South Asian ethnicity as a risk factor for coronary heart disease

Diverse impacts of red palm olein, extra virgin coconut oil and extra virgin olive oil on cardiometabolic risk markers in individuals with central obesity: a randomised trial

PURPOSE

Dietary fats with an abundance of phytonutrients have garnered public attention beyond fatty acids per se. This study was set to investigate the impact of consuming diets with red palm olein (RPOO), extra virgin coconut oil (EVCO) and extra virgin olive oil (EVOO, as a control) on cardiometabolic risk biomarkers and lipid profile.

METHODS

We recruited a total of 156 individuals with central obesity, aged 25-45 years, with waist circumference ≥ 90 cm for men and ≥ 80 cm for women in a parallel single-blind 3-arm randomised controlled trial. The participants consumed isocaloric diets (~ 2400 kcal) enriched with respective test fats (RPOO, EVCO or EVOO) for a 12-week duration.

RESULTS

The mean of the primary outcome plasma high sensitivity C-reactive protein was statistically similar between the three diets after a 12-week intervention. EVOO resulted in significantly lower mean LDL cholesterol compared with RPOO and EVCO, despite similar effects on LDL and HDL cholesterol subfractions. The RPOO diet group showed elevated mean α and β -carotenes levels compared with EVCO and EVOO diet groups (P < 0.05), corresponding with the rich carotenoid content in RPOO.

CONCLUSION

The three oils, each of which has unique phytonutrient and fatty acid compositions, manifested statistically similar cardiometabolic effects in individuals with central obesity at risk of developing cardiovascular diseases with distinct circulating antioxidant properties.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT05791370).

Assessing Glycosylated Hemoglobin Thresholds for Development of Cardiovascular Disease by Racial and Ethnic Groups

BACKGROUND

Diabetes is the strongest risk factor for cardiovascular disease, and although glycosylated hemoglobin (HbA1c) levels are known to vary by race, no racial and ethnic-specific diagnostic thresholds exist for diabetes in prediction of cardiovascular disease events. The purpose of this study is to determine whether HbA1c thresholds for predicting major adverse cardiovascular events (MACEs) differ among racial and ethnic groups.

METHODS AND RESULTS

This is a retrospective cohort study of Kaiser Permanente Northern California adult members (n=309 636) with no history of cardiovascular disease who had HbA1c values and race and ethnicity data available between 2014 and 2019. Multivariable logistic regression was used to evaluate the odds of MACEs by the following racial and ethnic groups: Filipino, South Asian, East Asian, Black, White, and Hispanic. A Youden index was used to calculate HbA1c thresholds for MACE prediction by each racial and ethnic group, stratified by sex. Among studied racial and ethnic groups, South Asian race was associated with the greatest odds of MACEs (1.641 [95% CI, 1.456-1.843]; P<0.0001). HbA1c was a positive predictor for MACEs, with an odds ratio of 1.024 (95% CI, 1.022-1.025) for each 0.1% increment increase in HbA1c. HbA1c values varied between 6.0% and 7.6% in MACE prediction by race and ethnicity and sex. White individuals, South Asian individuals, East Asian women, and Black men had HbA1c thresholds for MACE prediction in the prediabetic range, between 6.0% and 6.2%. Black women, Hispanic men, and East Asian men had HbA1c thresholds of 6.2% to 6.6%, less than the typical threshold of 7.0% that is used as a treatment goal.

CONCLUSIONS

Findings suggest that the use of race and ethnic- and sex-specific HbA1c thresholds may need to be considered in treatment goals and cardiovascular disease risk estimation.

The utility of coronary artery calcium scoring to enhance cardiovascular risk assessment for South Asian adults

South Asian individuals represent a highly diverse population and are one of the fastest growing ethnic groups in the United States. This population has a high prevalence of traditional and non-traditional cardiovascular disease (CVD) risk factors and a disproportionately high prevalence of coronary heart disease. To reflect this, current national society guidelines have designated South Asian ancestry as a "risk enhancing factor" which may be used to guide initiation or intensification of statin therapy. However, current methods of assessing cardiovascular risk in South Asian adults may not adequately capture the true risk in this diverse population. Coronary artery calcium (CAC) scoring provides a reliable, reproducible, and highly personalized method to provide CVD risk assessment and inform subsequent pharmacotherapy recommendations, if indicated. This review describes the utility of CAC scoring for South Asian individuals.

Early Intervention in Psychosis and Management of First Episode Psychosis in Low- and Lower-Middle-Income Countries: A Systematic Review

BACKGROUND AND HYPOTHESIS

People with first-episode psychosis (FEP) in low- and lower-middle-income countries (LMIC) experience delays in receiving treatment, resulting in poorer outcomes and higher mortality. There is robust evidence for effective and cost-effective early intervention in psychosis (EIP) services for FEP, but the evidence for EIP in LMIC has not been reviewed. We aim to review the evidence on early intervention for the management of FEP in LMIC.

STUDY DESIGN

We searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) to identify studies describing EIP services and interventions to treat FEP in LMIC published from 1980 onward. The bibliography of relevant articles was hand-searched. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

STUDY RESULTS

The search strategy produced 5074 records; we included 18 studies with 2294 participants from 6 LMIC countries. Thirteen studies (1553 participants) described different approaches for EIP. Pharmacological intervention studies (n = 4; 433 participants) found a high prevalence of metabolic syndrome among FEP receiving antipsychotics (P ≤ .005). One study found a better quality of life in patients using injectables compared to oral antipsychotics (P = .023). Among the non-pharmacological interventions (n = 3; 308 participants), SMS reminders improved treatment engagement (OR = 1.80, CI = 1.02-3.19). The methodological quality of studies evidence was relatively low.

CONCLUSIONS

The limited evidence showed that EIP can be provided in LMIC with adaptations for cultural factors and limited resources. Adaptations included collaboration with traditional healers, involving nonspecialist healthcare professionals, using mobile technology, considering the optimum use of long-acting antipsychotics, and monitoring antipsychotic side effects.

