Eisenmenger Syndrome Among Children with Unrepaired Congenital Heart Defects in Yunnan, China.

Eisenmenger syndrome is a life-threatening complication of congenital heart defects (CHD). Since Eisenmenger syndrome among children of repaired CHD is rare, very few studies have had the necessary data to investigate its distribution in children. The current study used data collected in rural China to investigate the prevalence of Eisenmenger syndrome in children with unrepaired CHD. Data were from the 2006 to 2016 patient medical records of China California Heart Watch, which is a traveling cardiology clinic in Yunnan Province, China. Patients were included if they (1) aged 18 or below, (2) had CHD(s), and (3) the defect was not repaired by the time of the clinic visit. The prevalence of Eisenmenger syndrome was calculated in each age and defect group. Using logistic regression models, we tested whether oxygen saturation, Down syndrome, sex, and age were significantly associated with Eisenmenger syndrome. Of the 1301 study participants, ventricular septum defect (VSD), atrial septal defect (ASD), and patent ductus arteriosus (PDA) were the most common CHD. About one-sixth of the patients had pulmonary hypertension and 1.5% had Eisenmenger syndrome. The percentages of Eisenmenger syndrome were 1.8% in VSD patients, 0 in ASD patients, and 0.9% in PDA patients. Patients in the age group between 15 and 18 years had the highest percentages of Eisenmenger syndrome (11.5%). Age and presence of Down syndrome were significantly associated with the presence of Eisenmenger syndrome. Our finding highlights the importance of early detection and correction of CHD.

Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease (ASCVD) events: the multi-ethnic study of atherosclerosis (MESA).

Aims: While coronary artery calcium (CAC) has been extensively validated for predicting clinical events, most outcome studies of CAC have evaluated coronary heart disease (CHD) rather than atherosclerotic cardiovascular disease (ASCVD) events (including stroke). Also, virtually all CAC studies are of short- or intermediate-term follow-up, so studies across multi-ethnic cohorts with long-term follow-up are warranted prior to widespread clinical use. We sought to evaluate the contribution of CAC using the population-based MESA cohort with over 10 years of follow-up for ASCVD events, and whether the association of CAC with events varied by sex, race/ethnicity, or age category. Methods and results: We utilized MESA, a prospective multi-ethnic cohort study of 6814 participants (51% women), aged 45-84 years, free of clinical CVD at baseline. We evaluated the relationship between CAC and incident ASCVD using Cox regression models adjusted for age, race/ethnicity, sex, education, income, cigarette smoking status, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, diabetes, lipid-lowering medication, systolic blood pressure, antihypertensive medication, intentional physical exercise, and body mass index. Only the first event for each individual was used in the analysis. Overall, 500 incident ASCVD (7.4%) events were observed in the total study population over a median of 11.1 years. Hard ASCVD included 217 myocardial infarction, 188 strokes (not transient ischaemic attack), 13 resuscitated cardiac arrest, and 82 CHD deaths. Event rates in those with CAC = 0 Agatston units ranged from 1.3% to 5.6%, while for those with CAC > 300, the 10-year event rates ranged from 13.1% to 25.6% across different age, gender, and racial subgroups. At 10 years of follow-up, all participants with CAC > 100 were estimated to have >7.5% risk regardless of demographic subset. Ten-year ASCVD event rates increased steadily across CAC categories regardless of age, sex, or race/ethnicity. For each doubling of CAC, we estimated a 14% relative increment in ASCVD risk, holding all other risk factors constant. This association was not significantly modified by age, sex, race/ethnicity, or baseline lipid-lowering use. Conclusions: Coronary artery calcium is associated strongly and in a graded fashion with 10-year risk of incident ASCVD as it is for CHD, independent of standard risk factors, and similarly by age, gender, and ethnicity. While 10-year event rates in those with CAC = 0 were almost exclusively below 5%, those with CAC ≥ 100 were consistently above 7.5%, making these potentially valuable cutpoints for the consideration of preventive therapies. Coronary artery calcium strongly predicts risk with the same magnitude of effect in all races, age groups, and both sexes, which makes it among the most useful markers for predicting ASCVD risk.

