Risk Factors for Incidence of Cardiovascular Diseases and All-Cause Mortality in a Middle Eastern Population over a Decade Follow-up: Tehran Lipid and Glucose Study

Association of Helicobacter pylori Infection and Risk of Dyslipidemia: A Systematic Review and Meta-Analysis

Background

Although Helicobacter pylori (H. pylori) infections are widespread throughout the world, it is yet unknown whether they are linked to systemic illnesses like dyslipidemia. The purpose of this systematic review and meta-analysis was to examine the connection between lipid metabolism and H. pylori infection, with a particular emphasis on how it affects dyslipidemia.

Methods

We conducted a thorough search up until October 10, 2024, across databases such as PubMed, Web of Science, and Embase. Studies that reported lipid profiles in both H. pylori-infected and non-infected patients were considered eligible. The primary outcomes were triglyceride, LDL-C, HDL-C, and total cholesterol levels, which were examined using a random-effects model in R software version 4.4.

Results

There were 17 studies with more than 150,000 participants from 681 screened publications. Higher levels of LDL (MD: 5.32 mg/dL; 95% CI: 1.315 to 9.319) and total cholesterol (MD: 6.28 mg/dL; 95% CI: 0.718 to 11.842), as well as lower levels of HDL (MD: -2.06 mg/dL; 95% CI: -3.212 to -0.915), were the results of the meta-analysis. Among those infected, triglyceride levels were likewise higher (MD: 7.93 mg/dL; 95% CI: 0.413 to 15.436), but the odds ratio (OR) did not show a significant increase in risk (OR: 1.002; 95% CI: 0.995 to 1.010).

Conclusion

H. pylori infection is associated with significant dyslipidemia, suggesting a potential link between chronic bacterial infection and lipid metabolism. The findings emphasize the need for further research to explore the mechanisms and potential therapeutic interventions.

Assessing the predictive value of elevated triglycerides, triglyceride-glucose index (TyG), and TG/HDL ratios for cardiovascular disease and mortality during 20 years of follow-up: Tehran lipid and glucose study

OBJECTIVES

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality globally, influenced by a complex interplay of risk factors including lipid disorders and insulin resistance (IR). The triglyceride-glucose (TyG) index and the triglyceride to high-density lipoprotein cholesterol (TG/HDL) ratio have emerged as potential indicators for assessing cardiovascular risk. This study aimed to evaluate the predictive value of hypertriglyceridemia, the TyG index, and the TG/HDL ratio for mortality and CVD occurrence within an Iranian population.

DESIGN AND METHODS

Conducted within the Tehran Lipid and Glucose Study over 20 years, this research analyzed 7,117 participants to assess the association between these lipid biomarkers and CVD risk and mortality. Participants were stratified by their TyG and TG/HDL indices, with Cox proportional hazards models determining risk ratios across three adjusted models considering various demographic and clinical variables.

RESULTS

The study found significant associations between elevated triglycerides, TyG, and TG/HDL levels with increased risks of mortality and CVD during the 20-year follow-up. Specifically, the hazard ratios for CVD events were notably significant in the second triglyceride group (150-250 mg/dL), with a hazard ratio of 1.36 (1.19-1.55) in both Model 1 and Model 2, and in the third group (250-400 mg/dL), with ratios of 1.88 (1.63-2.17) in Model 1, 1.90 (1.65-2.19) in Model 2, and 1.44 (1.24-1.67) in Model 3.

CONCLUSION

Hypertriglyceridemia, the TyG index, and the TG/HDL ratio are easily calculable and clinically relevant markers for cardiovascular risk assessment. Their integration into routine health evaluations could facilitate early detection and management of at-risk individuals, potentially reducing the incidence and impact of CVD within the community.

Optimal Cut-off Points of the Standardized Continuous Metabolic Syndrome Severity Score (cMetS-S) for Predicting Cardiovascular Disease (CVD) and CVD Mortality in the Tehran Lipid and Glucose Study (TLGS)

Background

Metabolic Syndrome (MetS) is a prevalent condition associated with an increased risk of cardiovascular disease (CVD) and CVD mortality. Due to the limited clinical applicability of MetS, the standardized continuous metabolic syndrome severity score (cMetS-S) has the potential to provide continuous assessment of metabolic risk.

Objectives

This study evaluated the optimal cMetS-S cut-off points in the Tehran Lipid and Glucose Study (TLGS) for predicting CVD and CVD mortality.

Methods

The study included 7,776 participants over 30 years old at baseline, followed for 18 years. Sex-specific sensitivity (SS) and specificity (SP) of cMetS-S measures for predicting CVD and CVD mortality were evaluated using a receiver operating characteristic (ROC) curve, along with the area under the curve (AUC), employing a naive estimator and considering event failure status and MetS variables.

Results

The cut-off point of cMetS-S for CVD was 0.13 (SS: 65.5%, SP: 59.6%) for the total population, 0.44 (SS: 49.6%, SP: 68.1%) for men, and 0.27 (SS: 64.2%, SP: 69.2%) for women. The cut-off point of cMetS-S for CVD mortality was 0.53 (SS: 51.3%, SP: 71.9%) for the total population, 0.76 (SS: 35.1%, SP: 76.2%) for men, and 0.28 (SS: 78.8%, SP: 66.4%) for women. The AUC (95% CI) of MetS based on the International Diabetes Federation (IDF) and Joint Interim Statement (JIS) definitions were 60.0 (65.3 - 56.8) and 61.1 (59.6 - 56.8) for CVD, and 59.3 (56.0 - 62.5) and 59.4 (56.3 - 62.6) for CVD mortality.

Conclusions

The cut-off points of cMetS-S for CVD and CVD mortality differ between men and women. The cMetS-S could be a better predictive tool for CVD and CVD mortality than MetS.

Evaluating the effect of green tea intake on cardiovascular diseases: A Mendelian randomization study in European and East Asian populations

Previous research shows that more than 70% of cardiovascular diseases (CVDs) are attributed to modifiable risk factors. Here, we investigated relationship between consumption of green tea in European and East Asian populations and risk of CVDs using Mendelian randomization (MR). Instrumental variables for green tea intake were obtained from genome-wide association studies (GWASs) of 64,949 Europeans and 152,653 East Asians. GWASs for CVDs were derived from UK BioBank and BioBank Japan projects. The main method selected for MR analysis was either the inverse variance weighted (IVW) or Wald ratio, depending on the quantity of single nucleotide polymorphisms. Furthermore, we performed sensitivity analyses to confirm the reliability of the findings. Based on the results of IVW, there is no causal relationship between consumption of green tea and risk of 4 CVDs among Europeans (atrial fibrillation: OR = 1.000, 95% CI: 0.995-1.005, P = .910; heart failure: OR = 1.003, 95% CI: 0.994-1.012, P = .542; ischemic stroke: OR = 1.002, 95% CI: 0.993-1.011, P = .690; coronary artery disease: OR = 1.001, 95% CI: 0.996-1.007, P = .677). Sensitivity analyses and supplementary MR analyses also verify the robustness of the findings. Likewise, there was no correlation between the consumption of green tea and the occurrence of CVDs in East Asians. The consumption of green tea is not associated with a reduced risk of CVDs in populations from Europe and East Asia. This means that those who are trying to reduce their risk of CVDs by drinking more green tea may not benefit from doing so.

The contribution of metabolic risk factors to cardiovascular mortality in Golestan cohort study: Population attributable fraction estimation

Background

Cardiovascular diseases (CVDs) are the leading causes of global mortality and disability. Several studies demonstrated that metabolic risk factors increase cardiovascular mortality. The aim of this study is to examine CVDs deaths and population attributable fractions (PAFs) of their metabolic risk factors in Iran.

Methods

This is a study on 8621 participants aged 45-75 years and older, recruited in the repeated measurement phase of the Golestan cohort study (GCS) in northeast of Iran. The Cox proportional hazards model was used to determine the adjusted hazard ratios (HRs). PAFs were calculated to enumerate CVDs mortality avoidable in the population if metabolic risk factors were eliminated.

Results

The mortality of CVDs was attributable to metabolic factors, including high waist circumference (PAF, 28 %, [95 % CI: 16%-38 %]), high fasting blood sugar (FBS) (20 %, [15%-24 %]), overweight and obesity (19 %, [8%-28 %]), high blood pressure (16 %, [11%-21 %]), high low-density lipoprotein cholesterol (LDL-C) (8 %, [1%-15 %]), and high triglyceride (TG) (7 %, [3%-11 %]). Collectively, these metabolic risk factors accounted for 50 % of CVDs deaths. Females (67 %, [50%-78 %]) had a higher joint PAF of metabolic risk factors compared to males (43 %, [27%-55 %]).

Conclusions

The pattern of CVDs mortality attributable to metabolic risk factors in this study is not the same as similar studies in other parts of the world and previous studies in Iran. It is imperative that CVDs risk factors be specifically evaluated and addressed in various populations due to variety in geographical and temporal patterns in contribution of metabolic risk factors to CVD mortality.

The impact of obesity on different glucose tolerance status with incident cardiovascular disease and mortality events over 15 years of follow-up: a pooled cohort analysis

BACKGROUND

The effect of obesity in different glucose tolerance statuses i.e. normoglycemia (NGT), pre-diabetes, and type 2 diabetes (T2DM) on cardiovascular disease (CVD) and mortality has been an area of ongoing debate and uncertainty. In the present study, we aimed to examine the impact of being obese, whether general or central separately, in comparison with non-obese in different glucose tolerance statuses on the above outcomes.

METHODS

The study population included 18,184 participants aged 30-60 years (9927 women) from three longitudinal studies, including Atherosclerosis Risk in Communities, Multi-Ethnic Study of Atherosclerosis, and Tehran Lipid and Glucose Study. Glucose tolerance status was defined as NGT (fasting plasma glucose < 5.55 mmol/L), pre-diabetes (5.55-7.00 mmol/L), and T2DM (≥ 7 mmol/L or taking any medication for diabetes). Moreover, general and central obesity were defined based on body mass index and waist circumference (WC), respectively. Multivariable stratified Cox regression analysis was used to estimate hazard ratios (HRs (95% CI)) for CVD and mortality events.

RESULTS

During a 16-year follow-up, 2733 CVD events, 1101 CV mortality, and 3678 all-cause mortality events were recorded. We observed that being generally obese in comparison with non-obese increased the risk of CV and all-cause mortality in all glucose tolerance statuses; while considering CVD events, only among individuals with T2DM, the presence of general obesity was associated with marginally significant higher risk [1.19 (0.98-1.43); p-value = 0.07]. Regarding central adiposity, multivariate analysis revealed that elevated WC in NGT participants is associated with incident CVD [1.27(1.12-1.46)] and all-cause mortality [1.13(1.00-1.28)]. Moreover, central adiposity increased the risk of CV mortality in pre-diabetes individuals [1.47 (1.11-1.95)].

