 and 2.92% in the PCE model and CHINA-PAR model, respectively, with nearly 85% sensitivity and an average specificity of 74%. For low retinal fractal dimension, at the cut-off point of 3.8%, we acquired an acceptable sensitivity of 66.27-68.24% and specificity of 62.57-67.45%. All the C-statistics presented a significant improvement from the PCE model to the CHINA-PAR model (P < 0.05). For all categories-net reclassification improvement (NRI) values were significant and clearly varied (0.329, 0.183, and 0.104, respectively) depending on the cut-off set at 3%.

CONCLUSION

Our study demonstrated that the CHINA-PAR equations rather than PCE could provide better identification of macro- and microcirculation abnormalities. A lower cut-off point for the subclinical vascular changes may be selected in a population from southeast China.

Study of cardiovascular disease prediction model based on random forest in eastern China

Cardiovascular disease (CVD) is the leading cause of death worldwide and a major public health concern. CVD prediction is one of the most effective measures for CVD control. In this study, 29930 subjects with high-risk of CVD were selected from 101056 people in 2014, regular follow-up was conducted using electronic health record system. Logistic regression analysis showed that nearly 30 indicators were related to CVD, including male, old age, family income, smoking, drinking, obesity, excessive waist circumference, abnormal cholesterol, abnormal low-density lipoprotein, abnormal fasting blood glucose and else. Several methods were used to build prediction model including multivariate regression model, classification and regression tree (CART), Naïve Bayes, Bagged trees, Ada Boost and Random Forest. We used the multivariate regression model as a benchmark for performance evaluation (Area under the curve, AUC = 0.7143). The results showed that the Random Forest was superior to other methods with an AUC of 0.787 and achieved a significant improvement over the benchmark. We provided a CVD prediction model for 3-year risk assessment of CVD. It was based on a large population with high risk of CVD in eastern China using Random Forest algorithm, which would provide reference for the work of CVD prediction and treatment in China.

Associations of egg consumption with incident cardiovascular disease and all-cause mortality

Eggs are nutrient-dense while also loaded with abundant cholesterol, thus making the public hesitant about their consumption. We conducted the study to investigate if egg consumption is associated with incident cardiovascular disease (CVD) and all-cause mortality. Using the project of Prediction for Atherosclerotic Cardiovascular Disease Risk in China, we included 102,136 adults free of CVD and assessed their egg consumption with food-frequency questionnaires. CVD endpoints and all-cause mortality were confirmed during follow-ups by interviewing participants or their proxies and checking hospital records/death certificates. The HRs (95% CIs) were calculated using the cohort-stratified Cox regression models. During 777,163 person-years of follow-up, we identified 4,848 incident CVD and 5,511 deaths. U-shaped associations of egg consumption with incident CVD and all-cause mortality were observed. Compared with consumption of 3-<6/week, the multivariable-adjusted HRs (95% CIs) of <1/week and ≥10/week for incident CVD were 1.22 (1.11 to 1.35) and 1.39 (1.28 to 1.52), respectively. The corresponding HRs (95% CIs) for all-cause mortality were 1.29 (1.18 to 1.41) and 1.13 (1.04 to 1.24). Our findings identified that both low and high consumption were associated with increased risk of incident CVD and all-cause mortality, highlighting that moderate egg consumption of 3-<6/week should be recommended for CVD prevention in China.

Sex Differences in Primary and Secondary Prevention of Cardiovascular Disease in China

BACKGROUND

Despite improvements in diagnostic and therapeutic interventions to combat cardiovascular disease (CVD) in recent decades, there are significant ongoing access gaps and sex disparities in prevention that have not been adequately quantified in China.

METHODS

A representative, cross-sectional, community-based survey of adults (aged ≥45 years) was conducted in 7 geographic regions of China between 2014 and 2016. Logistic regression models were used to determine sex differences in primary and secondary CVD prevention, and any interaction by age, education level, and area of residence. Data are presented as adjusted odds ratios (ORs) and 95% CIs.

RESULTS

Of 47 841 participants (61.3% women), 5454 (57.2% women) had established CVD and 9532 (70.5% women) had a high estimated 10-year CVD risk (≥10%). Only 48.5% and 48.6% of women and 39.3% and 59.8% of men were on any kind of blood pressure (BP)-lowering medication, lipid-lowering medication, or antiplatelet therapy for primary and secondary prevention, respectively. Women with established CVD were significantly less likely than men to receive BP-lowering medications (OR, 0.79 [95% CI, 0.65-0.95]), lipid-lowering medications (OR, 0.69 [95% CI, 0.56-0.84]), antiplatelets (OR, 0.53 [95% CI, 0.45-0.62]), or any CVD prevention medication (OR, 0.62 [95% CI, 0.52-0.73]). Women with established CVD, however, had better BP control (OR, 1.31 [95% CI, 1.14-1.50]) but less well-controlled low-density lipoprotein cholesterol (OR, 0.66 [95% CI, 0.57-0.76]), and were less likely to smoke (OR, 13.89 [95% CI, 11.24-17.15]) and achieve physical activity targets (OR, 1.92 [95% CI, 1.61-2.29]). Conversely, women with high CVD risk were less likely than men to have their BP, low-density lipoprotein cholesterol, and bodyweight controlled (OR, 0.46 [95% CI, 0.38-0.55]; OR, 0.60 [95% CI, 0.52-0.69]; OR, 0.55 [95% CI, 0.48-0.63], respectively), despite a higher use of BP-lowering medications (OR, 1.21 [95% CI, 1.01-1.45]). Younger patients (<65 years) with established CVD were less likely to be taking CVD preventive medications, but there were no sex differences by area of residence or education level.

CONCLUSIONS

Large and variable gaps in primary and secondary CVD prevention exist in China, particularly for women. Effective CVD prevention requires an improved overall nationwide strategy and a special emphasis on women with established CVD, who have the greatest disparity and the most to benefit.

Potassium selenocyanoacetate reduces the blood triacylglycerol and atherosclerotic plaques in high-fat-dieted mice

Background

Controlling blood lipid levels at the early stage of cardiovascular disease is a major focus of global disease prevention studies on atherosclerosis. The aim of our study was to investigate the effects of potassium selencyanoacetate on the blood lipid profiles and the formation of atherosclerotic plaques in mice fed with a high-fat diet.

Methods

Forty ApoE^-/- male mice aged 8-10 weeks were randomly divided into the treatment group (n=20) and control group (n=20). The mice in the treatment group were given the high-fat diet supplemented with potassium selencyanoacetate (4.63 mg/kg/day) through a gavage, whereas the control group were fed with a same high-fat diet with 1.5 mL of normal saline only. After 16 weeks, the mice were euthanized using inhalation anesthetic methods. The aortas were isolated and stained with oil red O to observe the formation of plaques. Blood samples were collected from each animal to examine the levels of total cholesterol (TC), triacylglycerol (TG), HDL cholesterol (HDL-Ch), LDL cholesterol (LDL-Ch), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and plasma urea.

