Comparison of fatal coronary heart disease occurrence based on population surveys in Japan and the USA

Association between dietary inflammatory index and serum C-reactive protein concentrations in the Japan Collaborative Cohort Study

Diet plays an important role in the regulation of chronic inflammation, which is linked to cardiovascular disease (CVD) and several cancers. The dietary inflammatory index (DII^®) was developed to estimate the inflammatory potential of an individual’s diet. We examined the association between DII scores and serum high-sensitivity C-reactive protein (hs-CRP) concentrations using the baseline data from the Japan Collaborative Cohort Study (JACC Study). Data were from 1176 control subjects (650 men and 526 women) in a nested case-control study of several cancers and CVD in the JACC Study who were free of cancer and CVD at baseline. DII scores were calculated from 26 food parameters that were derived from a validated food frequency questionnaire administered at the baseline. Energy-adjusted DII scores were calculated using the residual method. Serum hs-CRP concentrations were measured by latex-enhanced nephelometry or enzyme-immunoassay. In multivariable logistic regression analysis adjusting for potential confounders including sex, age, smoking habits, drinking habits, body mass index, and history of hypertension, the odds ratio (OR) and 95% confidence intervals (CI) for high serum hs-CRP concentrations (>1.0 mg/L) was significantly higher in the highest versus the lowest DII quartile (OR_Quartile4vs1 = 1.32, 95% CI = 1.01 to 2.52). Likewise, a 1-point increase in DII score was associated with a 14% increased risk of high serum hs-CRP concentrations (OR_Continuous = 1.09, 95%CI = 1.01 to 1.19). A pro-inflammatory diet, as represented by high DII scores, was associated with high serum hs-CRP concentrations in this Japanese population.

Impact of Major Cardiovascular Risk Factors on the Incidence of Cardiovascular Disease among Overweight and Non-Overweight Individuals: The Circulatory Risk in Communities Study (CIRCS)

Aim: We aimed to examine the impact of high-risk levels of cardiovascular risk factors on the incidence of cardiovascular disease (CVD) in overweight and non-overweight individuals without treatment for the risk factors.

Methods: A total of 8,051 individuals aged 40–74 years without a history of CVD and/or without treatment for hypertension, diabetes, hyperlipidemia, and kidney disease at baseline in 1995–2000 were followed up for a median of 14.1 years. We classified the participants into three risk categories (low-, intermediate-, and high-risk groups) on the basis of individual risk factors (blood pressure, serum glucose, low-density lipoprotein cholesterol [LDL-C], and urinary protein) according to the guidelines of Japanese clinical societies. The high-risk group (systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 100 mmHg, fasting serum glucose ≥ 130 mg/dL or non-fasting serum glucose ≥ 180 mg/dL, LDL-C ≥ 180 mg/dL, proteinuria ≥ 2+) needed to refer to physicians or start treatment immediately. Overweight was defined as a body mass index of ≥ 25 kg/m ² .

Results: Compared with those in the non-overweight low-risk group, the hazard ratios (HRs) (95% confidence intervals, population-attributable fractions [PAFs]) of CVD in the high-risk categories of blood pressure were 2.0 (1.4–2.9, 7.0%) in the non-overweight high-risk group and 2.9 (1.9–4.3, 6.8%) in the overweight high-risk group. The corresponding HRs (95% confidence intervals, PAFs) of serum glucose were 2.0 (1.2–3.4, 2.5%) and 2.2 (1.1–4.3, 1.5%) in the non-overweight and overweight high-risk groups, respectively. Such associations were not observed for the high-risk group of LDL-C and proteinuria.

Conclusions: The present long-term observational study implies that targeting persons with non-treated severe hypertension and diabetes is prioritized to prevent CVD regardless of overweight status.

Relationship between non-fasting triglycerides and cardiovascular disease mortality in a 20-year follow-up study of a Japanese general population: NIPPON DATA90

Background

Non-fasting triglycerides (TG) are considered a better predictor of cardiovascular disease (CVD) than fasting TG. However, the effect of non-fasting TG on fatal CVD events remains unclear. In the present study, we aimed to explore the relationship between non-fasting TG and CVD mortality in a Japanese general population.

Methods

A total of 6,831 participants without a history of CVD, in which those who had a blood sampling over 8 hours or more after a meal were excluded, were followed for 18.0 years. We divided participants into seven groups according to non-fasting TG levels: ≤59 mg/dL, 60–89 mg/dL, 90–119 mg/dL, 120–149 mg/dL, 150–179 mg/dL, 180–209 mg/dL, and ≥210 mg/dL, and estimated the multivariable-adjusted hazard ratios (HRs) of each TG group for CVD mortality after adjusting for potential confounders, including high density lipoprotein cholesterol. Additionally, we performed analysis stratified by age <65 and ≥65 years.

Results

During the follow-up period, 433 deaths due to CVD were detected. Compared with a non-fasting TG of 150–179 mg/dL, non-fasting TG ≥210 mg/dL was significantly associated with increased risk for CVD mortality (HR 1.56: 95% CI, 1.01–2.41). Additionally, lower levels of non-fasting TG were also significantly associated with increased risk for fatal CVD. In participants aged ≥65 years, lower levels of non-fasting TG had a stronger impact on increased risk for CVD mortality, while higher levels of non-fasting TG had a stronger impact in those aged <65 years.

Conclusion

In a general Japanese population, we observed a U-shaped association between non-fasting TG and fatal CVD events.

Cause-specific mortality rates in patients with diabetes according to comorbid macro- and microvascular complications: BioBank Japan Cohort

Objective

This study aimed to compare cause-specific mortality rates in patients with type 2 diabetes with and without various vascular complications.

Methods

In Japanese hospitals, we followed up 30 834 patients with a mean age of 64.4 (standard deviation [SD]: 11.1) years. Patients were followed up from 2003 to 2007 for a median of 7.5 (interquartile range: 6.1-9.7) years. We calculated cause-specific mortality rates (number of deaths/1000 person-years) and confounder-adjusted hazard ratios in patients with macrovascular disease and in those with diabetic nephropathy, neuropathy and retinopathy, allowing for overlap of complications.

Results

All-cause mortality rate was highest (51.4) in the nephropathy group, followed by the macrovascular disease group (45.2), the neuropathy group (39.5), the retinopathy group (38.7) and the nonvascular complication group (18.1). In the nephropathy group, morality rates of ischaemic heart, cerebrovascular, and infectious diseases and cancer were also highest among the groups. However, the cancer mortality rate was similar among the vascular complication groups. Relative to the nonvascular complication group, covariate-adjusted hazard ratios for ischaemic heart and cerebrovascular disease mortality were triple to quadruple in the macro- and microvascular complication groups. All-cause mortality rates rose exponentially according to age.