CONCLUSION

Findings from this pooled prospective cohort studies provide evidence that general obesity shows an unfavorable association with CV and all-cause mortality among the general population irrespective of their glucose tolerance statusThe findings imply that it's important to take into account the requirement and magnitude of weight reduction in people who are obese when offering guidance.

Kidney function decline is associated with mortality events: over a decade of follow-up from Tehran Lipid and Glucose Study

BACKGROUND

To investigate the association between estimated glomerular filtration rate (eGFR) change and mortality risk in a cohort from the Middle East and North Africa region with increasing chronic kidney disease burden.

METHODS

We included 2210 participants aged ≥ 50 years from the prospective cohort of the Tehran Lipid and Glucose Study. The interval for eGFR measurement was between the examinations in 2002-2005 to 2009-2011, and participants were followed through March 2018. Glomerular filtration rate was estimated from serum creatinine using the CKD-EPI creatinine equation. We assessed the association of rapid kidney function decline, (defined as annual eGFR decline ≥ 3 ml/min/1.73 m2 per year); ≥ 30% eGFR decline over six years; and certain drop in kidney function (≥ 25% eGFR decline plus drop in eGFR category) with mortality outcomes.

RESULTS

During a median follow-up of 14.3 years after recruitment, 315 all-cause and 112 cardiovascular disease deaths were recorded. The multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause death for rapid kidney function decline, ≥ 30% decline in eGFR over 6 years, and drop in kidney function were 1.68 (1.24-2.27), 2.01 (1.46-2.78), and 1.49 (1.11-1.98), respectively. The HRs of all-cause death and for rapid kidney function decline in those without and with chronic kidney disease were 1.41 (1.03-1.91) and 3.38 (1.69-6.76), respectively. Similar findings were observed regarding cardiovascular disease-related and non-cardiovascular disease-related mortality.

CONCLUSIONS

Estimated GFR decline is associated with an increased mortality risk, indicating its ability to provide additional prognostic information beyond traditional risk predictors in the general population.

Change in blood pressure status defined by 2017 ACC/AHA hypertension guideline and risk of cardiovascular disease: results of over a decade of follow-up of the Iranian population

Background

Hypertension (HTN) is known to be the leading cause of cardiovascular disease (CVD) and mortality. We aimed to assess the impact of changes in 3 years in different blood pressure (BP) categories on incident CVD.

Methods

In this study, 3,685 Tehranians aged ≥30 years (42.2% men) free of prevalent CVD with BP level <140/90 mmHg and not on BP-lowering medications were enrolled. Participants were grouped according to baseline BP category using the 2017 ACC/AHA hypertension guideline definition: normal BP (<120/80 mmHg), elevated BP (120-129/<80), and stage 1 HTN (130-139 and/or 80-89). The hazard ratio of incident CVD by changes in the BP category was estimated after adjustment for traditional risk factors using Cox's proportional hazard model, with stable normotension as a reference.

Results

During a median follow-up of 11.7 years, 346 CVD events (men = 208) occurred. Compared to the reference group, among participants with normal BP at baseline, only those with BP rising to stage 1 HTN [1.47 (0.99-2.16)], and among those with stage 1 HTN at baseline, regression to elevated BP [1.80 (1.11-2.91)], remaining at stage 1 [1.80 (1.29-2.52)], and progression to stage 2 HTN [1.81 (1.25-2.61)] had a higher risk for CVD; however, regression to normal BP attenuated this risk [1.36 (0.88-2.12)]. Conversion from elevated BP to any other categories had no significant association with CVD risk.

Conclusions

Generally, prevalent stage 1 HTN (regardless of changing category) and incident stage 1 HTN were significantly associated with a higher risk of CVD; even regression to elevated BP did not attenuate the risk. Accordingly, these populations are potential candidates for antihypertensive management.

Dietary insulin index and load and cardiometabolic risk factors among people with obesity: a cross-sectional study

BACKGROUND

The hypothesis of the effect of the insulinogenic effects of diet on the development of cardiometabolic disorders has been suggested, but limited data are available for adults with obesity. This study aimed to determine the association of dietary insulin index (DII) and dietary insulin load (DIL) with cardiometabolic risk factors among Iranian adults with obesity.

METHODS

The study was conducted with a total of 347 adults aged 20-50 years in Tabriz, Iran. Usual dietary intake was assessed through a validated 147-item food frequency questionnaire (FFQ). DIL was computed using published food insulin index (FII) data. DII was calculated by dividing DIL by the total energy intake of each participant. Multinational logistic regression analysis was performed to evaluate the association between DII and DIL and cardiometabolic risk factors.

RESULTS

Mean age of participants was 40.78 ± 9.23 y, and mean body mass index (BMI) was 32.62 ± 4.80 kg/m2. Mean of DII and DIL was 73.15 ± 37.60 and 196,242 ± 100,181. Participants with higher DII had higher BMI, weight, waist circumference (WC), and blood concentrations of triglyceride (TG) and Homeostasis model assessment insulin resistance index (HOMA-IR) (P < 0.05). After taking potential confounders into account, DIL was positively associated with MetS (OR: 2.58; 95% CI: 1.03-6.46), and high blood pressure (OR: 1.61; 95% CI: 1.13-6.56). Moreover, after adjustment for potential confounders, moderate DII was associated with increased odds of MetS (OR: 1.54, 95% CI: 1.36-4.21), high TG (OR, 1.25; 95% CI, 1.17-5.02), and high blood pressure (OR: 1.88; 95% CI: 1.06-7.86).

CONCLUSION

This population-based study revealed that adults with higher DII and DIL associated with cardiometabolic risk factors and consequently, replacement of high with low DII and DIL may have reduce the risk of cardiometabolic disorders. Further studies with longitudinal design are required to confirm these findings.

Population attributable fraction estimates of cardiovascular diseases in different blood pressure levels in a large-scale cross-sectional study: a focus on prevention strategies and treatment coverage

OBJECTIVE

Hypertension is one of the major modifiable risk factors in developing cardiovascular diseases (CVD). Hence, we aimed to ascertain age- and sex-specific population attributable fraction (PAF) for CVD in different blood pressure levels to implement efficient preventive strategies at the population level.

METHODS

Participants' data were obtained from the Iranian stepwise approach for surveillance of noncommunicable disease risk factors (STEPs) survey to calculate PAF in four subsequent phases. In phase 0, PAF was measured, irrespective of the diagnosis status. In phase 1, the theoretical minimum range of 115 ≤SBP less than 130 mmHg was considered as the low-risk and measurements equal to or higher than 130 mmHg as the high-risk group. Across phase 2, patients were divided into normal and hypertensive groups based on the American College of Cardiology/American Heart Association guideline. In phase 3, patients were divided into two categories based on treatment coverage.

RESULTS

A total number of 27 165 participants aged ≥25 years had valid blood pressure measurements and were enrolled. Phase 0: PAF generally had an upward trend with age advancing. Phase 1: participants with BP ≥130 mmHg comprised the largest PAF, extending from 0.31 (0.25-0.37) in older male individuals to 0.85 (0.79-0.91) in younger females. Phase 2: higher values were found in younger ages for hypertension. Phase 3 represented that attributable fractions among hypertensive patients who received treatment were much lower than drug-naïve hypertensive participants.

CONCLUSION

Our study enlightens the necessity for implementing effective screening strategies for the younger generation and providing adequate access to antihypertensive medications for the low-risk population.

Mean versus variability of lipid measurements over 6 years and incident cardiovascular events: More than a decade follow-up

Background

Lipid variability (LV) has emerged as a contributor to the incidence of cardiovascular diseases (CVD), even after considering the effect of mean lipid levels. However, these associations have not been examined among people in the Middle East and North Africa (MENA) region. We aimed to investigate the association of 6-year mean lipid levels versus lipid variability with the risk of CVD among an Iranian population.

Methods

A total of 3,700 Iranian adults aged ≥ 30 years, with 3 lipid profile measurements, were followed up for incident CVD until March 2018. Lipid variability was measured as standard deviation (SD), coefficient of variation (CV), average real variability (ARV), and variability independent of mean (VIM). The effects of mean lipid levels and LV on CVD risk were assessed using multivariate Cox proportional hazard models.

Results

During a median 14.5-year follow-up, 349 cases of CVD were recorded. Each 1-SD increase in the mean levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), TC/high-density lipoprotein cholesterol (HDL-C), and non-HDL-C increased the risk of CVD by about 26-29%; for HDL-C, the risk was significantly lower by 12% (all p-values < 0.05); these associations resisted after adjustment for their different LV indices. Considering LV, each 1-SD increment in SD and ARV variability indices for TC and TC/HDL-C increased the risk of CVD by about 10%; however, these associations reached null after further adjustment for their mean values. The effect of TC/HDL-C variability (measured as SD) and mean lipid levels, except for LDL-C, on CVD risk was generally more pronounced in the non-elderly population.

Conclusion

Six-year mean lipid levels were associated with an increased future risk of incident CVD, whereas LV were not. Our findings highlight the importance of achieving normal lipid levels over time, but not necessarily consistent, for averting adverse clinical outcomes.

Ideal cardiovascular health status and risk of cardiovascular disease and all-cause mortality: over a decade of follow-up in the Tehran lipid and glucose study

Objective

To quantify the association between ideal cardiovascular health (CVH) metrics and incident cardiovascular disease (CVD) including different subtypes [coronary heart disease (CHD), stroke, and sudden death], and all-cause mortality in an Iranian population.

Methods

The study population included 6,388 participants (2,726 men) aged 48.0 ± 12.4 years free of CVD at baseline. We utilized the American Heart Association’s 2020 impact target criteria of ideal, intermediate, and poor CVH. The multivariate Cox proportional Hazard model, adjusted for age, sex, educational level, marital status, and family history of CVD, was applied to estimate the hazard ratio (HR) of outcomes per one additional metric of ideal CVH metrics. Furthermore, the risk was also calculated for ideal and intermediate categories considering poor category as a reference.

Results

During the median follow-up of 11.26 years, 692 CVD, 589 CHD, 130 stroke, 111 sudden death, and 519 all-cause mortality events were reported. All of the individual ideal CVH metrics were independent predictors except intermediate physical activity level for CVD, BMI &lt; 25 kg/m2, and intermediate physical activity for all-cause mortality. Each additional metrics of ideal CVH decreased the risk by 31 (0.69, 0.65–0.73) for CVD, 32 (0.68, 0.64–0.73) for CHD, 31 (0.69, 0.60–0.80) for stroke, 25 (0.75, 0.64–0.88) for sudden death, and 13% (0.87, 0.81–0.93) for all-cause mortality events. Moreover, intermediate and ideal categories of CVH metrics were associated with lower risk for different CVD outcomes, i.e., 44 (0.56, 0.48–0.65) and 76% (0.24, 0.17–0.35) for CVD; 43 (0.57, 0.47–0.67) and 75% (0.25, 0.16–0.37) for CHD, 58 (0.42, 0.29–0.61) and 86% (0.14, 0.04–0.44) for stroke; 56 (0.44, 0.29–0.66) and 55% (0.45, 0.21–0.99) for sudden death; and 25 (0.75, 0.62–0.90) and 46% (0.54, 0.37–0.80) for all-cause mortality events, respectively. We also assessed the impact of changes in ideal CVH status from phase III to phase IV (2008–2011) on CVD events among 5,666 participants. Accordingly, compared to those remaining in the poor category, all of the changes in ideal CVH categories showed a lower risk for CVD events.