Mounting Stroke Crisis in India: A Systematic Review

Stroke, a neurological disorder, has emerged as a formidable health challenge in India, with its incidence on the rise. Increased risk factors, which also correlate with economic prosperity, are linked to this rise, including hypertension, diabetes, obesity, sedentary lifestyle, and alcohol intake. Particularly worrisome is the impact on young adults, a pivotal segment of India's workforce. Stroke encompasses various clinical subtypes and cerebrovascular disorders (CVDs), contributing to its multifaceted nature. Globally, stroke's escalating burden is concerning, affecting developing nations. To combat this trend effectively and advance prevention and treatment strategies, comprehensive and robust data on stroke prevalence and impact are urgently required. In India, these encompass individuals with elevated BMIs, and those afflicted by hypertension, diabetes, or a familial history of stroke. Disparities in stroke incidence and prevalence manifest across India, with differences in urban and rural settings, gender-based variations, and regional disparities. Early detection, dietary changes, effective risk factor management, and equitable access to stroke care are required to address this issue. Government initiatives, like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) 2019, provide guidelines, but effective implementation and awareness campaigns are vital. Overcoming barriers to stroke care, especially in rural areas, calls for improved infrastructure, awareness campaigns, and support systems. Data standardization and comprehensive population studies are pivotal for informed public health policies.

Ethnic differences in cardiac structure and function assessed by MRI in healthy South Asian and White European people: A UK Biobank Study

BACKGROUND

Echocardiographic studies indicate South Asian people have smaller ventricular volumes, lower mass and more concentric remodelling than White European people, but there are no data using cardiac MRI (CMR). We aimed to compare CMR quantified cardiac structure and function in White European and South Asian people.

METHODS

Healthy White European and South Asian participants in the UK Biobank Imaging CMR sub-study were identified by excluding those with a history of cardiovascular disease, hypertension, obesity or diabetes. Ethnic groups were matched by age and sex. Cardiac volumes, mass and feature tracking strain were compared.

RESULTS

121 matched pairs (77 male/44 female, mean age 58 ± 8 years) of South Asian and White European participants were included. South Asian males and females had smaller absolute but not indexed left ventricular (LV) volumes, and smaller absolute and indexed right ventricular volumes, with lower absolute and indexed LV mass and lower LV mass:volume than White European participants. Although there were no differences in ventricular or atrial ejection fractions, LV global longitudinal strain was higher in South Asian females than White European females but not males, and global circumferential strain was higher in both male and South Asian females than White European females. Peak early diastolic strain rates were higher in South Asian versus White European males, but not different between South Asian and White European females.

CONCLUSIONS

Contrary to echocardiographic studies, South Asian participants in the UK Biobank study had less concentric remodelling and higher global circumferential strain than White European subjects. These findings emphasise the importance of sex- and ethnic- specific normal ranges for cardiac volumes and function.

Prevalence of Cardiovascular Diseases in South Asians: Scrutinizing Traditional Risk Factors and Newly Recognized Risk Factors Sarcopenia and Osteopenia/Osteoporosis

One of the primary reasons for complications and death worldwide are cardiovascular diseases (CVDs), with a death toll of approximately 18 million per year. CVDs include cardiomyopathy, hypertension, ischemic heart disease, coronary heart disease, myocardial infarction, heart attack, hearth failure, etc. Over 80% of the CVD mortality is recorded from lower and middle-income countries. Records from the past decade have highlighted the increase of CVDs among the South Asian populations, and the prime purpose of the review is to jot down the reasons for the steep spike in CVDs. Studies analyzing the causative factors for the increase of CVDs in South Asians are still to be verified. Apart from known predisposing and lifestyle factors, other emerging risk factors associated with CVDs, namely the musculoskeletal diseases sarcopenia and osteopenia, should be tracked to tackle research gaps in upcoming analyses. This requires loads of scientific efforts. With proper monitoring, the raising alarm that the CVD burden generates can be reduced. This review discusses the already established signs and recognizes important clues to the emerging etiology of CVDs in the Asian population and prevention measures to keep it at bay.

Beyond the Basics: Unraveling the Complexity of Coronary Artery Calcification

Coronary artery calcification (CAC) is mainly associated with coronary atherosclerosis, which is an indicator of coronary artery disease (CAD). CAC refers to the accumulation of calcium phosphate deposits, classified as micro- or macrocalcifications, that lead to the hardening and narrowing of the coronary arteries. CAC is a strong predictor of future cardiovascular events, such as myocardial infarction and sudden death. Our narrative review focuses on the pathophysiology of CAC, exploring its link to plaque vulnerability, genetic factors, and how race and sex can affect the condition. We also examined the connection between the gut microbiome and CAC, and the impact of genetic variants on the cellular processes involved in vascular calcification and atherogenesis. We aimed to thoroughly analyze the existing literature to improve our understanding of CAC and its potential clinical and therapeutic implications.

PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT): a prospective longitudinal study protocol investigating the prevalence, severity and determinants of atherosclerotic cardiovascular disease in the young adult Pakistani population

INTRODUCTION

Atherosclerotic cardiovascular disease (ASCVD) is a major cause of morbidity, mortality and health expenditures worldwide. Despite having higher ASCVD in the Pakistani population, data on subclinical coronary atherosclerosis in young Pakistanis remain scarce. The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) aims to assess the prevalence, severity and determinants of subclinical coronary atherosclerosis among Pakistani men (35-60 years) and women (35-65 years) free of clinically symptomatic ASCVD and will assess 5-year rates of ASCVD events.

METHODS AND ANALYSIS

PAK-SEHAT is an ongoing prospective cohort study with 2000 participants from all provinces of Pakistan who will be interviewed at the baseline along with phlebotomy, measurement of carotid intima-media thickness (CIMT) and coronary CT angiography (CCTA). Phlebotomy will be repeated at 2.5 years, whereas CIMT and CCTA will be repeated at 5 years. We will report the frequency of maximal coronary stenosis ≥50% and ≥70%, number of coronary vessels with plaque and the number of coronary segments affected per participant on CCTA. We will use Cox proportional hazards regression models to evaluate the association between baseline characteristics and incident ASCVD events during follow-up. These associations will be presented as HRs with 95% CIs.

ETHICS AND DISSEMINATION

The study protocol was approved by the Tabba Heart Institute Institutional Review Board (THI/IRB/FQ/22-09-2021/016). All study procedures are consistent with the principles of the Declaration of Helsinki. Findings of the study will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05156736.