Conclusion

Highest risks of all-cause, cancer, and ischaemic heart, infectious, and cerebrovascular disease mortality were determined in Japanese patients with diabetic nephropathy. Although cancer is the primary cause of death in Japanese patients with diabetes, cancer mortality rates are similar among those with and without vascular complications.

Associations of Overweight, Obesity, and Underweight With High Serum Total Cholesterol Level Over 30 Years Among the Japanese Elderly: NIPPON DATA 80, 90, and 2010

Background

The trend of association between overweight and high serum total cholesterol (TC) among the elderly is unclear. In addition, there is little evidence of risk of underweight for high TC. Therefore, we examined the trend of association of overweight or underweight with high TC among Japanese elderly people using nationwide population-based data.

Methods

Data of the National Survey on Circulatory Disorders and National Health and Nutrition Survey for 1980, 1990, 2000, and 2010 were used in the analysis. High TC was defined as 220 mg/dL and above. For participants aged ≥50 years, sex-specific odds ratios (ORs) of overweight or underweight compared with normal body mass index participants for high TC were calculated using a logistic regression model adjusted for age, smoking, drinking, exercise, food, and treatment of hyperlipidemia.

Results

A total of 5,734, 4,673, 5,059, and 2,105 participants enrolled in these surveys in 1980, 1990, 2000, and 2010, respectively. Although overweight was positively and significantly associated with high TC in 1980, the association has gradually weakened since (ORs in 1980 and 2010 were 2.44; 95% confidence interval [CI], 1.83–3.24 and 0.92; 95% CI, 0.66–1.27 among men and 1.43; 95% CI, 1.18–1.72 and 1.08; 95% CI, 0.81–1.44 among women, respectively). While underweight was inversely and significantly associated with high TC in 1980, the association also gradually weakened among women (ORs in 1980 and 2010 were 0.28; 95% CI, 0.12–0.60 and 0.37; 95% CI, 0.10–1.28 among men and 0.39; 95% CI, 0.26–0.57 and 0.96; 95% CI, 0.58–1.57 among women, respectively).

Conclusions

These findings provide evidence that high TC prevention efforts must expand the target to not only overweight but also to normal and underweight people.

Efficacy and Safety of Pitavastatin in Children and Adolescents with Familial Hypercholesterolemia in Japan and Europe

Aim: Children with Familial Hypercholesterolemia (FH) are widely prescribed statins, and it has been suggested that the effects of statins differ among ethnicities. We compared the efficacy and safety of pitavastatin in children and adolescents with FH in clinical trials conducted in Japan and Europe.

Methods: Low-density lipoprotein cholesterol (LDL-C) reductions, adjusted for confounding factors, and safety were compared between the studies in Japan and Europe. In the Japanese study, 14 males with heterozygous FH, aged 11.8 ± 1.6 years, were randomized to 52-week double-blind treatment with 1 or 2 mg/day pitavastatin. In the European study, 106 children and adolescents with high risk hyperlipidemia (103 heterozygous FH), aged 10.6 ± 2.9 years, were randomized to 12-week double-blind treatment with 1, 2 or 4 mg/day pitavastatin or placebo; 84 of these patients and 29 new patients participated in a 52-week open-label extension study.

Results: Age, body weight and baseline LDL-C were identified as factors influencing LDL-C reduction. There were no significant differences in the adjusted mean percentage reduction in LDL-C in Japanese and European children by pitavastatin (24.5% and 23.6%, respectively at 1 mg/day and 33.5% and 30.8%, respectively at 2 mg/day). Pitavastatin was well tolerated without any difference in the frequency or nature of adverse events between the treatment groups, or between the studies.

Conclusion: There were no significant differences between the efficacy or safety of pitavastatin in Japanese and European children and adolescents with FH, suggesting no relevant ethnic differences in the safety or efficacy of pitavastatin.

Association of high-density lipoprotein cholesterol concentration with different types of stroke and coronary heart disease: The Japan Public Health Center-based prospective (JPHC) study

BACKGROUND AND AIMS

Although low high-density lipoprotein (HDL) cholesterol concentration is an established risk factor for coronary heart disease (CHD), information regarding subtypes of stroke is very limited, especially in Asian populations.

METHODS

A prospective study was conducted among 30,736 individuals aged 40-69 years, who lived in nine communities in Japan and did not have a history of cardiovascular disease (CVD). CHD and stroke, including its subtypes, were assessed, and sex-specific hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes were estimated according to quintiles of HDL cholesterol using Cox proportional models adjusted for other CVD risk factors.

RESULTS

We identified 296 CHD and 1712 stroke events over a median 15 yr of follow-up. HDL cholesterol concentration showed an inverse association with CHD in men and women. A low HDL cholesterol concentration slightly raised the risk for total strokes in men, but not in women. When analyzed by subtypes, we observed an inverse relationship between HDL cholesterol concentration and the incidence of lacunar infarction, with an adjusted HR for the lowest quintile of HDL cholesterol concentration compared with the highest quintile of 1.63 (95% CI, 1.00-2.66) in men and 1.97 (95% CI, 1.19-3.26) in women. HDL cholesterol concentration was positively associated with the risk of intracerebral hemorrhage (ICH) in a linear manner in women (p for trend = 0.028), but not in men.

CONCLUSIONS

The associations of HDL cholesterol concentration with lacunar infarction and ICH may be related to different functional properties of HDL rather than to its protective function against lipid-rich atherosclerosis.

Significant association of RNF213 p.R4810K, a moyamoya susceptibility variant, with coronary artery disease

Background

The genetic architecture of coronary artery disease has not been fully elucidated, especially in Asian countries. Moyamoya disease is a progressive cerebrovascular disease that is reported to be complicated by coronary artery disease. Because most Japanese patients with moyamoya disease carry the p.R4810K variant of the ring finger 213 gene (RNF213), this may also be a risk factor for coronary artery disease; however, this possibility has never been tested.

Methods and results

We genotyped the RNF213 p.R4810K variant in 956 coronary artery disease patients and 716 controls and tested the association between p.R4810K and coronary artery disease. We also validated the association in an independent population of 311 coronary artery disease patients and 494 controls. In the replication study, the p.R4810K genotypes were imputed from genome-wide genotyping data based on the 1000 Genomes Project. We used multivariate logistic regression analyses to adjust for well-known risk factors such as dyslipidemia and smoking habits. In the primary study population, the frequency of the minor variant allele was significantly higher in patients with coronary artery disease than in controls (2.04% vs. 0.98%), with an odds ratio of 2.11 (p = 0.017). Under a dominant model, after adjustment for risk factors, the association remained significant, with an odds ratio of 2.90 (95% confidence interval: 1.37–6.61; p = 0.005). In the replication study, the association was significant after adjustment for age and sex (odds ratio = 4.99; 95% confidence interval: 1.16–21.53; p = 0.031), although it did not reach statistical significance when further adjusted for risk factors (odds ratio = 3.82; 95% confidence interval: 0.87–16.77; p = 0.076).