Conclusion

Among the Iranian population, meeting higher ideal CVH metrics is associated with a lower risk of different CVD events and mortality outcomes.

The ten-year risk of developing cardiovascular disease among public health workers in North-Central Nigeria using Framingham and atherogenic index of plasma risk scores

BACKGROUND

Estimation of total cardiovascular disease (CVD) risk with the use of risk prediction charts such as the Framingham risk score and Atherogenic index of plasma score is a huge improvement on the practice of identifying and treating each of the risk factors such as high blood pressure and elevated blood cholesterol. The estimation of the total risk highlights that CVD risk factors occur together and thereby predicts who should be treated. There is scarcity of data on the risk scoring of adults in Nigeria including health workers. Therefore, this study was done to estimate the cardiovascular risks of health workers in public health services in north-central Nigeria.

METHODS

A cross-sectional survey was performed using validated Framingham risk score calculator and calculation of risk based on the lipid profile of 301 randomly selected health workers in North-central Nigeria. Descriptive analysis was done using frequency counts and percentages while inferential statistics were done using chi square and correlation analyses using statistical Package for Social Sciences (SPSS) version 21.0. The confidence level was 95% and the level of significance was set at 0.05.

RESULTS

The 10-year risk of developing CVD was generally low in the health workers. Using Framingham risk score, 98.3% of health workers have low risk, 1.0% have moderate risk and 0.7% have high risk. Among the cadres of health workers, 1.5% of the nurses have moderate risk while 2.5% of the doctors and 3.3% of the CHEWs have high risk of developing CVD in 10 years. Using Atherogenic index of plasma scoring, only 2% of the health workers have high risk, 4.7% have intermediate risk while 93.4% have low risk. Across the cadres, 6.3% of the nurses and 3.3% of the CHEWs have intermediate risk while 2.4% of the nurses and 3.3% of the CHEWs have high risk. These findings were however not statistically significant.

CONCLUSIONS

The 10-year risk of developing cardiovascular disease was low in the health workers in this study using both Framingham's risk score and atherogenic index of plasma scores.

A Copper-Based Biosensor for Dual-Mode Glucose Detection

Glucose is a source of energy for daily activities of the human body and is regarded as a clinical biomarker, due to the abnormal glucose level in the blood leading to many endocrine metabolic diseases. Thus, it is indispensable to develop simple, accurate, and sensitive methods for glucose detection. However, the current methods mainly depend on natural enzymes, which are unstable, hard to prepare, and expensive, limiting the extensive applications in clinics. Herein, we propose a dual-mode Cu₂O nanoparticles (NPs) based biosensor for glucose analysis based on colorimetric assay and laser desorption/ionization mass spectrometry (LDI MS). Cu₂O NPs exhibited excellent peroxidase-like activity and served as a matrix for LDI MS analysis, achieving visual and accurate quantitative analysis of glucose in serum. Our proposed method possesses promising application values in clinical disease diagnostics and monitoring.

Screening Colonoscopy Findings Are Associated With Noncolorectal Cancer Mortality

INTRODUCTION

Controversy exists regarding the impact of various risk factors on noncolorectal cancer (CRC) mortality in healthy screening populations. We examined the impact of known CRC risk factors, including baseline colonoscopy findings, on non-CRC mortality in a screening population.

METHODS

Cooperative Studies Program (CSP) #380 is comprised of 3,121 veterans aged 50-75 years who underwent screening colonoscopy from 1994 to 97 and were then followed for at least 10 years or until death. Hazard ratios (HRs) for risk factors on non-CRC mortality were estimated by multivariate Cox proportional hazards.

RESULTS

Current smoking (HR 2.12, 95% confidence interval [CI] 1.78-2.52, compared with nonsmokers) and physical activity (HR 0.89, 95% CI 0.84-0.93) were the modifiable factors most associated with non-CRC mortality in CSP#380. In addition, compared with no neoplasia at baseline colonoscopy, non-CRC mortality was higher in participants with ≥3 small adenomas (HR 1.43, 95% CI 1.06-1.94), advanced adenomas (HR 1.32, 95% CI 0.99-1.75), and CRC (HR 2.95, 95% CI 0.98-8.85). Those with 1-2 small adenomas were not at increased risk for non-CRC mortality (HR 1.15, 95% CI 0.94-1.4).

DISCUSSION

In a CRC screening population, known modifiable risk factors were significantly associated with 10-year non-CRC mortality. Furthermore, those who died from non-CRC causes within 10 years were more likely to have had high-risk findings at baseline colonoscopy. These results suggest that advanced colonoscopy findings may be a risk marker of poor health outcomes. Integrated efforts are needed to motivate healthy lifestyle changes during CRC screening, particularly in those with high-risk colonoscopy findings and unaddressed risk factors.

Association of different lipid measures with incident bone fractures: Tehran Lipid and Glucose Study

OBJECTIVE

to investigate the association between different lipid measures and long-term hospitalization-required incident fracture among Iranian men and women.

METHODS

A total of 3309 individuals aged ≥50 years (men = 1598) were included in the study. Multivariate Cox proportional hazard analyses were performed to assess the risk of incident fracture across quintiles, considering first quintile as reference, as well as for 1-standard deviation (SD) increase in each lipid measures i.e. total cholesterol (TC), triglycerides (TG), low and high density lipoprotein cholesterol (LDL-C and HDL-C, respectively), non-HDL-C, and related indices (TG/HDL-C and TC/HDL-C). Covariates included age, body mass index, current smoking, type 2 diabetes mellitus, hypertension, lipid lowering-drugs, and steroid medications (for women).

RESULTS

During a median follow-up of 18 years, incident fracture was observed in 201 cases (men=87). In both gender no linear association were found between different lipid measures and incident fracture. Among men only the fourth quartile of TG was associated with lower risk of fracture in the age adjusted analysis with hazard ratio (HR) and 95% confidence interval (CI) as [0.45 (0.21-0.95)]. Among women, the age-adjusted HRs and 95% CIs for the second, third, fourth and fifth quintiles of non-HDL-C were [0.46 (0.25-0.87)], [0.73 (0.42-1.25)], [0.90 (0.54-1.51)], [0.52 (0.29-0.95)], respectively; the corresponding values in the multivariate model, were [[0.48 (0.26-0.90)], [0.76 (0.4-1.32)], [0.94 (0.56-1.58)], and [0.52 (0.28-0.95)], respectively. The second quintile of LDL-C was also associated with lower risk for incident fracture in the multivariate analysis [0.53 (0.29-0.98)].

CONCLUSIONS

Among Iranian women a nonlinear association between non-HDL-C and LDL-C and incident fracture were found as the second and fifth quintile of the former and the second quintile of the latter were associated with about 50% lower risk of fracture .Generally our findings did not support harmful impact of these lipid measures on incident fracture.

Application of the 2017 American college of cardiology/American Heart Association Blood Pressure Guidelines for cardiovascular outcomes among Tehranian residents

OBJECTIVES

To evaluate the associations of cardiovascular disease (CVD) outcomes with elevated blood pressure (BP), stage I of isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic diastolic hypertension (SDH), defined by 2017 ACC/AHA guidelines among the Tehranian adult population.

METHOD

We enrolled 7068 residents of Tehran (district No. 13) aged at least 30 years, who were free of CVD and not taking antihypertensive medications at baseline. Participants were categorized into eight categories: normal BP (reference group), elevated BP, stage I IDH, stage I ISH, stage I SDH, and all stage II phenotypes. Significant interactions were found between age groups (<60 versus ≥60 years) and BP categories (P value: 0.017); hence, the analysis was performed in each age group, separately. We used multivariable Cox proportional regression analysis to evaluate the association of different BP categories with incident CVD.

RESULTS

During 18 years of follow-up, 1053 CVD events occurred. In the younger group, stage I of IDH and SDH were associated with increased CVD risk with hazard ratios of 1.23 (95% confidence interval: 0.99-1.52) and 1.42 (1.04-1.94), respectively. In the older group, stage I of IDH had a lower risk for coronary heart disease (CHD) [hazard ratio 0.53 (0.29-0.96)]. As a sensitivity analysis, among high CVD risk individuals (10-year risk >10%), we found a higher risk for CVD among those with elevated BP and stage I of SDH. For individuals with 10-year risk less than 10%, all BP parameters, except stage I of IDH, were associated with increased CVD risk. Although there was no significant interaction between sex and BP categories, elevated BP and stage I of SDH significantly increased the risk of CVD only among men.

CONCLUSION

Age is an important potential modifier in the association between stage I of hypertension and CVD/CHD risk. Stage I of IDH was not an alarming status for CVD development, whether the participants had a high CVD risk or not.

Hypertension and pre-hypertension in Middle East and North Africa (MENA): A meta-analysis of prevalence, awareness, treatment, and control

Hypertension (HTN) is one of the most important public health challenges, especially in developing countries. Despite individual studies, information on the exact prevalence of prehypertension (pre-HTN) and HTN in the Middle East and North Africa (MENA) is lacking. This meta-analysis was conducted to evaluate prevalence of pre-HTN and HTN, awareness, treatment, and control in the MENA region. PubMed, Web of Science, and Scopus databases were searched from inception to April 30, 2021. Keywords included hypertension, pre-hypertension, awareness, treatment, and control. The quality of the included studies was evaluated using the Hoy scale. A random-effects model was evaluated based on overall HTN. The heterogeneity of the preliminary studies was evaluated using the I² test. A total of 147 studies involving 1,312,244 participants were included in the meta-analysis. Based on the results of the random-effects method (95% CI), the Prevalence of pre-HTN and HTN were 30.6% (95% CI: 25.2, 36.0%; I² = 99.9%), and 26.2% (95% CI: 24.6, 27.9%; I² = 99.8%), respectively. The prevalence of HTN awareness was 51.3% (95% CI: 47.7, 54.8; I² = 99.0%). The prevalence of HTN treatment was 47.0% (95% CI: 34.8, 59.2; I² = 99.9%). The prevalence of HTN control among treated patients was 43.1% (95% CI: 38.3, 47.9; I² = 99.3%). Considering the high prevalence of HTN, very low awareness, and poor HTN control in the region, more attention should be paid to preventive programs for HTN reduction.