Postprocedural outcomes of rural children undergoing correction of congenital heart lesions in Yunnan Province, China.

The management of congenital heart disease (CHD) remains a significant challenge in developing regions. Since 2006, China California Heart Watch has provided cardiac services in China's Yunnan province. Our Grants for Kids program aims to diagnose and fund surgical and nonsurgical treatments for underprivileged children with congenitally malformed hearts. This report analyzes our patient outcomes. From 2007 to 2010, 36 children with CHD underwent either surgical or percutaneous procedures at local Chinese medical centers, and 94% of our patients could be contacted for follow-up assessment. The mortality and complication rates of our patient population compare favorably with international data. Our study provides a model through which networking with local hospitals and regional cardiac centers can be an effective way to assist developing areas in providing cardiac care to rural underserved populations.

Does coronary calcium score predict future cardiac function? Association of subclinical atherosclerosis with left ventricular systolic and diastolic dysfunction at MR imaging in an elderly cohort.

PURPOSE: To evaluate subclinical atherosclerosis measured by using coronary artery calcium (CAC) as a predictor of future left ventricular (LV) systolic and diastolic function in asymptomatic elderly participants. MATERIALS AND METHODS: The institutional review boards of the University of Southern California and the Harbor University of California Los Angeles Research and Education Institute (where the South Bay Heart Watch study was initially conducted) approved this HIPAA-compliant study of 386 participants (mean age, 75.2 years) from among the original 1461 participants in the longitudinal South Bay Heart Watch prospective investigation of subclinical atherosclerosis. CAC at computed tomography was correlated with LV ejection fraction (LVEF), regional wall motion abnormalities (RWMAs), and peak filling rate (PFR) assessed a mean of 11.4 years ± 0.6 (standard deviation) later with cardiac magnetic resonance imaging. Analysis of variance and covariance testing was performed with the Wald test, testing for trends across the CAC groups. Covariates included age, level of total cholesterol, level of high-density lipoprotein cholesterol, systolic blood pressure, use of lipid-lowering medication, and smoking status. RESULTS: Mean LVEF was 60.3% ± 9.9, with 11 (2.8%) of 386 participants having an LVEF of less than 40%. Forty-six (11.9%) of 386 participants had RWMAs. Higher CAC scores were associated with slightly lower LVEF (P for trend = .04) and a greater percentage of participants with decreased PFR (P for trend = .47) and RWMAs (P for trend = .01). After age- and risk factor-adjustment, only RWMA (P = .05) was associated with higher CAC. RWMAs were associated with significantly (P < .001) lower mean LVEF and PFR. Nineteen (41%) of 46 participants with RWMAs had documented Q-wave myocardial infarction, and three (7%) underwent coronary revascularization. CAC scores of 100 or greater were associated with a 2.2-fold (95% confidence interval: 1.30, 3.75) increase in RWMA (P < .001). CONCLUSION: Subclinical atherosclerosis assessed by using CAC is associated with an increased future likelihood of RWMA, as a marker of previous and possible subclinical coronary artery disease.

