Dysglycemia and Abnormal Adiposity Drivers of Cardiometabolic-Based Chronic Disease in the Czech Population: Biological, Behavioral, and Cultural/Social Determinants of Health.

In contrast to the decreasing burden related to cardiovascular disease (CVD), the burden related to dysglycemia and adiposity complications is increasing in Czechia, and local drivers must be identified. A comprehensive literature review was performed to evaluate biological, behavioral, and environmental drivers of dysglycemia and abnormal adiposity in Czechia. Additionally, the structure of the Czech healthcare system was described. The prevalence of obesity in men and diabetes in both sexes has been increasing over the past 30 years. Possible reasons include the Eastern European eating pattern, high prevalence of physical inactivity and health illiteracy, education, and income-related health inequalities. Despite the advanced healthcare system based on the compulsory insurance model with free-for-service healthcare and a wide range of health-promoting initiatives, more effective strategies to tackle the adiposity/dysglycemia are needed. In conclusion, the disease burden related to dysglycemia and adiposity in Czechia remains high but is not translated into greater CVD. This discordant relationship likely depends more on other factors, such as improvements in dyslipidemia and hypertension control. A reconceptualization of abnormal adiposity and dysglycemia into a more actionable cardiometabolic-based chronic disease model is needed to improve the approach to these conditions. This review can serve as a platform to investigate causal mechanisms and secure effective management of cardiometabolic-based chronic disease.

Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006-2019: A cohort study.

BACKGROUND: Type 2 diabetes is 2-3 times more prevalent in people of South Asian and African/African Caribbean ethnicity than people of European ethnicity living in the UK. The former 2 groups also experience excess atherosclerotic cardiovascular disease (ASCVD) complications of diabetes. We aimed to study ethnic differences in statin initiation, a cornerstone of ASCVD primary prevention, for people with type 2 diabetes. METHODS AND FINDINGS: Observational cohort study of UK primary care records, from 1 January 2006 to 30 June 2019. Data were studied from 27,511 (88%) people of European ethnicity, 2,386 (8%) people of South Asian ethnicity, and 1,142 (4%) people of African/African Caribbean ethnicity with incident type 2 diabetes, no previous ASCVD, and statin use indicated by guidelines. Statin initiation rates were contrasted by ethnicity, and the number of ASCVD events that could be prevented by equalising prescribing rates across ethnic groups was estimated. Median time to statin initiation was 79, 109, and 84 days for people of European, South Asian, and African/African Caribbean ethnicity, respectively. People of African/African Caribbean ethnicity were a third less likely to receive guideline-indicated statins than European people (n/N [%]: 605/1,142 [53%] and 18,803/27,511 [68%], respectively; age- and gender-adjusted HR 0.67 [95% CI 0.60 to 0.76], p < 0.001). The HR attenuated marginally in a model adjusting for total cholesterol/high-density lipoprotein cholesterol ratio (0.77 [95% CI 0.69 to 0.85], p < 0.001), with no further diminution when deprivation, ASCVD risk factors, comorbidity, polypharmacy, and healthcare usage were accounted for (fully adjusted HR 0.76 [95% CI 0.68, 0.85], p < 0.001). People of South Asian ethnicity were 10% less likely to receive a statin than European people (1,489/2,386 [62%] and 18,803/27,511 [68%], respectively; fully adjusted HR 0.91 [95% CI 0.85 to 0.98], p = 0.008, adjusting for all covariates). We estimated that up to 12,600 ASCVD events could be prevented over the lifetimes of people currently affected by type 2 diabetes in the UK by equalising statin prescribing across ethnic groups. Limitations included incompleteness of recording of routinely collected data. CONCLUSIONS: In this study we observed that people of African/African Caribbean ethnicity with type 2 diabetes were substantially less likely, and people of South Asian ethnicity marginally less likely, to receive guideline-indicated statins than people of European ethnicity, even after accounting for sociodemographics, healthcare usage, ASCVD risk factors, and comorbidity. Underuse of statins in people of African/African Caribbean or South Asian ethnicity with type 2 diabetes is a missed opportunity to prevent cardiovascular events.

Heterogeneity of Cardiovascular Disease Risk Factors Among Asian Immigrants: Insights From the 2010 to 2018 National Health Interview Survey.