Results

The percentage of the atherosclerotic plaques area was significantly lower in the treatment group than the control group (P=0.017). The levels of TG, ALT, AST, and plasma urea were significantly lower in the treatment group than the control group (all P<0.05). However, the levels of TC, HDL-Ch, and LDL-Ch were not significantly different between two groups (all P>0.05).

Conclusions

Potassium selencyanoacetate could safely reduce the TG level and high-fat-diet induced atherosclerotic plaques in mice, which could be used as a potential drug to prevent cardiovascular atherosclerotic diseases.

A Nomogram Based on Apelin-12 for the Prediction of Major Adverse Cardiovascular Events after Percutaneous Coronary Intervention among Patients with ST-Segment Elevation Myocardial Infarction

Objective

This study aimed to establish a clinical prognostic nomogram for predicting major adverse cardiovascular events (MACEs) after primary percutaneous coronary intervention (PCI) among patients with ST-segment elevation myocardial infarction (STEMI).

Methods

Information on 464 patients with STEMI who performed PCI procedures was included. After removing patients with incomplete clinical information, a total of 460 patients followed for 2.5 years were randomly divided into evaluation (n = 324) and validation (n = 324) and validation (

Results

Apelin-12 change rate, apelin-12 level, age, pathological Q wave, myocardial infarction history, anterior wall myocardial infarction, Killip's classification > I, uric acid, total cholesterol, cTnI, and the left atrial diameter were independently associated with MACEs (all P < 0.05). After incorporating these 11 factors, the nomogram achieved good concordance indexes of 0.758 (95%CI = 0.707–0.809) and 0.763 (95%CI = 0.689–0.837) in predicting MACEs in the evaluation and validation cohorts, respectively, and had well-fitted calibration curves. The decision curve analysis (DCA) revealed that the nomogram was clinically useful.

Conclusions

We established and validated a novel nomogram that can provide individual prediction of MACEs for patients with STEMI after PCI procedures in a Chinese population. This practical prognostic nomogram may help clinicians in decision making and enable a more accurate risk assessment.

Mediation effect of platelet indices on the association of daytime nap duration with 10-year ASCVD risk

Daytime nap is associated with the risk of atherosclerotic cardiovascular disease (ASCVD). However, the contribution of platelet to the association of daytime nap with ASCVD remains unclear. We analyzed the mediation effect of abnormal platelet indices on the association between daytime nap and 10-year ASCVD risk. The participants of this study were 2445 adults aged 30 to 74 years without ASCVD from the baseline Wuhan residents (n = 3053) of the Wuhan-Zhuhai (WHZH) Cohort Study. Participants completed the questionnaire and physical examination (including blood pressure, height, weight, and blood biochemical indicators). We assessed the association of daytime nap or nocturnal sleep duration with 10-year ASCVD risk and mediation effects of platelet indices on the associations using generalized linear models (GLM). Individuals with daytime nap duration of 30 or 60 min had a 1.37- (95%CI: 1.05, 1.78) or 1.44- (95%CI: 1.17, 1.78) fold increased risk of 10-year ASCVD compared with non-nappers. As compared with non-nappers, MPV values or MPV/PLT ratio mediated 15.29% or 6.18% of the association of daytime nap duration of 30 min with 10-year ADCVD risk as well as 19.21% or 7.61% of the association of daytime nap duration of 60 min with 10-year ADCVD risk (all p < .05). Platelet might partially contribute to increased 10-year ASCVD risk in individuals with daytime nap duration of 30 or 60 min.

Beneficial effects of moderate to vigorous physical activity on cardiovascular disease among Chinese adults

BACKGROUND

In China, lack of evidence remains a significant challenge for the national initiative to promote physical activity (PA). We aimed to quantify the beneficial effects of meeting or maintaining the recommended PA level [150 minutes per week (min/wk) of moderate PA or 75 min/wk of vigorous PA or an equivalent combination] on incident cardiovascular disease (CVD) among Chinese population.

METHODS

We included 100,560 participants without history of CVD from three cohorts in the Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD events and its subtypes, including stroke, coronary heart disease, heart failure, and CVD death.

RESULTS

During a median follow-up of 7.3 years (range: 6-15 years), 777,163 person-years and 4693 incident CVD events were observed. Compared with participants who were inactive at baseline, the multivariable adjusted HR (95% CI) of developing CVD was 0.74 (0.69-0.79) for those who met recommended moderate to vigorous physical activity (MVPA) level at baseline. Furthermore, the risk of CVD incidence was reduced with increment of MVPA (P trend < 0.001), and the HR (95% CI) of highly-active versus inactive category was 0.62 (0.56-0.68). Compared with individuals who were inactive both at the baseline and follow-up, those keeping active over the period of follow-up had a substantial lower risk of incident CVD with the HR (95% CI) of 0.57 (0.43-0.77).

CONCLUSIONS

The findings demonstrated that meeting and maintaining the recommended MVPA level could reduce the cardiovascular risk. Wider adoption of the PA recommendations would have considerable health impacts to the Chinese population.

Quantitative Comparison of the Performance of Piezoresistive, Piezoelectric, Acceleration, and Optical Pulse Wave Sensors

The accurate measurement of the arterial pulse wave is beneficial to clinical health assessment and is important for the effective diagnosis of many types of cardiovascular disease. A variety of sensors have been developed for the non-invasive detection of these waves, but the type of sensor has an impact on the measurement results. Therefore, it is necessary to compare and analyze the signals obtained under a range of conditions using various pulse sensors to aid in making an informed choice of the appropriate type. From the available types we have selected four: a piezoresistive strain gauge sensor (PESG) and a piezoelectric Millar tonometer (the former with the ability to measure contact force), a circular film acceleration sensor, and an optical reflection sensor. Pulse wave signals were recorded from the left radial, carotid, femoral, and digital arteries of 60 subjects using these four sensors. Their performance was evaluated by analyzing their susceptibilities to external factors (contact force, measuring site, and ambient light intensity) and by comparing their stability and reproducibility. Under medium contact force, the peak-to-peak amplitude of the signals was higher than that at high and low force levels and the variability of signal waveform was small. The optical sensor was susceptible to ambient light. Analysis of the intra-class correlation coefficients (ICCs) of the pulse wave parameters showed that the tonometer and accelerometer had good stability (ICC > 0.80), and the PESG and optical sensor had moderate stability (0.46 < ICC < 0.86). Intra-observer analysis showed that the tonometer and accelerometer had good reproducibility (ICC > 0.75) and the PESG and optical sensor had moderate reproducibility (0.42 < ICC < 0.91). Inter-observer analysis demonstrated that the accelerometer had good reproducibility (ICC > 0.85) and the three other sensors had moderate reproducibility (0.52 < ICC < 0.96). We conclude that the type of sensor and measurement site affect pulse wave characteristics and the careful selection of appropriate sensor and measurement site are required according to the research and clinical need. Moreover, the influence of external factors such as contact pressure and ambient light should be fully taken into account.