Reproducibility of coronary artery calcified plaque with cardiac 64-MDCT: the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: The Multi-Ethnic Study of Atherosclerosis is a longitudinal study evaluating determinants of future cardiac events and progression of atherosclerosis. Emerging data are showing that coronary artery calcification (CAC) is a robust independent predictor of future cardiac events and that measurement of progression depends on reproducibility of the measure. Reproducibility previously was reported on baseline scans obtained with both electron-beam tomography (EBT) and MDCT. The aim of this study was to compare the interscan variability for both Agatston and volume scores derived with newer (16- and 64-MDCT) scanners with that derived with older scanners in the Multi-Ethnic Study of Atherosclerosis. SUBJECTS AND METHODS: The participants in this study were 4,054 persons who underwent dual scanning with EBT (n = 1,716), 4-MDCT (n = 370), 16-MDCT (n = 1,245), or 64-MDCT (n = 723). Agreement on the presence or absence of CAC was assessed with logistic regression models adjusted for age, sex, body mass index, and scanner type. Among participants with CAC, the log-transformed interscan difference was regressed on log-transformed amount of CAC, age, sex, and body mass index. RESULTS: The percentage agreement for the presence or absence of CAC was high and similar across scanner groups (EBT, 16-MDCT, and 64-MDCT). The greatest adjusted average absolute CAC differences between scans were found with the Aquilion 64 (24%; 95% CI, 20.9-27.6) and LightSpeed Pro 16 (19%; 95% CI, 17.4-21.0) scanners, both differences being significantly greater than with the EBT scanner (16%; 95% CI, 15.4-17.5) (p < 0.05). No differences were found between the EBT, Sensation 16, and Sensation 64 scanners. For volume score, the Aquilion 64 was the only scanner with significantly greater average absolute interscan differences than the EBT scanner (p < 0.001). Volume scoring resulted in lower rescan differences for all scanners. CONCLUSION: For CAC scoring, interscan variability with newer-generation MDCT scanners was similar to but not superior to that with the EBT scanner.

Molecular, endocrine, and genetic mechanisms of arterial calcification.

Pathologists have recognized arterial calcification for over a century. Recent years have witnessed a strong resurgence of interest in atherosclerotic plaque calcification because it: 1) can be easily detected noninvasively; 2) closely correlates with the amount of atherosclerotic plaque; 3) serves as a surrogate measure for atherosclerosis, allowing preclinical detection of the disease; and 4) is associated with heightened risk of adverse cardiovascular events. There are two major types of calcification in arteries: calcification of the media tunica layer (sometimes called Mönckeberg's sclerosis), and calcification within subdomains of atherosclerotic plaque within the intimal layer of the artery. There are important similarities and differences between these two entities. Of particular interest are increasing parallels between cellular and molecular features of arterial calcification and bone biology, and this has led to accelerating interest in understanding how and why bone-like mineral deposits may form in arteries. Here, we review the two major pathological types of arterial calcification, the proposed models of calcification, and endocrine and genetic determinants that affect arterial calcification. In addition, we highlight areas requiring further investigation.

Implications of C-reactive protein or coronary artery calcium score as an adjunct to global risk assessment for primary prevention of CHD.

BACKGROUND: C-reactive protein (CRP) or coronary artery calcium (CAC) score have been suggested to identify a higher risk subset of intermediate-risk individuals, who potentially could be considered for more aggressive therapy. In the Multi-Ethnic Study of Atherosclerosis (MESA), we estimated the proportion of intermediate-risk participants whose risk status might change based on additional testing using CRP and/or CAC score. METHODS: Framingham 10-year CHD risk scores (FRS) were calculated and cross tabulations were used to determine the percent of individuals at intermediate-risk by FRS with a CRP >3mg/L and/or CAC score >100 AU. Similar analyses were performed using the gender-specific 75th percentile for CRP and CAC. RESULTS: Of the 30% of participants (N=1450) classified as intermediate-risk by FRS, 30% had a CRP >3mg/L and 33% had a CAC score >100 AU. Among intermediate-risk women, 49% had a CRP >3mg/L compared to 27% of intermediate-risk men (p<0.0001) while the same percent of intermediate-risk women and men (33%) had a CAC score >100 AU. Eleven percent or less of men or women had both a high CRP and CAC score whether conventional or gender-specific cut points were used. When the percent of intermediate-risk individuals with an elevated CRP and/or CAC score in MESA were applied to NHANES III data, over a million intermediate-risk individuals would move to high risk status if CRP or CAC screening directed treatment strategies were uniformly adopted in the U.S. CONCLUSION: There were differences in the number of intermediate-risk individuals reclassified as high risk depending on the screening test used, the cut points selected, and the demographics of the individuals being screened. These data highlight current limitations of broadly using risk markers such as CRP and CAC score in an intermediate-risk population.

