Prevalence of plasma lipid disorders with an emphasis on LDL cholesterol in selected countries in the Asia-Pacific region.

Cardiovascular disease (CVD) is a major cause of mortality and morbidity within the Asia-Pacific region, with the prevalence of CVD risk factors such as plasma lipid disorders increasing in many Asian countries. As members of the Cardiovascular RISk Prevention (CRISP) in Asia network, the authors have focused on plasma lipid disorders in the six countries within which they have clinical experience: Indonesia, Malaysia, Philippines, Thailand, Vietnam, and Australia. Based on country-specific national surveys, the prevalence of abnormal levels of total cholesterol, low- and high-density lipoprotein cholesterol (LDL-C and HDL-C, respectively), and triglycerides (TG) are reported. An important caveat is that countries have used different thresholds to define plasma lipid disorders, making direct comparisons difficult. The prevalence of abnormal lipid levels was as follows: high total cholesterol (30.2-47.7%, thresholds: 190-213 mg/dL); high LDL-C (33.2-47.5%; thresholds: 130-135 mg/dL); low/abnormal HDL-C (22.9-72.0%; thresholds: 39-50 mg/dL); and high/abnormal TG (13.9-38.7%; thresholds: 150-177 mg/dL). Similarities and differences between country-specific guidelines for the management of plasma lipid disorders are highlighted. Based on the authors' clinical experience, some of the possible reasons for suboptimal management of plasma lipid disorders in each country are described. Issues common to several countries include physician reluctance to prescribe high-dose and/or high-intensity statins and poor understanding of disease, treatments, and side effects among patients. Treatment costs and geographical constraints have also hampered disease management in Indonesia and the Philippines. Understanding the factors governing the prevalence of plasma lipid disorders helps enhance strategies to reduce the burden of CVD in the Asia-Pacific region.

Monocyte to High-Density Lipoprotein Ratio (MHR) as a predictor of mortality and Major Adverse Cardiovascular Events (MACE) among ST Elevation Myocardial Infarction (STEMI) patients undergoing primary percutaneous coronary intervention: a meta-analysis.

BACKGROUND: Monocyte to High Density Lipoprotein Ratio (MHR) is a new marker that has been associated with major adverse cardiovascular outcomes among STEMI patients. We sought to strengthen the association between MHR and mortality and major adverse cardiovascular events (MACEs) among STEMI patients who underwent primary percutaneous coronary intervention. METHODS: Studies were included if they satisfied the following criteria:1) Observational Studies; 2) Adult patients with ST-elevation Myocardial Infarction (STEMI) who underwent primary percutaneous intervention (PCI); and 3) Reported data on mortality and major adverse cardiovascular events. Using MEDLINE, Clinical Key, Science Direct, Scopus, and Cochrane Central Register of Controlled Trials databases, a search for eligible studies was conducted until September 2017. Our primary outcome of interest was all-cause cardiovascular (CV) mortality. We also investigated the association between MHR and major adverse cardiovascular events (MACEs). RESULTS: We identified 3 studies involving 2793 STEMI patients, showing that in STEMI patients who underwent primary PCI, a high admission MHR is associated with a significantly higher in-hospital mortality [RR 4.71, (95% CI 2.36 to 9.39, p < 0.00001] and in-hospital MACE [RR 1.90, (95% CI 1.44 to 2.50), p < 0.00001]. This significant association was not observed in long term mortality or MACE. CONCLUSION: A high admission MHR among STEMI patients who underwent primary PCI is associated with a higher in-hospital mortality and MACE. This novel marker can be used as an inexpensive and readily available tool for risk stratification.

Community Health Workers' Concept and Understanding of Diabetes: A Qualitative Study.