Estimated risk of cardiovascular events and long-term complications: The projected future of diabetes patients in Delhi from the DEDICOM-II survey

PROBLEM

Despite high prevalence and ethnic susceptibility, limited published estimates are available on long term complication risks among known diabetes patients in India. Hence, we undertook evaluation of the cardiovascular risk of known diabetes patients from Delhi.

METHODS

The community-survey was conducted using a probability-proportionate-to-size(systematic) 2-stage cluster design. Thirty areas were selected for a house-to-house survey to recruit 25 to 30 subjects (known diabetes ≥1 year; 35-65 years of age) per area. Scores from the UKPDS 2.1, UKPDS 2.0, Framingham, ASCVD, WHO, NHS and SCORE studies were used for 10-year risk calculation.

RESULTS

We enrolled 843 subjects of which 800 consented for blood sampling. The mean age of the subjects was 53.0(52.1-54.0) years, the mean duration since diagnosis was 7.1(6.7-7.5) years, with 49.8 % women. 61.8 % were hypertensive, 81.5 % were dyslipidaemic and 53.3 % had poor glycaemic control. Although variable, risk engines estimates were consensual in projecting a high ten-year Coronary-Heart-Disease risk of 10-16 %, a stroke risk of 3.7-5.0 %, and a 5.0-5.7% risk of cardiovascular fatality. These risks were 1.5-3 times the 'risk at target levels' suggesting mitigability. Only 9.3 %, 16.0 %, and 30.0 % were taking aspirin, lipid lowering drugs and antihypertensives respectively.

CONCLUSION

The study highlights the impending impact of, and the scope for improvement in the cardiovascular risk profile of diabetes patients in Delhi, including the use of cardioprotective medications. It strengthens the case for developing and testing potential interventions for improvement.

Risk Assessment for Cardiovascular Disease Using the Framingham Risk Score and Globorisk Score Among Newly Diagnosed Metabolic Syndrome Patients

Purpose

The presence of metabolic syndrome (MetS) is linked to an increased risk of cardiovascular disease (CVD) development. In this study, CVD risk was calculated among individuals with newly diagnosed MetS using the Framingham Risk Score (FRS) and Globorisk Score. The FRS and Globorisk score are particularly relevant in predicting CVD risk as these scores include key MetS-related risk factors like blood pressure, cholesterol levels, and age.

Patients and Methods

A community-based cross-sectional study was conducted at various sites in Karachi, Pakistan, from February 2022 to August 2022. Newly diagnosed cases of MetS with no physical disability, known illness, and not taking any regular medication were recruited. MetS was defined based on the definition of International Diabetes Federation. The major outcome was 10-year risk for CVD using the FRS and Globorisk Score.

Results

Of 304 patients, 59.2% were classified as low risk according to FRS, while 20.4% were classified as moderate and high risk each. Using the Globorisk score, 44.6% of 224 patients were classified as low risk, 34.4% as moderate risk, and 21.0% as high risk. A moderate positive correlation was observed between the two CVD risk scores (r = 0.651, 95% CI 0.58-0.71). Both risk scores have reported age, gender, and current smokers as significant risk factors in predicting CVD in 10-years (P < 0.05).

Conclusion

The outcome of both CVD risk scores predicted moderate-to-high risk of CVD in 10-years in almost half of the newly diagnosed patients with MetS. In particular, the risk of development of CVD in 10-years in newly diagnosed MetS is higher with increasing age, in male gender, and current smokers.

Risk factors, lab parameters, angiographic characteristics and outcomes of coronary artery disease in young South Asian patients: a systematic review

This systematic review provides a qualitative summary of the risk factors, angiographic characteristics, treatment, and complications of young South Asians with coronary artery disease (CAD). PubMed, Embase, and Google Scholar were searched to identify research articles published between 1 January 2010 and 13 November 2022. Studies in patients aged 18 to 45 years that were conducted in South Asian countries, were published in the English language, and included information on patients' clinical profiles and at least two risk factors for young CAD were included in the review. Smoking, dyslipidemia, high body mass index, increased high-sensitivity C-reactive protein, and hyperhomocysteinemia were observed in high proportions in young patients with CAD. Single-vessel disease was more common than multi-vessel disease in young CAD. The complications of CAD such as arrhythmias, cardiogenic shock, and heart failure were also commonly observed in young patients. Large-scale health promotion activities that curb modifiable risk factors such as smoking, obesity, and a sedentary lifestyle should be conducted in South Asian countries.

Heart health for South Asians: improved cardiovascular risk factors with a culturally tailored health education program

BACKGROUND/AIM

The Kaiser Permanente (KP) Northern California Heart Health for South Asians (HHSA) Program is a two-hour educational class that provides culturally relevant lifestyle and dietary recommendations to South Asian (SA) patients, in an effort to reduce their known disproportionate burden of cardiovascular (CV) disease. We evaluated the impact of the HHSA Program on CV risk factors and major adverse CV events (MACE).

METHODS

A retrospective cohort study identified 1517 participants of SA descent, ≥ 18 years old from 2006 to 2019. We evaluated the change in risk factors with program attendance (median follow up of 6.9 years) for systolic blood pressure (SBP), diastolic blood pressure (DBP), triglycerides (TG), LDL, HDL, BMI, and HbA1c. We also performed a propensity matched analysis to evaluate differences in MACE including stroke, myocardial infarction (MI), coronary revascularization, and all-cause mortality.

RESULTS

There were significant improvements in DBP, TG, LDL-c, HDL-c, BMI, and HbA1c at one year follow up and sustained improvements in DBP (-1.01mmHg, p = 0.01), TG (-13.74 mg/dL, p = 0.0001), LDL-c (-8.43 mg/dL, p = < 0.0001), and HDL-c (3.16 mg/dL, p = < 0.0001) levels at the end of follow up. In the propensity matched analysis, there was a significant reduction in revascularization (OR 0.33, 95% CI 0.14-0.78, p = 0.011) and mortality (OR 0.41, 95% CI 0.22-0.79, p = 0.008), and a trend towards reduction in stroke.

CONCLUSIONS

Our study demonstrates the efficacy of a culturally tailored SA health education program in improving CV risk factors and reducing MACE. The program highlights the importance and value of providing culturally tailored health education in primary CV disease prevention.