Effect of scanner type on the reproducibility of extracoronary measures of calcification: the multi-ethnic study of atherosclerosis.

RATIONALE AND OBJECTIVES: Cardiac computed tomography (CT) has been used extensively to measure coronary artery calcification. However, extracoronary calcifications, such as aortic valve calcification (AVC), may have independent clinical significance as well. The ability to track calcification is dependent on the reproducibility of the original measurement, and the variability of extracoronary calcification measurements still is unknown. Accurate quantification of calcification of the aortic valve, mitral annulus (MAC), and thoracic aortic (TAC) may be possible by using cardiac CT. METHODS: A total of 1,729 randomly chosen participants (ages 45-84, 53% female, 28% African-American, 36% Caucasian, 11% Chinese, 25% Hispanic) of the Multi-Ethnic Study of Atherosclerosis underwent dual scanning by electron beam CT (EBT) or multidetector CT (MDCT) to assess coronary and extra-coronary calcifications. Two calcium measurement methods--Agatston score (AS) and volume score (VS)--were measured for each scan. Concordance for calcium positivity was assessed among all scans. Mean absolute and relative differences between calcium measures on scans 1 and 2, excluding cases for which both scans had a measure of zero, was modeled by using linear regression to compare variability between scanner types. A repeated measures analysis of variance test was used to compare variability across calcium measures, with mean percentage absolute difference as the outcome measure. RESULTS: Concordances for the presence of calcium between duplicate scans were high and similar for both EBT and MDCT. Concordance was high for all three extracoronary measures, with a kappa statistic of kappa = 0.94-0.96. For all three extracoronary sites, Bland-Altman plots demonstrated excellent agreement, with almost all measures falling within the boundaries of the 95% confidence limits of reproducibility. AVC interscan variability was approximately 8% for both AS and VS, with improved variability for EBT as compared with MDCT. Mitral annular calcification demonstrated slightly lower variability than AVC for both scanner types (approximately 6%), with no significant differences between MDCT and EBT. Of the three extracoronary sites, TAC had the highest variability (10%), with MDCT variability slightly lower than EBT variability (9.3 vs. 10.2%, respectively, P = NS). Agatson and volume scores for each of the three extracoronary sites were similar. CONCLUSIONS: Overall rescan measurement variabilities for extracoronary calcification are low and should not be an impediment to the use of this test for studying progression of extracoronary calcification over time.

Relation of echocardiographic left ventricular mass, geometry and wall stress, and left atrial dimension to coronary calcium in young adults (the CARDIA study).

We examined the relation of measures of echocardiographic left ventricular mass and geometry with coronary artery calcium (CAC) in 2,724 young adults. After adjustment for other coronary risk factors, left atrial dimension remained associated with the presence of CAC, and among subjects positive for CAC, left ventricular mass, end-systolic stress, and septal and posterior wall thicknesses in diastole remained associated with an increased extent of CAC.

Value of coronary artery calcium scanning by computed tomography for predicting coronary heart disease in diabetic subjects.