Background The Asian population is the fastest-growing immigrant population in the United States. Prior studies have examined the Asian immigrant population as a homogenous group. We hypothesized that there will be heterogeneity in cardiovascular disease risk factors among Asian immigrant subgroups (Indian subcontinent, Southeast Asia, Asia) compared with the non-Hispanic White population. Methods and Results A cross-sectional analysis of the 2010 to 2018 National Health Interview Survey was conducted among 508 941 adults who were born in Asian regions or were non-Hispanic White and born in the United States. Generalized linear models with Poisson distribution were fitted to compare the prevalence of self-reported hypertension, overweight/obesity, diabetes mellitus, high cholesterol, physical inactivity, and current smoking among Asian immigrants compared with White adults, adjusting for known confounders. We included 33 973 Asian immigrants from Southeast Asia (45%), Asia (29%), the Indian subcontinent (26%), and 474 968 White adults. Compared with non-Hispanic White adults, Indian subcontinent immigrants had the highest prevalence of overweight/obesity (prevalence ratio, 1.22; 95% CI, 1.19-1.25); Southeast Asian immigrants had the highest prevalence of high cholesterol (prevalence ratio, 1.16; 95% CI, 1.10-1.23); Indian subcontinent (prevalence ratio, 1.69; 95% CI, 1.49-1.93) and Southeast Asian (prevalence ratio, 1.38; 95% CI, 1.26-1.52) immigrants had a higher prevalence of diabetes. All Asian immigrant subgroups were more likely to be physically inactive and less likely to smoke than White adults. Conclusions We observed significant heterogeneity in cardiovascular disease risk factors among Asian immigrants and a varied prevalence of risk factors compared with non-Hispanic White adults. Providers caring for Asian immigrants should provide tailored and culturally informed care to improve the cardiovascular health of this diverse group.

Joint effect of race/ethnicity or location of residence and sex on low density lipoprotein-cholesterol among veterans with type 2 diabetes: a 10-year retrospective cohort study.

BACKGROUND: Cardiovascular (CV) disease is the leading cause of death among United States women. Rural residence and ethnic-minority status are individually associated with increased CV mortality. Managing dyslipidemia is important in the prevention of CV mortality. However, the impact of race/ethnicity and location of residence on sex differences in dyslipidemia management is not well understood. Therefore, we sought to understand the joint effects of race/ethnicity and location of residence on lipid management differences between veteran men and women with type 2 diabetes (T2D). METHODS: Veterans Health Administration and Centers for Medicare and Medicaid Services data were used to perform a longitudinal cohort study of veterans with T2D (2007-2016). Mixed effects logistic regression with a random intercept was used to model the association between sex and low-density lipoprotein (LDL) > 100 mg/dL and its interaction with race/ethnicity and location of residence after adjusting for all measured covariates. RESULTS: When female sex and rural location of residence were both present, they were associated with an antagonistic harmful effect on LDL. Similar antagonistic harmful effects on LDL were observed when the joint effect of female sex and several minority race/ethnicity groups were evaluated. After adjusting for measured covariates, the odds of LDL > 100 mg/dL were higher for urban women (OR = 2.66, 95%CI 2.48-2.85) and rural women (OR = 3.26, 95%CI 2.94-3.62), compared to urban men. The odds of LDL > 100 mg/dL was the highest among non-Hispanic Black (NHB) women (OR = 5.38, 95%CI 4.45-6.51) followed by non-Hispanic White (NHW) women (OR = 2.59, 95%CI 2.44-2.77), and Hispanic women (OR = 2.56, 95%CI 1.79-3.66). CONCLUSION: Antagonistic harmful effects on LDL were observed when both female sex and rural location of residence were present. These antagonistic effects on LDL were also present when evaluating the joint effect of female sex and several minority race/ethnicity groups. Disparities were most pronounced in NHB and rural women, who had 5.4 and 3.3 times the odds of elevated LDL versus NHW and urban men after adjusting for important covariates. These striking effect sizes in a population at high cardiovascular risk (i.e., older with T2D) suggest interventions aimed at improving lipid management are needed for individuals falling into one or more groups known to face health disparities.

The relationship between payer type and lipid outcomes in response to clinical lifestyle interventions in youth with dyslipidemia.