ASCVD risk stratification modifies the effect of HbA1c on cardiovascular events among patients with type 2 diabetes mellitus with basic to moderate risk

OBJECTIVE

To investigate the association between hemoglobin A1c (HbA1c) 7.0%-8.0% and cardiovascular disease (CVD) risk among Chinese patients with type 2 diabetes mellitus (T2DM) with different baseline 10-year atherosclerotic CVD (ASCVD) risk stratification.

RESEARCH DESIGN AND METHODS

A prospective population-based cohort of 10 060 adults aged 40-70 years in Chongming District of Shanghai was established in 2011. These participants were followed up for 3.25 years and CVD information was recorded. We investigated this association between HbA1c categories and incident CVD stratified by the 10-year ASCVD risk using multiple Cox regression analysis among 1880 patients with T2DM without CVD history. CVD events were defined as cardiovascular death, non-fatal myocardial infarction or non-fatal stroke.

RESULTS

The corresponding incidence of CVD per 1000 person-years for the HbA1c≤6.5%, 6.6%-6.9%, 7.0%-8.0% and >8.0% groups were 12.5, 21.8, 22.9 and 28.9, respectively. The HbA1c>8.0% group was significantly associated with a higher CVD risk in patients with T2DM. The HbA1c 7.0%-8.0% group was significantly associated with a higher CVD risk in patients with T2DM with moderate baseline ASCVD risk (HR 2.48; 95% CI 1.15 to 5.32).

CONCLUSION

HbA1c of 7.0%-8.0% may result in a significantly higher CVD risk among patients with T2DM with moderate baseline ASCVD risk, which support the use of HbA1c combined with baseline ASCVD risk assessment to determine future glucose-lowering treatment decisions among patients with T2DM with basic to moderate risk.

Long term exposure to ambient fine particulate matter and incidence of stroke: prospective cohort study from the China-PAR project

OBJECTIVE

To study the effect of long term exposure to ambient fine particulate matter of diameter ≤2.5 μm (PM2.5) on the incidence of total, ischemic, and hemorrhagic stroke among Chinese adults.

DESIGN

Population based prospective cohort study.

SETTING

Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project carried out in 15 provinces across China.

PARTICIPANTS

117 575 Chinese men and women without stroke at baseline in the China-PAR project.

MAIN OUTCOME MEASURES

Incidence of total, ischemic, and hemorrhagic stroke.

RESULTS

The long term average PM2.5 level from 2000 to 2015 at participants' residential addresses was 64.9 μg/m3, ranging from 31.2 μg/m3 to 97.0 μg/m3. During 900 214 person years of follow-up, 3540 cases of incident stroke were identified, of which 63.0% (n=2230) were ischemic and 27.5% (n=973) were hemorrhagic. Compared with the first quarter of exposure to PM2.5 (<54.5 μg/m3), participants in the highest quarter (>78.2 μg/m3) had an increased risk of incident stroke (hazard ratio 1.53, 95% confidence interval 1.34 to 1.74), ischemic stroke (1.82, 1.55 to 2.14), and hemorrhagic stroke (1.50, 1.16 to 1.93). For each increase of 10 μg/m3 in PM2.5 concentration, the increased risks of incident stroke, ischemic stroke, and hemorrhagic stroke were 13% (1.13, 1.09 to 1.17), 20% (1.20, 1.15 to 1.25), and 12% (1.12, 1.05 to 1.20), respectively. Almost linear exposure-response relations between long term exposure to PM2.5 and incident stroke, overall and by its subtypes, were observed.

CONCLUSIONS

This study provides evidence from China that long term exposure to ambient PM2.5 at relatively high concentrations is positively associated with incident stroke and its major subtypes. These findings are meaningful for both environmental and health policy development related to air pollution and stroke prevention, not only in China, but also in other low and middle income countries.

Development and validation of prediction models for hypertension risks in rural Chinese populations

Background

Various hypertension predictive models have been developed worldwide; however, there is no existing predictive model for hypertension among Chinese rural populations.

Methods

This is a 6-year population-based prospective cohort in rural areas of China. Data was collected in 2007-2008 (baseline survey) and 2013-2014 (follow-up survey) from 8319 participants ranging in age from 35 to 74 years old. Specified gender hypertension predictive models were established based on multivariate Cox regression, Artificial Neural Network (ANN), Naive Bayes Classifier (NBC), and Classification and Regression Tree (CART) in the training set. External validation was conducted in the testing set. The estimated models were assessed by discrimination and calibration, respectively.

Results

During the follow-up period, 432 men and 604 women developed hypertension in the training set. Assessment for established models in men suggested men office-based model (M1) was better than others. C-index of M1 model in the testing set was 0.771 (95% confidence Interval (CI) = 0.750, 0.791), and calibration χ² = 6.3057 (P = 0.7090). In women, women office-based model (W1) and ANN were better than the other models assessed. The C-indexes for the W1 model and the ANN model in the testing set were 0.765 (95% CI = 0.746, 0.783) and 0.756 (95% CI = 0.737, 0.775) and the calibrations χ² were 6.7832 (P = 0.1478) and 4.7447 (P = 0.3145), respectively.

Conclusions

Not all machine-learning models performed better than the traditional Cox regression models. The W1 and ANN models for women and M1 model for men have better predictive performance which could potentially be recommended for predicting hypertension risk among rural populations.

Association of Lipids With Ischemic and Hemorrhagic Stroke: A Prospective Cohort Study Among 267 500 Chinese

Background and Purpose- Previous results on the association between lipids and stroke were controversial. We investigated the association of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C ), high-density lipoprotein cholesterol (HDL-C), and triglyceride with stroke. Methods- Six cohort studies in China with 267 500 participants were included. Cox proportional hazards regression models and restricted cubic spline analyses were used to estimate hazard ratios and 95% CIs and explore linear and nonlinear relationships of lipids and stroke, respectively. Results- The median follow-up duration ranged from 6 to 19 years. During 2 295 881 person-years, 8072 people developed stroke. Multivariable adjusted hazard ratios (95% CIs) per 1 mmol/L increase in TC, LDL-C, triglyceride were 1.08 (1.05-1.11), 1.08 (1.04-1.11), 1.07 (1.05-1.09) for ischemic stroke, respectively. Compared with participants with TC 160-199.9 mg/dL, hazard ratios (95% CIs) were 1.43 (1.11-1.85) for hemorrhagic stroke in those with TC <120 mg/dL. Compared with participants with HDL-C 50 to 59.9 mg/dL, hazard ratios (95% CIs) were 1.23 (1.12-1.35), 1.13 (1.04-1.22) for ischemic stroke, and 1.28 (1.10-1.49), 1.17 (1.03-1.33) for hemorrhagic stroke in those with HDL-C <40 and 40 to 49.9 mg/dL, respectively. Restricted cubic spline analyses showed linear relationships of TC and LDL-C, and nonlinear relationships of HDL-C and triglyceride with ischemic stroke (all P<0.001). Hemorrhagic stroke showed linear relationships with TC and HDL-C (P=0.029 and <0.001 respectively), but no relationship with LDL-C and triglyceride (all P>0.05). Conclusions- TC, LDL-C, and triglyceride showed positive associations with ischemic stroke. The risk of hemorrhagic stroke was higher when TC was lower than 120 mg/dL. LDL-C and triglyceride showed no association with hemorrhagic stroke. The risks of ischemic and hemorrhagic stroke might be higher when HDL-C was lower than 50 mg/dL.