OBJECTIVE: The South Bay Heart Watch is a cohort study designed to determine the significance of coronary calcium in high-risk asymptomatic patients. This is a report of the relative risk (RR) for outcomes of coronary artery calcium in diabetic and nondiabetic subjects. RESEARCH DESIGN AND METHODS: A total of 1312 diabetic and nondiabetic subjects underwent risk factor screening and computed tomography testing for coronary calcium at baseline and were followed clinically for 6.3 +/- 1.4 years. End points were either 1). hard events of nonfatal myocardial infarction (MI) or coronary death or 2). any cardiovascular event (nonfatal MI, coronary death, coronary revascularization, or stroke). RESULTS: The incidence rates of a hard event and any cardiovascular event for diabetic and nondiabetic subjects were 14.5 and 6.1% and 23.8 and 12.2%, respectively (P < 0.001). Cox regression analyses of the combined risk relationship of diabetes status and calcium score demonstrated that relative to nondiabetic subjects with low calcium scores (<2.8), diabetic subjects with calcium scores >or=2.8 exhibited at least a fourfold increase in the risk of either a hard or any cardiovascular event (P < 0.001). Cox regression analyses conducted separately for nondiabetic and diabetic subjects revealed that coronary calcium score risk groups were significantly associated with events in nondiabetic subjects (RR >or= 2.6, P 0.05). CONCLUSIONS: The risk of coronary heart disease increases with increasing calcium scores and diabetes status. Calcium scores have less prognostic value in diabetic subjects.

Coronary calcium and cardiovascular event risk: evaluation by age- and sex-specific quartiles.

BACKGROUND: Wide differences in risks for cardiovascular disease (CVD) events associated with coronary artery calcium (CAC) have been reported. We evaluated the relationship of the coronary calcium quartile, on the basis of age-sex cut points from a large sample of asymptomatic patients, to CVD events as a possible standardized means for reporting event risks associated with CAC, in comparison with quartiles of absolute CAC scores. METHODS: We applied age/sex-stratified cut points to 928 asymptomatic men and women (mean age 54 years) followed up for an average of 3.3 years, during which 28 CVD events were confirmed. Cox regression was used to evaluate the relation of the 2nd, 3rd, and 4th quartiles (compared with the 1st), with and without age/sex stratification, to the risk of future CVD events. RESULTS: The number of events (and percent incidence) that occurred in the 1st, 2nd, 3rd, and 4th quartiles of coronary calcium was 4 (0.9%), 2 (2.0%), 9 (4.5%), and 13 (6.4%) events (P =.001) for the age/sex-stratified quartiles and 4 (1.0%), 0 (0%), 7 (3.0%), and 17 (7.3%) for the absolute score quartiles (P =.001). In multivariable analysis adjusted for other risk factors, there was a modest increase in CVD events seen among those in the 3rd quartile (relative risk [RR] 4.3, P =.02), with a greater risk seen among those in the 4th quartile (RR 6.0, P <.01) (compared with the 1st quartile). This did not differ from use of absolute CAC scores, where RR = 2.6 (P =.14) for the 3rd quartile and RR = 6.4 (P <.01) for the 4th quartile. CONCLUSIONS: Our results suggest that age-sex stratification by percentile rank of CAC is as accurate as absolute CAC scores for predicting CVD events in asymptomatic persons. Ongoing longitudinal population-based studies will provide more definitive data.

Coronary artery calcification in black women and white women.

BACKGROUND: Coronary calcification is a potent independent predictor of coronary risk. Sex-specific risk categories based on calcium scores have been established, but ethnic differences in coronary calcification have been little studied. This prospective cohort study compares coronary calcification, assessed by computed tomography, in postmenopausal black women and white women. METHODS AND RESULTS: Computed tomographic scans were performed on 128 black women and 733 white women without known coronary artery disease (mean age 63 +/- 8 years). Although coronary risk factors were more prevalent among black women (P <.0001), total calcium scores were similar to those in white women. By use of the Framingham algorithm, higher calcium scores were associated with higher 10-year risk of myocardial infarction or coronary death. In multiple regression analysis, age was independently associated with higher calcium scores in both ethnic groups (P =.002 for black women, P <.0001 for white women). Diabetes mellitus and not exercising at least 3 times per week were independently associated with higher calcium scores in white women but not black women. Educational level, body mass index, current hormone replacement therapy, hysterectomy, dietary fat consumption, family history of premature coronary disease, hypertension, self-reported high cholesterol, and current smoking were not independently associated with coronary calcium score in black women, white women, or the combined cohort; neither was ethnicity an independent predictor of coronary calcification. CONCLUSIONS: Despite higher dietary fat consumption, higher body mass index, and greater prevalence of hypertension, diabetes, and smoking, black women had coronary calcium scores similar to those of white women. Ethnicity was not an independent predictor of coronary calcification.