BACKGROUND: Payer-type (government-sponsored health coverage versus private health insurance) has been shown to influence a variety of cardiovascular disease outcomes in adults. However, it is unclear if the payer-type impacts the response to a lifestyle intervention in children with dyslipidemia. METHODS: We analyzed data prospectively collected from patients under the age of 25 years who were referred to a large regional preventive cardiology clinic from 2010 to 2016 in Massachusetts. We compared baseline high density lipoprotein cholesterol (HDL-C), triglycerides (TG), non-HDL-C, and low density lipoprotein cholesterol (LDL-C) by payer-type. Further, we analyzed the change in lipid values in response to a clinic-based multidisciplinary intervention over a nearly six-year period by payer-type with multi-variable adjusted linear regression models. We also tested for effect modifications by age, sex, race, and body mass index (BMI) category. RESULTS: Of the 1739 eligible patients (mean age 13 years, 52% female, 60% overweight and obese, 59% White), we found that patients with government-sponsored coverage (n = 354, 20%) presented to referral lipid clinic with lower HDL-C (- 3.5 mg/dL [1.0], p < 0.001) and higher natural log-transformed TG (+ 0.14 [0.04], p < 0.001) as compared to those with private insurance; however, the association was attenuated to the null after additionally adjusting for BMI category (- 1.1 [0.9], p = 0.13, and + 0.05 [0.04], p = 0.2 for HDL-C and natural log-transformed TG, respectively). We found no difference in baseline LDL-C between payer-types (+ 3.4 mg/dL [3.0], p = 0.3). However, longitudinally, we found patients with private insurance and a self-reported race of White to have a clinically meaningful additional improvement in LDL-C, decreasing 12.8 (5.5) mg/dL (p = 0.02) between baseline and first follow-up, as compared to White patients with government-sponsored health coverage, after adjusting for age, sex, time between visits, and baseline LDL-C. CONCLUSIONS: Our results suggest that youth with government-sponsored coverage are referred with poorer lipid profiles than those with private insurance, although this is largely explained by higher rates of overweight and obesity in the government-sponsored health coverage group. White patients with private insurance had substantially better improvement in LDL-C longitudinally, suggesting that higher socioeconomic status facilitates improvement in LDL-C, but is less beneficial for HDL-C and triglyceride levels.

Associations between cardiovascular disease, cancer, and very low high-density lipoprotein cholesterol in the REasons for Geographical and Racial Differences in Stroke (REGARDS) study.

Aims: Relatively little is known about the health outcomes associated with very low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) mainly because of the small numbers of individuals with such extreme values included in clinical trials. We, therefore, investigated the association between low and very low HDL-C concentration at baseline and incident all-cause-mortality, death from malignant disease (i.e. cancer), and with fatal or non-fatal incident coronary heart disease (CHD) in individuals from the Reasons for Geographical And Racial Differences in Stroke (REGARDS) study. Methods and results: Analysis was based on 21 751 participants from the REGARDS study who were free of CHD, other cardiovascular disease, and cancer at baseline and were categorized by baseline HDL-C into <30 mg/dL (very low), 30-<40 mg/dL (low), and ≥40 mg/dL (reference). A series of incremental Cox proportional hazards models were employed to assess the association between the HDL-C categories and outcomes. Statistical analysis was performed using both complete case methods and multiple imputations with chained equations. After adjustment for age, race, and sex, the hazard ratios (HRs) comparing the lowest and highest HDL-C categories were 1.48 [95% confidence interval (CI) 1.28-1.73] for all-cause mortality, 1.35 (95% CI 1.03-1.77) for cancer-specific mortality and 1.39 (95% CI 0.99-1.96) for incident CHD. These associations became non-significant in models adjusting for demographics, cardiovascular risk factors, and treatment for dyslipidaemia. We found evidence for an HDL paradox, whereby low HDL (30-<40 mg/dL) was associated with reduced risk of incident CHD in black participants in a fully adjusted complete case model (HR 0.63; 95% CI 0.46-0.88) and after multiple imputation analyses (HR 0.76; 95% CI 0.58-0.98). HDL-C (<30 mg/dL) was significantly associated with poorer outcomes in women for all outcomes, especially with respect to cancer mortality (HR 2.31; 95% CI 1.28-4.16) in a fully adjusted complete case model, replicated using multiple imputation (HR 1.81; 95% CI 1.03-3.20). Conclusion: Low HDL-C was associated with reduced risk of incident CHD in black participants suggesting a potential HDL paradox for incident CHD. Very low HDL-C in women was significantly associated with cancer mortality in a fully adjusted complete case model.

National Trends in Nonstatin Use and Expenditures Among the US Adult Population From 2002 to 2013: Insights From Medical Expenditure Panel Survey.