Tehran cohort study (TeCS) on cardiovascular diseases, injury, and mental health: Design, methods, and recruitment data

Cardiovascular disease, mental health, and injury are among the top health issues globally. In Tehran Cohort Study, we aimed to determine the prevalence, incidence, and trend of cardiovascular diseases, psychiatric symptoms, injury, and risk factors in Tehran households. We enrolled 4215 households in the recruitment phase from March 2016 to March 2019. Demographic characteristics, past medical history, medications, and familial history of the participants were collected. Rose angina pectoris, general health Questionnaire-28 (GHQ-28), and injury questionnaires were completed. Fasting blood samples were collected to measure routine biochemistry and store samples in the biobank. Anthropometric and physiological measurements and electrocardiograms were performed. The participants are followed every three years for up to 12 years. In total, 8296 individuals participated in the cardiovascular section, 10247 completed the GHQ-28, and 4167 households completed the injury questionnaire. The mean age of the participants was 48.2 (16.41), and 46.5% were male. 64.3% of recruited individuals had no symptoms of psychiatric disorders, and 3729 (89.5%) households did not have any severe injury requiring treatment. The participants' diversity and their invaluable data will help us provide a general picture of the current prevalence and incidence of the main study objectives.

Cardiovascular co-morbidities, inflammation and cerebral small vessel disease

Cerebral small vessel disease (cSVD) is the most common cause of vascular cognitive impairment and affects all levels of the brain's vasculature. Features include diverse structural and functional changes affecting small arteries and capillaries that lead to a decline in cerebral perfusion. Due to an aging population, incidence of cerebral small vessel disease (cSVD) is continually rising. Despite its prevalence and its ability to cause multiple debilitating illnesses, such as stroke and dementia, there are currently no therapeutic strategies for the treatment of cSVD. In the healthy brain, interactions between neuronal, vascular and inflammatory cells are required for normal functioning. When these interactions are disturbed, chronic pathological inflammation can ensue. The interplay between cSVD and inflammation has attracted much recent interest and this review discusses chronic cardiovascular diseases, particularly hypertension, and explores how the associated inflammation may impact on the structure and function of the small arteries of the brain in cSVD. Molecular approaches in animal studies are linked to clinical outcomes in patients and novel hypotheses regarding inflammation and cSVD are proposed that will hopefully stimulate further discussion and study in this important area.

Long term prognostic implication of newly detected abnormal glucose tolerance among patients with stable cardiovascular disease: a population-based cohort study

Background

Fasting plasma glucose (FPG) and 2-h post challenge plasma glucose (2 h-PCPG), whether as continuous or categorical variables, are associated with incident cardiovascular disease (CVD) and diabetes; however, their role among patients with existing CVD is a matter of debate. We aimed to evaluate associations of different glucose intolerance states with recurrent CVD and incident diabetes among subjects with previous CVD.

Methods

From a prospective population-based cohort, 408 Iranians aged  ≥  30 years, with history of CVD and without known diabetes were included. Associations of impaired fasting glucose (IFG) according to the American Diabetes Association (ADA) and World Health Organization (WHO) criteria, impaired glucose tolerance (IGT), newly diagnosed diabetes (NDM) with outcomes of interest were determined by multivariable Cox proportional hazard models after adjustment for traditional risk factors. Furthermore, FPG and 2 h-PCPG were entered as continuous variables.

Results

Over a decade of follow-up, 220 CVD events including 89 hard events (death, myocardial infarction and stroke) occurred. Regarding prediabetes, only IFG-ADA was associated with increased risk of hard CVD [hazard ratio(HR), 95%CI: 1.62,1.03–2.57] in the age-sex adjusted model. In patients with NDM, those with FPG ≥ 7 mmol/L were at higher risk of incident CVD/coronary heart disease(CHD) and their related hard outcomes (HR ranged from 1.89 to 2.84, all P < 0.05). Moreover, those with 2 h-PCPG ≥ 11.1 mmol/L had significant higher risk of CVD (1.46,1.02–2.11), CHD (1.46,1.00–2.15) and hard CHD (1.95:0.99–3.85, P = 0.05). In the fully adjusted model, each 1 SD increase in FPG was associated with 20, 27, 15 and 25% higher risk of CVD, hard CVD, CHD and hard CHD, respectively; moreover each 1 SD higher 2 h-PCPG was associated with 21% and 16% higher risk of CVD, and CHD, respectively. Among individuals free of diabetes at baseline (n = 361), IFG-ADA, IFG-WHO and IGT were significantly associated with incident diabetes (all P < 0.05); significant associations were also found for FPG and 2 h-PCPG as continuous variables (all HRs for 1-SD increase > 2, P < 0.05).

Conclusions

Among subjects with stable CVD, NDM whether as high FPG or 2 h-PCPG, but not pre-diabetes status was significantly associated with CVD/CHD and related hard outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-02950-y.

Sex-specific incidence rates and risk factors for fracture: A 16-year follow-up from the Tehran lipid and glucose study

OBJECTIVE

To examine the population-based incidence of any-fracture and its potential risk factors in a sex-split cohort of the Iranian population.

MATERIALS AND METHODS

A total of 3477 men and 4085 women with a mean (SD) age of 47.92(13.1) and 45.88(11.47) years, respectively were entered into the study. The age-standardized incidence rates per 100,000 person-years were reported for the whole population and each sex separately. Cox proportional hazard models were used to estimate hazard ratios (HR) for potential risk factors. Only fractures requiring inpatients' care were considered as the outcome. We also defined major osteoporotic fractures (MOF) as the composite of the fractures that occurred in the vertebral, wrist, hip and pelvic sites among population aged ≥50 years.

RESULTS

During the median (IQR) follow-up of 15.9 years, 4.34%men and 3.75% women experienced at least one incident any-fracture. The annual age-standardized incidence rates (95% CI) among men and women were 330.9 (279.6-388.9) and 319.4(268.1-377.3) per 100,000 person-years, respectively; the corresponding values for incidence of MOF was 202.2(142.3-278.6) in men and 342.1(260.4-441.0) per 100,000 person-years for women. In the multivariable model, among the whole population, age groups ≥50 years, central obesity [HR: 95% CI 1.77(1.32-2.39)], current smoking [1.59(1.15-2.20)] and using steroid medications [2.20(1.04-4.67)] significantly increased the risk of incident fracture (all P < 0.05); however the impact of the first two risk factors were more prominent among women (P for interaction ≤0.01). Moreover, being obese was associated with a lower risk of incident first fracture in the total population [HR: 95% CI: 0.61(0.40-0.92)]. Being men [HR: 95% CI: 0.54(0.30-0.99)] and prediabetes status [HR: 95% CI: 0.53(0.30-0.95)] were also associated with lower risk for MOF.

CONCLUSION

This is the first report of long-term incidence rate of any-fracture and MOF conducted in the metropolitan city of Tehran. Among modifiable risk factors of fracture, in the whole population smoking habit and using steroid medications and particularly for women central obesity should be considered as main risk factors for preventive strategies. Prediabetes status was associated with lower risk of MOF.

Impact of short- and long-term exposure to air pollution on blood pressure: A two-decade population-based study in Tehran

Plenty of recent studies on the impact of air pollution on blood pressure (BP) exist; however, there is a lack of data for the highly polluted Eastern Mediterranean region. We evaluated the associations of short-term exposure to air pollutants with systolic BP (SBP) and diastolic BP (DBP) and the long-term impact of air pollutants on incident hypertension, among Tehranian adults. In the Tehran Lipid and Glucose Study, 4580 nonhypertensive participants aged 20-69 years (41.6% male) were followed from 2001 to 2018 through 3-year follow-ups and 4-5 examinations of them were recorded. The air pollutants included particulate matter with a diameter ≤10 μm (PM₁₀), carbon monoxide (CO), ozone (O₃), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂). The mixed-effects transition model estimated the air pollution impact on BP. The proportional hazards Weibull model measured the long-term effects of air pollutants on the multivariate hazard of incident hypertension. The air pollutants were put in the models in the form of mean annual level, applying three versions of 1, 2, and 3 years before the follow-ups. During a median follow-up of 12.3 years, 1618 cases of hypertension were found. In the short-term, increase in CO did not affect SBP but decreased DBP with a delay effect lasting for 14 days; increase in NO₂ raised SBP with a 14-day lag, however did not change DBP; increase in O₃ reduced SBP with a 14-day lag but made slight non-significant increase in DBP; rise in PM₁₀ concentrations led to increased SBP (lag 0-3 days) and DBP with lags of 0-3 days and 12-14 days and increase in SO₂ made the largest increases in DBP with lags lasting for 14 days, but did not affect SBP. Regarding incident hypertension in the long-term, the increase in CO had no significant effect; increase in NO₂ decreased the risk over the 2- and 3-year time spans; rise in O₃, PM₁₀, and SO₂ levels increased the risk in all time spans; the largest hazard ratio [1.96 (95% CI: 1.48, 2.62)] for incident hypertension was attributable to PM₁₀ in 3 years. Considering the major effects of air pollutants including O₃, SO₂, and especially PM₁₀ on incident hypertension, urgent public health policies should be implemented to reduce the burden of air pollution in metropolitan city of Tehran.

National trends in cardiovascular health metrics among Iranian adults using results of three cross-sectional STEPwise approaches to surveillance surveys

To examine the trends of 7 cardiovascular health metrics (CVH metrics) incorporate of smoking, physical activity, diet, body mass index (BMI), fasting plasma glucose (FPG), total cholesterol (TC), and blood pressure (BP) level during three cross-sectional STEPwise approaches to surveillance (STEPS), 2007-2016, among Iranian adults. The study population consisted of 19,841 women and 17,243 men, aged 20-65 years. The CVH metrics were categorized as 'ideal', 'intermediate', and 'poor'. The sex-stratified weighted prevalence rate of each CVH metrics was reported. The conditional probability of each poor versus combined intermediate and ideal metric was analyzed using logistic regression. In 2016 compared to 2007, the prevalence of poor BP level (20.4% vs. 23.7%), smoking (13.7% vs. 23.8%), TC ≥ 240 mg/dl (2.4% vs. 11.2%) and FPG < 100 mg/dl (75.6% vs. 82.3%) declined, whereas poor physical activity level (49.7% vs. 30%), poor healthy diet score (38.1% vs. 4.1%), BMI levels ≥ 25 kg/m2 (62.8% vs. 57.8%) increased. Despite a high prevalence of obesity among women, it remained constant in women but showed an increasing trend in men; moreover, the trends of low physical activity and current smoking were better for women. Despite some improvement in CVH metrics, < 4% of Iranian adults meet ≥ 6 CVH metrics in 2016; this issue needs intervention at the public health level using a multi-component strategy.