Conclusions

The RNF213 p.R4810K variant appears to be significantly associated with coronary artery disease in the Japanese population.

Impacts of chronic kidney disease and diabetes on cardiovascular mortality in a general Japanese population: A 20-year follow-up of the NIPPON DATA90 study

Background Studies have shown significant associations of chronic kidney disease (CKD) and diabetes mellitus (DM) with cardiovascular disease (CVD) mortality. The impact on the general population is an important public health issue. However, the population attributable fraction (PAF) of CVD because of CKD and/or DM in a general population is uncertain. Methods We followed 7229 participants (age: ≥30 years) with no history of CVD in a Japanese community. We divided participants into four categories according to CKD and/or DM and calculated hazard ratios (HRs) of CVD mortality for each category using a Cox proportional hazards model adjusted for age, dyslipidemia, smoking and alcohol consumption. In addition, PAFs of CVD were estimated among populations with CKD and/or DM. Results During 20-year follow-up, 488 participants died. HRs for CVD were 1.63 [95% confidence interval (CI): 1.16-2.30] with DM only, 1.42 (95% CI: 1.08-1.86) with CKD only and 2.37 (95% CI: 1.40-4.01) with CKD + DM. In men, the corresponding HRs for CVD were 1.88 (95% CI: 1.19-2.97), 1.71 (95% CI: 1.15-2.56) and 3.26 (95% CI: 1.69-6.30), respectively; the corresponding PAFs of CVD were 4.1%, 5.1% and 2.9%, respectively. PAFs for CVD among women were lower than those in men, 1.6% for DM only, 2.0% for CKD only and 0.7% for CKD + DM. Conclusions PAFs of CVD mortality due to CKD and/or DM were not so high in past 20 years; however, they might increase in the future because of recent increase in prevalence of these in Japanese population.

The Relationship between Very High Levels of Serum High-Density Lipoprotein Cholesterol and Cause-Specific Mortality in a 20-Year Follow-Up Study of Japanese General Population

AIMS

There is no community-based cohort study to examine the effect of very high level of high-density lipoprotein cholesterol (HDL-C) on coronary heart disease (CHD) and other cause-specific mortality. Therefore, we investigated the relationship between HDL-C including very high level and cause-specific mortality in a 20-year cohort study of the representative sample of Japanese.

METHODS

We followed 7,019 individuals from the Japanese general population (2,946 men and 4,073 women). We defined HDL-C levels as follow: low (HDL-C ＜1.04 mmol/L), reference (1.04-1.55 mmol/L), high (1.56-2.06 mmol/L), very high (≥2.07 mmol/L). The multivariate adjusted hazard ratio (HR) for all-cause or cause-specific mortality was calculated using a Cox proportional hazards model adjusted for other traditional risk factors.

RESULTS

During follow-up, we observed 1,598 deaths. No significant association was observed between HDL-C and all-cause mortality. Serum HDL-C also showed no association with stroke. In contrast, the risk for CHD among high HDL-C was lower than reference, HRs were 0.51 [95% confidence interval (CI): 0.21-1.23] in men, 0.33 (95% CI: 0.11-0.95) in women, and 0.41 (95% CI: 0.21-0.81) when men and women were combined. However, very high HDL-C did not show significant association with CHD and other cause-specific mortality.

CONCLUSIONS

HDL-C was not associated with all-cause and stroke mortality. In contrast, high serum HDL-C levels, at least up to 2.06 mmol/L, were protective against CHD, although further high levels were not. However, sample size of cause-specific death in very high HDL-C group was not enough even in this 20-year follow-up of 7,019 Japanese; larger cohort studies should be warranted.

Effects of evolocumab (AMG 145), a monoclonal antibody to PCSK9, in hypercholesterolemic, statin-treated Japanese patients at high cardiovascular risk--primary results from the phase 2 YUKAWA study

BACKGROUND

YUKAWA is a 12-week, randomized, double-blind, placebo-controlled, phase 2 study evaluating the efficacy and safety of evolocumab (AMG 145) in statin-treated Japanese patients at high cardiovascular risk.

METHODS AND RESULTS

310 eligible patients receiving stable statin (±ezetimibe) therapy were randomized to 1 of 6 treatments: placebo every 2 weeks (Q2W) or monthly (QM), evolocumab 70 mg or 140 mg Q2W, or evolocumab 280 mg or 420 mg QM. The primary endpoint was the percentage change from baseline in low-density lipoprotein cholesterol (LDL-C) measured by preparative ultracentrifugation (UC). Secondary endpoints included percentage changes in other lipid parameters and the proportion of patients with LDL-C <1.8 mmol/L. Mean (SD) age was 62 (10) years; 37% were female; and the mean (SD) baseline LDL-C was 3.7 (0.5) mmol/L (by UC). Mean (SE) changes vs. placebo in LDL-C were greatest in the high-dose groups: -68.6 (3.0) % and -63.9 (3.2) % with 140 mg Q2W and 420 mg QM dosing, respectively. Up to 96% of evolocumab-treated patients achieved LDL-C <1.8 mmol/L. Adverse events (AEs) were more frequent in evolocumab (51%) vs. placebo (38%) patients; 4 patients taking evolocumab discontinued treatment because of an AE. There were no significant differences in AE rates based on dose or dose frequency.

CONCLUSIONS

In Japanese patients at high cardiovascular risk with hypercholesterolemia on stable statin therapy, evolocumab significantly reduced LDL-C and was well tolerated during this 12-week study.

Second-line treatments for dyslipidemia in patients at risk of cardiovascular disease

Previous studies have shown that approximately 50% patients at risk of cardiovascular disease do not achieve lipid management goals. Thus, improvements dyslipidemia management are needed. We investigated the clinical choice and efficacy of second-line treatments for dyslipidemia in the Japanese clinical setting. Using a retrospective cohort design, we collected lipid profile data from patients who had been treated with hypolipidemic agents at a stable dosage for at least 12 weeks. These patients had then been administered a second-line treatment for dyslipidemia because they had not achieved the low-density lipoprotein cholesterol (LDL-C) management goals. We included data from 641 patients in our analysis. The top three choices for second-line treatment were adding ezetimibe, switching to strong statins (statin switching), and doubling the original statin dosage (statin doubling). Adding ezetimibe, statin switching, and statin doubling decreased LDL-C levels by 28.2 ± 14.5%, 23.2 ± 24.4%, and 23.5 ± 17.2%, respectively. Among these three strategies, adding ezetimibe decreased LDL-C levels to the maximum extent. In patients with dysglycemia, baseline-adjusted change in hemoglobin A1c (HbA1c) levels decreased slightly in the adding-ezetimibe, statin-switching, and statin-doubling groups, but the differences were not statistically significant among the groups (-0.10 ± 0.62%, -0.22 ± 0.54%, and -0.12 ± 0.52%, p = 0.19). In conclusion, the most common second-line treatment options for dyslipidemia were adding ezetimibe, statin switching, or statin doubling. Adding ezetimibe resulted in the highest reduction in LDL-C levels. These strategies did not increase HbA1c levels when administered with conventional diabetes treatment.