BACKGROUND: Evidence supporting nonstatin lipid-lowering therapy in atherosclerotic cardiovascular disease risk reduction is variable. We aim to examine nonstatin utilization and expenditures in the United States between 2002 and 2013. METHODS AND RESULTS: We used the Medical Expenditure Panel Survey database to estimate national trends in nonstatin use and cost (total and out-of-pocket, adjusted to 2013 US dollars using a gross domestic product deflator) among adults 40 years or older. Nonstatin users increased from 3 million (2.5%) in 2002-2003 (20.1 million prescriptions) to 8 million (5.6%) in 2012-2013 (45.8 million prescriptions). Among adults with atherosclerotic cardiovascular disease, nonstatin use increased from 7.5% in 2002-2003 to 13.9% in 2012-2013 after peaking at 20.3% in 2006-2007. In 2012-2013, 15.9% of high-intensity statin users also used nonstatins, versus 9.7% of low/moderate-intensity users and 3.6% of statin nonusers. Nonstatin use was significantly lower among women (odds ratio 0.80; 95% confidence interval 0.75-0.86), racial/ethnic minorities (odds ratio 0.41; 95% confidence interval 0.36-0.47), and the uninsured (odds ratio 0.47; 95% confidence interval 0.40-0.56). Total nonstatin expenditures increased from $1.7 billion (out-of-pocket cost, $0.7 billion) in 2002-2003 to $7.9 billion (out-of-pocket cost $1.6 billion) in 2012-2013, as per-user nonstatin expenditure increased from $550 to $992. Nonstatin expenditure as a proportion of all lipid-lowering therapy expenditure increased 4-fold from 8% to 32%. CONCLUSIONS: Between 2002 and 2013, nonstatin use increased by 124%, resulting in a 364% increase in nonstatin-associated expenditures.

Changes in Statin Adherence Following an Acute Myocardial Infarction Among Older Adults: Patient Predictors and the Association With Follow-Up With Primary Care Providers and/or Cardiologists.

BACKGROUND: Hospitalizations for acute myocardial infarctions (AMIs) are associated with changes in statin adherence. It is unclear to what extent adherence changes, which patients are likely to change, and how post-discharge follow-up is associated with statin adherence change. METHODS AND RESULTS: This retrospective study used Medicare data for all fee-for-service beneficiaries 66 years and older with an AMI hospitalization in 2008-2010 and statin use before their index AMI. Multivariable multinomial logistic regression models (odds ratio [OR] and 99% confidence interval [CI]) were applied to assess associations between both patient characteristics and follow-up with a primary care provider and/or cardiologist with the outcome of statin adherence change (increase or decrease) from the 6-month pre- to 6-month post-AMI periods. Of 113 296 patients, 64.0% had no change in adherence, while 19.7% had increased and 16.3% had decreased adherence after AMI hospitalization. Black and Hispanic patients were more likely to have either increased or decreased adherence than white patients. Patients who required coronary artery bypass graft surgery (OR, 1.34; 99% CI, 1.21-1.49) or percutaneous transluminal coronary angioplasty/stent procedure (OR, 1.25; 99% CI, 1.17-1.32) during their index hospitalization were more likely to have increased adherence. Follow-up with a primary care provider was only mildly associated with increased adherence (OR, 1.08; 99% CI, 1.00-1.16), while follow-up with a cardiologist (OR, 1.15; 99% CI, 1.05-1.25) or both provider types (OR, 1.21; 99% CI, 1.12-1.30) had stronger associations with increased adherence. CONCLUSIONS: Post-AMI changes in statin adherence varied by patient characteristics, and improved adherence was associated with post-discharge follow-up care, particularly with a cardiologist or both a primary care provider and a cardiologist.

Better Indigenous Risk stratification for Cardiac Health study (BIRCH) protocol: rationale and design of a cross-sectional and prospective cohort study to identify novel cardiovascular risk indicators in Aboriginal Australian and Torres Strait Islander adults.

BACKGROUND: Of the estimated 10-11 year life expectancy gap between Indigenous (Aboriginal and Torres Strait Islander people) and non-Indigenous Australians, approximately one quarter is attributable to cardiovascular disease (CVD). Risk prediction of CVD is imperfect, but particularly limited for Indigenous Australians. The BIRCH (Better Indigenous Risk stratification for Cardiac Health) project aims to identify and assess existing and novel markers of early disease and risk in Indigenous Australians to optimise health outcomes in this disadvantaged population. It further aims to determine whether these markers are relevant in non-Indigenous Australians. METHODS/DESIGN: BIRCH is a cross-sectional and prospective cohort study of Indigenous and non-Indigenous Australian adults (≥ 18 years) living in remote, regional and urban locations. Participants will be assessed for CVD risk factors, left ventricular mass and strain via echocardiography, sleep disordered breathing and quality via home-based polysomnography or actigraphy respectively, and plasma lipidomic profiles via mass spectrometry. Outcome data will comprise CVD events and death over a period of five years. DISCUSSION: Results of BIRCH may increase understanding regarding the factors underlying the increased burden of CVD in Indigenous Australians in this setting. Further, it may identify novel markers of early disease and risk to inform the development of more accurate prediction equations. Better identification of at-risk individuals will promote more effective primary and secondary preventive initiatives to reduce Indigenous Australian health disadvantage.

Vulnerabilities to Health Disparities and Statin Use in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study.