Estimating the attributable risk of vascular disorders in different ranges of fasting plasma glucose and assessing the effectiveness of anti-diabetes agents on risk reduction; questioning the current diagnostic criteria

INTRODUCTION

Attributable risk of cardiovascular disorders (CVDs) and chronic kidney disease (CKD) in association with diabetes and pre-diabetes is under debate. Moreover, the role of anti-diabetes agents in risk reduction of such conditions is obscure. The purpose of this work is to define the population attributable fraction (PAF) of CVDs and CKD in different rages of plasma glucose.

METHOD

Iranian stepwise approach for surveillance of non-communicable disease risk factors (STEPs) was used to calculate PAF in four subsequent phases. Phase 0: whole population regardless of diagnosis; Phase I: in three CVD risk groups: minimal risk (FPG < 100 mg/dL), low risk (FPG 100-126 mg/dL), and high risk (FPG ≥ 126 mg/dL) groups; Phase II: three diagnostic groups: normal, pre-diabetes, and diabetes; Phase III: diabetes patients either receiving or not receiving anti-diabetes agents.

RESULT

A total of 19,503 participants [female-to-male ratio 1.17:1] had at least one FPG measurement and were enrolled. Phase 0: PAF of young adults was lower in the general population (PAF range for CVDs 0.05 ─ 0.27 [95% CI 0.00 ─ 0.32]; CKD 0.03 ─ 0.41 [0.00 ─ 0.62]). Phase I: High-risk group comprised the largest attributable risks (0.46 ─ 0.97 [0.32 ─ 1]; 0.74 ─ 0.95 [0.58 ─ 1]) compared to low-risk (0.16 ─ 0.41 [0.04 ─ 0.66]; 0.29 ─ 0.35 [0.07 ─ 0.5]) and minimal risk groups (negligible estimates) with higher values in young adults. Phase II: higher values were detected in younger ages for diabetes (0.38 ─ 0.95 [0.29 ─ 1]; 0.65 ─ 0.94 [0.59 ─ 1] and pre-diabetes patients (0.15 ─ 0.4 [0.13 ─ 0.45]; 0.26 ─ 0.35 [0.22 ─ 0.4]) but not normal counterparts (negligible estimates). Phase III: Similar estimates were found in both treatment (0.31 ─ 0.98 [0.17 ─ 1]; 0.21 ─ 0.93 [0.12 ─ 1]) and drug-naïve (0.39 ─ 0.9 [0.27 ─ 1]; 0.63 ─ 0.97 [0.59 ─ 1]) groups with larger values for younger ages.

CONCLUSION

Globalized preventions have not effectively controlled the burden of vascular events in Iran. CVDs and CKD PAFs estimated for pre-diabetes were not remarkably different from normal and diabetes counterparts, arguing current diagnostic criteria. Treatment strategies in high-risk groups are believed to be more beneficial. However, the effectiveness of medical interventions for diabetes in controlling CVDs and CKD burden in Iran is questionable.

Role of Cannabis in the Incidence of Myocardial Infarction: A Review

Legalizing cannabis use in various states in the United States has caused increased substance abuse, mostly among young people. There are very little data focussing on marijuana use and myocardial infarction (MI) incidence. The objective of the study is to analyze the published papers for cannabis-induced MI and derive a strong relation between cannabis use and MI and understand the pathophysiology. An online search was conducted in PubMed, Google Scholar, and PubMed Central to find relevant publications examining patients who developed MI due to cannabis use. Out of 32 articles that were identified for this review, 17 are case reports, one is a letter to the editor, eight are observational studies, and six are review articles. Many studies have proposed different mechanisms by which cannabis affects the body. Our study shows that marijuana can precipitate MI even if it is used for the first time. Limited data is available to comment on the mortality of patients after cannabis-induced MI. These findings highlight the necessity for public awareness to prevent the ill-effects of cannabis, especially for teenagers and older people.

Sex-specific prevalence of coronary heart disease among Tehranian adult population across different glycemic status: Tehran lipid and glucose study, 2008-2011

Background

Coronary heart disease (CHD) is one of the leading causes of death. Alarmingly Iranian populations had a high rank of CHD worldwide. The current study aimed to assess the prevalence of CHD across different glycemic categories.

Methods

This study was conducted on 7718 Tehranian participants (Men = 3427) aged ≥30 years from 2008 to 2011. They were categorized based on glycemic status. The prevalence of CHD was calculated in each group separately. CHD was defined as hospital records adjudicated by an outcome committee. The association of different glycemic categories with CHD was calculated using multivariate logistic regression, compared with normal fasting glucose /normal glucose tolerance (NFG/NGT) group as reference.

Results

The age-standardized prevalence of isolated impaired fasting glucose (iIFG), isolated impaired glucose tolerance (iIGT), both impaired fasting glucose and impaired glucose tolerance (IFG/IGT), newly diagnosed diabetes mellitus (NDM), and known diabetes mellitus (KDM) were 14.30% [95% confidence interval (CI): 13.50–15.09], 4.81% [4.32–5.29], 5.19% [4.71–5.67], 5.79% [5.29–6.28] and 7.72% [7.17–8.27], respectively.

Among a total of 750 individuals diagnosed as cases of CHD (398 in men), 117 (15.6%), 453 (60.4%), and 317 (42.3%) individuals had a history of myocardial infarction (MI), cardiac procedure, and unstable angina, respectively. The age-standardized prevalence of CHD for the Tehranian population was 7.71% [7.18–8.24] in the total population, 8.62 [7.81–9.44] in men and 7.19 [6.46–7.93] in women. Moreover, among diabetic participants, the age-standardized prevalence of CHD was 13.10 [9.83–16.38] in men and 10.67 [8.90–12.44] in women, significantly higher than corresponding values for NFG/NGT and prediabetic groups.

Across six levels of glycemic status, CHD was associated with IFG/IGT [odds ratio (OR) and 95% CI: 1.38 (1.01–1.89)], NDM [1.83 (1.40–2.41)], and KDM [2.83 (2.26–3.55)] groups, in the age- and sex-adjusted model. Furthermore, in the full-adjusted model, only NDM and KDM status remained to be associated with the presence of CHD by ORs of 1.40 (1.06–1.86) for NDM and 1.91 (1.51–2.43) for KDM.

Conclusion

The high prevalence of CHD, especially among diabetic populations, necessitates the urgent implementation of behavioral interventions in the Tehranian population, according to evidence-based guidelines for the clinical management of diabetic patients.

The impact of triglyceride-glucose index on incident cardiovascular events during 16 years of follow-up: Tehran Lipid and Glucose Study

BACKGROUND

To investigate whether the Triglyceride-Glucose index (TyG-index) is associated with increased risk of cardiovascular diseases (CVD)/coronary heart disease (CHD).

METHODS

A total of 7521 Iranians aged ≥ 30 years (male = 3367) were included in the study. Multivariate Cox regression analyses (adjusted for age, gender, waist circumference, body mass index, educational level, smoking status, physical activity, family history of CVD, type 2 diabetes, hypertension, low and high density lipoprotein cholesterol, and lipid lowering drugs) were used to assess the risk of incident CVD/CHD across quintiles and for 1-standard deviation (SD) increase in the TyG-index. The cut off point for TyG-index was assessed by the minimum value of [Formula: see text]. We also examined the added value of the TyG-index in addition to the Framingham risk score when predicting CVD.

RESULTS

During follow-up, 1084 cases of CVD (male = 634) were recorded. We found a significant trend of TyG-index for incident CVD/CHD in multivariate analysis (both Ps for tend ≤ 0.002). Moreover, a 1-SD increase in TyG-index was associated with significant risk of CVD/CHD in multivariate analysis [1.16 (1.07-1.25) and 1.19 (1.10-1.29), respectively]. The cut-off value of TyG-index for incident CVD was 9.03 (59.2% sensitivity and 63.2% specificity); the corresponding value of TyG-index for incident CHD was 9.03 (60.0% sensitivity and 62.8% specificity), respectively. Although no interaction was found between gender and TyG-index for CVD/CHD in multivariate analysis (both Ps for interaction > 0.085), the significant trend of TyG-index was observed only among females for incident CVD (P = 0.035). A significant interaction was found between age groups (i.e. ≥ 60 vs < 60 years) and TyG-index for CVD outcomes in the multivariate model (P-value for interaction = 0.046). Accordingly, a significant association between the TyG-index and outcomes was found only among the younger age group. Among the population aged < 60 the addition of TyG-index to the Framingham risk score (FRS) did not show improvement in the predictive ability of the FRS, using integrated discrimination improvement.

CONCLUSION

The TyG-index is significantly associated with increased risk of CVD/CHD incidence; this issue was more prominent among the younger population. However, adding TyG-index to FRS does not provide better risk prediction for CVD.

Estimation of Generalized Impact Fraction and Population Attributable Fraction of Hypertension Based on JNC-IV and 2017 ACC/AHA Guidelines for Cardiovascular Diseases Using Parametric G-Formula: Tehran Lipid and Glucose Study (TLGS)

Purpose

An area of interest to health policymakers is the effect of interventions aimed at risk factors on decreasing the number of new cardiovascular disease (CVD) cases. The aim of this study was to estimate the generalized impact fraction (GIF) and population attributable fraction (PAF) of hypertension (HTN) for CVD in Tehran.

Patients and Methods

In this population-based cohort study, 8071 participants aged ≥30 years were followed for a median of 16 years. A survival model was used to estimate the 10- and 18-year risk of CVD. JNC-IV and 2017 ACC/AHA guidelines were used to categorize blood pressure (BP). PAF and GIF were estimated in different scenarios using the parametric G-formula.

Results

Of 7378 participants included in analyses, 22.7% and 52.3% were classified as hypertensive according to the JNC-IV and 2017 ACC/AHA guidelines, respectively. According to the 2017 ACC/AHA, the 10-year risk of CVD was 5.1% (4.3–6.0%), 8.9% (6.7–12.0%), and 7.1% (6.1–8.4%) for normal BP, elevated BP, and stage 1 HTN, respectively, and 20.8% (18.8–23.0%) for stage 2 of the 2017 ACC/AHA and JNC-IV. The PAF of stage 2 vs stage 1 and vs normal BP for CVD was 17.4% (11.5–21.8%) and 20.4% (14.6–26.4%), respectively. The GIF of 30% reduction in the prevalence of stage 2 HTN to stage 1 and to normal BP for CVD was 5.1% (3.4–6.6%) and 6.1% (4.4–8.0%), respectively. Based on JNC-IV, the PAF and GIF of 30% for CVD were 17.8% (12.7–22.9%) and 5.4% (4.0–6.9%), respectively.

Conclusion

By reducing the prevalence of HTN by 30%, a remarkable number of new CVD cases would be prevented. In an Iranian population, the comparison of HTN cases with normal BP showed no association between stage 1 HTN and CVD, whereas elevated BP was a significant risk factor for the incidence of CVD.