Association of Coronary Artery Calcium Density and Volume With Predicted Atherosclerotic Cardiovascular Disease Risk and Cardiometabolic Risk Factors in South Asians: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study

Individuals of South Asian (SA) ancestry are predisposed to a higher risk of atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium (CAC) volume and density can identify coronary plaque characteristics unique to SA that may provide important prognostic information to identify high risk individuals beyond traditional CAC scores. We used data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA). CAC density and volume were assessed according to established protocols. ASCVD risk was estimated using the pooled cohort equations (PCE). Multivariable-adjusted linear regression models were used to study the association between the PCE and advanced CAC measures, and between cardiovascular risk factors and CAC density and volume. Our analyses included 1,155 participants (mean age 57 (SD 9) years, 52% men) with information on advanced CAC measures. After multivariable-adjustment, the PCE was associated with both CAC density (β 0.24, 95% CI 0.12,0.35) and CAC volume (β 0.43, 95% CI 0.38,0.48). High-density lipoprotein cholesterol was directly associated with CAC density while waist circumference was inversely associated with it. Body mass index, hypertension status, statin use, diabetes, and HOMA-IR were all directly associated with CAC volume. Estimated ASCVD risk was associated with both CAC volume and density. Different cardiometabolic risk factors are associated with CAC density and volume. Future longitudinal studies are required to demonstrate the interrelationship of advanced CAC measures and cardiovascular risk factors with incident ASCVD outcomes.

Heightened risks of cardiovascular disease in South Asian populations: causes and consequences

INTRODUCTION

South Asian individuals comprise almost a quarter of the world's population and have an excess risk of atherosclerotic cardiovascular disease (ASCVD) compared to other ethnicities. In part, this can be explained by higher prevalence, earlier onset, and suboptimal control of traditional cardiovascular risk factors, such as insulin resistance, metabolic syndrome, and dyslipidaemia. However, there remains a significant residual excess risk associated with South Asian ethnicity after controlling for traditional risk factors.

AREAS COVERED

In this review, we describe the epidemiology of ASCVD in both native and diaspora South Asian populations. We explore how traditional cardiovascular risk factors, novel cardiovascular risk factors, and social determinants of health may contribute to the excess ASCVD risk seen in South Asian populations.

EXPERT OPINION

There should be increased awareness of the relative importance of South Asian ethnicity and related social determinants of health, as risk factors for ASCVD. Systematic screening processes should be tailored to this population, and modifiable risk factors should be treated aggressively. Further research is required to quantify determinants of the excess ASCVD risk seen in South Asian populations and to develop targeted interventions to address these factors.

Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.

Differential Associations of Cystatin C Versus Creatinine-Based Kidney Function With Risks of Cardiovascular Event and Mortality Among South Asian Individuals in the UK Biobank

Background South Asian individuals have increased cardiovascular disease and mortality risks. Reliance on creatinine- rather than cystatin C-based estimated glomerular filtration rate (eGFRcys) may underestimate the cardiovascular disease risk associated with chronic kidney disease. Methods and Results Among 7738 South Asian UK BioBank participants without prevalent heart failure (HF) or atherosclerotic cardiovascular disease, we investigated associations of 4 eGFRcys and creatinine-based estimated glomerular filtration rate categories (<45, 45-59, 60-89, and ≥90 mL/min per 1.73 m2) with risks of all-cause mortality, incident HF, and incident atherosclerotic cardiovascular disease. The mean age was 53±8 years; 4085 (53%) were women. Compared with creatinine, cystatin C identified triple the number of participants with estimated glomerular filtration <45 (n=35 versus n=113) and 6 times the number with estimated glomerular filtration 45 to 59 (n=80 versus n=481). After multivariable adjustment, the eGFRcys 45 to 59 category was associated with higher risks of mortality (hazard ratio [HR], 2.38 [95% CI, 1.55-3.65]) and incident HF (sub-HR [sHR], 1.87 [95% CI, 1.09-3.22]) versus the eGFRcys ≥90 category; the creatinine-based estimated glomerular filtration rate 45 to 59 category had no significant associations with outcomes. Of the 7623 participants with creatinine-based estimated glomerular filtration rate ≥60, 498 (6.5%) were reclassified into eGFRcys <60 categories. Participants who were reclassified as having eGFRcys <45 had higher risks of mortality (HR, 4.88 [95% CI, 2.56-9.31]), incident HF (sHR, 4.96 [95% CI, 2.21-11.16]), and incident atherosclerotic cardiovascular disease (sHR, 2.29 [95% CI, 1.14-4.61]) versus those with eGFRcys ≥90; those reclassified as having eGFRcys 45 to 59 had double the mortality risk (HR, 2.25 [95% CI, 1.45-3.51]). Conclusions Among South Asian individuals, cystatin C identified a high-risk chronic kidney disease population that was not detected by creatinine and enhanced estimated glomerular filtration rate-based risk stratification for mortality, incident HF, and incident atherosclerotic cardiovascular disease.

Impact of a simple educational intervention on awareness regarding cardiovascular disease among school-going adolescents in a rural area of Bengaluru district, India

BACKGROUND

Cardiovascular disease (CVD) is the number one cause of death in India. Atherosclerosis begins in the second decade of life; thus, preventive efforts beginning in adolescence are crucial. Yet, there are no national or regional school-based educational programs in India for the prevention of CVD. We aimed to assess the impact of a simple educational intervention on the awareness regarding CVD among school-going adolescents in a rural area of Bengaluru.

MATERIALS AND METHODS

This study was conducted using a convenience sample of school-going adolescents of classes 8, 9, and 10 in three schools in a rural area of Anekal subdistrict, Bengaluru, with a sample size of 170. A standardized, validated questionnaire testing CVD awareness was administered, followed by a simple lecture with audio-visual aids on key aspects of CVD. Three weeks later, the same questionnaire was administered to the same students. The results were then analyzed using appropriate descriptive (mean, percentage) and inferential analyses (Chi-square, paired t-test).

RESULTS

The mean (SD) age was 14.5 (1.0) years, and 54% (n = 100) were boys. 75% (139) belonged to privately funded schools. 23% (43) belonged to class 8, 37% (69) to class 9, and 40% (74) to class 10. The mean (SD) total score on baseline assessment was 27.4 (9.3) out of 100, with girls and students of private schools scoring higher. The mean (SD) post-test total score was 48.5 (15.7), with significant increases in all domains of awareness, and in all categories of students.