Expert consensus on the management of hypertension in the young and middle-aged Chinese population

Hypertension, defined as blood pressure (BP) ≥140/90 mmHg, is one of the most common, yet reversible, risk factors for cardiovascular disease (CVD). Globally, 9.40 million people died from hypertension in 2010, accounting for 17.8% of total deaths; disability-adjusted life years (DALYs) caused by hypertension were 170 million person-years, or 7.0% of the total global DALYs.1 Data from China showed that hypertension accounted for 24.6% of all deaths, and 12.0% of total DALYs,2 and the direct medical cost of hypertension in China has reached 36.6 billion yuan per year.3.

Predicting 10-Year and Lifetime Stroke Risk in Chinese Population

Background and Purpose—

Risk assessment is essential for the primary prevention of stroke. However, the current available tools derived from Chinese populations are insufficient for individualized 10-year and lifetime stroke risk prediction. Our study aims to develop and validate personalized 10-year and lifetime stroke risk equations incorporating 4 large Chinese cohorts.

Methods—

We used 2 prospective cohorts of 21 320 participants with similar survey protocols as the derivation cohort to develop sex-specific 10-year and lifetime stroke risk equations. Two other independent cohorts with 14 123 and 70 838 participants were used for external validation. In addition, the performance of the 10-year stroke risk equations among participants aged ≥55 years was compared with the new Framingham Stroke Risk Profile.

Results—

The sex-specific equations for predicting 10-year stroke risk had C statistics being 0.810 for men and 0.810 for women, with calibration χ 2 being 15.0 ( P =0.092) and 7.8 ( P =0.550), respectively. The lifetime stroke risk equations also showed C statistics around 0.800 and calibration χ 2 below 20 for both sexes. In the validation cohorts, we found good agreement between the observed and predicted stroke probabilities for both the 10-year and lifetime stroke risk equations. Further compared with the new Framingham Stroke Risk Profile, our 10-year stroke risk equations displayed better prediction capability. In addition, based on lifetime stroke risk assessment, 5.7% of study participants aged 35 to 49 years old were further reclassified as high risk, who were initially categorized as low 10-year risk.

Conclusions—

We developed a well-performed tool for predicting personalized 10-year and lifetime stroke risk among the Chinese adults, which will facilitate the further identification of high-risk individuals and community-based stroke prevention in China.

Identification and validation of four hub genes involved in the plaque deterioration of atherosclerosis

In recent years, intense research has been conducted to explore the diagnostic value of mRNA expression differences in atherosclerosis (AS). Nevertheless, because various technology platforms are applied and sample sizes are small, the results are inconsistent among the studies. We conducted a comprehensive analysis of a total of 161 tissue samples from 4 published studies after evaluating 230 datasets from the Gene Expression Omnibus and ArrayExpress. Adopting the newly published robust rank aggregation approach, combined with Kyoto Encyclopedia of Genes and Genomes pathway analysis, Gene Ontology functional enrichment analysis, and protein-protein interaction network construction, we identified four significantly upregulated genes (CCL4, CCL18, MMP9 and SPP1) for diagnosing AS, even in the advanced stage. Then, we performed gene set enrichment analysis to identify the pathways that were most affected by altered mRNA expression in atherosclerotic plaques. We found that four hub genes cooperatively targeted lipid metabolism and inflammatory immune-related pathways and validated their high expression levels in ruptured plaques by qRT-PCR, western blot analysis and immunohistochemical staining. In summary, our study showed that these genes can be used as interventional targets for plaque progression, and the results suggested we should focus on small changes in these key indicators in the clinical setting.

Heart rate variability mediates the association between polycyclic aromatic hydrocarbons exposure and atherosclerotic cardiovascular disease risk in coke oven workers

Polycyclic aromatic hydrocarbons (PAHs) metabolites was related to heart rate variability (HRV) reduction and atherosclerotic cardiovascular disease (ASCVD), and ASCVD was also affected by HRV. However, the mediating role of HRV in the association between PAHs exposure and ASCVD risk was largely unknown. We aimed to investigate whether the relation of PAHs exposure with ASCVD risk was mediated by HRV among coke oven workers. A total of 1100 subjects with complete data were qualified in the current study. We measured 12 urinary PAHs metabolites by gas chromatography-mass spectrometry (GC-MS) and HRV indices by 3-channel digital Holter monitors. The associations between urinary PAHs metabolites, HRV indices, and ASCVD risk were explored using generalized linear models or multivariate logistic regression models. A mediation analysis was conducted to examine the role of HRV on the association between PAHs exposure and ASCVD risk. We found that urinary 1-hydroxynaphthalene (1-OHNa), 2-OHNa, and total PAH metabolites (ΣOH-PAH) were dose-responsive associated with increased risk of ASCVD. Compared with lowest quartile, the adjusted odds ratio (OR) for ASCVD risk in the highest quartile were 2.36 for 1-OHNa, 6.58 for 2-OHNa, and 1.60 for ΣOH-PAH (all P_trend<0.05). In addition, significant dose-dependent relationships were found across 2-OHNa quartiles with decreasing HRV indices, which in turn, were positively associated with elevated risk of ASCVD (all P_trend<0.05). Mediation analyses indicated that HRV mediate 2.7%-4.3% of the association between 2-OHNa exposure and higher ASCVD risk. Our data suggested that occupational exposure to PAHs may increase ASCVD risk, which was partially mediated by HRV.

Clinical outcomes and economic impact of the 2017 ACC/AHA guidelines on hypertension in China

The 2017 guidelines on the diagnosis and treatment of high blood pressure in adults were published by the American College of Cardiology and the American Heart Association. The impact on clinical outcomes and costs needs to be estimated prior to adopting these guidelines in China. Data from a nationally representative sample in China were analyzed. The prevalence and treatment were calculated based on the criteria of the 2017 guidelines and 2018 Chinese guidelines among participants aged ≥35 years old. Direct medical costs, as well as the averted disability adjusted of life years and cost saving from cardiovascular disease events prevented by controlling hypertension, were also estimated. The prevalence and treatment rate of hypertension were 32.0% and 43.4% according to the 2018 Chinese guidelines. Based on the 2017 guidelines, another 24.5% of the adult population (estimated 168.1 million) would be classified as having hypertension; of whom, about 32.1 million would need to be pharmaceutically treated to reach the current treatment rate of 43.4%. As a result, an estimated additional 42.7 billion US dollars  of the direct medical cost would be required for lifetime therapy. By preventing cardiovascular events, the new guidelines would reduce lifetime costs by 3.77 billion US dollars, while preventing 1.41 million disability adjusted of life years lost. Application of the 2017 guidelines in China will substantially increase the prevalence of hypertension and produce a large increase in therapy costs, although it would prevent cardiovascular disease events and save disability adjusted of life years.