Objectives: Community health workers (CHWs) fill in the insufficiency of health professionals in low-income countries. The CHWs' roles include health education of their constituents whose health they likewise take care. This study aimed to describe the concept and understanding of diabetes among CHWs in the Philippines. Methods: Fifty female CHWs currently working in rural and urban areas participated in six focus group discussions with guidance from Kleinman's eight questions. With the written informed consent of the participants, discussions were recorded and transcribed by the Research Assistant. A multi-disciplinary team manually analyzed the data. Disagreements were discussed among them and the physicians provided clinical analyses and explanations on the results. Quotations of an important point of view were also presented. Pseudonyms were utilized to uphold anonymity. Results: CHWs were aged 32 to 72 years; older participants reside in rural areas. Majority were married, housekeepers, and high school graduates. Some CHWs and their family were suffering from diabetes or dyabetis, the disease of the rich according to them. Its causes were food and lifestyle, and believed to be hereditary. Complications lead to death. Amputation was feared the most. Diabetes is incurable. Persons with diabetes should take maintenance medicines, and seek physicians' and family's help. Together with the patient, the family must decide on its management. Balanced diet, healthy lifestyle, maintenance medicines, food supplements, and herbal plants were perceived treatments. The internist should lower blood sugar level as well as prolong life span. Proper diet and regular check-up prevent diabetes. Conclusions: CHWs' concept and understanding of diabetes reflect some of the biomedical causes, effects, treatment, and prevention of diabetes as well as its social determinants. The efficacy and safety of herbal plants in the treatment of diabetes, however, should be further studied. Training on diabetes care should be provided to address their fears of amputation, insulin injection, and complications.

Dyslipidemia management for primary prevention of cardiovascular events: Best in-clinic practices.

Dyslipidemia is a fundamental risk factor for cardiovascular diseases (CVDs) and can worsen the prognosis, if unaddressed. Lipid guidelines are still evolving as dyslipidemia is affecting newer patient subsets. However, these guidelines are governed by regional demographics and ethnic data. Primary care practitioners (PCPs) are the first to offer treatment, and hence placed early in the healthcare continuum. PCPs shoulder a huge responsibility in early detection of dyslipidemia for primary prevention of future cardiovascular (CV) events. Therefore, as members of Cardiovascular RISk Prevention (CRISP) in Asia network, the authors intend to align and shape-up the daily clinical practice workflow for PCPs and have a goal-directed strategy for managing dyslipidemia. This paper reviews the major international lipid guidelines, namely the American and European guidelines, and the regional guidelines from Indonesia, Malaysia, Philippines, Thailand, and Vietnam to identify their commonalities and heterogeneities. The authors, with a mutual consensus, have put forth, best in-clinic practices for screening, risk assessment, diagnosis, treatment, and management of dyslipidemia, particularly to reduce the overall risk of CV events, especially in the Asian context. The authors feel that PCPs should be encouraged to work in congruence with patients to decide on best possible therapy, which would be a holistic approach, rather than pursuing a "one-size-fits-all" approach. Since dyslipidemia is a dynamic field, accumulation of high-quality evidence and cross-validation studies in the future are warranted to develop best in-clinic practices at a global level.

The rs1458038 variant near FGF5 is associated with poor response to calcium channel blockers among Filipinos.

ABSTRACT: Genetic variation is known to affect response to calcium channel blockers (CCBs) among different populations. This study aimed to determine the genetic variations associated with poor response to this class of antihypertensive drugs among Filipinos.One hundred eighty one hypertensive participants on CCBs therapy were included in an unmatched case-control study. Genomic deoxyribonucleic acid were extracted and genotyped for selected genetic variants. Regression analysis was used to determine the association of genetic and clinical variables with poor response to medication.The variant rs1458038 near fibroblast growth factor 5 gene showed significant association with poor blood pressure-lowering response based on additive effect (CT genotype: adjusted OR 3.41, P = .001; TT genotype: adjusted OR 6.72, P < .001).These findings suggest that blood pressure response to calcium channels blockers among Filipinos with hypertension is associated with gene variant rs1458038 near fibroblast growth factor 5 gene. Further studies are recommended to validate such relationship of the variant to the CCB response.

Executive Summary of the 2020 Clinical Practice Guidelines for the Management of Dyslipidemia in the Philippines.

Dyslipidemia is a cardiovascular risk factor that is increasing in prevalence in the country. The need to treat and manage elevated cholesterol levels, both pharmacologic and non-pharmacologic, is of utmost importance. Different medical societies and groups bonded together to formulate the 2020 Philippine Clinical Practice Guidelines for dyslipidemia. The group raised nine clinical questions that are important in dyslipidemia management. A technical working group analyzed the clinical questions dealing with non-pharmacologic management, primary prevention for both non-diabetic and individuals with diabetes, familial hypercholesterolemia, secondary prevention, adverse events of statins and the use of other lipid parameters as measurement of risk for cardiovascular disease. Randomized controlled trials and meta-analyses were included in the GRADE-PRO analysis to come up with the statements answering the clinical questions. The statements were presented to a panel consisting of government agencies, members of the different medical societies, and private institutions, and the statements were voted upon to come up with the final statements of the 2020 practice guidelines. The 2020 CPG is aimed for the Filipino physician to confidently care for the individual with dyslipidemia and eventually lower his risk for cardiovascular disease.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee.