DISCUSSION

Awareness regarding CVD among adolescents from rural Bengaluru was poor, highlighting the need for educational interventions to aid preventive efforts. A simple educational intervention resulted in significant improvements in CVD awareness, even after 3 weeks.

Evaluating Social Determinants of Health Variables in Advanced Analytic and Artificial Intelligence Models for Cardiovascular Disease Risk and Outcomes: A Targeted Review

Introduction/Purpose

Predictive models incorporating relevant clinical and social features can provide meaningful insights into complex interrelated mechanisms of cardiovascular disease (CVD) risk and progression and the influence of environmental exposures on adverse outcomes. The purpose of this targeted review (2018-2019) was to examine the extent to which present-day advanced analytics, artificial intelligence, and machine learning models include relevant variables to address potential biases that inform care, treatment, resource allocation, and management of patients with CVD.

Methods

PubMed literature was searched using the prespecified inclusion and exclusion criteria to identify and critically evaluate primary studies published in English that reported on predictive models for CVD, associated risks, progression, and outcomes in the general adult population in North America. Studies were then assessed for inclusion of relevant social variables in the model construction. Two independent reviewers screened articles for eligibility. Primary and secondary independent reviewers extracted information from each full-text article for analysis. Disagreements were resolved with a third reviewer and iterative screening rounds to establish consensus. Cohen's kappa was used to determine interrater reliability.

Results

The review yielded 533 unique records where 35 met the inclusion criteria. Studies used advanced statistical and machine learning methods to predict CVD risk (10, 29%), mortality (19, 54%), survival (7, 20%), complication (10, 29%), disease progression (6, 17%), functional outcomes (4, 11%), and disposition (2, 6%). Most studies incorporated age (34, 97%), sex (34, 97%), comorbid conditions (32, 91%), and behavioral risk factor (28, 80%) variables. Race or ethnicity (23, 66%) and social variables, such as education (3, 9%) were less frequently observed.

Conclusions

Predictive models should adjust for race and social predictor variables, where relevant, to improve model accuracy and to inform more equitable interventions and decision making.

Development and External Validation of Nomogram to Identify Risk Factors for CHD in T2DM in the Population of Northwestern China

Purpose

Cardiovascular disease is the leading cause of mortality in patients with type 2 diabetes mellitus (T2DM). This study aimed to develop and validate a nomogram for predicting the risk factors for coronary heart disease (CHD) in T2DM in the population of northwestern China.

Patients and Methods

The records of 2357 T2DM patients who were treated in the First Affiliated Hospital of Xinjiang Medical University from July 2021 to July 2022 were reviewed. After some data (n =239) were excluded, 2118 participants were included in the study and randomly divided into a training set (n =1483) and a validation set (n = 635) at a ratio of 3:1. Univariate and stepwise regression analysis was performed to screen risk factors and develop predictive models. The results of logistic regression are presented through a nomogram. The C-index, receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) were employed to verify the distinction, calibration, and clinical practicality of the model.

Results

The stepwise logistic regression analysis suggested that independent factors in patients with T2DM combined with CHD were age, gender, hypertension (HTN), glycated hemoglobin (HbA1c), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and Uygur, which were associated with the occurrence of CHD. The nomogram demonstrated good discrimination with a C-index of 0.771 (95% CI, 0.741, 0.800) in the training set and 0.785 (95% CI, 0.743, 0.828) in the validation set. The area under curve (AUC) of the ROC curves were 0.771 (95% CI, 0.741, 0.800) and 0.785 (95% CI, 0.743, 0.828) in the training and validation sets, respectively. The nomogram was well-calibrated. The DCA revealed that the nomogram was clinically valuable.

Conclusion

A nomogram based on 7 clinical characteristics was developed to predict CHD in patients with T2DM.

The Relationship Between the Incidence of Coronary Heart Disease and Ethnic Minorities

The study aimed at the determination of risk factors, their relationship with the development of stenosing lesions of the coronary arteries in different ethnic groups in Kazakhstan.

Primary coronary angiographies of n=640 patients diagnosed with coronary heart disease (CHD) (2017-2019) have been analysed (Almaty, Kazakhstan). The patients were subdivided into: Kazakhs (n=338) and Russians (n=302).

In the Russian group, the chance of arterial hypertension incidence was higher (44% and 33%, p<0.05). In the Russian group, the percentage of obstructive CHD was higher than in the Kazakhs (66% and 57%, p<0.05). There was association between obstructive CHD and risk factors such as male sex, diabetes, smoking, and diastolic blood pressure (DBP) in the Kazakhs (p<0.05). In the Russian group, the relationship between development of CHD and age, level of total cholesterol and high-density lipoprotein (HDL) was higher (p<0.05). There is an association between smoking, diabetes, sex, DBP and the development of CHD in Kazakhs. In the Russian group, CHD was associated with risk factors such as older age, dyslipidaemia and arterial hypertension.

There were significant ethnic differences in the risk factors and CHD, in the Russian group the probability of development of obstructive CHD was higher. There was an association between smoking, diabetes, sex, DBP and the development of CHD in Kazakhs. In the Russian group, CHD was associated with risk factors such as older age, dyslipidaemia and arterial hypertension. These finding indicate the need to develop differentiated programmes for the screening, preventive measures for different ethnic groups.

Performance of the pooled cohort equation in South Asians: insights from a large integrated healthcare delivery system

South Asian ethnicity is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk and has been identified as a "risk enhancer" in the 2018 American College of Cardiology/American Heart Association Guidelines. Risk estimation and statin eligibility in South Asians is not well understood; we studied the accuracy of 10-years ASCVD risk prediction by the pooled cohort equation (PCE), based on statin use, in a South Asian cohort. This is a retrospective cohort study of Kaiser Permanente Northern California South Asian members without existing ASCVD, age range 30-70, and 10-years follow up. ASCVD events were defined as myocardial infarction, ischemic stroke, and cardiovascular death. The cohort was stratified by statin use during the study period: never; at baseline and during follow-up; and only during follow-up. Predicted probability of ASCVD, using the PCE was calculated and compared to observed ASCVD events for low < 5.0%, borderline 5.0 to < 7.5%, intermediate 7.5 to < 20.0%, and high ≥ 20.0% risk groups. A total of 1835 South Asian members were included: 773 never on statin, 374 on statins at baseline and follow-up, and 688 on statins during follow-up only. ASCVD risk was underestimated by the PCE in low-risk groups: entire cohort: 1.8 versus 4.9%, p < 0.0001; on statin at baseline and follow-up: 2.58 versus 8.43%, p < 0.0001; on statin during follow-up only: 2.18 versus 7.77%, p < 0.0001; and never on statin: 1.37 versus 2.09%, p = 0.12. In this South Asian cohort, the PCE underestimated risk in South Asians, regardless of statin use, in the low risk ASCVD risk category.