Hypertriglyceridemia is frequent in endometrial cancer survivors

Objective

Previous studies have reported an association between endometrial cancer and the risk of metabolic syndrome; however, the pattern of endometrial cancer-associated dyslipidemia is not well understood. The standard therapy for endometrial cancer is total abdominal hysterectomy and bilateral salpingo-oophorectomy. Premenopausal bilateral salpingo-oophorectomy may cause adverse events, including dyslipidemia. Gynecologists have to care dyslipidemia in endometrial cancer survivors at cancer follow-up clinic.

Methods

This study included 693 patients who had undergone bilateral salpingo-oophorectomy, and included 412 women with incident endometrial cancer and 281 controls. We divided the patients into two categories according to whether they had a premenopausal or postmenopausal bilateral oophorectomy. Serum lipid levels were measured and statistically analyzed.

Results

Hypertriglyceridemia was statistically more frequent in patients who had undergone bilateral salpingo-oophorectomy both before and after menopause than in the corresponding non-endometrial cancer controls. High levels of low-density lipoprotein cholesterol and a high low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio were statistically more frequent in patients who had undergone bilateral salpingo-oophorectomy before menopause than in non-endometrial cancer controls.

Conclusions

Our report highlights the importance of the relationship between endometrial cancer and lipid metabolism, which may aid in preventing cerebrovascular or cardiovascular diseases due to dyslipidemia and improving the quality of life in endometrial cancer survivors.

Cumulative impact of axial, structural, and repolarization ECG findings on long-term cardiovascular mortality among healthy individuals in Japan: National Integrated Project for Prospective Observation of Non-Communicable Disease and its Trends in the Aged, 1980 and 1990

AIMS

Various cohort studies have shown a close association between long-term cardiovascular disease (CVD) outcomes and individual electrocardiographic (ECG) abnormalities such as axial, structural, and repolarization changes. The combined effect of these ECG abnormalities, each assumed to be benign, has not been thoroughly investigated.

METHODS AND RESULTS

Community-dwelling Japanese residents from the National Integrated Project for Perspective Observation of Non-Communicable Disease and its Trends in the Aged, 1980-2004 and 1990-2005 (NIPPON DATA80 and 90), were included in this study. Baseline ECG findings were classified using the Minnesota Code and categorized into axial (left axis deviation, clockwise rotation), structural (left ventricular hypertrophy, atrial enlargement), and repolarization (minor and major ST-T changes) abnormalities. The hazard ratios of the cumulative impacts of ECG findings on long-term CVD death were estimated by stratified Cox proportional hazard models, including adjustments for cohort strata. In all, 16,816 participants were evaluated. The average age was 51.2 ± 13.5 years; 42.7% participants were male. The duration of follow up was 300,924 person-years (mean 17.9 ± 5.8 years); there were 1218 CVD deaths during that time. Overall, 4203 participants (25.0%) had one or more categorical ECG abnormalities: 3648 (21.7%) had a single abnormality, and 555 (3.3%) had two or more. The risk of CVD mortality increased as the number of abnormalities accumulated (single abnormality HR 1.29, 95% CI 1.13-1.48; ≥2 abnormalities HR 2.10, 95% CI 1.73-2.53).

CONCLUSIONS

Individual ECG abnormalities had an additive effect in predicting CVD outcome risk in our large-scale cohort study.

LOX-1 ligands containing apolipoprotein B and carotid intima-media thickness in middle-aged community-dwelling US Caucasian and Japanese men

OBJECTIVE

The serum level of LOX-1 ligand containing ApoB (LAB) may reflect atherogenicity better than LDL cholesterol (LDLC), total LDL particles and usual measurement of oxidized LDL. The association between LAB and intima-media thickness (IMT) of carotid artery was investigated by ultrasound in US and Japan men.

METHODS

Participants were 297 US Caucasian and 310 Japanese men, aged 40-49 years without past history of cardiovascular disease. Serum LAB levels were measured by ELISAs with recombinant LOX-1 and monoclonal anti-apolipoprotein B antibody.

RESULTS

Serum LAB levels [median (interquartile range), μg/L] were 1321 (936, 1730) in US Caucasians and 940 (688, 1259) in Japanese. For Caucasian men, average IMT was higher in higher LAB quartile, which was 0.653, 0.667, 0.688, and 0.702 mm, respectively (p for trend = 0.02). Linear regression analysis showed serum LAB was significantly associated with IMT after adjustment for LDLC or total LDL particles in addition to other traditional or novel risk factors for atherosclerosis such as C-reactive protein. However, there was no significant relationship between LAB and IMT in Japanese men.

CONCLUSION

Serum LAB, a new candidate biomarker for residual risk, was associated with an increased carotid IMT in US Caucasian men independently of various risk factors; however, ethnic difference should be clarified in the future.

Cultural diversity in physical diseases among patients with mental illnesses

OBJECTIVE

People with psychiatric diseases have a severely increased risk for physical morbidity and premature death from physical diseases. The aims of the study were to investigate the occurrence of cardiovascular diseases (CVD), diabetes (DM) and obesity in schizophrenia and depression in three different geographical areas - Asia (Japan), Africa (Nigeria) and Western Europe (Switzerland, Germany and Denmark) - and to search for possible transcultural differences in these correlations, which would also reflect the differences between low-income areas in Africa (Nigeria) and high-income areas in Europe and Japan.

METHOD

Patients with International Classification of Diseases (ICD-10) F2 diseases (schizophrenia spectrum disorders) and F3 diseases (affective disorders) admitted to one Nigerian, one Japanese, two Swiss, two German and six Danish centres during 1 year were included. Physical diseases in accordance with ICD-10 were also registered. Psychiatric and physical comorbidity were calculated and standardized rate ratio incidences of background populations were our primary measures.

RESULTS

Incidence rate ratios were increased for both CVD, DM and overweight in both F2 and F3 in all cultures (Western Europe, Nigeria and Japan) within the same ranges (however, the Japanese results should be interpreted conservatively owing to the limited sample size). Overweight among the mentally ill were marked in Nigeria. A parallelism of the incidence of overweight, CVD and diabetes with the occurrence in background populations was seen and was most marked in overweight.

CONCLUSIONS

Overweight, CVD and DM were increased in schizophrenia spectrum disorders and affective disorders in all three cultures investigated (Western Europe, Nigeria and Japan). Lifestyle diseases were also seen in Nigeria and Japan. The results from this study indicate that cultural background might be seen as an important factor in dealing with lifestyle diseases among people with a severe mental illness, as it is in the general population.