Exosomal CagA derived from Helicobacter pylori-infected gastric epithelial cells induces macrophage foam cell formation and promotes atherosclerosis

BACKGROUND

Seroepidemiological studies have highlighted a positive relation between CagA-positive Helicobacter pylori (H. pylori), atherosclerosis and related clinic events. However, this link has not been well validated. The present study was designed to explore the role of H. pylori PMSS1 (a CagA-positive strain that can translocate CagA into host cells) and exosomal CagA in the progression of atherosclerosis.

METHODS

To evaluate whether H. pylori accelerates or even induces atherosclerosis, H. pylori-infected C57/BL6 mice and ApoE^-/- mice were maintained under different dietary conditions. To identify the role of H. pylori-infected gastric epithelial cells-derived exosomes (Hp-GES-EVs) and exosomal CagA in atherosclerosis, ApoE^-/- mice were given intravenous or intraperitoneal injections of saline, GES-EVs, Hp-GES-EVs, and recombinant CagA protein (rCagA).

FINDINGS

CagA-positive H. pylori PMSS1 infection does not induce but promotes macrophage-derived foam cell formation and augments atherosclerotic plaque growth and instability in two animal models. Meanwhile, circulating Hp-GES-EVs are taken up in aortic plaque, and CagA is secreted in Hp-GES-EVs. Furthermore, the CagA-containing EVs and rCagA exacerbates macrophage-derived foam cell formation and lesion development in vitro and in vivo, recapitulating the pro-atherogenic effects of CagA-positive H. pylori. Mechanistically, CagA suppresses the transcription of cholesterol efflux transporters by downregulating the expression of transcriptional factors PPARγ and LXRα and thus enhances foam cell formation.

INTERPRETATION

These results may provide new insights into the role of exosomal CagA in the pathogenesis of CagA-positive H. pylori infection-related atherosclerosis. It is suggested that preventing and eradicating CagA-positive H. pylori infection could reduce the incidence of atherosclerosis and related events.

Economic Evaluation of the 2016 Chinese Guideline and Alternative Risk Thresholds of Initiating Statin Therapy for the Management of Atherosclerotic Cardiovascular Disease

OBJECTIVE

The 2016 Chinese guidelines for the management of dyslipidemia recommended mixed rules that centered around a 10% 10-year risk threshold to initiate statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). The present study aimed to evaluate the cost-effectiveness of the guideline statin-initiation strategy and alternative strategies.

METHODS

A decision analytic model using discrete event simulation with event probabilities based on a validated ASCVD risk prediction tool for Chinese was constructed. Risk factor inputs were from the dataset of a nationally representative survey of middle-aged and elderly Chinese. Data of statin treatment effectiveness were from a published meta-analysis. Other key input data were identified from the literature or relevant databases. The strategies we evaluated were the guideline strategy, a 15% 10-year risk threshold strategy and a 20% 10-year risk threshold strategy. After excluding any extended dominance strategies, the incremental costs per quality-adjusted life year (QALY) gained of each strategy was calculated.

RESULTS

The 20% 10-year risk threshold strategy was an extended dominance option. The incremental costs per QALY gained from the 15% 10-year risk threshold strategy compared with no treatment and the guideline strategy compared with the 15% 10-year risk threshold strategy were CN¥69,309 and CN¥154,944, respectively. The results were robust in most sensitivity analyses.

CONCLUSIONS

The guideline strategy and the 15% 10-year risk threshold strategy are optimal when using the three times and the two times the gross domestic product per capita willingness-to-pay standards, respectively.

Goals of non-high density lipoprotein cholesterol need to be adjusted in Chinese acute coronary syndrome patients: Findings from the CCC-ACS project

BACKGROUND

Guidelines recommended non-high density lipoprotein cholesterol (non-HDL-C) as a co-primary target, and set non-HDL-C goals as 30 mg/dl higher than low-density lipoprotein cholesterol (LDL-C) goals. However, the value is largely uncertain in Chinese patients.

METHODS

We assigned non-HDL-C values at the same percentiles correspondent to LDL-C goals for patients from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project. We calculated the differences between non-HDL-C and LDL-C and proposed appropriate adding values according to LDL-C and TG concentrations.

RESULTS

Among 73,495 patients, 17.7% used lipid-lowering agents before admission. Of these, 27.2% achieved LDL-C <70 mg/dl while 39.4% achieved non-HDL-C <100 mg/dl. The mean difference between non-HDL-C and LDL-C was 23.2 mg/dl, which could be affected by LDL-C and TG concentrations. Importantly, of patients with LDL-C concentrations ≤100 mg/dl, the mean differences were 19.1 mg/dl in patients with TG ≤150 mg/dl and 24.6 mg/dl in patients with TG >150 mg/dl.

CONCLUSIONS

There are significant differences between LDL-C and non-HDL-C in Chinese ACS patients. For secondary prevention, on average, the adding values should be 20 mg/dl for patients with TG ≤150 mg/dl and 25 mg/dl for patients with TG >150 mg/dl when LDL-C goals of 70 mg/dl is achieved.

Osteocalcin value to identify subclinical atherosclerosis over atherosclerotic cardiovascular disease (ASCVD) risk score in middle-aged and elderly Chinese asymptomatic men

BACKGROUND

Our study examined whether osteocalcin contributed to identifying carotid intima-media thickness (C-IMT) over the atherosclerotic cardiovascular disease (ASCVD) risk score.

METHODS

We recruited 618 middle-aged and elderly men from communities in Shanghai. Serum osteocalcin levels were determined using an electrochemiluminescence immunoassay. C-IMT was measured by ultrasonography.

RESULTS

The study included 245 men with low ASCVD risk and 373 men with moderate-to-high ASCVD risk. Serum osteocalcin levels were lower in the moderate-to-high risk vs. low risk men (p=0.042). Multivariate stepwise regression analysis showed that body mass index (BMI) and glycated hemoglobin were predictors for reduced osteocalcin levels (both p<0.001). Among all subjects, the proportion with an elevated C-IMT was higher in the low-osteocalcin group than in the high-osteocalcin group (p=0.042), and the significance of this result was greater when considering only subjects with a moderate-to-high ASCVD risk (p=0.011). The recognition rate of elevated C-IMT was superior with both low osteocalcin and moderate-to-high ASCVD risk vs. either parameter alone (p<0.001 and p=0.015, respectively). Osteocalcin was independently and inversely associated with elevated C-IMT after adjusting for the 10-year ASCVD risk score (p=0.004). The negative relationship remained statistically significant in subjects with a moderate-to-high ASCVD risk in particular (standardized β=-0.104, p=0.044).