Multi-state analysis of hypertension and mortality: application of semi-Markov model in a longitudinal cohort study

Background

Most previous research has studied the association of hypertension with cardiovascular disease (CVD) and all-cause mortality by focusing on the transition from the initial state to a single outcome. We investigated the impact of hypertension, defined according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) (new) and the Seventh Report of the Joint National Committee (JNC7) (old), on CVD death and all-cause mortality considering non-fatal CVD as an intermediate event between two CVD-free and mortality states.

Methods

A total of 3002 Iranian population (47.4% men), aged ≥50 years were followed from 1999 to 2014. Two multi-state semi-Markov models with three transitions were defined for CVD death and all-cause mortality as two outcomes. The multivariable Cox model was used to estimate the effect of hypertension on transition hazards. The mean of 15-year life expectancy of participants in each transition was estimated using the restricted mean survival time.

Results

The ACC/AHA guideline increased the prevalence of hypertension from 43.3 to 68.6%. Among CVD-free individuals, hypertension was significantly associated with increased risk of non-fatal CVD [Hazard Ratio, 1.52 (1.28–1.81) and 1.48 (1.21–1.80)], CVD death [2.96 (2.06–4.25) and 1.98 (1.30–3.04)] and all-cause mortality [1.64 (1.32–2.05) and 1.31 (1.01–1.69)] according the old and new guidelines, respectively. However, after incident non-fatal CVD, the association between hypertension and mortality events was not significant according to both definitions. Hypertensive participants experienced a first non-fatal CVD about 0.9 and 0.6 years earlier than normotensive population according to JNC7 and the 2017 ACC/AHA guidelines, respectively.

Conclusion

Hypertension, according to JNC7 and the ACC/AHA guidelines, significantly increased the risk of mortality events among CVD-free population although the risk was attenuated using ACC/AHA guideline. Hypertension also decreased the number of years lived without CVD and early onset of CVD, and consequently, an increase in the time spent with these diseases. After non-fatal CVD, hypertension had no significant impact on mortality risk according to both guidelines.

External validation of the European risk assessment tool for chronic cardio-metabolic disorders in a Middle Eastern population

BACKGROUND

High burden of chronic cardio-metabolic disorders including type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and cardiovascular disease (CVD) have been reported in the Middle East and North Africa region. We aimed to externally validate a non-laboratory risk assessment tool for the prediction of the chronic cardio-metabolic disorders in the Iranian population.

METHODS

The predictors included age, body mass index, waist circumference, use of antihypertensive medications, current smoking, and family history of cardiovascular disease and/or diabetes. For external validation of the model in the Tehran lipids and glucose study (TLGS), the Area under the curve (AUC) and the Hosmer-Lemeshow (HL) goodness of fit test were performed for discrimination and calibration, respectively.

RESULTS

Among 1310 men and 1960 women aged 28-85 years, 29.5% and 47.4% experienced chronic cardio-metabolic disorders during the 6 and 9-year follow-up, respectively. The model showed acceptable discrimination, with an AUC of 0.72 (95% CI 0.69-0.75) for men and 0.73 (95% CI 0.71-0.76) for women. The calibration of the model was good for both genders (min HL P = 0.5). Considering separate outcomes, AUC was highest for CKD (0.76 (95% CI 0.72-0.79)) and lowest for T2DM (0.65 (95% CI 0.61-0.69)), in men. As for women, AUC was highest for CVD (0.82 (95% CI 0.78-0.86)) and lowest for T2DM (0.69 (95% CI 0.66-0.73)). The 9-year follow-up demonstrated almost similar performances compared to the 6-year follow-up. Using Cox regression in place of logistic multivariable analysis, model's discrimination and calibration were reduced for prediction of chronic cardio-metabolic disorders; the issue which had more effect on the prediction of incident CKD among women. Moreover, adding data of educational levels and marital status did not improve, the discrimination and calibration in the enhanced model.

CONCLUSION

This model showed acceptable discrimination and good calibration for risk prediction of chronic cardio-metabolic disorders in short and long-term follow-up in the Iranian population.

Prevalence of modifiable cardiovascular risk factors in Yazd inner-city municipalities

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the world. With effective intervention and control of cardiovascular risk factors, mortality rates may be reduced. The aim of this study was to investigate the prevalence of modifiable risk factors across five municipalities in Yazd city.

METHODS

Ten thousand residents of the Yazd greater area aged 20-69 years were selected using cluster random sampling method. Overall, 200 clusters were randomly selected based on the postcodes of residents who lived in the five municipalities of Yazd. Those who lived in Yazd annexed cities and rural areas were excluded. A valid questionnaire was completed and physical examination performed as done (94.9% response rate). Instances of self-reported diabetes mellitus, high blood cholesterol, tobacco smoking, and unhealthy diet were recorded. Blood pressure, height, and weight were measured and physical activity was classified by International Physical Activity Questionnaire (IPAQ). A chi-square test was used to analyze the differences in variables across municipalities. Statistical analyses were performed using SPSS V. 16.

RESULTS

We analyzed 8749 participants' data from Yazd city. The prevalence of diabetes mellitus, hypercholesterolemia, and hypertension were 14.1, 16.7 and 18.6%, respectively. One in every four people consumed the recommended five servings of vegetables per day. Fish consumption was less than 5% at least once a week among participants. An unhealthy diet (85.7%); low physical activity (52.2%), hypertension (36.7%) and obesity (26.3%) were the most common cardiovascular risk factors. Only 2.1% of adults had no risk factors for CVD, and almost 75% of people had more than one risk factor. The prevalence of risk factors (excluding hypertension) was significantly different across the municipalities. Residents of region three had the highest prevalence of all risk factors aside from inactivity and unhealthy diet.

CONCLUSION

unhealthy dietary habits and inactivity are the most common modifiable risk factors of CVD in Yazd. Spatial variations of cardiovascular risk factors observed. This geographic health inequality requires more attention from policymakers to control CVD risk factors across different municipalities accordingly. Promoting healthy lifestyle is the top priority of health intervention programs. It is recommended to increase access to sport arenas and restrict access to tobacconist in high-risk areas.

Risk of complications among diabetics self-reporting oral health status in Canada: A population-based cohort study

BACKGROUND

Periodontitis has been associated with diabetes and poor health. While clear associations have been identified for the diabetes-oral health link, less is known about the implications of poor oral health status for incident complications of diabetes. This study investigated the risk of diabetes complications associated with self-reported "poor to fair" and "good to excellent" oral health among diabetics living in Ontario, Canada.

METHODS

This was a cohort study of diabetics who took part in the Canadian Community Health Survey (2003 and 2007-08). Self-reported oral health was linked to electronic health records held at the Institute for Clinical Evaluative Sciences. Participants aged 40 years and over, who self-reported oral health status in linked databases were included (N = 5,183). Cox proportional hazard models were constructed to determine the risk of diabetes complications. Participants who did not experience any complications were censored. Models were adjusted for age and sex, followed by social characteristics and behavioural factors. The population attributable risk of diabetes complications was calculated using fully adjusted hazard ratios.

RESULTS

Diabetes complications differed by self-reported oral health; 35% of the total sample experienced a complication and 34% of those reporting "good to excellent" oral health (n = 4090) experienced a complication in comparison to 38% of those with "fair to poor" oral health (n = 1093). For those reporting "poor to fair" oral health, the hazard of a diabetes complication was 30% greater (HR 1.29; 95% CI: 1.03, 1.61) than those reporting "good to excellent" oral health. The population level risk of complications attributable to oral health was 5.2% (95% CI: 0.67, 8.74).

CONCLUSIONS

Our findings indicate that reporting "poor to fair" oral health status may be attributed to health complications among diabetics, after adjusting for a wide range of confounders. This has important public health implications for diabetics in Ontario, Canada.

Is enneagram personality system able to predict perceived risk of heart disease and readiness to lifestyle modification?

BACKGROUND

Studying personality traits and patterns is of significant importance in adopting healthy behaviors. Therefore, the current study investigates the relationship between Enneagram personality types and perceived risk of heart disease and readiness to lifestyle modification.

METHODS

In this cross-sectional study, 190 noncardiac patients (82.3% female) in an outpatient clinic in western Iran were selected using a simple random sampling method to fill out standard questionnaires. The obtained data were analyzed using Pearson's correlation coefficient and linear regression analysis.

RESULTS

The findings show that the performer personality (Type 3) can directly predict increasing readiness to lifestyle modification (P < 0.001). In contrast, there is a reverse significant relationship between the challenger personality (Type 8) and readiness to lifestyle modification (P = 0.019). Moreover, the helper personality (Type 6) is able to directly predict increasing the perceived risk of heart disease (P = 0.012).

CONCLUSIONS

In the Enneagram system, unique personality types possess a unique risk perception and readiness to adopt healthy behaviors. The results of the current study can provide valuable information for healthy lifestyle programs professionals with regard to preventing cardiovascular diseases.

Gestational diabetes mellitus in mothers and long term cardiovascular disease in both parents: Results of over a decade follow-up of the Iranian population

BACKGROUND AND AIMS

We aimed at evaluating whether the presence of gestational diabetes mellitus (GDM) in mothers is associated with increased risk of incident cardiovascular disease (CVD) in both mothers and fathers.

METHODS

In this population-based study, 4308 Iranian women, aged 18-64 years, with at least 1 live-birth delivery, and free of CVD at baseline, were followed. Corresponding spouses were identified in 2547 cases. The association between history of GDM and incident CVD was assessed using multivariate Cox's proportional hazard in 3 models: model 1, unadjusted; model 2, adjusted for age, body mass index, smoking (for men), maternal parity, miscarriage, physical activity, hypertension and hypercholesterolemia, and model 3, further adjusted for diabetes mellitus.

RESULTS

After a median follow-up of 14.1 years, 314 mothers and 424 fathers experienced CVD. Women with history of GDM had an adjusted hazard ratio (HR), 95% CI of 1.85 (1.38-2.48) and 1.29 (0.96-1.75) for CVD in models 1 and 2, respectively. Furthermore, an independent association with CVD was observed in fathers with an adjusted HR of 1.35 (1.02-1.79) in the confounder adjusted model and even after further controlling for diabetes [1.36 (1.03-1.80)]. Moreover, all traditional risk factors, excluding BMI, showed an independent risk for CVD in both genders.

CONCLUSIONS

Women with prior GDM showed an increased risk of CVD that was not independent of important CVD risk factors. However, among men, spousal history of GDM was an independent risk factor for incident CVD, even after considering important traditional risk factors, including diabetes.