The occurrence rate of cerebrovascular and cardiac events in patients receiving antihypertensive therapy from the post-marketing surveillance data for valsartan in Japan (J-VALID)

It is well known that blood pressure (BP) management reduces the incidence of cerebrovascular and cardiovascular events. However, it is unclear how many of these events occur in hypertensive patients who receive pharmacological treatment. The aim of this survey was to evaluate the occurrence rate of both types of events in patients receiving valsartan-based treatment. Of 30 366 patients treated with valsartan, 28 356 patients were observed for 2.93 years. Antihypertensive drugs other than valsartan were used in 56.8% of patients. After the administration of valsartan, the systolic and diastolic BP significantly decreased from 161.1±19.1/90.4±13.1 to 139.9±18.1/79.6±11.9 mm Hg. Cerebrovascular events were observed in 550 patients (1.94%, 9.29/1000 patient-years), and cardiac events were observed in 576 patients (2.03%, 9.73/1000 patient-years). A comparative analysis of the hazard ratios for cerebrovascular and cardiac events according to the BP level at the endpoint showed a BP-dependent reduction of risk for cerebrovascular events, and the change in risk exhibited a J-curve phenomenon in the relationship between cardiac events and systolic BP. The J-curve phenomenon was not observed in patients aged <75 years, but it was observed for the systolic BP in patients aged 75 years. Adverse drug reactions were observed in 1925 of 28 420 patients (6.77%). This post-marketing surveillance data for valsartan showed the outcomes for treated hypertensive patients in a large population in Japan who were followed for up to 3 years. These data will add important knowledge regarding the treatment of hypertension in Japan.

Risk factors for sudden cardiac death among Japanese: the Circulatory Risk in Communities Study

OBJECTIVE

There is little evidence concerning risk factors for sudden cardiac death (SCD) among Asians.

PATIENTS AND METHODS

A prospective, nested, case-control study of Japanese patients aged between 30 and 84 years was undertaken using data collected from 26 870 participants in cardiovascular risk surveys conducted in four communities between 1975 and 2005. The incidence of SCD was ascertained by systematic surveillance, with 239 cases of SCD identified over this period. For each case of SCD, three control patients were selected, matched by age, sex, examination year, follow-up time, and community.

RESULTS

Hypertension, diabetes mellitus, smoking, major ST-T abnormalities, left high amplitude R waves, and increased heart rate (≥77 beat/min) were all independently associated with a 1.5-3.2-fold increase in SCD risk, whereas no associations were observed for body mass index and hypercholesterolemia. The population-attributable fraction [95% confidence interval (CI)] was 23.0% (2.9-39.0) for hypertension, 15.3% (3.8-25.5) for current smoking, 14.5% (8.0-20.5) for major ST-T abnormalities, and 8.1% (2.2-13.7) for diabetes mellitus. The number of SCD risk factors (hypertension, diabetes, smoking, and ECG abnormalities) was positively associated with increased SCD risk. The odds ratio for increased SCD risk with three or more risk factors versus zero risk factors was 5.76 (95% CI 3.20-10.39).

CONCLUSIONS

Among the Japanese population, hypertension, smoking, major ST-T abnormalities, left high amplitude R waves, and diabetes mellitus were associated with an increased incidence of SCD, whereas there were no associations of body mass index or hypercholesterolemia with SCD incidence.

Self-reported snoring frequency and incidence of cardiovascular disease: the Circulatory Risk in Communities Study (CIRCS)

Background

Although associations between snoring and cardiovascular disease have been reported in several prospective studies, there is limited evidence from Asian populations. The objective of this study was to determine if there is an association between self-reported snoring frequency and the incidence of cardiovascular disease in Japanese.

Methods

The subjects were 2350 men and 4163 women aged 40 to 69 years who lived in 3 communities in Japan. All subjects were participants in the Circulatory Risk in Communities Study (CIRCS) and were followed for 6 years. Incidence of cardiovascular disease during the follow-up period comprised events of myocardial infarction, angina pectoris, sudden cardiac death and stroke.

Results

During the 6-year follow-up period, 97 participants (56 men and 41 women) had cardiovascular events. After adjustment for potential confounding factors, self-reported snoring frequency was associated with an increased risk of cardiovascular events among women but not men. The hazard ratios (95% CI) for cardiovascular events were 0.9 (0.4–2.0) for sometimes snoring and 2.5 (1.0–6.1) for everyday snoring in women and 0.7 (0.3–1.3) and 1.0 (0.5–2.1), respectively, in men. Further adjustment for body mass index attenuated the association in women; the respective hazard ratios for cardiovascular events were 0.9 (0.4–1.9) and 2.1 (0.9–5.4).

Conclusions

Self-reported habitual snoring was associated with increased risk of cardiovascular events among Japanese women. Overweight may partly mediate this association.

Trends in sudden cardiac death and its risk factors in Japan from 1981 to 2005: the Circulatory Risk in Communities Study (CIRCS)

OBJECTIVE

There is little evidence whether sudden cardiac death (SCD) is increasing in Asia, although the incidence of coronary heart disease among urban middle-aged Japanese men has increased recently. We examined trends in the incidence of SCD and its risk factors in the Circulatory Risk in Communities Study.

DESIGN AND SETTING

This was a population-based longitudinal study. Surveillance of men and women for SCD incidence and risk factors was conducted from 1981 to 2005.

SUBJECTS

The surveyed population was all men and women aged 30-84 years who lived in three rural communities and one urban community in Japan.

MAIN OUTCOME MEASURES

Trends in SCD incidence and its risk factors.

RESULTS

Age-adjusted and sex-adjusted incidence of SCD decreased from 1981-1985 to 1991-1995, and plateaued thereafter. The annual incidence per 100 000 person-years was 76.0 in 1981-1985, 57.9 in 1986-1990, 39.3 in 1991-1995, 31.6 in 1996-2000 and 36.8 in 2001-2005. The prevalence of hypertension decreased from 1981-1985 to 1991-1995, and plateaued thereafter for men and women. The age-adjusted prevalence of current smoking for men decreased while that of diabetes mellitus increased for both sexes from 1981-1985 to 2001-2005.

CONCLUSIONS

The incidence of SCD decreased from 1981 to 1995 but was unchanged from 1996 to 2005. Continuous surveillance is necessary to clarify future trends in SCD in Japan because of an increasing incidence of diabetes mellitus.

Variation in rates of fatal coronary heart disease by neighborhood socioeconomic status: the atherosclerosis risk in communities surveillance (1992-2002)

PURPOSE

Racial and gender disparities in out-of-hospital deaths from coronary heart disease (CHD) have been well-documented, yet disparities by neighborhood socioeconomic status (nSES) have been less systematically studied in US population-based surveillance efforts.

METHODS

We examined the association of nSES, classified into tertiles, with 3,743 out-of-hospital fatal CHD events, and a subset of 2,191 events classified as sudden, among persons aged 35 to 74 years in four US communities under surveillance by the Atherosclerosis Risk in Communities (ARIC). Poisson generalized linear mixed models generated age-, race- (white, black) and gender-specific standardized mortality rate ratios and 95% confidence intervals (RR, 95% CI).