CONCLUSIONS

In middle-aged and elderly men, serum osteocalcin levels strengthen identifying subclinical atherosclerosis over ASCVD risk score, especially among subjects with a moderate-to-high ASCVD risk.

Association of Three Simple Insulin Resistance Indexes with Prehypertension in Normoglycemic Subjects

Background: Insulin resistance (IR) is the common pathophysiology of prehypertension and prediabetes. Recognition of IR in one of the two disease states is critical for carrying out preventive strategies of another disease state. This study aimed to explore which simple IR indexes were significantly associated with prehypertension in subjects with normoglycemia. Methods: A total of 108,370 adults without elevated fasting plasma glucose and hypertension were included in this study. The three simple IR indexes [triglycerides to high-density lipoprotein cholesterol ratio, the product of fasting triglycerides and glucose, and metabolic score for IR (METS-IR)] were calculated. Partial correlation was used to analyze the correlation between the three indicators and blood pressure (BP) levels, and logistic regression analysis was used to explore their association with prehypertension. Results: Among the three indicators, only METS-IR had positive correlations with systolic and diastolic blood pressure levels. Furthermore, METS-IR was also significantly associated with prehypertension, irrespective of the categorization of waist circumference (WC). The odds ratios of the highest quartile were 2.223 (95% confidence interval [CI]: 2.044-2.417) in all subjects, 2.022 (95% CI: 1.501-2.725) in elevated WC subgroup, and 1.815 (95% CI: 1.620-2.034) in normal WC subgroup. Conclusions: METS-IR was associated with prehypertension in normoglycemic Chinese subjects, which bypasses the impact of WC and might be valuable for the management of prehypertension and the prevention of prediabetes in different ethnic groups.

Performance of the Framingham risk models and pooled cohort equations for predicting 10-year risk of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

The Framingham risk models and pooled cohort equations (PCE) are widely used and advocated in guidelines for predicting 10-year risk of developing coronary heart disease (CHD) and cardiovascular disease (CVD) in the general population. Over the past few decades, these models have been extensively validated within different populations, which provided mounting evidence that local tailoring is often necessary to obtain accurate predictions. The objective is to systematically review and summarize the predictive performance of three widely advocated cardiovascular risk prediction models (Framingham Wilson 1998, Framingham ATP III 2002 and PCE 2013) in men and women separately, to assess the generalizability of performance across different subgroups and geographical regions, and to determine sources of heterogeneity in the findings across studies.

METHODS

A search was performed in October 2017 to identify studies investigating the predictive performance of the aforementioned models. Studies were included if they externally validated one or more of the original models in the general population for the same outcome as the original model. We assessed risk of bias for each validation and extracted data on population characteristics and model performance. Performance estimates (observed versus expected (OE) ratio and c-statistic) were summarized using a random effects models and sources of heterogeneity were explored with meta-regression.

RESULTS

The search identified 1585 studies, of which 38 were included, describing a total of 112 external validations. Results indicate that, on average, all models overestimate the 10-year risk of CHD and CVD (pooled OE ratio ranged from 0.58 (95% CI 0.43-0.73; Wilson men) to 0.79 (95% CI 0.60-0.97; ATP III women)). Overestimation was most pronounced for high-risk individuals and European populations. Further, discriminative performance was better in women for all models. There was considerable heterogeneity in the c-statistic between studies, likely due to differences in population characteristics.

CONCLUSIONS

The Framingham Wilson, ATP III and PCE discriminate comparably well but all overestimate the risk of developing CVD, especially in higher risk populations. Because the extent of miscalibration substantially varied across settings, we highly recommend that researchers further explore reasons for overprediction and that the models be updated for specific populations.

Long-Term Exposure to Fine Particulate Matter and Hypertension Incidence in China

The risk of incident hypertension associated with long-term exposure to fine particulate matter (PM2.5) was still unclear by studies conducted in North America and Europe, and this relationship has rarely been quantified at higher ambient concentrations typically found in developing countries. We aimed to investigate the association between PM2.5 and incident hypertension using the large-scale prospective cohorts in China. We included 59 456 participants without hypertension aged ≥18 years from the China-PAR (Prediction for Atherosclerotic Cardiovascular Disease Risk in China) project. Data on ambient PM2.5 at participants' residential address were obtained during 2004 to 2015 using a satellite-based spatial-temporal model. Hazard ratios and 95% CIs were calculated for incident hypertension using stratified Cox proportional hazards models with adjustment of potential confounders. The findings indicated that average PM2.5 concentration from 2004 to 2015 at study participants' address was 77.7 μg/m3. During the follow-up of 364 947 person-years, we identified 13 981 incident hypertension cases. Compared with the lowest quartile exposure of PM2.5, participants in the highest quartile had an increased risk of incident hypertension with a hazard ratio (95% CI) of 1.77 (1.56-2.00). Each 10 μg/m3 increment of PM2.5 concentration could increase 11% risk of hypertension (hazard ratio, 1.11; 95% CI, 1.05-1.17). This cohort study provided the first evidence from China that long-term exposure to PM2.5 was independently associated with incident hypertension at relatively high ambient concentrations. Stringent strategies on PM2.5 pollution control are warranted to improve the air quality and contribute to the reduction of disease burden of hypertension in China.

Long-term exposure to ambient fine particulate matter and incidence of diabetes in China: A cohort study

BACKGROUND

Diabetes caused substantial economic and health burden worldwide. However, the associations between air pollution and diabetes incidence were rarely reported in the developing countries, especially in China with relatively high PM_2.5 concentrations.

OBJECTIVES

A cohort-based study was conducted to assess the diabetes incidence associated with long-term exposure to ambient PM_2.5.

METHODS

We collected individual health data and risk factors from the project of Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR Project) from 15 provinces over China. Diabetes was defined as fasting glucose levels ≥7.0 mmol/L at the follow-ups and/or the use of insulin or oral hypoglycemic agents and/or diagnosed medical history of diabetes during 2004 to 2015. Individual-level PM_2.5 exposures were estimated from satellite-based PM_2.5 concentrations (10 km spatial resolution) during the study period. Cox proportional hazards models with random intercepts of each cohort and region were employed to estimate the diabetes incidence attributable to PM_2.5, after the adjustment for age, gender, body mass index, smoking status, education, work-related physical activity level, hypertension, urbanicity, county-level averaged years of education, and long-term levels of temperature and relative humidity.