BACKGROUND: Statins may be underutilized in certain vulnerable populations, but the effect of cumulative vulnerabilities within 1 individual is not well described. We sought to determine the likelihood of receiving statins with an increasing number of vulnerabilities in an individual, after controlling for factors known to influence health services utilization. METHODS AND RESULTS: We identified 18 216 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study who had a statin indication or who were taking statins, as verified by pill bottle review. Statin use was assessed with respect to 5 major vulnerability domains alone and in combination: older age, black race, female sex, high area-level poverty, and lack of health insurance. The study included 5286 white men, 4180 black men, 2791 white women, and 4194 black women; 5.6% of the sample had no vulnerabilities, 20.6% had 1 vulnerability, 29.2% had 2 vulnerabilities, 27.3% had 3 vulnerabilities, and 17.3% had 4 or 5 vulnerabilities. All race-sex groups were less likely than white men to use statins; prevalence of use was 0.80 in black women with reference to white men (P<0.0001). In both unadjusted and adjusted models, as the number of vulnerabilities increased, statin use steadily decreased. After adjusting for factors that influence health services utilization, compared with those without any vulnerabilities, statin use prevalence was 0.91, 0.83, 0.74 and 0.68 (P<0.0001) in those with 1, 2, 3, and 4 or 5 vulnerabilities, respectively. CONCLUSIONS: Participants with more simultaneously occurring vulnerabilities experienced the greatest disparities in statin use. Black women and those without health insurance were at particularly high risk of underutilization.

Associations between body fat distribution, insulin resistance and dyslipidaemia in black and white South African women.

AIM: The aim was to examine differences in body fat distribution between premenopausal black and white South African (SA) women and explore the ethnic-specific associations with cardiometabolic risk. METHODS: Body composition, using dual-energy X-ray absorptiometry (DXA) and computerised tomography, insulin resistance (HOMA-IR) and lipid levels were assessed in 288 black and 197 white premenopausal SA women. RESULTS: Compared to the white women, black women had less central and more peripheral (lower-body) fat, and lower serum lipid and glucose concentrations, but similar homeostasis models for insulin resistance (HOMA-IR) values. The associations between body fat distribution and HOMA-IR, triglyceride and high-density lipoprotein cholesterol concentrations were similar, while the associations with fasting glucose, total and low-density lipoprotein cholesterol levels differed between black and white women. CONCLUSION: Ethnic differences in body fat distribution are associated, in part, with differences in cardiometabolic risk between black and white SA women.

An Evaluation on the Effect of Health Education and of Low-Dose Statin in Dyslipidemia among Low-Income Rural Uyghur Adults in Far Western China: A Comprehensive Intervention Study.

OBJECTIVE: To evaluate the effect of comprehensive intervention by health education and medical intervention to dyslipidemia Uyghur patients in low-income rural areas in Xinjiang, China. METHOD: A multistaged (prefecture-county-township-village) stratified cluster random sampling method was used to select participants in southern Xinjiang. Twelve villages in Jiangbazi Township in Jiashi County were chosen. These villages were randomly divided into six intervention groups and six control groups, and local Uyghur aged 18 years or older residing in the village for at least 6 months were interviewed for a baseline prevalence study and to select participants for two years of comprehensive intervention including low dose simvastatin and the effects of the interventions were observed. RESULTS: A total of 655 participants (347 participants in the intervention groups, 308 participants in the control groups) were randomly selected from 12 villages in Jiangbazi Township, follow-up rate is 87.0%. Compared to baseline mean levels of TG and LDL-C were reduced by 1.39 mmol/L (p < 0.01) and 2.12 mmol/L (p < 0.01) respectively and levels of HDL-C increased by1.22 mmol/L (p < 0.01) in the intervention group. Lipids were controlled in 38.61% of the intervention groups vs. 3.57% of the control groups (p < 0.01). Compared with baseline lipid levels, TG, TC, LDL-C and HDL-C was significantly improved, compared with it was in control groups. CONCLUSIONS: Blood lipid levels of Uygur patients with dyslipidemia can be effectively improved through health education combined with low-dose statin administration. This suggests that national strategies in public health be developed to improve the treatments to low-income rural minorities with dyslipidemia.

Ethnic differences in the association between lipid metabolism genes and lipid levels in black and white South African women.