RESULTS

Regardless of nSES measure used, inverse associations of nSES with all out-of-hospital fatal CHD and sudden fatal CHD were seen in all race-gender groups. The magnitude of these associations was larger among women than men. Further, among blacks, associations of low nSES (vs. high nSES) were stronger for sudden cardiac deaths (SCD) than for all out-of-hospital fatal CHD.

CONCLUSIONS

Low nSES was associated with an increased risk of out-of-hospital CHD death and SCD. Measures of the neighborhood context are useful tools in population-based surveillance efforts for documenting and monitoring socioeconomic disparities in mortality over time.

Experimental pig model of old myocardial infarction with long survival leading to chronic left ventricular dysfunction and remodeling as evaluated by PET

A pig model of reduced left ventricular (LV) function and remodeling or chronic heart failure with long survival after myocardial infarction (MI) has not been established. The aim of this study was to evaluate the pathophysiologic status of a pig model of old MI using a series of PET studies.

METHODS

Twenty-seven male farm pigs were divided into 2 groups: 7 animals in the control group and 20 animals that underwent a proximal coronary artery (CA) occlusion using an ameroid constrictor after distal CA ligation. A series of PET examinations was performed to assess LV volumes, LV functions, myocardial perfusion response to adenosine, and viability as water-perfusable tissue index.

RESULTS

The distal CA ligation inhibited arrhythmia during and after the operation, and a transmural anteroseptal MI, with an infarction area of 27% ± 5% of the whole left ventricle, was generated with a survival rate of 75% at 4 mo. Wall motion evaluated by (18)F-FDG PET was diffusely reduced, including the noninfarcted wall. Global LV ejection fraction as assessed by gated C(15)O PET was reduced (39% ± 16%) in the group undergoing occlusion, compared with the control group (66% ± 16%, P < 0.05). LV end-systolic (31.4 ± 9.2 cm(3)) and end-diastolic (52.7 ± 10.2 cm(3)) volumes were increased, compared with controls (15.2 ± 9.4 cm(3), P < 0.01, and 41.7 ± 11.5 cm(3), P < 0.05, respectively). Histology showed hypertrophy and development of microscopic fibrosis in noninfarcted myocardium. PET demonstrated the reduced myocardial perfusion response to adenosine and also reduced water-perfusable tissue index in remote segments.

CONCLUSION

The pig model of old MI generated by the chronic proximal CA obstruction after distal ligation was characterized by LV dysfunction and remodeling, with a high survival rate.

Effects of toremifene and tamoxifen on lipid profiles in post-menopausal patients with early breast cancer: interim results from a Japanese phase III trial

OBJECTIVE

Toremifene and tamoxifen have been used for adjuvant therapy in post-menopausal patients with breast cancer in Japan. Dyslipidemias are common in post-menopausal women. However, limited data are available on the effects of these agents on lipid profiles in Japanese patients. The Japan Toremifene Cooperative Study Group has been conducting a Phase III randomized trial of post-menopausal patients with breast cancer. One of its secondary endpoints is to confirm the effects of these agents on serum lipid profiles.

METHODS

The subjects were post-menopausal Japanese patients who had undergone surgery for early breast cancer. Toremifene or tamoxifen was administered for 2 years. Lipid levels were measured before and up to 24 months after initiation.

RESULTS

Compared with baseline, at 24 months, the toremifene group (n = 123) showed significantly decreased total cholesterol (P < 0.001) and low-density lipoprotein cholesterol levels (P < 0.001), and significantly increased high-density lipoprotein cholesterol levels (P < 0.001). Their triglyceride levels were not affected (P = 0.677). The tamoxifen group (n = 120) also showed significantly decreased total cholesterol (P < 0.001) and low-density lipoprotein cholesterol levels (P < 0.001); no significant changes occurred in high-density lipoprotein cholesterol (P = 0.297) or triglyceride levels (P = 0.120).

CONCLUSIONS

Distinct differences between two selective estrogen receptor modulators on lipids were observed. Toremifene improved lipid profiles, particularly as an enhancer of high-density lipoprotein cholesterol. To a large extent, tamoxifen improved low-density lipoprotein cholesterol levels. The impact of these improved lipid profiles on the risk of cardiovascular diseases needs further confirmation.

Polyunsaturated fatty acid levels of serum and red blood cells in apparently healthy Japanese subjects living in an urban area

AIM

We assessed levels of polyunsaturated fatty acid (PUFA) in serum and red blood cells (RBCs) among groups stratified by generation and its clinical significance in Japanese subjects living in an urban area.

METHODS

We enrolled 200 apparently healthy Japanese (126 males, mean age: 50.3+/-9.2 years) living in an urban area. Levels of PUFA, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid (AA), and dihomo-gamma-linolenic acid (DGLA) in serum and RBCs were measured for each generation (G1 <35y, G2 35y-<45y, G3 45y-<55y, G4 55y-<65y, G5>or=65y).

RESULTS

No significant differences in EPA, DHA, AA, or EPA/AA were observed between males and females. After dividing into generations, stepwise increases in EPA and DHA, but not DGLA or AA, were observed in serum (all p<0.0001). EPA/AA ratios were stepwisely increased in serum (mean: G1:0.26, G2:0.29, G3:0.43, G4:0.58, G5:0.68, p<0.0001) and RBCs (mean: G1:0.10, G2:0.09, G3:0.15, G4:0.20, G5:0.23, p<0.0001). Positive correlations of EPA (r=0.83), DHA (r=0.55), DGLA (r=0.54), AA (r=0.29), and EPA/AA (r=0.91) were demonstrated between serum and RBCs. In addition, a significant positive correlation between EPA/AA ratios and insulin sensitivity as well as a negative correlation between those ratios and insulin resistance were observed in subjects with metabolic syndrome.

CONCLUSION

Low levels of EPA/AA, which were associated with insulin resistance, were demonstrated in young Japanese adults living in an urban area.

Alcohol intake and 19-year mortality in diabetic men: NIPPON DATA80

Although moderate alcohol intake in diabetic Caucasians is associated with a reduction in coronary heart disease mortality, no study in Japanese with diabetes has examined the association between alcohol intake and mortality outcomes. We analyzed the relationship between alcohol intake and all-cause and cause-specific mortality using the database from NIPPON DATA80. At the baseline in 1980, data on history, lifestyle, and physical examinations were collected on study participants aged 30 years and older from randomly selected areas in Japan. After excluding participants with comorbidities, we followed 4,018 male participants (3,614 nondiabetics, 195 with impaired glucose tolerance and 209 diabetic) for 19 years. During the 19 years of follow-up, there were 990 deaths; 328 were from cardiovascular disease and 157 from all-heart diseases. With the never-drinking category serving as a reference, the Cox multivariate-adjusted hazard ratios for non-daily and daily drinkers for cardiovascular mortality were 0.43 (95% confidence intervals: 0.19-0.95) and 0.45 (0.25-0.80), respectively, and 0.33 (0.12-0.91) and 0.31 (0.15-0.67) for all-heart disease mortality in the combined impaired glucose tolerance and diabetic Japanese men. Alcohol drinking in men with glucose intolerance was associated with a significant reduction in cardiovascular and all-heart disease mortality as seen in the general population in Japan.