Role of perceived heart risk factors by outpatient population in predicting cardiovascular risk

Introduction: Regarding the expanding population in developing countries who are at risk for cardiovascular diseases (CVDs), identification and management of effective factors are important in reducing the risk of CVDs. So, the present study aimed to assess the role of perceived heart risk factors (PHRFs) in the prediction of cardiovascular risk among outpatient patients. Methods: The samples of this cross-sectional study included 150 outpatient patients who attend the clinic of Imam Reza hospital during October-December 2016. The participants were completed the Perceived Heart Risk Factors Scale (PHRFS) and Cardiovascular Risk Assessment Questionnaire (CRAQ). Data analyzed through Pearson correlation and multiple regression analyses. Results: Based on the findings, 28%, 40%, 22.7%, and 9.3% of patients were low, medium, high, and severely high-risk, respectively. The strongest predictors of the cardiovascular risk were physiological (β=-0.273; P=0.004), psychological (β=0.236; P=0.020), and biological risk factors (β=0.209; P=0.016), respectively. In addition, the strongest predictor of the lifestyle risk was physiological risk factors (β=-0.264; P=0.007). Other variables do not play a significant role in predict the lifestyle risk (P>0.05). Our model was able to explain 9.2% of cardiovascular risk variance and 5.7% of cardiovascular risk caused by lifestyle variance. Conclusion: The higher patients' perception about biological and psychological risk factors is concerned as an alarm for increased cardiovascular risk while higher perception about physiological risk factors is associated with reduced cardiovascular risk caused by lifestyle and total cardiovascular risk. The programs reducing cardiovascular risk should target the high-risk groups to save cost and time.

Physiological, anthropometric parameters, and balance skill response of healthy bankers to fitness training

Sedentary lifestyle as a predisposing factor of chronic diseases like hypertension, diabetes, stroke and obesity is a common phenomenon in the banking job. Studies suggest that fitness training improves health of bankers but has not been established among Ghanaian bankers. This study examined the physiological, anthropometric parameters, and balance skill responses of relatively healthy bankers to fitness training. Twelve bankers aged 28 to 55 years (36.41±7.16 years) in Kumasi completed a 6-month fitness training program (FTP) of 30-min gym workouts and 1-hr swimming per session. Physiological, anthropometric parameters, and balance skill variables assessments were conducted in three trials: pretraining, midtraining and post-FTP. FTP caused significant decrease in pre-post systolic blood pressure (P=0.001), diastolic blood pressure (P=0.000), heart rate (P=0.006), waist circumference (P= 0.007), waist-to-hip ratio (P=0.007), and bone density (P=0.038). There was significance decrease in body mass index (P=0.047) between pre- and midtraining status. Weight significantly decreased among the three trials (P=0.017). Pre-post opened (P=0.043) and closed (P=0.015) eye balance skills increased significantly. Effects of FTP were significantly higher in female (P<0.05). Participants who were at the stage 1 and 2 hypertensions pretraining became normotensive posttraining. Six months FTP has beneficial effects on the physiological, anthropometric parameters, and balance skill of relatively healthy bankers.

Serum nitric oxide metabolites and hard clinical endpoints: a population-based prospective study

Objective. Limited data are available regarding prognostic value of nitric oxide metabolites (NOx) for clinical hard end points. In this study, we defined optimum cut-off values of serum NOx for predicting all-cause and cardiovascular disease (CVD) mortality events and prospectively investigated their hazards in the presence of traditional risk factors. Design. Serum NOx concentrations were measured at baseline (2006-2008) and 3520 adult men and women were followed during 7.7 years for all-cause and cardiovascular disease (CVD) mortality. To determine the optimal cut-off points of serum NOx, the receiver operator characteristic (ROC) curve analysis was used. Multivariate Cox proportional hazard models were used to estimate the hazard ratios (HRs) with 95% confidence intervals (95% CIs) of all-cause and CVD mortality below and above the defined optimal cut-off points of serum NOx. Results. Mean age of participants was 44.5 ± 16.0 years at baseline and 40.2% were male. Median (inter-quartile range) of serum NOx levels was 25.0 µmol/L (19.0-37.0), at baseline. The optimal cut-off points of serum NOx levels for predicting CVD and all-cause mortality were 30.5 and 32.5 µmol/L, respectively. In the presence of age, sex, body mass index, smoking, type 2 diabetes, hypertension, and history of CVD, a significant increased risk of CVD mortality (HR = 1.98, 95% CI = 1.10-3.58) and all-cause mortality (HR = 1.52, 95% CI = 1.05-2.21) was observed for serum NOx values higher than their cut-offs. Conclusion. Serum NOx level may be predictor of CVD mortality and death, in general populations.

Prevalence of Stroke and Associated Risk Factors in Sleman District of Yogyakarta Special Region, Indonesia

BACKGROUND

Stroke remains one of the most common noncommunicable diseases among Indonesian populations. This study aimed to identify the prevalence of stroke and its associated risk factors in the Sleman District of Yogyakarta Special Region, Indonesia.

METHOD

This study was a secondary analysis of community-based data collected by the Sleman Health and Demographic Surveillance System (HDSS) in 2016. Basic demographic and socioeconomic data were collected. Additional questions about history of stroke and other chronic diseases were interviewed as a self-reported diagnosis. History of hormonal contraceptives use and dietary patterns were also collected. We examined the association between the prevalence of stroke and risk factors, namely, age, gender, self-reported history of chronic diseases, hormonal contraceptives use, and high-risk dietary patterns.

RESULTS

The survey included 4,996 households composed of 20,465 individuals. Data regarding stroke incidents were available from 13,605 subjects aged ≥20 years old. Among them, a total of 4,884 subjects also have data regarding stroke risk factors. The overall prevalence of stroke in Sleman District was 1.4% (0.5% men and 0.90% women). The prevalence increased with additional decades of age (p<0.001). In a multivariable model, increasing age, self-reported history of hypertension (OR=8.37, 95%CI: 4.76 to 14.69), and self-reported history of diabetes mellitus (OR=2.87, 95%CI: 1.54 to 5.35) were significantly associated with stroke.

CONCLUSIONS

A community-based survey in Indonesia showed a high prevalence of stroke which was associated with increasing age, hypertension, and diabetes mellitus. These findings suggest that preventive actions against the aforementioned modifiable risk factors should be prioritized.

Body mass index trajectories from adolescent to young adult for incident high blood pressure and high plasma glucose

Objectives

To explore the association between sex-specific adiposity trajectories among Adolescents to early adulthood with incident high blood pressure (HBP) and high plasma glucose (HPG).

Methods

We studied body mass index (BMI) trajectories among1159 (male = 517) and 664 (male = 263) Iranian adolescents, aged 12–20 years, for incident HPG and HBP, respectively. Latent Class Growth Mixture Modeling (LCGMM) on longitudinal data was used to determine sex-specific and distinct BMI trajectories. Logistic regressions were applied to estimate the relationship between latent class membership with HBP and HPG, considering normal trajectory as the reference.

Results

For both HBP and HPG, LCGMM determined two and three distinct BMI trajectories in males and females, respectively. During a follow-up of 12Years 104 (male = 62) and 111(male = 59) cases of HPG and HBP were found, respectively. Among females, faster BMI increases (i.e. overweight to early obese trajectory) but not overweight (i.e. those with BMI = 27.3 kg/m² at baseline) trajectories increased the risk of HPG by adjusted odds ratios (ORs), 2.74 (1.10–5.80) and 0.79 (0.22–2.82), respectively; regarding HBP, the corresponding value for overweight to late obese trajectory was 3.72 (1.37–11.02). Among males, for HBP, the overweight trajectory increased the risk [2.09 (1.04–4.03)]; however, for incident HPG, none of the trajectories showed significant risk.

Conclusions

Among females, trend of increasing BMI parallel with age can be a better predictor for risk of developing HPG and HBP than those with higher BMI at baseline.

Status of Hypertension in Tehran: Potential impact of the ACC/AHA 2017 and JNC7 Guidelines, 2012-2015

This study aimed to determine the prevalence of hypertension, the recommended anti-hypertensive therapy and the percentage of hypertensive patients who had achieved the blood pressure (BP) target according to 2017 American College of Cardiology/American Heart Association (ACC/AHA) versus JNC7 and 8 guidelines, among Iranian population. Data of participants aged ≥20 years from the fifth phase (2012-2015) of the Tehran lipid and glucose study (N = 10,576) were analyzed, using survey analysis. The weighted prevalence of hypertension among those not on anti-hypertensive medications was 42.7 and 12.6%, applying the ACC/AHA and JNC7 guideline definitions, respectively; the corresponding values with including BP-lowering medication in definition of hypertension were 47.1% and 20.4%, respectively. However, 90% of these hypertensive people were found to have a 10-year cardiovascular disease risk of <10%. Applying the ACC/AHA guideline, anti-hypertensive medication was recommended for 21.9% of Tehranians, compared to 19.3 and 12.2% according to the JNC7 and 8 guidelines, respectively. Among Tehranians taking anti-hypertensive medication, 20% achieved the BP goal according to the ACC/AHA guideline, compared to the 42.1 and 53.6%, using JNC7 and 8 guidelines, respectively. Despite the tremendous increase in the prevalence of hypertension, most of the newly identified cases did not belong to the high-risk group.

Associations of marital status with diabetes, hypertension, cardiovascular disease and all-cause mortality: A long term follow-up study

Background

To investigate the associations of marital status with major clinical outcomes including type 2 diabetes (T2D), hypertension, cardiovascular disease (CVD) and all-cause mortality.

Methods

The study cohort (1999–2014) included 9,737 (45% male) Iranian adults with a mean age of 47.6 years. Marital status was defined as married versus never married, divorced and widowed. The relationship between marital status and the four above mentioned outcomes were investigated using Cox regression models adjusted for the main confounders, specific to each outcome.

Results

After more than 12 years of follow-up, 1,889 (883 men) individuals developed hypertension, 1,038 (468 men) T2D, 1015 (597 men) CVD and 668 (409 men) all-cause mortality. Compared with married, being never married in men was associated with higher risk of hypertension [hazard ratio (HR): 1.55; 95% confidence interval (CI), 1.11–2.16] and all-cause mortality (2.17; 0.95–5.00; p-value = 0.066) after adjusting for confounders. Among women, compared with married status, widowed status was associated with a lower risk of T2D (0.74; 0.56–0.97) in the confounders adjusted model. Moreover, never married women had a lower risk of hypertension (0.58; 0.37–0.90) compared to married ones in the age adjusted model, a finding that did not achieve significance, after further adjustment for confounders.

Conclusion

We found that the relationship between marital status and health outcomes varied by gender. Being never married was an important risk factor for hypertension and tended to be a significant risk factor for mortality in men. However, among women, being widowed was associated with a lower risk of T2D.