OBJECTIVE: Dyslipidaemia can lead to the development of atherosclerosis and cardiovascular disease (CVD), however its prevalence has been shown to differ between ethnic groups in South Africa (SA). Therefore the aim of this study was to investigate ethnic differences in the association between serum lipid levels and polymorphisms within genes involved in lipid metabolism in black and white SA women. METHODS: In a convenient sample of 234 white and 209 black SA women of Xhosa ancestry, body composition (DXA) and fasting serum lipids were measured. Participants were genotyped for the cholesteryl ester transfer protein (CETP, rs708272, B1/B2), lipoprotein lipase (LPL, rs328, S/X), hepatic lipase (LIPC, rs1800588, C/T) and proprotein convertase subtilisin/kexin type 9 (PCSK9, rs28362286, C/X) polymorphisms. RESULTS: Compared to white women, black women had lower concentrations of serum total cholesterol (TC, P < 0.001), low density lipoprotein cholesterol (LDL-C, P < 0.001), high density lipoprotein cholesterol (HDL-C, P < 0.001) and triglycerides (TG, P < 0.001). There were significant differences in the genotype and allele frequency distributions between black and white women for the LPL S/X (P < 0.001), PCSK9 C679X (P = 0.002) and LIPC 514C/T (P < 0.001) polymorphisms. In black women only, there were genotype effects on serum lipid levels. Specifically, women with the LPL SX genotype had lower TC and LDL-C and higher HDL-C concentrations than those with the SS genotype and women with the CETP B2 allele had lower LDL-C concentrations than those with the B1B1 genotype. CONCLUSION: Polymorphisms within the LPL and CETP genes were associated with a more protective lipid profile in black, but not white SA women. This supports the hypothesis that the more favorable lipid profile of black compared to white SA women is associated with polymorphisms in lipid metabolism genes, specifically the LPL and CETP genes.

Race is a key variable in assigning lipoprotein(a) cutoff values for coronary heart disease risk assessment: the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: We aimed to examine associations of lipoprotein(a) (Lp(a)) concentrations with coronary heart disease (CHD) and determine whether current Lp(a) clinical laboratory cut points identify risk of disease incidence in 4 races/ethnicities of the Multi-Ethnic Study of Atherosclerosis (MESA). APPROACH AND RESULTS: A subcohort of 1323 black, 1677 white, 548 Chinese American, and 1044 Hispanic MESA participants were followed up during a mean 8.5-year period in which 235 incident CHD events were recorded. Lp(a) mass concentrations were measured using a turbidimetric immunoassay. Cox regression analysis determined associations of Lp(a) with CHD risk with adjustments for lipid and nonlipid variables. Lp(a) concentrations were continuously associated with risk of CHD incidence in black (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.09-2.04] and white participants (HR, 1.22; 95% CI, 1.02-1.45). Examining Lp(a) risk by the 50 mg/dL cut point revealed higher risks of incident CHD in all races except Chinese Americans: blacks (HR, 1.69; 95% CI, 1.03-2.76), whites (HR, 1.82; 95% CI, 1.15-2.88); Hispanics (HR, 2.37; 95% CI, 1.17-4.78). The lower Lp(a) cut point of 30 mg/dL identified higher risk of CHD in black participants alone (HR, 1.87; 95% CI, 1.08-3.21). CONCLUSIONS: Our findings suggest that the 30 mg/dL cutoff for Lp(a) is not appropriate in white and Hispanic individuals, and the higher 50 mg/dL cutoff should be considered. In contrast, the 30 mg/dL cutoff remains suitable in black individuals. Further research is necessary to develop the most clinically useful Lp(a) cutoff values in individual races/ethnicities.

Elevated cholesteryl ester transfer protein (CETP) activity, a major determinant of the atherogenic dyslipidemia, and atherosclerotic cardiovascular disease in South Asians.

AIMS: Why South Asians are at increased risk of premature atherosclerotic cardiovascular diseases compared with other ethnic groups is not fully understood. Atherogenic dyslipoproteinemia - hypertriglyceridemia, elevated numbers of low-density lipoprotein (LDL) particles and low high-density lipoprotein cholesterol (HDL-C) - is more common in South Asians but the mechanisms responsible have not been explicated. Here we examined whether the circulating lipid transfer protein, cholesteryl ester transfer protein (CETP), plays a role in the pathogenesis of the atherogenic dyslipoproteinemia among South Asians. METHODS AND RESULTS: CETP activity was determined by exogenous substrate assay in the serum of healthy, metabolically well-characterized individuals of South Asian and European descent (N = 244 and 238, respectively). Serum and lipoprotein lipids and apolipoproteins were measured and lipoprotein particle number and size were quantified via nuclear magnetic resonance spectroscopy. All the elements of the atherogenic dyslipoproteinemia were more severe in South Asians and CETP activity was significantly greater by 30% in South Asians compared with Europeans, adjusted for age, sex, body mass index and waist circumference (p < 0.0001). CETP activity was directly associated with serum triglycerides and inversely with HDL-C in the whole population. CETP activity was also directly related to apoB and LDL particle number. Finally, increased CETP activity was associated with pro-atherogenic reductions in HDL and LDL particle size. CONCLUSIONS: We identified novel associations between elevated CETP activity and the triad of quantitative and qualitative lipoprotein abnormalities in the atherogenic dyslipidemia in South Asians, a major contributor of increased atherosclerotic cardiovascular diseases in South Asians.