C-reactive protein levels and risk of mortality from cardiovascular disease in Japanese: the JACC Study

OBJECTS

Limited evidence of association between C-reactive protein levels and cardiovascular disease has been produced for Japanese whose median protein levels are low by western standards.

METHODS

We conducted a nested case-control study as part of the Japan Collaborative Cohort Study for evaluation of cancer risk (JACC Study). A total of 39,242 subjects 40-79 years of age provided serum samples at baseline between 1988 and 1990. During the 13-year follow-up, there were 525 deaths from total strokes (ICD10: I60-I69), 209 coronary heart diseases (I20-I25) and 939 total cardiovascular diseases (I00-I99). The control subjects were matched for sex, age, area of residence and year of serum storage, and analyses were conducted after further adjustment for cardiovascular risk factors. Serum high-sensitivity C-reactive protein (hs-CRP) levels were measured with ultra-sensitive latex-enhanced immunoassay.

RESULTS

Median hs-CRP levels for controls were 0.40 mg/L for men and 0.41 mg/L for women. Hs-CRP levels were positively associated with risks of mortality from stroke, coronary heart disease, and total cardiovascular disease for men. The respective multivariable odds ratios (OR 95% CI) for the highest (>or=0.85 mg/L) vs. lowest (<0.19 mg/L) quartiles of hs-CRP for men were 1.60 (0.90-2.85), 3.68 (1.02-13.3), and 2.31 (1.49-3.59). For women, positive associations with hs-CRP levels were weaker, reaching statistical significance only for total cardiovascular disease: OR=1.69 (1.06-2.68). The positive association with total cardiovascular disease did not vary according to sex, age, smoking status, or body mass index.

CONCLUSIONS

Higher serum hs-CRP levels were associated with higher mortality from cardiovascular disease in Japanese.

Risk factor effects and total mortality in older Japanese men in Japan and Hawaii

PURPOSE

We sought to identify factors related to total mortality in older Japanese men in Japan and Hawaii.

METHODS

Baseline data were collected from 1980 to 1982 in 1379 men in Hawaii and 954 men in Japan. Ages ranged from 61 to 81 years, with mortality follow-up during a 19-year period.

RESULTS

Compared with Japan, men in Hawaii had a 2-fold excess of diabetes and a 4-fold excess of prevalent coronary heart disease (P < .001). Total cholesterol and body mass index were also greater in Hawaiian men (P < .001). In contrast, men in Japan had greater systolic blood pressure and were nearly 3 times more likely to smoke cigarettes (P < .001). Although each cohort had elements of a poor risk factor profile, there was a 1.4-fold excess in the risk of death in Japan (49.4 vs. 36.2/1,000 person-years, P < .001). Although mortality was similar after risk factor adjustment, only blood pressure and cigarette smoking accounted for the higher risk of death in Japan.

CONCLUSIONS

Cigarette smoking and hypertension explain much of the excess mortality in Japan versus Hawaii. In this comparison of genetically similar cohorts, evidence further suggests that Japanese in Japan are equally susceptible to develop the same adverse risk factor conditions that exist in Hawaii.

Self-reported stroke and myocardial infarction had adequate sensitivity in a population-based prospective study JPHC (Japan Public Health Center)-based Prospective Study

OBJECTIVE

We sought to clarify the validity of self-reported stroke and myocardial infarction (MI) among Japanese population, because information on the validity, particularly on the sensitivity, of self-reported cardiovascular disease is limited and may differ among countries.

STUDY DESIGN AND SETTING

Using the 10-year follow-up questionnaire and a stroke and MI registry in the Japan Public Health Center-based prospective Study (JPHC Study) cohort (n=91,186), we calculated sensitivity and positive predictive values of self-reported stroke and MI incidence over 10 years.

RESULTS

Sensitivity of self-reported incident stroke was 73%, and that for MI was 82%. Positive predictive values were 57% for stroke and 43% for MI. The supplemental inclusion of self-reported angina pectoris increased the sensitivity of MI to 89%, but attenuated the positive predictive value to 18%. Sensitivity of self-reported stroke was highest for subarachnoid hemorrhage (88%), but did not differ greatly among other stroke subtypes, affected sites or size.

CONCLUSION

Self-reported stroke and MI seem sensitive enough to use for exclusion of stroke and MI at baseline in Japanese cohort studies. However, self-report has too many false positives to be used as the only criterion for incident stroke and MI.

A Japanese diet and 19-year mortality: national integrated project for prospective observation of non-communicable diseases and its trends in the aged, 1980

Few studies have examined the association between Japanese diet and mortality outcomes. We analysed the relationship between a healthy Japanese diet and all-cause and cause-specific mortality using the database from the National Integrated Project for Prospective Observation of Non-Communicable Diseases and its Trends in the Aged, 1980. At baseline in 1980, data were collected on study participants aged > or =30 years from randomly selected areas in Japan. We defined a measure of a healthy reduced-salt Japanese diet based on seven components from FFQ. The total score ranged from 0 to 7, with 0 being least healthy and 7 being most healthy. Participants were divided into approximate tertiles of dietary scores (0-2, 3 and 4-7 scores). After excluding participants with co-morbidities, we followed 9086 participants (44 % men) for 19 years. There were 1823 all-cause and 654 cardiovascular deaths during the follow-up. With the dietary score group 0-2 serving as a reference, the Cox multivariate-adjusted hazard ratios for groups with scores 3 and 4-7 were 0.92 (95 % CI 0.83, 1.04) and 0.78 (95 % CI 0.70, 0.88) for all-cause mortality (trend P < 0.0001), and 0.91 (95 % CI 0.75, 1.10) and 0.80 (95 % CI 0.66, 0.97) for cardiovascular mortality (trend P = 0.022). Adherence to a healthy reduced-salt Japanese diet was associated with an approximate 20 % lower rate of all-cause and cardiovascular mortality.

Fish, omega-3 polyunsaturated fatty acids, and mortality from cardiovascular diseases in a nationwide community-based cohort of Japanese men and women the JACC (Japan Collaborative Cohort Study for Evaluation of Cancer Risk) Study

OBJECTIVES

The objective of our study was to test the hypothesis that fish or omega-3 polyunsaturated fatty acids (PUFA) intakes would be inversely associated with risks of mortality from ischemic heart disease, cardiac arrest, heart failure, stroke, and total cardiovascular disease.

BACKGROUND

Data on associations of dietary intake of fish and of omega-3 PUFA with risk of cardiovascular disease among Asian societies have been limited.