Comparison of calcium scores from thick- and thin image slice-computed tomography scanning in predicting future coronary events.

Computed tomographic image slices between 2.5 and 3.0 mm are commonly used for coronary calcium scanning. To evaluate the comparative accuracy of thicker image slices (5 to 6 mm) for predicting coronary events, we acquired both types of scans in 280 research participants and clinically followed them up for 7 years. We found that thick-slice image scanning and image assessment ranked calcium scores similarly and that measurements from both scanning methods predicted coronary heart disease events equally.

Genetic determinants of arterial calcification associated with atherosclerosis.

Increasing research interest has focused on arterial calcification in the setting of atherosclerosis. Many features of atherosclerosis-related calcification provide useful clinical information. For example, calcium mineral deposits frequently form in atherosclerotic plaque, and intimal arterial calcification can be used as a surrogate marker for atherosclerosis; also, calcium deposits are readily and noninvasively quantified, which is useful because greater amounts of coronary calcification predict a higher risk of myocardial infarction and death. Several mechanisms leading to calcification associated with atherosclerosis have been proposed; however, no direct testing of proposed mechanisms has yet been reported. Studies in genetically altered animals and in humans have shed light on potential genetic determinants, which in turn could form the basis for a more comprehensive understanding of the factors affecting calcification within plaque and the associated pathobiologic implications. We review proposed molecular and cellular mechanisms of atherosclerosis-associated arterial calcification, summarize genetic influences, and suggest areas in which further investigation is needed. Understanding the molecular and genetic determinants of specific structural plaque components such as calcification can provide a solid foundation for the development of novel therapeutic approaches to favorably alter plaque structure and minimize vulnerability to arterial rupture.

Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals.

CONTEXT: Guidelines advise that all adults undergo coronary heart disease (CHD) risk assessment to guide preventive treatment intensity. Although the Framingham Risk Score (FRS) is often recommended for this, it has been suggested that risk assessment may be improved by additional tests such as coronary artery calcium scoring (CACS). OBJECTIVES: To determine whether CACS assessment combined with FRS in asymptomatic adults provides prognostic information superior to either method alone and whether the combined approach can more accurately guide primary preventive strategies in patients with CHD risk factors. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational population-based study, of 1461 asymptomatic adults with coronary risk factors. Participants with at least 1 coronary risk factor (>45 years) underwent computed tomography (CT) examination, were screened between 1990-1992, were contacted yearly for up to 8.5 years after CT scan, and were assessed for CHD. This analysis included 1312 participants with CACS results; excluded were 269 participants with diabetes and 14 participants with either missing data or had a coronary event before CACS was performed. MAIN OUTCOME MEASURE: Nonfatal myocardial infarction (MI) or CHD death. RESULTS: During a median of 7.0 years of follow-up, 84 patients experienced MI or CHD death; 70 patients died of any cause. There were 291 (28%) participants with an FRS of more than 20% and 221 (21%) with a CACS of more than 300. Compared with an FRS of less than 10%, an FRS of more than 20% predicted the risk of MI or CHD death (hazard ratio [HR], 14.3; 95% confidence interval [CI]; 2.0-104; P =.009). Compared with a CACS of zero, a CACS of more than 300 was predictive (HR, 3.9; 95% CI, 2.1-7.3; P<.001). Across categories of FRS, CACS was predictive of risk among patients with an FRS higher than 10% (P<.001) but not with an FRS less than 10%. CONCLUSION: These data support the hypothesis that high CACS can modify predicted risk obtained from FRS alone, especially among patients in the intermediate-risk category in whom clinical decision making is most uncertain.