Alarming rise in prevalence of atherogenic dyslipidaemia in the black population of Cape Town: the Cardiovascular Risk in Black South Africans (CRIBSA) study.

OBJECTIVES: To determine the prevalence, determinants, and management of dyslipidaemia in the 25-74-year-old urban black population of Cape Town and examine the changes between 1990 and 2008/09 in the 25-64-year-old sample. METHODS: In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Cardiovascular disease (CVD) risk factors were determined by questionnaires, clinical measurements, and fasting biochemical analyses. Survey logistic regression analysis assessed the determinants of raised low-density lipoprotein cholesterol (LDL-C). RESULTS: There were 1099 participants in 2008/09 (392 men and 707 women; response rate 86%). The prevalence of raised total cholesterol (TC), raised LDL-C, and reduced high-density lipoprotein cholesterol (HDL-C) were 25.2% (95% confidence interval, CI, 20.0-31.3), 37.8% (95% CI 32.5-43.4), and 55.2% (95% CI 49.9-60.4) in men and 23.1% (95% CI 20.0-26.5), 47.0% (95% CI 43.1-50.9), and 66.8% (95% CI 62.9-70.5) in women, respectively. Between 1990 and 2008/09, raised LDL-C and reduced HDL-C prevalence increased significantly with no change for raised TC. Among participants with raised LDL-C, only 2.6% were aware of their diagnosis, 2.7% were on treatment, and 1.5% had LDL-C <3 mmol/l. In the logistic model, increasing age (odds ratio, OR, 1.04, 95% CI 1.03-1.05; p < 0.001), rising body mass index (OR 1.03, 95% CI 1.01-1.05; p = 0.003), and fat intake ≥30% of diet (OR 1.37, 95% CI 1.02-1.85; p = 0.035) were significantly associated with LDL-C ≥3 mmol/l but not sex, physical activity, or urbanization. CONCLUSIONS: The dyslipidaemia pattern in this population requires full lipogram screening in high-risk individuals and demands improved management using a total CVD risk approach.

Assessment of baseline characteristics, glycemic control and oral antidiabetic treatment in Asian patients with diabetes: The Registry for Assessing OAD Usage in Diabetes Management (REASON) Asia study.

BACKGROUND: To assess baseline characteristics, glycemic control, and treatment with oral antidiabetic drugs (OAD) in type 2 diabetes mellitus (T2DM) patients. METHODS: This multinational, observational study recruited patients ≥ 21 years of age who were newly diagnosed and/or treated with OAD monotherapy for <6 months but were inadequately controlled. In cross-sectional phase, data on demographics, medical history, diabetic complications and comorbidities, OAD treatment, glycosylated hemoglobin (HbA1c), and fasting blood glucose (FBG) were collected. In longitudinal phase evaluating 6-month follow-up of sulfonylurea (SU)-treated patients, additional data on reasons for not achieving HbA1c targets were collected. RESULTS: Of 1487 patients (mean [± SD] age 52.0 ± 11.6 years; 46.7% men; mean BMI 25.8 ± 4.4 kg/m(2) ) recruited, 75.9% were newly diagnosed, 73.3% had central obesity, 43.8% had hypertension, and 60.5% had dyslipidemia. The mean HbA1c was 9.8 ± 2.4%, and the mean FBG was 11.3 ± 4.3 mmol/L. At T0 (baseline) and T6 (month 6 visit), 99.8% (n=1066) and 97.1% (n=830) patients received SU, respectively. There was decrease from T0 to T6 in mean HbA1c (10.2% vs 7.3%, respectively; P<0.0001) and mean FBG (12.0 vs 7.6 mmol/L, respectively; P<0.0001). Number of patients with HbA1c <7% increased from T0 (4.5%) to T6 (46.8%). Reasons for not achieving target HbA1c included poor diabetes education (50.7%), non-compliance to OADs (21.4%), and fear of hypoglycemia (19.7%). CONCLUSION: Marked reductions in HbA1c and FBG are achievable in T2DM patients managed with OADs. However, patient education and compliance are important for achieving and maintaining treatment targets.

Disparities in stroke type and vascular risk factors between 2 Hispanic populations in Miami and Mexico city.