METHODS

We conducted a prospective study consisting of 57,972 Japanese men and women. Dietary intakes of fish and omega-3 PUFA were determined by food frequency questionnaire, and participants were followed up for 12.7 years. Hazard ratios and 95% confidence intervals were calculated according to quintiles of fish or omega-3 PUFA intake.

RESULTS

We observed generally inverse associations of fish and omega-3 PUFA intakes with risks of mortality from heart failure (multivariable hazard ratio [95% confidence interval] for highest versus lowest quintiles = 0.76 [0.53 to 1.09] for fish and 0.58 [0.36 to 0.93] for omega-3 PUFA). Associations with ischemic heart disease or myocardial infarction were relatively weak and not statistically significant after adjustment for potential risk factors. Neither fish nor omega-3 PUFA dietary intake was associated with mortality from total stroke, its subtypes, or cardiac arrest. For mortality from total cardiovascular disease, intakes of fish and omega-3 PUFA were associated with 18% to 19% lower risk.

CONCLUSIONS

We found an inverse association between fish and omega-3 PUFA dietary intakes and cardiovascular mortality, especially for heart failure, suggesting a protective effect of fish intake on cardiovascular diseases.

A low level of C-reactive protein in Japanese adults and its association with cardiovascular risk factors: The Japan NCVC-Collaborative Inflammation Cohort (JNIC) Study

High-sensitivity C-reactive protein (hs-CRP) levels vary remarkably by race and ethnic group. We examined hs-CRP levels and their association with cardiovascular risk factors in the Japanese general population. The Japan National Cardiovascular Center (NCVC)-collaborative Inflammation Cohort (JNIC) Study recruited 5213 men and 7071 women aged > or = 40 years from seven communities in Japan during 2002-2004. hs-CRP was measured using nephelometry calibrated with CRM 470, the international plasma protein reference material. Traditional cardiovascular risk factors and their aggregation were studied in multivariate logistic models, stratified by overweight status. Median hs-CRP levels in men and women were 0.60 and 0.45 mg/L, respectively. The percentage of subjects with hs-CRP levels < 1.0, 1.0-3.0, and > 3.0 mg/L was 67.4%, 22.0%, and 10.6% in men, respectively, and 76.3%, 16.7%, and 7.0% in women. hs-CRP levels showed significant linear associations with traditional risk factors. Overweight, hypertension, dyslipidemia (men only), smoking (men only), and diabetes (women only) contributed significantly to elevated hs-CRP levels. Overweight individuals with hypertension, dyslipidemia, and diabetes had a high prevalence of elevated hs-CRP levels in both sexes. Japanese adults have very low hs-CRP levels. An aggregation of metabolic risk factors is associated with elevated hs-CRP levels among overweight individuals, particularly in women.

Cerebral small vessel disease and C-reactive protein: results of a cross-sectional study in community-based Japanese elderly

BACKGROUND AND PURPOSE

Inflammatory processes are involved in the pathogenesis of atherosclerosis. Inflammation has been known as a risk factor for coronary heart disease, whereas inflammation as a risk for cerebrovascular disease is less well established. Whether inflammatory processes, excluded from their involvement in large-vessel disease, are implicated in the pathogenesis of cerebral small vessel disease remains unclear. We assessed whether higher C-reactive protein (CRP) levels were associated with an increased number of lacunar infarcts or severity of white matter lesions.

METHODS AND RESULTS

In a community-based group of Japanese elderly (n=689), CRP concentrations were measured using a highly sensitive assay. All participants underwent magnetic resonance imaging (MRI), and cerebral small vessel disease-related lesions (lacunar infarcts and white matter hyperintensity) were subsequently evaluated. Furthermore, carotid atherosclerosis was also assessed with ultrasonography. As the grades of white matter hyperintensity and the numbers of lacunes were considered small vessel disease-related lesions, we evaluated the relationships between CRP levels and small vessel disease-related brain lesions. Interestingly, the median CRP concentration of our participants was remarkably lower, being approximately one third or one quarter of the value of Western populations. Subjects with higher CRP levels tended to have more small vessel disease-related lesions; however, these associations were not seen after adjustment for cardiovascular risk factors and carotid atherosclerosis.

CONCLUSIONS

The relationship between CRP levels and small vessel disease-related lesions was not apparent in the community-based Japanese elderly. The impact of inflammation in the pathogenesis of small vessel disease-related brain lesions seems to be weak among the Japanese elderly.

Application of the Recent American Practice Resources for Risk Stratification System for Patients Presenting to a Japanese Emergency Department Because of Syncope

BACKGROUND

The American College of Physicians (ACP) and the American College of Emergency Physicians (ACEP) recently published practice guidelines and recommendations for evaluation of patients with syncope based on historical, physical, and ECG findings. The objective of the present study was to determine if risk stratification using these practice resources is valid in a series of Japanese patients.

METHODS AND RESULTS

A total of 912 consecutive patients brought to our emergency department between 1988 and 1997 because of syncope were identified. Follow-up information about mortality was obtained for 707 patients by means of mailed questionnaires and from medical records, and the mortality data were analyzed by the actuarial life-table method. A total of 187 patients who fulfilled the admission criteria according to the ACP guidelines were found to have higher overall and cardiac mortality than the other 520 patients (P < 0.0001), and 153 patients who fulfilled the admission criteria according to the ACEP recommendations also had higher overall and cardiac mortality than the other 554 patients (P < 0.0001).

CONCLUSIONS

The recent American practice recommendations can be used for risk stratification of syncope patients in Japan. Historical, physical, and ECG findings available on presentation can be used to stratify the risk of mortality in patients brought to Japanese emergency departments because of syncope.

The relationship between serum total cholesterol and all-cause or cause-specific mortality in a 17.3-year study of a Japanese cohort

No study has shown a positive relationship between hypercholesterolemia and all-cause mortality in the Japanese population. Therefore, a cohort study of 17.3 years' duration was conducted on 9216 participants aged 30 years or older, selected randomly from throughout Japan. In both the lowest (<4.14mmol/L, 160mg/dl) and highest (>or=6.71mmol/L, 260mg/dl) total cholesterol (TC) groups, there was a positive association between TC and risk of all-cause mortality (hazard ratio (HR) 1.19; 95% confidence interval (CI), 1.03-1.37 and 1.36 (95% CI, 1.05-1.77), respectively). The lowest TC group had an increased risk of liver disease (HR 3.03; 95% CI, 1.70-5.43), whereas the highest TC group had an increased risk of coronary heart disease (HR 3.81; 95% CI, 1.70-5.43). After exclusion of deaths due to liver disease during the entire follow-up period and all-cause deaths within the first 5 years of follow-up, the increased HR in the lowest TC group disappeared (HR 1.05; 95% CI, 0.89-1.24). Although the cut-off point seemed to be higher than that for Western populations, hypercholesterolemia was shown to be positively associated with all-cause mortality in Japan.