Risk and the physics of clinical prediction.

The current paradigm of primary prevention in cardiology uses traditional risk factors to estimate future cardiovascular risk. These risk estimates are based on prediction models derived from prospective cohort studies and are incorporated into guideline-based initiation algorithms for commonly used preventive pharmacologic treatments, such as aspirin and statins. However, risk estimates are more accurate for populations of similar patients than they are for any individual patient. It may be hazardous to presume that the point estimate of risk derived from a population model represents the most accurate estimate for a given patient. In this review, we exploit principles derived from physics as a metaphor for the distinction between predictions regarding populations versus patients. We identify the following: (1) predictions of risk are accurate at the level of populations but do not translate directly to patients, (2) perfect accuracy of individual risk estimation is unobtainable even with the addition of multiple novel risk factors, and (3) direct measurement of subclinical disease (screening) affords far greater certainty regarding the personalized treatment of patients, whereas risk estimates often remain uncertain for patients. In conclusion, shifting our focus from prediction of events to detection of disease could improve personalized decision-making and outcomes. We also discuss innovative future strategies for risk estimation and treatment allocation in preventive cardiology.

Progression of coronary calcium and incident coronary heart disease events: MESA (Multi-Ethnic Study of Atherosclerosis).

OBJECTIVES: The study examined whether progression of coronary artery calcium (CAC) is a predictor of future coronary heart disease (CHD) events. BACKGROUND: CAC predicts CHD events and serial measurement of CAC has been proposed to evaluate atherosclerosis progression. METHODS: We studied 6,778 persons (52.8% female) aged 45 to 84 years from the MESA (Multi-Ethnic Study of Atherosclerosis) study. A total of 5,682 persons had baseline and follow-up CAC scans approximately 2.5 ± 0.8 years apart; multiple imputation was used to account for the remainder (n = 1,096) missing follow-up scans. Median follow-up duration from the baseline was 7.6 (max = 9.0) years. CAC change was assessed by absolute change between baseline and follow-up CAC. Cox proportional hazards regression providing hazard ratios (HRs) examined the relation of change in CAC with CHD events, adjusting for age, gender, ethnicity, baseline calcium score, and other risk factors. RESULTS: A total of 343 and 206 hard CHD events occurred. The annual change in CAC averaged 24.9 ± 65.3 Agatston units. Among persons without CAC at baseline (n = 3,396), a 5-unit annual change in CAC was associated with an adjusted HR (95% Confidence Interval) of 1.4 (1.0 to 1.9) for total and 1.5 (1.1 to 2.1) for hard CHD. Among those with CAC >0 at baseline, HRs (per 100 unit annual change) were 1.2 (1.1 to 1.4) and 1.3 (1.1 to 1.5), respectively. Among participants with baseline CAC, those with annual progression of ≥300 units had adjusted HRs of 3.8 (1.5 to 9.6) for total and 6.3 (1.9 to 21.5) for hard CHD compared to those without progression. CONCLUSIONS: Progression of CAC is associated with an increased risk for future hard and total CHD events.

Abdominal aortic calcium and multi-site atherosclerosis: the Multiethnic Study of Atherosclerosis.