RESULTS

A total of 88,397 subjects were analyzed with 580,928 person-years of follow-up after 2004, among which 6439 new cases of diabetes were observed. The mean age of the subjects was 51.7 years at baseline. For an increase of 10 μg/m³ in long-term PM_2.5 exposure, the multivariable-adjusted percent increase in the diabetes incidence was estimated to be 15.66% (95% confidence interval: 6.42%, 25.70%). The adverse effects of PM_2.5 were larger among females, rural subjects, non-smokers, normotensives, subjects younger than 65 years and subjects with body mass index <25 kg/m².

CONCLUSIONS

Our findings provided evidence for the association of long-term exposure to PM_2.5 with diabetes incidence in China. A sustained improvement of air quality will benefit the reduction for diabetes epidemic in China.

Performance of atherosclerotic cardiovascular risk prediction models in a rural Northern Chinese population: Results from the Fangshan Cohort Study

BACKGROUND

Performance of Pooled Cohort Equations (PCEs) for atherosclerotic cardiovascular disease (ASCVD) risks varied across populations. Whether the recently developed Prediction for ASCVD Risk in China (China-PAR) model could accurately predict cardiovascular risks in real practice remains unclear.

METHODS

A population-based cohort study in rural Beijing in the "stroke belt" in North China was used to externally validate PCE and China-PAR models for 5-year ASCVD risk prediction. Expected 5-year prediction risk using China-PAR model was compared with PCE (white). The models were assessed for calibration, discrimination, and reclassification.

RESULTS

Among 11,169 adults aged 40 to 79 years over a median 6.44 years of follow-up, 1,921 participants developed a first ASCVD event during total 70,951 person-years. China-PAR model fairly predicted ASCVD risk in men but overestimated by 29.4% risk in women (calibration χ² = 81.4, P < .001). Underestimations were shown by PCE as 76.2% in men and 88.2% in women with poor calibration (both P < .001). However, discrimination was similar in both models: C-statistics in men were 0.685 (95% CI 0.660-0.710) for China-PAR and 0.675 (95% CI 0.649-0.701) for PCE; C-statistics in women were 0.711 (95% CI 0.694-0.728) for China-PAR and 0.714 (95% CI 0.697-0.731) for PCE. Moreover, China-PAR did not substantially improve accuracy of reclassification compared with PCE.

CONCLUSIONS

China-PAR outperformed PCE in 5-year ASCVD risk prediction in this rural Northern Chinese population at average population risk level, fairly predicted risk in men, but overestimated risk in women; however, China-PAR did not meaningfully improve the accuracy of discrimination and reclassification at individual risk level.

10-year ASCVD risk is positively correlated with depressive symptoms in a large general population

BACKGROUND

To explore the potential correlation between 10-year atherosclerotic cardiovascular disease (ASCVD) risk and depressive symptoms in a general population.

METHODS

A cross-sectional study involving 11,956 permanent residents of Liaoning Province in China ≥35 years of age was conducted. Depressive symptoms were assessed with the Patient Health Questionnaire-9 (PHQ-9) while 10-year ASCVD risk was calculated using the tool suitable for China.

RESULTS

Males had significantly higher 10-year ASCVD risk than females (14.2 ± 10.7% vs. 9.3 ± 9.1%; P <  0.001) but lower PHQ-9 score (2.34 ± 3.13 vs. 3.63 ± 4.02; P <  0.001). The mean PHQ-9 score increased significantly with advancing 10-year ASCVD risk category in both males (from 2.03 to 2.61; P for trend < 0.001) and females (from 3.04 to 4.61; P for trend < 0.001), and the increasing trend was more apparent in females (P <  0.001). Pearson correlation analyses showed that 10-year ASCVD risk positively correlated with PHQ-9 score in both sexes (Ps <  0.001). In multivariate linear regression analyses adjusting for confounding risk factors, the independent associations of 10-year ASCVD risk with PHQ-9 score were all significant in the total (β = 2.61; P <  0.001), male (β = 1.64; P = 0.001), and female subjects (β = 3.71; P <  0.001). Further, the interaction analysis proved the impacts of 10-year ASCVD risk on PHQ-9 score were more apparent in females than males (Ps < 0.001).

CONCLUSIONS

The 10-year ASCVD risk was positively associated with depressive symptoms in both males and females, which was more apparent in the latter. These findings provided some novel data about the value of 10-year ASCVD risk in estimating depressive symptoms.

Derivation and Evaluation of the Ischemic Risk Model in High-Risk Chinese Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

PURPOSE

Coronary artery disease is the top cause of death among the Chinese population. With the establishment of a Chinese prediction model, it is urgent to assess factors related to the prognosis of patients with acute coronary syndrome at extremely high risk.

METHODS

In this retrospective study, we enrolled 601 patients assessed as being of extremely high risk, according to specific criteria from the China-PAR (Prediction for Atherosclerotic Cardiovascular Disease Risk) project, and investigated various clinical parameters using Cox multivariate analysis to establish a risk nomogram. C-index and calibration curves were involved to assess the internal identification. By using the all-cause death risk model, we stratified patients by risk level and compared the effects of clopidogrel and ticagrelor on end points.

FINDINGS

We identified several factors, including body mass index, angiopathy, smoking status, β-blocker usage, history of myocardial infarction, total number of stents, and usage of antiplatelet agents, related to ischemic end points, all-cause death, cardiovascular events, and cardiac death. A C-index of >0.7 and the calibration curve demonstrated good concordance. In a subsequent analysis, we used the all-cause death model to stratify patients by risk level, and compared the effects of clopidogrel and ticagrelor. In the subgroup with a 2-year death rate of >50%, ticagrelor showed a positive effect (P = 0.045), but in the subgroup with a 2-year death rate of <50%, the difference between clopidogrel and ticagrelor was not significant. Considering the duration of effect of antiplatelet agents, we also compared these 2 agents at 1-year follow up, with ticagrelor showing no advantage.

IMPLICATIONS

We determined the probability of ischemic risk in patients at extremely high ischemic risk and developed new risk models for this specific group. Ticagrelor, compared with clopidogrel, may improve the prognosis of patients at high risk for death after 2 years.

A nomogram for the prediction of cerebrovascular disease among patients with brain necrosis after radiotherapy for nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

This study sought to develop and validate a nomogram to predict cerebrovascular disease (CVD) among patients with brain necrosis after radiotherapy for nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

A total of 346 eligible patients with brain necrosis after radiotherapy for NPC were divided into a training set (n = 231) and a validation set (n = 115). A multivariate Cox proportional hazards regression model was used to select the significant variables for CVD prediction in the training set. Then, a nomogram was developed based on the regression model. The performance of the nomogram was assessed with respect to discrimination and calibration. All patients were classified into high- or low-risk groups based on the risk scores derived from the nomogram. Moreover, a decision curve analysis was performed with the combined training and validation sets to evaluate the clinical usefulness of the nomogram.