BACKGROUND: The heterogeneous nature and determinants of stroke among different Hispanic groups was examined by comparing hospitalized Hispanic stroke patients in Miami, where the Hispanic population is largely of Caribbean origin, to a Mestizo population in Mexico City. METHODS: Consecutive Hispanic patients who were admitted with stroke or transient ischemic attack (TIA) and included in the prospective stroke registries of 2 tertiary care teaching hospitals were studied. Demographic factors, stroke subtypes, vascular risk factors, stroke severity, and outcomes were compared. Vascular risk factor definitions were standardized. RESULTS: A total of 928 patients (520 Mexicans and 408 Miami Hispanics) were analyzed. Mexicans were younger, with a greater proportion of women. More cerebral venous thromboses (CVTs) were admitted in Mexico, while TIA and stroke mimics were more commonly admitted in Miami; cardioembolic strokes were more commonly ascertained in Miami, and more cryptogenic strokes in Mexico. Stroke severity was similar for intracerebral hemorrhages, but more severe ischemic strokes and CVTs were included in the Mexican registry. Outcome at 1 and 3 months was similar in both registries after adjusting for age and baseline stroke severity. After adjusting for age and sex, hypertension, dyslipidemia, and atrial fibrillation were more frequent, and diabetes mellitus was less frequent, among Miami Hispanics compared to Mexicans. CONCLUSIONS: We found significant differences in the frequency of hypertension, diabetes, dyslipidemia, and atrial fibrillation in Miami Hispanics and Mexican stroke patients, highlighting the heterogeneity of the Hispanic ethnic group. Future studies are needed to clarify the relative contribution of genetic and environmental disparities amongst Mexican and Caribbean Hispanic stroke patients.

Disparities in prevalence of key chronic diseases by gender and race/ethnicity among antiretroviral-treated HIV-infected adults in the US.

BACKGROUND: Certain sociodemographic subgroups of HIV-infected patients may experience more chronic disease than others due to behavioural risk factors, advanced HIV disease or complications from extended use of combination antiretroviral therapy (cART), but recent comparative data are limited. METHODS: We studied HIV-infected adult patients in care during 2006-2010 who had been prescribed ≥ 6 months of cART. We analysed the prevalence of selected key chronic conditions and polymorbidity (having 2 or more out of 10 key conditions) by gender and race/ethnicity. RESULTS: Of the 3,166 HIV-infected patients (median age 47 years, CD4⁺ T-cell count 496 cells/mm³, duration of cART use 6.8 years), 21% were female, 57% were non-Hispanic White and over half were current or former tobacco smokers. The five most frequent conditions among women (median age 45 years) were dyslipidaemia (67.3%), hypertension (57.4%), obesity (31.7%), viral hepatitis B or C coinfection (29.0%) and low high-density lipoprotein cholesterol (HDLc; 27.3%). The five most frequent conditions in men (median age 47 years) were dyslipidaemia (81.2%), hypertension (54.4%), low HDLc (41.1%), elevated triglycerides (32.3%) and elevated non-HDLc (26.8%). In multivariable analyses, Hispanic patients had higher prevalence of obesity and diabetes than White patients; Black patients had higher prevalence of obesity and hypertension but lower rates of lipid abnormalities. Of all patients, 73.7% of women and 66.8% of men had polymorbidity, with no evidence of disparities by race/ethnicity. CONCLUSIONS: Among contemporary cART-treated HIV-infected adults, chronic conditions and polymorbidity were common, underscoring the importance of chronic disease prevention and management among ageing HIV-infected patients.

Adverse events associated with psychotropic treatment in African American children and adolescents.

To identify the types of adverse events associated with psychotropic treatment in African American children and adolescents, analyses were performed using a retrospective cohort design evaluating medical and pharmacy claims from South Carolina's Medicaid program covering outpatient and inpatient medical services and medication prescriptions between January 1996 and December 2005. All children and adolescents prescribed 1 of 7 antipsychotic medications, 1 of 26 antidepressants, or 1 of 3 antimanic agents, and a random sample of 4500 children not treated with psychotropic medications were identified. Antipsychotics were more closely associated with the development of obesity and sexual/reproductive adverse events in African American patients. In the antidepressant-treated cohort, incident obesity/weight gain, dyslipidemia, and type 2 diabetes mellitus were more likely in African American patients. Obesity/weight gain, dyslipidemia, and sexual/reproductive problems were significantly more likely for African American patients treated with antimanic agents. Practitioners need to carefully weigh the risks/benefits of prescribing all types of psychotropic agents to African American children, taking into consideration preexisting/comorbid conditions or individual risk factors for adverse reactions, especially when multiple medications are prescribed.