BACKGROUND: Abdominal aortic calcification (AAC) is a measure of subclinical cardiovascular disease (CVD). Data are limited regarding its relation to other measures of atherosclerosis. METHODS: Among 1812 subjects (49% female, 21% black, 14% Chinese, and 25% Hispanic) within the population-based Multiethnic Study of Atherosclerosis, we examined the cross-sectional relation of AAC with coronary artery calcium (CAC), ankle brachial index (ABI), and carotid intimal medial thickness (CIMT), as well as multiple measures of subclinical CVD. RESULTS: AAC prevalence ranged from 34% in those aged 45-54 to 94% in those aged 75-84 (p < 0.0001), was highest in Caucasians (79%) and lowest in blacks (62%) (p < 0.0001). CAC prevalence, mean maximum CIMT ≥ 1mm, and ABI < 0.9 was greater in those with vs. without AAC: CAC 60% vs. 16%, CIMT 38% vs. 7%, and ABI 5% vs. 1% for women and CAC 80% vs. 37%, CIMT 43% vs. 16%, and ABI 4% vs. 2% for men (p < 0.01 for all except p < 0.05 for ABI in men). The substantially greater prevalence for CAC in men compared to women all ages is not seen for AAC. By age 65, 97% of men and 91% of women have AAC, CAC, increased CIMT, and/or low ABI. The presence of multi-site atherosclerosis (≥ 3 of the above) ranged from 20% in women to 30% in men (p < 0.001), was highest in Caucasians (28%) and lowest in Chinese (16%) and ranged from 5% in those aged 45-54 to 53% in those aged 75-84 (p < 0.01 to p < 0.001). Finally, increased AAC was associated with 2-3-old relative risks for the presence of increased CIMT, low ABI, or CAC. CONCLUSIONS: AAC is associated with an increased likelihood of other vascular atherosclerosis. Its additive prognostic value to these other measures is of further interest.

High blood pressure in Chinese ethnic minorities: report from rural Yunnan province.

BACKGROUND: Hypertension (HTN) is a growing cause of morbidity and mortality among rural Chinese. While HTN has been studied in various regions of China, little is known about HTN among ethnic minorities in rural China. METHODS: A total of 36 villages were randomly selected from Yunnan province, China. From these villages, a total of 1,676 subjects from 10 ethnic minorities and the Han ethnic majority were selected for interview and blood pressure (BP) measurement. From each village, 50-80 men and women between the ages of 50 and 70 years were randomly selected. HTN prevalence, treatment, and control rates of HTN were evaluated in these 11 ethnic groups. RESULTS: After controlling for age, gender, body mass index (BMI), smoking, alcohol, and monosodium glutamate intake, prevalence of HTN varied between 25% in the Hani minority and 64% in the Tibetan minority (P < 0.001). Treatment rates varied between 0% in the Hani minority and 41% in the Tibetan minority (P = 0.006). Control rates varied between 0% in the Hani minority and 17% in the Tibetan minority (P = 0.28). Prevalence, treatment, and control rates in the Han ethnic group were 35, 22, and 12%, respectively. CONCLUSIONS: The prevalence of HTN varies widely among China's ethnic groups. Treatment and control rates of HTN also vary and are inadequate in the minority ethnic groups as well as in the Han majority.

The farther from town the lower the blood pressure: report from rural Yunnan province.

BACKGROUND: Hypertension (HTN) is a major cause of death in Chinese farmers. Remoteness from population centers may independently affect HTN prevalence and severity. METHODS: We used random cluster sampling to select 27 villages in Yunnan province, China. Within each village, we randomly selected 50-80 men and women between the ages of 50 and 70 years. A total of 1,177 participants underwent interviews and blood pressure (BP) measurement. We evaluated the relationship between BP and distance of the participants' village from the town and county centers with and without adjustment for covariates. RESULTS: There was a significant (P < 0.001) inverse relationship between BP and distance from populations centers. For every 10 km from the town center, the mean systolic BP (SBP) in the village decreased by 1.2 mm Hg and the mean diastolic by 0.5 mm Hg. After adjustment for age, gender, ethnicity, body mass index, smoking, and drinking, we found that SBP decreased by 1.8 mm Hg (P = 0.03) and diastolic BP by 1.0 mm Hg (P = 0.02) for every 10 km distance from the town center. CONCLUSIONS: HTN prevalence and severity are significantly linked to distance from population centers in rural Chinese farmers. The farther a farmer's village is from larger population centers, the greater is the probability that his/her BP will be normal. This relationship is independent of age, gender, ethnicity, body mass index, smoking, and alcohol use. Strategies in addressing HTN in rural regions should take account of this geographic dependence on distance from population centers.