Impact of temperature and air pollution on cardiovascular disease and death in Iran: A 15-year follow-up of Tehran Lipid and Glucose Study

In this, the first study to be conducted in the Middle East and North Africa (MENA) on the subject, we examined the impact of temperature and air pollution on cardiovascular disease (CVD) and all-cause mortality. The Tehran Lipid and Glucose Study followed 9731 participants, aged ≥30years (men=4409), during the period 1999-2014, reporting 1350 CVDs (men=796) and 725 deaths (men=447). Air pollution level was measured using the air quality index (AQI). Data were analyzed using the distributed lag nonlinear model, with 30°C temperature and AQI=50 minimum risk values, as the relative risks' (RR) reference values. Although for the whole sample, no significant effect of air pollution was observed on CVD, for the under 60year olds, two significant peaks occurred in AQI=180 at lags 2 and 6days (RR=1.94, 95% CI: 1.02-3.67 and 2.06, 95% CI: 1.09-3.88, respectively). Temperature had no significant effect on CVD, yet the closest case to significance happened at 36°C and lag 5days (RR=1.43, 95% CI: 0.97-2.11), for ages ≥60y. The largest significant effects of air pollution on death, occurred in AQI=180 and lag 1day (RR=2.40, 95% CI: 1.0.-5.59 and 3.29, 95% CI: 1.15-9.36, for the whole sample and the <60year olds, respectively). Interestingly, for those aged over 60years, the peak belonged to AQI=180 and lag 7days (RR=2.16, 95% CI: 1.11-4.19). Regarding the effect of temperature on death among the whole sample, the highest risk was for 6°C and lag 0 (RR=3.91, 95% CI: 1.12-13.61). For the ≥60year olds, it occurred in 9⁺ and lag 0 (RR=6.81, 95% CI: 1.69-27.44), though notably, the peak went to -3°C and lag 3 (RR=5.69, 95% CI: 1.12-28.87), for those aged <60years. Overall, the effect of low temperature on death had the highest risk, for the over 60-year-olds, without any lag. Moreover, the <60-year-olds were the most vulnerable group to air pollution with a one day lag, in terms of mortality risk.

Association between duration of endogenous estrogen exposure and cardiovascular outcomes: A population - based cohort study

AIMS

Duration of endogenous estrogen exposure is apparently associated with risk of cardiovascular disease, the longer durations being more cardiovascular disease protective in women. We aimed to investigate the association of cumulative duration of endogenous estrogen exposure over women's reproductive lifespans with cardiovascular disease outcomes.

MAIN METHODS

For the purpose of the present study, of 10,192 female participants, after excluding those using HRT (n = 84), 3656 women, aged ≥30 years, who met eligibility criteria were selected and divided into three groups based on tertiles (T1, T2, T3) of exposure durations to endogenous estrogen. Cox proportional hazards regression model was used to estimate associations between exposure durations and cardiovascular disease outcomes.

KEY FINDINGS

Cardiovascular events occurred in 352 participants over a median follow-up of 14.2 (13.5, 14.6) years (7.7 per 1000 person years; 95% CI: 6.9-8.5). Incidence of outcome was 10.9 per 1000 person years (CI, 9.4-12.8) in T1, 7.2 per 1000 person years (CI, 6.0-8.7) in T2, and 5.1 per 1000 person years (CI, 4.1-6.4) in T3. The hazard ratio of cardiovascular events in T1 was significantly higher than that inT3, before and after adjustment for confounding variables. Before adjustment, women in T2 had a 40% higher risk of CVD, compared to T3; after adjustment however the risk was similar to that of women in T3.

SIGNIFICANCE

Shorter durations of exposure to endogenous estrogen may increase the risk of cardiovascular diseases among these women later in life. Future studies should target women with short duration of exposure for timely screening and implementation of preventative interventions.

Long-Term Effectiveness of a Lifestyle Intervention: A Pragmatic Community Trial to Prevent Metabolic Syndrome

INTRODUCTION

The purpose of this study is to evaluate the long-term effectiveness of a community-based lifestyle education on primary prevention of metabolic syndrome in a middle-income country.

STUDY DESIGN

This study followed 3,180 individuals free of metabolic syndrome who were under the coverage of three health centers in Tehran from 1999 until 2015. They were undergoing triennial examinations resulting in four re-exams. People in one of three areas received interventions consisting of family-, school-, and community-based educational programs, including a face-to-face educational session at baseline. Data were analyzed considering the incidence of metabolic syndrome at each re-exam and also repeated-measure analysis including all re-exams together. Weighting was considered to correct selection bias because of loss to follow-up. Data were analyzed in 2017.

RESULTS

After 3 years, 149 of 852 participants in the intervention and 471 of 2,328 people in control area developed metabolic syndrome at first re-exam resulting in a RR of 0.78 (95% CI=0.67, 0.92). The difference between groups remained unchanged up to the 6-year follow-up (RR=0.79, 95% CI=0.66, 0.93, at second re-exam), but disappeared during the third and fourth re-exams (RR=1.04, 95% CI=0.91, 1.18 and RR=1.03, 95% CI=0.91, 1.16, respectively). Marginal models for longitudinal data showed a significant interaction between intervention and time of re-exams. Further analyses showed that the effect of the intervention might have been rooted in improvement of lipid profile and glucose level.

CONCLUSIONS

In a middle-income country, face-to-face educational sessions followed by a long-term maintenance community-level educational program could reduce the risk of metabolic syndrome for up to 6 years. A booster face-to-face session is recommended to retain this preventive effect.

TRIAL REGISTRATION

This study is registered at Iran Registry for Clinical Trials (http://irct.ir) IRCT138705301058N1.

Sex specific impact of different obesity phenotypes on the risk of incident hypertension: Tehran lipid and glucose study

Background

To investigate the association between different obesity phenotypes and the risk of incident hypertension among both genders.

Methods

The study population included 3659 Iranians (men = 1540), aged ≥20 years free of hypertension at baseline. Participants were classified into six categories of body mass index (BMI)-metabolic health status, in which unhealthy metabolic status was defined based on the presence of > 1 component of metabolic syndrome (MetS) using the joint interim statement (JIS) criteria or the presence of insulin resistance (IR). The association between different obesity phenotypes and incident hypertension was assessed using multivariate Cox's proportional hazard models adjusted for age, current smoking, low physical activity, diabetes mellitus, family history of premature cardiovascular disease, estimated glomerular filtration rate, phase of recruitment, BMI and systolic blood pressure, considering metabolically healthy normal weight group as the reference.

Results

After a median follow-up of 11.6 years 1122 participants (men = 493) experienced hypertension. Using JIS criteria, a significant higher risk of hypertension was observed among metabolically healthy obese and well as metabolically unhealthy groups among men in the age adjusted model; however, a significant higher risk in the fully adjusted model was seen among women in the metabolically healthy obese [hazard ratio (HR) 95% confidence interval (CI) 1.96(1.16-3.32)] as well as metabolically unhealthy normal weight [1.98(1.37-2.86)], overweight [2.08(1.49-2.90)] and obese [2.06(1.27-3.30)] groups. Using insulin sensitive normal weight group as the reference, among men, being overweight or obese with and without IR was significant predictors of incident hypertension in the age adjusted model; however, among women, insulin resistant overweight [1.46(1.06-2.02)] and obese groups, [1.63(1.01-2.62)] showed significant risk in the fully adjusted model.

Conclusion

We concluded that first, there was significant difference between genders in the associations between obesity phenotypes and incident hypertension. Second, in general, metabolic status defined by MetS components as compared to IR could do better in identifying high risk women for hypertension. Third, women populations who are metabolically healthy obese using MetS definition or those with either > 1 component of metabolic syndrome or overweight/obese ones with IR should be prioritized for implementing urgent preventive strategies against hypertension focusing on lifestyle changes.

Circulating nitric oxide metabolites and the risk of cardiometabolic outcomes: a prospective population-based study

Aim: This study was conducted to investigate whether serum NO metabolites (NOx) could predict the occurrence of type 2 diabetes (T2DM), hypertension (HTN) and metabolic syndrome (MetS). Methods: We measured serum NOx concentrations in the Tehran Lipid and Glucose Study participants (aged ≥19 years) and followed them for a median of 7.7 years for the incidence of outcomes. To determine the appropriate cut-off points of serum NOx for predicting clinical events, a random sampling method (50:50 ratio) was used for the population and for analysis, receiver operator characteristic curve was used. Multivariable Cox proportional hazard models were used to estimate the hazard ratios (HRs) with 95% confidence intervals (95% CIs) of T2DM, HTN and MetS in response to serum NOx values. Results: The optimal cut-off points of serum NOx levels for predicting T2DM, HTN and MetS were 26.5, 25.5 and 25.5 µmol/L, respectively. Participants with serum NOx levels ≥25.5 µmol/L had increased risk of MetS (HR = 1.31, 95% CI = 1.01-1.72). No evidence was found for any association of serum NOx with incidence of T2DM and HTN (HR = 1.03, 95% CI = 0.83-1.77 and HR = 1.09, 95% CI = 0.88-1.35). Conclusion: In this prospective population-based investigation, a higher circulating NOx was associated with development of MetS.

Serum alkaline phosphatase and the risk of coronary heart disease, stroke and all-cause mortality: Tehran Lipid and Glucose Study

OBJECTIVES

To investigate the association of alkaline phosphatase (ALP) levels with the risk of the composite end point of cardiovascular disease (CVD), and all-cause mortality as well as each of them separately.

DESIGN

Prospective cohort study.

SETTING

Within the framework of the Tehran Lipid and Glucose Study (TLGS) cohort, participants were followed from baseline examination (1999-2001) until March 2014.

PARTICIPANTS

A total of 2578 participants, aged ≥30 years free of prevalent CVD at baseline examination.

PRIMARY OUTCOME

The main outcome measures were composite end point of coronary heart disease (CHD), stroke, all-cause mortality and each per se.

RESULTS

During a median follow-up of 11.3 years, 369, 68, 420, 170 and 495 participants experienced CHD, stroke, CVD, all-cause mortality and the composite outcome, respectively. In the multivariable Cox regression models, the adjusted HRs (95% CI) for mentioned events per one SD increase in ALP level after full adjustment were 1.11 (1.01 to 1.22), 1.20 (0.97 to 1.49, p=0.058), 1.10 (1.01 to 1.21), 1.16 (1.01 to 1.33) and 1.11 (1.02 to 1.21), respectively. Furthermore, participants with ALP levels in the highest tertile had significant adjusted HRs (95% CI) for stroke (1.88 (1.00 to 3.61)), CVD (1.30 (1.01 to 1.68)) and composite outcome (1.27 (1.00 to 1.61)). The cut-off value of ALP ≥199 IU/L for predicting composite outcome was derived using Youden's index, based on which this cut-off point was associated with significant risk of 80%, 26%, 43% and 26% for incident stroke, CVD, all-cause mortality and composite outcome. Additionally, no improvement was seen in the predictive ability of traditional risk factors models after adding ALP values, considering the levels of Akaike information criterion, C-index and Net Reclassification Index.

CONCLUSION

Independent associations between ALP levels and the risks of CVD and mortality events were shown, despite the fact that adding the data of ALP to known risk factors did not improve the prediction of these events.