Were US Asian Indian decedents with atherosclerosis more likely to have concurrent diabetes mellitus? Analysis of national multiple cause of mortality data (2012-2019)

BACKGROUND

Asian Indians (AI) are at high risk for both atherosclerotic diseases (ATH) and diabetes mellitus (DM). We analyze the clustering of these two comorbidities as contributing causes of death in AI versus Non-AI populations in the US.

METHODS

Using Mortality Multiple Cause-of-Death Files (2012-2019) from the National Center for Health Statistics, we included deaths at age ≥ 45 years among US residents where AI versus Non-AI status could be ascertained (n = 55,461 AI; n = 20,090,038 Non-AI) and identsified ATH (ICD10: I20-I25, I63, I70) and DM (ICD10: E10-E14) as contributing causes of death. We calculated the tetrachoric correlation (Rho) between these contributing causes and the difference in the fraction of deaths involving DM in those with versus without ATH.

RESULTS

Among AI decedents, 29.9% of deaths included ATH as a contributing cause, 16.4% included DM as a contributing cause with 8.3% deaths being included in the overlap (Rho = 0.36, SE = 0.007) whereas, among Non-AI, 22.4% of deaths included ATH as a contributing cause, 10.0% included DM as a contributing cause with 4.1% deaths being included in the overlap (Rho = 0.31, SE = 0.001). Thus, DM and ATH as co-occurring causes correlated more strongly in AI versus Non-AI (p < 0.001). Further, this difference in clustering of DM with ATH was highest for younger AI women (age < 60 years) compared to comparable Non-AI women.

CONCLUSIONS

The more frequent co-occurrence of DM and ATH as causes of death among AI compared to Non-AI suggest that the increased burden of these diseases among AI during life has vicious synergistic consequences in terms of mortality. Public health strategies targeted to AI should focus on prevention and clinical treatment of both conditions jointly, in all adults, and especially in women < 60 years.

Ethnic differences between South Asians and White Caucasians in cardiovascular disease-related mortality in developed countries: a systematic literature review

BACKGROUND

Cardiovascular disease is the leading cause of death worldwide, with significantly worse mortality-related outcomes in ethnic minorities in developed countries. A systematic literature review and meta-analysis of observational studies was conducted to investigate cardiovascular disease-related mortality inequalities between South Asian and White Caucasian ethnic groups.

METHODS

Published studies on mortality between South Asians and Whites in developed countries were retrieved from MEDLINE, PubMed, Embase, Web of Science, and grey literature sources (inception-April 2021) and critically appraised using the Quality in Prognosis Studies tool. Bayesian random-effects meta-analyses were performed for both primary and secondary outcomes. Heterogeneity was determined using the I² statistic.

RESULTS

Of the 9879 studies screened originally, 41 were deemed eligible. A further 3 studies were included via the later search. Of these, 15 reported cardiovascular disease-related mortality, 23 reported all-cause mortality, and 6 reported both. The meta-analysis results showed that South Asians had a significantly increased risk of cardiovascular disease mortality compared to Whites (risk ratio = 1.32; 95% credible interval = 1.14 to 1.54) and a decreased risk of all-cause mortality (risk ratio = 0.95; 95% credible interval = 0.83 to 1.12).

DISCUSSION

South Asians had statistically significantly higher odds of cardiovascular disease-related mortality compared to Whites, but not for all-cause mortality. Risk of bias was a serious concern mainly due to a lack of confounders being reported.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42021240865.

Do obesity, hypertension and dyslipidemia pose significant risks for coronary artery disease among Bangladeshi diabetics?

Background and objectives: For decades the global population has been experiencing diabetic epidemic. The risks related to obesity, diabetes mellitus (DM) and coronary artery diseases (CAD) are well known. This study aimed to assess the prevalence of coronary artery disease (CAD) and its related risks in Bangladeshi diabetics. Materials and methods: The study was conducted at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), a largest referral center for diabetes in Bangladesh. Socio-demographic and clinical history including biochemical investigation report were collected from the BIRDEM registry. The eligible criteria of study participants were: age 30 – 60 year, having DM, non-smoker, free from retinopathy, nephropathy and neuropathy. The prevalence of CAD, systolic hypertension (SHTN) and diastolic hypertension (DHTN) in the registered diabetic patients were estimated. Additionally, the study addressed the risk and predictors of CAD among those with DM. Investigations included – anthropometry, blood pressure, blood glucose, serum lipids and electrocardiogram (ECG). CAD was diagnosed on: (a) history of angina plus positive ECG - either on rest or on stress, post-myocardial infarction (MI) with Q-wave MI or non-Q-MI or echocardiographic evidences. Lipids namely triglycerides (TG), total cholesterol (T-Chol), high density lipoproteins (HDL) and low-density lipoproteins (LDL) were estimated by Hitachi-704 auto-analyzer using enzymatic method. Results: A total of 693 (M /W =295/398) participants volunteered. The prevalence of CAD, SHTN, DHTN and mean arterial hypertension (MAH) were 18.6%, 23.2%, 13.6% and 17.7%, respectively. Their mean (±SD) values of age, body mass index (BMI - kg/m2), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and mean arterial pressure (MAP) were 47 (8.6) years, 24.6 (3.5), 0.98(0.05), 0.56(0.06) and 101(11.3) mmHg, respectively. The mean (±SD) of FBG (mmol/L), T-Chol, TG and HDL (mg/dl) were 10.2 ± 4.0, 206 ± 44, 218 ± 86 and 47.5 ± 9.3 respectively. The women had significantly higher BMI (p<0.001), WHtR (p<0.001), SBP (<0.001), MAP (p<0.001), T-Chol (p<0.001) and TG (p=0.043) than men. The risk variables were categorized into quartiles and Chi-sq trend determined whether the increasing prevalence of CAD were significant. Higher quartile of age was found consistently significant (p<0.001). Of the obesity indices, only higher quartile of WHtR was significant (p< 0.05). For BP measures, higher MAP quartiles showed the trend significant (p<0.001). Likewise, for lipids, higher quartiles of TG (p<0.001) and lower quartile of HDL (p<0.001) were significant. Finally, logistic regression estimated the risk related to CAD. The highest age-quintile (>55y: 95% CI: 1.09 - 43.7) and highest TG-quintile (281mg/dl: 95% CI: 1.45-59.7) were proved to be significant predictor of CAD and HDL highest quintile (>54mg/dl) was proved to be significant protecting factor for CAD (95% CI: 0.005-0.583). Conclusion: The study observed the importance of MAP, TG, HDL, T-Chol/HDLR (T-Chol -to HDL ratio) and TG/HDLR (triglycerides-to HDL ratio) as risks for CAD among diabetics. Further study with investigations of echocardiogram, ETT, coronary angiogram and coronary calcium scoring would be helpful in confirming these findings related to CAD risks. IMC J Med Sci. 2023; 17(1): 002. DOI: https://doi.org/10.55010/imcjms.17.002 *Correspondence: M Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A, Ibrahim Sarani, Segunbagicha, Dhaka 1000, Bangladesh. Email: sayeed1950@gmail.com