BACKGROUND: Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD. OBJECTIVES: The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD. METHODOLOGY: A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique. RESULTS: A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

The Klotho Variant rs36217263 Is Associated With Poor Response to Cardioselective Beta-Blocker Therapy Among Filipinos.

A common drug used for hypertension among Filipinos is beta-blockers. Variable responses to beta-blockers are observed, and genetic predisposition is suggested. This study investigated the association of genetic variants with poor response to beta-blockers among Filipinos. A total of 76 Filipino adult hypertensive participants on beta-blockers were enrolled in an unmatched case-control study. Genotyping was done using DNA from blood samples. Candidate variants were correlated with clinical data using χ2 and logistic regression analysis. The deletion of at least one copy of allele A of rs36217263 near Klotho showed statistically significant association with poor response to beta-blockers (dominant; odds ratio (OR) = 3.89; P = 0.017), adjusted for diabetes and dyslipidemia. This association is observed among participants using cardioselective beta-blockers (crude OR = 5.60; P = 0.008) but not carvedilol (crude OR = 2.56; P = 0.67). The genetic variant rs36217263 is associated with poor response to cardioselective beta-blockers, which may become a potential marker to aid in the management of hypertension.

Pre-Operative Sildenafil for Patients With Pulmonary Hypertension Undergoing Mitral Valve Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Pulmonary hypertension is a usual complication of long-standing mitral valve disease. Perioperative pulmonary hypertension is a risk factor for right ventricular failure and is an important cause of morbidity and mortality in patients with pulmonary hypertension undergoing mitral valve surgery. Phosphodiesterase-5 inhibitors particularly sildenafil citrate have proven clinical benefit for pulmonary arterial hypertension but have shown discordant results in group 2 pulmonary hypertension patients. We sought to determine the effect of pre-operative sildenafil on the intra-operative hemodynamic parameters of these patients. METHODS: Studies were included if they satisfied the following criteria: 1) Randomized controlled trials; 2) Adult patients with pulmonary hypertension scheduled for elective mitral valve surgery; and 3) Reported data on changes in pre-, intra-, and post-operative hemodynamic parameters. Using PUBMED, Clinical Key, Science Direct, and Cochrane databases, a search for eligible studies was conducted from September 1 to December 31, 2018. The quality of each study was evaluated using the Cochrane Risk of Bias Tool. The primary outcome of interest is on the effect of pre-operative sildenafil on the improvement of intra-operative hemodynamic parameters such as systolic pulmonary artery pressure (sPAP), mean pulmonary arterial pressure, mean arterial pressure, pulmonary and systemic vascular resistances. We also investigated its effect on the post-operative mortality, length of cardiopulmonary bypass time, ventilation time, and inotrope support requirement. Review Manager 5.3 was utilized to perform analysis of random effects for continuous outcomes. RESULTS: We identified three studies involving 153 patients with pulmonary hypertension undergoing mitral valve surgery, showing that among those who received pre-operative sildenafil there is a significant decrease in intra-operative systolic pulmonary arterial pressure (mean difference -11.19 (95% confidence interval (CI), -20.23 to -2.15), P < 0.05) and post-operative sPAP (mean difference -13.67 (95% CI, - 19.56 to - 7.78), P < 0.05) without significantly affecting the mean arterial pressure (mean difference 1.94 (95% CI, -5.49 to 9.37), P < 0.05). The systemic and pulmonary vascular resistances were not affected as well. CONCLUSIONS: Administration of pre-operative sildenafil to patients with pulmonary hypertension undergoing mitral valve surgery decreases intra-operative and post-operative systolic pulmonary arterial pressure without significantly affecting other systemic hemodynamic parameters.

Cardiac events occurred commonly among apparently healthy Filipinos with the Brugada ECG pattern in the LIFECARE cohort.