RESULTS

Four significant predictors were identified: hypertension, statin treatment, serum level of high-density lipoprotein, and interval between radiotherapy and brain necrosis. The nomogram incorporating these four predictors showed favorable calibration and discrimination regarding the training set, with a C-index of 0.763 (95% CI, 0.694 to 0.832), which was confirmed using the validation set (C-index 0.768; 95% CI, 0.675 to 0.861). Furthermore, the nomogram successfully stratified patients into high- and low-risk groups. The decision curve indicated that our nomogram was clinically useful.

CONCLUSION

The nomogram showed favorable predictive accuracy for CVD among patients with brain necrosis after radiotherapy for NPC and might aid in clinical decision making.

Mean platelet volume mediated the relationships between heavy metals exposure and atherosclerotic cardiovascular disease risk: A community-based study

BACKGROUND

Heavy metals were related to increased risk of atherosclerotic cardiovascular disease (ASCVD). However, potential mechanisms under such associations remain unclear. We aimed to investigate the mediating role of mean platelet volume in the associations between heavy metals exposure and 10-year ASCVD risk.

METHOD

Urinary heavy metals and mean platelet volume were measured in 3081 adults from the Wuhan-Zhuhai cohort in China. The associations between urinary heavy metals, mean platelet volume and 10-year ASCVD risk were separately analyzed through generalized linear models and logistic regression models. Mediation analyses were conducted to assess the role of mean platelet volume in the associations between urinary heavy metals and 10-year ASCVD risk.

RESULTS

After adjusting for potential confounders, 10-year ASCVD risk was positively associated with urinary iron (odds ratio (OR) = 1.142, 95% confidence interval (1.038-1.256)), copper (OR = 1.384 (1.197-1.601)), zinc (OR = 1.520 (1.296-1.783)), cadmium (OR = 1.153 (0.990, 1.342)) and antimony (OR = 1.452 (1.237-1.704)), and negatively related with urinary barium (OR = 0.905 (0.831-0.985)). Also, we found significant dose-response relationships between urinary iron, zinc, antimony and mean platelet volume, as well as between mean platelet volume and 10-year ASCVD risk (all pfor trends < 0.05). Furthermore, mediation analyses indicated that mean platelet volume mediated 17.55%, 6.15% and 7.38% of the associations between urinary iron, zinc, antimony and 10-year ASCVD risk, respectively (all pvalue < 0.05).

CONCLUSIONS

Elevated concentrations of urinary iron, copper, zinc, cadmium and antimony were associated with increased risk of 10-year ASCVD. Mean platelet volume partially mediated the associations of urinary iron, zinc and antimony with 10-year ASCVD risk.

Controversies in the 2017 ACC/AHA Hypertension Guidelines: Who Can Be Eligible for Treatments Under the New Guidelines? - An Asian Perspective

Until the 2017 ACC/AHA Hypertension Guidelines were released, the target blood pressure (BP) for adults with hypertension (HTN) was 140/90 mmHg in most of the guidelines. The new 2018 ESC/ESH, Canadian, Korean, Japan, and Latin American hypertension guidelines have maintained the <140/90 mmHg for the primary target in the general population and encourage reduction to <130/80 if higher risk. This is more in keeping with the 2018 American Diabetes Association guidelines. However, the 2017 ACC/AHA guidelines classify HTN as BP ≥130/80 mmHg and generally recommend target BP levels below 130/80 mmHg for hypertensive patients independently of comorbid disease or age. Although the new guidelines mean that more people (nearly 50% of adults) will be diagnosed with HTN, the cornerstone of therapy is still lifestyle management unless BP cannot be lowered to this level; thus, more people will require BP-lowering medications. To date, there have been many controversies about the definition of HTN and the target BP. Targeting an intensive systolic BP goal can increase the adverse effects of multiple medications and the cardiovascular disease risk by excessively lowering diastolic BP, especially in patients with high risk, including those with diabetes, chronic kidney disease, heart failure, and coronary artery disease, and the elderly. In this review, we discuss these issues, particularly regarding the optimal target BP.

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current US prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general US clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (eg, family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current U.S. prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general U.S. clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (e.g., family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.

The Evolving Cardiovascular Disease Risk Scores for Persons with Diabetes Mellitus

PURPOSE OF REVIEW

We briefly introduce the concept and use of cardiovascular disease (CVD) risk scores and review the methodology for CVD risk score development and validation in patients with diabetes. We also discuss CVD risk scores for diabetic patients that have been developed in different countries.

RECENT FINDINGS

Patients with diabetes have a gradient of CVD risk that needs to be accurately assessed. Numerous CVD risk scores for diabetic patients have been created in various settings. The methods to develop risk scores are highly diverse and each choice has its own pros and cons. A well-constructed risk score for diabetic patients may be advocated by guidelines and adopted by healthcare providers to help determine preventive strategies. New risk factors are being investigated in order to improve the predictive accuracy of current risk scores. A suitable CVD risk score for the diabetes population should be accurate, low-cost, and beneficial to outcome. While the performance (accuracy) has all been internally validated, validation on external populations is still needed. Cost-effectiveness and clinical trials demonstrating improvement in outcomes are limited and should be the target of future research.

Effects of High Blood Pressure on Cardiovascular Disease Events Among Chinese Adults With Different Glucose Metabolism

OBJECTIVE

To investigate cardiovascular disease (CVD) risks caused by blood pressure (BP) of 130-139/80-89 mmHg among Chinese adults with different glucose metabolism.

RESEARCH DESIGN AND METHODS

A prospective population-based cohort of 2,132 adults in Shanghai was established in 2002, and CVD information was collected during 10.9 years of follow-up. After assessing the association between BP categories and incident CVD, we analyzed the risk for CVD by blood glucose categories and BP categories combined by using multiple Cox regression analysis among 1,419 participants at follow-up.

RESULTS

The corresponding incidence of CVD per 1,000 person-years for the BP <130/80 mmHg, 130-139/80-89 mmHg, and ≥140/90 mmHg or treated groups were 3.0, 6.0, and 13.9, respectively. After adjusting for age, sex, and other factors, BP ≥140/90 mmHg was significantly associated with a higher CVD risk in general (hazard ratio 2.68 [95% CI 1.36-5.25]) and in various blood glucose categories (normoglycemia 2.59, prediabetes 3.03, diabetes mellitus [DM] 4.98). However, BP of 130-139/80-89 mmHg was significantly associated with a higher CVD risk in an estimated baseline 10-year atherosclerotic CVD (ASCVD) risk ≥10% (3.82 [1.42-9.78]) or DM (3.54 [1.05-11.88]) but not in the general population or for a baseline 10-year ASCVD risk <10%, normoglycemia, or prediabetes.

CONCLUSIONS

BP of 130-139/80-89 mmHg may result in a significantly higher CVD risk in Chinese adults with an estimated 10-year ASCVD risk ≥10% or DM but not in those with normoglycemia or prediabetes.