A need for diet assessment technology for South Asians living in the USA

South Asians are among the fastest growing ethnic group in the USA yet remain understudied in epidemiologic studies. Due to their unique disease profile, identifying risk moderators and mitigators, such as dietary patterns and food intake, will help to determine the diet-disease relationship that is specific to this largely immigrant population group in the USA. The aim of this commentary is to highlight the dietary traditions and acculturated practices experienced by South Asians in the USA with a call for a diet assessment instrument that adequately captures their dietary diversity. Specifically, we call for (i) the inclusion of traditional food items, such as herbs and spices, that individualize diet assessment for participants; and (ii) leveraging technology that will enhance the experience of diet assessment for both researchers and participants, tailoring the collection of habitual dietary intake in this diverse population group.

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

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

Generation 1.5: Years in the United States and Other Factors Affecting Smoking Behaviors Among Asian Americans

Introduction

Generation 1.5, immigrants who moved to a different country before adulthood, are hypothesized to have unique cognitive and behavioral patterns. We examined the possible differences in cigarette smoking between Asian subpopulations who arrived in the United States at different life stages.

Methods

Using the Asian subsample of the 2015 Tobacco Use Supplement to the Current Population Survey, we tested this Generation 1.5 hypothesis with their smoking behavior. This dataset was chosen because its large sample size allowed for a national-level analysis of the Asian subsamples by sex, while other national datasets might not have adequate sample sizes for analysis of these subpopulations. The outcome variable was defined as whether the survey respondent had ever smoked 100 cigarettes or more, with the key independent variable operationalized as whether the respondent was: 1) born in the United States; 2) entered the United States before 12; 3) entered between 12 and 19; and 4) entered after 19. Logistic regressions were run to examine the associations with covariates including the respondent's age, educational attainment, and household income.

Results

Asian men who entered before 12 were less likely to have ever smoked 100 cigarettes than those who immigrated after 19; for Asian women, three groups (born in the United States, entered before 12, entered between 12 and 19) were more likely to have smoked 100 cigarettes than those who immigrated after 19.

Conclusions

While Asian men who came to the United States before 12 were less at risk for cigarette smoking than those who immigrated in adulthood, the pattern was the opposite among Asian women. Those who spent their childhood in the United States were more likely to smoke than those who came to the United States in adulthood. These patterns might result from the cultural differences between US and Asian countries, and bear policy relevance for the tobacco control efforts among Asian Americans.

Cardiovascular Disease in South Asian Immigrants: a Review of Dysfunctional HDL as a Potential Marker

South Asians (SAs) account for a quarter of the world's population and are one of the fastest-growing immigrant groups in the United States (US). South Asian Immigrants (SAIs) are disproportionately more at risk of developing cardiovascular disease (CVD) than other ethnic/racial groups. Atherosclerosis is a chronic inflammatory disorder and is the major cause of CVD. Traditional CVD risk factors, though important, do not fully explain the elevated risk of CVD in SAIs. High-density lipoproteins (HDLs) are heterogeneous lipoproteins that modify their composition and functionality depending on physiological or pathological conditions. With its cholesterol efflux, anti-inflammatory, and antioxidant functions, HDL is traditionally considered a protective factor for CVD. However, its functions can be compromised under pathological conditions, such as chronic inflammation, making it dysfunctional (Dys-HDL). SAIs have a high prevalence of type 2 diabetes and metabolic syndrome, which may further promote Dys-HDL. This review explores the potential association between Dys-HDL and CVD in SAIs and presents current literature discussing the role of Dys-HDL in CVD.

Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

An Embedded System Using Convolutional Neural Network Model for Online and Real-Time ECG Signal Classification and Prediction

This paper presents an automatic ECG signal classification system that applied the Deep Learning (DL) model to classify four types of ECG signals. In the first part of our work, we present the model development. Four different classes of ECG signals from the PhysioNet open-source database were selected and used. This preliminary study used a Deep Learning (DL) technique namely Convolutional Neural Network (CNN) to classify and predict the ECG signals from four different classes: normal, sudden death, arrhythmia, and supraventricular arrhythmia. The classification and prediction process includes pulse extraction, image reshaping, training dataset, and testing process. In general, the training accuracy achieved up to 95% after 100 epochs. However, the prediction of each ECG single type shows a differentiation. Among the four classes, the results show that the predictions for sudden death ECG waveforms are the highest, i.e., 80 out of 80 samples are correct (100% accuracy). In contrast, the lowest is the prediction for normal sinus ECG waveforms, i.e., 74 out of 80 samples are correct (92.5% accuracy). This is due to the image features of normal sinus ECG waveforms being almost similar to the image features of supraventricular arrhythmia ECG waveforms. However, the model has been tuned to achieve an optimal prediction. In the second part, we presented the hardware implementation with the predictive model embedded in an NVIDIA Jetson Nanoprocessor for the online and real-time classification of ECG waveforms.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

HDL associates with insulin resistance and beta-cell dysfunction in South Asian families at risk of type 2 diabetes

OBJECTIVE

Dyslipidemia precedes type 2 diabetes (T2D) and worsens with increasing glucose intolerance. First degree relatives of T2D patients have an increased risk to develop dyslipidemia and glucose intolerance. The aim of the present study was to assess the relation between the development of dyslipidemia and glucose intolerance in first-degree relatives of T2D patients.