BACKGROUND: Brugada syndrome is the mechanism for sudden unexplained death. The Brugada ECG pattern is found in 2% of Filipinos. There is a knowledge gap on the clinical outcome of these individuals. The clinical profile and 5-year cardiac event rate of individuals with the Brugada ECG pattern were determined in this cohort. METHODS: This is a sub-study of LIFECARE (Life Course Study in Cardiovascular Disease Epidemiology), a community based cohort enrolling healthy individuals 20 to 50 years old conducted in 2009-2010. ECGs of all enrollees were screened independently by three cardiologists. The prevalence of the coved Brugada ECG pattern was ascertained, and the 5-year cardiac event rate was determined among those individuals with this pattern. The participants were contacted to determine the occurrence of cardiac events, which included syncope, presyncope, seizures, cardiac arrest and unexplained vehicular accidents. RESULTS: A total of 3072 ECGs were reviewed, and 14 subjects (0.4%) with the coved Brugada ECG pattern were identified. Four had a cardiac event on follow-up at 5 years, but all remained alive. Most of these 14 coved Brugada individuals were healthy and asymptomatic at baseline. CONCLUSION: Cardiac events occurred commonly among initially asymptomatic Filipinos with the coved Brugada ECG pattern. Such patients need to be followed up closely.

Socio-demographic factors and the prevalence of metabolic syndrome among filipinos from the LIFECARE cohort.

BACKGROUND: Metabolic syndrome(MetS) is an aggregation of multiple metabolic risk factors shown to lead to the development of cardiovascular disease. The International Diabetes Federation(IDF) and the modified National Cholesterol Education Program Adult Treatment Panel Ⅲ(mNCEP) criteria are used in identifying MetS. This report will determine the prevalence of MetS and its component risk factors of the Philippine cohort of the LIFE course study in CARdiovascular disease Epidemiology(LIFECARE). METHODS: Our study recruited 3,072 participants aged 20-50 years old from Metro Manila and four nearby provinces. Baseline anthropometric and clinical parameters were measured. Prevalence of MetS and its component factors were determined. Associations with socio-demographic factors were determined. RESULTS: The prevalence of MetS was 19.7% and 25.6% by IDF and mNCEP, respectively(kappa 0.83). Both were associated with increasing age, urban residence, and employed status. It was higher in females by IDF and in males by mNCEP. IDF missed 40% of males and 10% of females identified with MetS by mNCEP. More males were identified by the mNCEP as MetS despite relatively normal waist circumference. CONCLUSION: MetS is common in the Philippines among older, educated, and urban residents. The mNCEP criteria identified more MetS than the IDF criteria.

A community-based validation study of the short-form 36 version 2 Philippines (Tagalog) in two cities in the Philippines.

OBJECTIVE: To evaluate the validity and reliability of the Philippines (Tagalog) Short Form 36 Health Survey version 2 (SF-36v2(®)) standard questionnaire among Filipinos residing in two cities. STUDY DESIGN AND SETTING: The official Philippines (Tagalog) SF-36v2 standard (4-week recall) version was pretested on 30 participants followed by formal and informal cognitive debriefing. To obtain the feedback on translation by bilingual respondents, each SF-36v2 question was stated first in English followed by Tagalog. No revisions to the original questionnaire were needed except that participants thought it was appropriate to incorporate "po" in the instructions to make it more polite. Face-to-face interviews of 562 participants aged 20-50 years living in two barangays (villages) in the highly urbanized city of Makati City (Metro Manila) and in urban and rural barangays in Tanauan City (province of Batangas) were subsequently conducted. Content validity, item level validity, reliability and factor structure of the SF-36v2 (Tagalog) were examined. RESULTS: Content validity of the SF-36v2 was assessed to be adequate for assessing health status among Filipinos. Item means of Philippines (Tagalog) SF-36v2 were similar with comparable scales in the US English, Singapore (English and Chinese) and Thai SF-36 version 1. Item-scale correlation exceeded 0.4 for all items except the bathing item in PF (correlation: 0.31). In exploratory factor analysis, the US two-component model was supported. However, in confirmatory factor analysis, the Japanese three-component model fit the Tagalog data better than the US two-component model. CONCLUSIONS: The Philippines (Tagalog) SF-36v2 is a valid and reliable instrument for measuring health status among residents of Makati City (Metro Manila) and Tanauan City (Province of Batangas).