RESEARCH DESIGN AND METHODS

Fasting lipoprotein profiles were determined by density gradient ultracentrifugation in T2D patients and their first-degree relatives (42 Caucasians and 33 South Asians), and in 29 normoglycemic controls from non-T2D families. Glucose tolerance, insulin sensitivity index (ISI) and insulin disposition index (DI) were assessed by an extended, frequently sampled oral glucose tolerance test (OGTT), and fractional insulin synthesis rate (FSR) was measured by ¹³C-leucine enrichment in urinary C-peptide during the OGTT.

RESULTS

Of the first-degree relatives, 40, 16 and 19 had NGT, prediabetes and T2D, respectively. NGT family members had lower plasma HDL-cholesterol (HDLC) (1.34 ± 0.07 vs 1.58 ± 0.06 mmol/L; p = 0.015), HDL₂-C (0.41 ± 0.05 vs 0.57 ± 0.05 mmol/L; p = 0.021) and HDL₃-C (0.62 ± 0.03 vs 0.72 ± 0.02 mmol/L; p = 0.043) than controls. HDL₂-C levels tended to decrease with increasing glucose intolerance state. In South Asians, buoyant LDL-C levels decreased with increasing glucose intolerance state (p = 0.006). In South Asian families, HDL-C correlated with both ISI and DI (β 0.42; p = 0.04 and β 0.53; p = 0.01, respectively), whereas HDL₂-C and HDL₃-C levels correlated with DI (β 0.64; p = 0.002 and β 0.57; p = 0.005, respectively). HDL₂-C and plasma triglyceride correlated with FSR (β 0.48; p = 0.033 and β -0.50; p = 0.029, respectively).

CONCLUSIONS

Low HDL₂-C and HDL₃-C levels are present in NGT first-degree relatives of T2D patients, and HDL₂-C tend to decrease further with increasing glucose intolerance. In South Asian families HDL₂-C and HDL₃-C levels linked predominantly to deteriorating beta cell function.

Heterogeneity in cardio-metabolic risk factors and atherosclerotic cardiovascular disease among Asian groups in the United States

OBJECTIVE

The Asian American population in the U.S. comprises various, ethnically diverse subgroups. Traditionally, this population has been studied as a single, aggregated group, potentially masking differences in risk among subgroups. Analyses using disaggregated data can help better characterize the health needs of different Asian subpopulations and inform targeted, effective public health interventions. We assessed the prevalence of cardiovascular disease (CVD) risk factors and atherosclerotic CVD (ASCVD) and their associations with socioeconomic factors among Chinese, Asian Indian, Filipino and Other Asian subjects, compared with non-Hispanic White (NHW) subjects in the U.S.

METHODS

: Cross-sectional study using data from 298,286 adults from the National Health Interview Survey (NHIS) from 2007 to 2018. We utilized chi-squared tests to compare characteristics across subgroups. Weighted proportions and unadjusted and adjusted logistic regression models were utilized to examine the associations between Asian subgroups, self-reported CVD risk factors and self-reported ASCVD, as well as between socioeconomic factors within each Asian subgroup.

RESULTS

: Asian Indian subjects had the highest prevalence of diabetes (12.5%), while Filipino subjects had the highest prevalence of hyperlipidemia (27.7%), hypertension (29.8%) and obesity (19.8%). Despite this, the prevalence of self-reported ASCVD was lower in all Asian groups compared with NHWs. Chinese subjects had the lowest odds of having each of the CVD risk factors assessed.

CONCLUSION

: We found considerable heterogeneity in the distribution of risk factors as well as ASCVD among Asian subgroups in the US. Compared with health system or community-based reports, the prevalence of risk factors and ASCVD may be underestimated in some Asian NHIS subgroups. There is an urgent need for efforts to improve recruitment of Asian participants of heterogeneous socioeconomic backgrounds in national surveys, as well as to perform a thorough assessment of risk factors and disease in this population, not relying solely on self-report.

Distribution of calcium volume, density, number, and type of coronary vessel with calcified plaque in South Asians in the US and other race/ethnic groups: The MASALA and MESA studies

BACKGROUND AND AIMS

South Asians (SA) experience disproportionately higher rates of atherosclerotic cardiovascular disease (ASCVD) events than non-Hispanic whites (NHW) and several other Asian groups. The coronary artery calcium (CAC) Agatston score may not capture the unique characteristics of coronary plaque in SA. We therefore evaluated the prevalence and patterns of advanced CAC measures (specific coronary vessel involvement, CAC volume and density) in SA versus other race/ethnicities.

METHODS

We combined data from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) and Multi-Ethnic Study of Atherosclerosis (MESA) cohorts. We used multivariable-adjusted linear regression models to compare advanced CAC measures between SA and other ethnicities.

RESULTS

Our analyses included 7,625 individuals (810 SA, 2,622 whites, 1,893 African Americans, 1,496 Hispanics, 803 Chinese Americans) with mean (SD) age 62 (10) years and 48% men. In adjusted analyses, compared to NHW, SA had lower overall CAC volume [beta coefficient (95% CI)] [-0.46 (-0.62,-0.29)] but higher overall CAC density [0.14 (0.11,0.18)]. These trends were similar when SA were compared to non-whites (Hispanics, Chinese Americans, and African Americans). SA had higher overall [0.07 (0.03,0.12)] and right coronary artery [0.09 (0.03,0.16)] CAC density compared to non-whites, while CAC volume was not significantly different between these two groups.

CONCLUSIONS

SA have lower CAC volume compared to NHW but similar compared to non-whites. Overall CAC density is higher among SA compared to NHW and non-whites. Future longitudinal studies of ASCVD events are required to confirm the prognostic significance of these findings among SA.